National data suggests that between 50% to 90% of all adolescents who access services for mental health or substance abuse treatment, actually have co-occurring mental health and substance abuse issues. Most of us know it exists, whether we see it in our children, or in our clients, we know it’s there. However, it is not often discussed, because those treatment providers who bill Medicaid for services rendered, cannot give a client two primary diagnoses. For so long, the system focused on treating one, then the other. So if a parent brought in a child, the treatment provider would need to diagnose him or her first with a mental health issue and then a substance abuse issue, or the other way around.

Over the course of time and research studies, more and more people are realizing that this system of diagnosing an adolescent, and “coding” him or her as one before the other, is not the best way to treat him or her. Parents and providers alike have learned that the best way to treat co-occurring is to treat both the mental health diagnosis and the substance abuse issue at the same time. However, it is very difficult to do so.

Many Kentuckians who access mental health and substance abuse treatment, also access Medicaid services. At this time, Medicaid does not recognize co-occurring treatment for adolescents, and therefore therapists cannot bill Medicaid for their services. Instead, therapists must still use the old way, and diagnose first the mental health issue, then diagnose the substance abuse issue as secondary to the mental health diagnosis, if they diagnose the substance abuse issue at all. Sometimes the substance abuse diagnosis is ignored because some providers fear they will lose Medicaid reimbursement, even though the substance abuse issue may show up in the adolescent’s case file. While this method gets them around billing Medicaid, it does not serve adolescents as well as being able to diagnose as co-occurring.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Under Medicaid, the EPSDT program covers Intensive Outpatient (IOP) treatment, residential treatment, and inpatient treatment for adolescent substance abuse, but it does not cover outpatient treatment or case management services, two services many adolescents benefit from. The only parties who are able to provide EPSDT services are community mental health centers (CMHC) or what is called a “health care provider”. Examples of what EPSDT defines as health care providers are Ten Broeck and The Ridge, both of which are private hospitals, and Eastern State, Western State and Central State Hospitals, which are all state run.

The problems that exist with EPSDT only providing specific services with specific providers is that it limits options for adolescents and their families. Medicaid spends most of the money they have set aside for adolescent services on inpatient treatment and residential treatment. This is the most expensive form of treatment, and is difficult to access since only three CMHCs provide residential services. Additionally, outpatient treatment (which is different from IOP) is not covered under EPSDT only the initial screening and assessment. These two barriers combined often create a situation that lets adolescents be discharged from inpatient programs to their home communities where there is often no form of continuing care.

If someone with a substance abuse issue goes back into the same environment where they began using the substance, and no changes are made or supports are available, they will very often relapse into the same habits they had before treatment, despite any and all progress they made in treatment. This is as much true for adolescents as it is for anyone. When the adolescent goes back into that same environment with no additional supports, the end result is all too often a high relapse rate, and what is called a “revolving door” effect. This revolving door effect is when an adolescent comes in and out of inpatient programs, which frustrates the adolescent, his or her family, and the treatment providers.

What further frustrates adolescents, family members, and providers is that, since treatment providers cannot be reimbursed for outpatient treatment or case management services, there is no real opportunity to treat adolescents earlier, and prevent them from going around the revolving door too often. It is often very difficult for treatment providers working in a CMHC to bill EPSDT. A lot of time and documentation is needed to get preauthorization from EPSDT. This is slightly easier for the health care providers with inpatient and residential programs because they have specific staff to work with Medicaid. Within CMHCs, the individual therapists are required to get the preauthorization, and the amount of time they must put into trying to bill EPSDT, takes away from the time they could be helping another client.

In Kentucky
In Kentucky, the Department for Medicaid Services addresses EPSDT and what services can be covered under this program. It is a very helpful question and answer guide for many consumers of Medicaid services, and it explains a lot of what EPSDT can and will cover for children under age 21, though it does not clearly explain how EPSDT serves adolescents with mental health and/or substance abuse problems.

Kentucky Medicaid explains EPSDT services as available “for medically necessary special services, but may not otherwise be covered under the Kentucky Medicaid Program. Services may be preventive, diagnostic or treatment, or rehabilitative. All EPSDT special services require prior authorization”.

Any substance abuse treatment that will be covered under EPSDT in Kentucky is covered under what is called EPSDT Special Services. Special Services “allows coverage for items or services which are medically necessary and which are not covered somewhere else in Medicaid. It is considered treatment”.

In Kentucky, EPSDT Special Services is available for children through age 21, but is not available for children who are eligible to receive KCHIP (Kentucky Children’s Health Insurance Program), although children receiving KCHIP can access EPSDT screenings. As mentioned above, EPSDT Special Services is only allowed for that which is considered “medically necessary”. According to the federal government, each state defines “medically necessary” and states “the standard of medical necessity used by a state must be one that ensures a sufficient level of coverage to not merely treat an already-existing illness or injury but also, to prevent the development or worsening of conditions, illnesses, and disabilities”.

Advocacy-What’s Going On
The Bazelon Center for Mental Health Law is a national legal organization dedicated to advocating for the rights of individuals with mental disabilities. In 2003, they conducted a research study which assessed behavioral health screening tool policies in the Medicaid programs of all 50 states. The study found that most states do not utilize the most effective Medicaid programs to identify mental health or substance abuse problems in children.

One of the researchers involved in the study, Rafael Semansky, stated that almost half of all states do not have Medicaid policies in place to identify children with mental health and substance abuse issues. He also stated that states need to do more to promote the use of effective tools so that each state’s Medicaid system can identify and provide treatment for children who need services.

Additionally, the study found that primary care providers, who generally do the first screening for behavioral health issues, receive no guidance from Medicaid agencies on screening tools that would help them accurately identify those health issues. Without knowledge of these screening tools, many physicians miss these important diagnoses. Some previous studies have indicated that more than 40 percent of children with a diagnosable disorder are left undiagnosed without the use of standardized, specialized screening tools.

With the proper tools available, the proper assistance from Medicaid, more young people stand to be diagnosed correctly and treated more effectively the first time. This potentially will help adolescents receive the proper treatment the first time, and could keep them from the revolving door effect. The proper tools may also help more families, providers, and decision-makers realize the need for co-occurring treatment instead of diagnosing and treating one or the other, or even diagnosing and treating one before the other.

Resources

Kentucky Youth First
(502) 564-4456
http://mhmr.ky.gov/mhsas/adolescent_services.asp

The Bazelon Center for Mental Health Law
(202) 467-5730
www.bazelon.org

The Centers for Medicare and Medicaid Services-EPSDT services overview
http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/
Kentucky Department for Medicaid Services
(800) 635-2570 or if you’re in Frankfort
(502) 564-9444
(800) 775-0296 for the hearing impaired
http://chfs.ky.gov/dms/

U.S. Department for Health and Human Services
Health Resources Services Administration
EPSDT Overview
http://www.hrsa.gov/epsdt/default.htm
comments@hrsa.gov