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Accessing Mental Health Services for Children in Maryland Through the Medical Assistance/Medicaid EPSDT Benefit
We want to hear from you: Complete the Children's Medical Assistance Survey What is EPSDT? EPSDT stands for Early & Periodic Screening, Diagnosis & Treatment. Federal Law requires the state to provide screening, diagnosis and all "medically necessary" treatment services, including mental health services, to all Medicaid recipients under 21. EPSDT is a way to obtain the individualized wrap-around treatment and support services necessary to allow children to remain at home and in their community, or to return there after a hospitalization or other out-of-home placement. Who is eligible for services under EPSDT? All children in Maryland under 21 years of age receiving Medical Assistance benefits or Maryland Children's Health Program benefits, including children enrolled under a waiver program, are eligible for services under EPSDT. Can children who are not eligible for Medical Assistance receive the same services through the Maryland Public Mental Health System (PMHS)? Possibly. Unlike children on Medical Assistance, PMHS recipients, who receive services through Maryland Health Partners (MHP), are not guaranteed these services. MHP may approve or deny services depending on the availability of State funds. What if a child has a developmental disability and does not have a diagnosed mental illness? Children with developmental disabilities also are entitled to receive these services under EPSDT. Unfortunately, they have not been provided. Currently, children with developmental disabilities have not been given access to mental or behavioral health services (other than medication management and assessments) through the Public Mental Health System or their managed care organization (MCO). But the State has agreed that MHP will accept referrals for in-home one to one behavioral aides even if a person with a developmental disability does not have a mental illness diagnosis. What mental health services should be covered by Medical Assistance through EPSDT? Virtually any service that is deemed "medically necessary" through an assessment or screening, and is recommended by a physician, psychologist, social worker or nurse (or other licensed health care practitioner) is covered by Medical Assistance through EPSDT. Please note that any visit or assessment can be considered an EPSDT "screening" under federal law. A screening does not need to be a formal process; it can include any visit or encounter by a child with a qualified professional, regardless of whether the professional is Medical Assistance-certified. Although the federal law lists a number of specific mandatory services, that list of covered mental health services is not exhaustive. Medicaid recipients have the right to virtually any home or community-based mental health service that a practitioner determines is medically necessary. Some of the services covered through EPSDT under federal Medical Assistance law include:
Are there any mental health services for children who are not covered by Medical Assistance? Room and board (for example, a group home) are not covered services. However, funding may be available through the local Core Service Agencies (CSAs), which coordinate mental health services in each local jurisdiction throughout the State. Respite care is also not a covered service because its purpose is to assist the family or community, and not to improve the child's medical condition. However, personal care services or a one-on-one behavioral aide for the child, which might provide the same relief to family members, are covered under EPSDT. Why is this wide range of services not being provided to all Medical Assistance-eligible children who need them? Unfortunately, the Public Mental Health System has not provided adequate outreach and information to consumers, family members and mental health professionals to inform them of the range of available services. As a result, families, physicians, practitioners, mental health professionals and providers have not made specific requests for the full range of "medically-necessary" services mandated by federal law. In addition, people often mistakenly believe that the CSA, MHP, and the private organizations providing services (e.g., Psychiatric Rehabilitation Programs, or PRPs) are permitted to deny community-based services based on availability and/or sufficient funding. This is not true for children who receive Medical Assistance benefits. How can I gain access to these mental health services for my child or patient? Maryland's Public Mental Health System requires that all mental health services be authorized through MHP. To secure services for a child with a mental illness diagnosis, contact MHP by telephone (1-800-888-1965). Access is available 24 hours a day. If you are requesting a one-on-one behavioral aide, ask for Thomasina O'Leary or Aisha Collins. Professionals: Telephone MHP with the specific services requested, including the frequency or number of hours per day/week (if applicable) and the anticipated duration of service needs. It is also recommended that the referral be confirmed in writing, be signed by a licensed professional and that it document all the specifics of the service request and that it is "medically necessary." Although the referring professional need not be a Medical Assistance provider, the professional providing the service must be a Medical Assistance provider. All mental health professionals providing referrals, assessments or services should review Maryland's Public Mental Health System Provider Manual (last revised May 2001) for further details. Families: Although families may choose to call MHP themselves, we recommend that, if possible, they obtain the assistance of a mental health professional to make the referral for services. Be sure to provide the professional with this document for assistance in the referral process. What information should the mental health professional provide in writing to MHP?
The individual or agency requesting authorization for services is not required to locate, arrange or provide the services. Medical Assistance is responsible for arranging corrective treatment through referral to appropriate and qualified individuals or agencies, that are willing and able to provide the requested service. The referring professional or the family may request a provider agency by name or MHP, and/or the CSA will refer a family to a provider agency. Is there a legal timeframe for approving and providing EPSDT services? Yes. Under federal law, Medical Assistance services must be approved and provided with "reasonable promptness." Maryland's regulations for the Public Mental Health System require MHP to approve or deny a request for services within 24 hours unless there is (1) an emergency (in which case services must be approved or denied within one hour) or (2) there is a clinical basis for an extension. The regulations also require services to be provided within ten business days after approval, unless the need is urgent or there is a clinical rationale for an extension of no more than 30 days. What should be done if the requested services are denied, not available, or are not actually provided? Call MDLC at 410-727-6352 or 1-800-233-7201, or Email Cathy Surace at CathyS@mdlcbalto.org for assistance if:
EPSDT Services |
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