Introduction
Medicaid is a means-tested program that finances health and mental health
services for children and adults who meet certain eligibility criteria.
Although a broad array of mental health services can be covered by Medicaid,
some services needed by families of children with serious mental or emotional
disorders can only be covered through a waiver for home- and community-based
services.
This waiver, which must be approved by the federal Centers on Medicare
and Medicaid Services, can both expand the range of services for Medicaid
-eligible children and families and can also be used—at the state’s
option—to expand Medicaid eligibility to those whose incomes exceed
standard Medicaid eligibility requirements in the state. To be eligible,
children must have disorders so severe that they would otherwise need
hospital-level care.
A home- and community-based care waiver of Medicaid rules can also address
the issue of families who lack private insurance or whose insurance fails
to cover needed services. Although children in these families may not
normally qualify for Medicaid due to their family’s income, the waiver
can be used to expand eligibility so children can access services available
through Medicaid.Without adequate insurance or the waiver, families sometimes
turn to the child welfare system, relinquishing custody of their child
to access needed mental health services.
However, some states have been reluctant to implement the waiver. Bazelon
Center staff surveyed officials from 17 states that are not currently
utilizing a home- and community-based waiver for children with serious
emotional disturbance and asked them to identify the barriers to applying
for such a waiver. We then conducted an extensive interview with state-level
officials from New York, Vermont and Kansas, the three states that are
currently implementing a waiver for this population, to discover how they
overcame these barriers.
Overall, these interviews revealed the ingenuity and dedication of the
state officials responsible for designing and implementing the waiver
and the need to take advantage of funding opportunities . When faced with
barriers, these individuals found ways to surmount them. They devised
program initiatives that started out small and have built upon their successes.
Sometimes drawing on their state’s experience with developmental
disability waivers, they were able to advance the waiver application and
implementation processes without a large investment of staff or resources.
State officials found that overcoming barriers to applying for the waiver
did not complete their work. They have had to work actively to eliminate
additional roadblocks to ensure that the waiver actually leads to adequate
community-based services for all children with severe mental health needs.
Based on our conversations with officials in states that have not applied
for waivers and the experiences of state officials and families in states
with the waiver, we have analyzed the principal barriers and developed
a set of recommendations. As the three states with the waiver have demonstrated,
expanded medicaid coverage can make a tremendous difference for families
and children with severe mental healthcare needs and drastically reduce
the incidence of custody relinquishment to get care.
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