Medicaid

Community Services

• Amend Medicaid law to cover intensive community mental health services. This would allow states to reimburse for comprehensive programs that provide services that normally fall within a broad array of services, such as targeted case management, clinic, rehabilitation and personal care. Bipartisan legislation introduced in both houses of Congress would accomplish this (see H.R. 2364 and S. 2072 ).
  
  
• Issue a State Medicaid Director Letter clarifying psychiatric rehabilitation rules. Such policy guidance would also need to ensure that services now covered in at least a third of the states are recognized in federal rules. At a minimum, these services include: skills-training to enable individuals to maintain their living situation; educational placement or employment; assertive community treatment; peer-provided services; intensive in-home services for children; school-based; after-school and summer day treatment programs; mentors and multi-systemic therapy for children and youth.
  
  
• Amend Medicaid to include residential treatment centers as institutions for purposes of home- and community-based waivers (Section 1915(c)).
  
  
• Create a template so states can provide community-based services for adults at risk of placement in Medicaid-covered institutions (psychiatric hospital, nursing home or IMD) that specifically addresses unique issues of a home and community based waiver for a person with mental illness. For example, the institutional eligibility categories have special rules for this population and service needs may differ from those with developmental disabilities or who are elderly. Secondly, as specified for these other populations in the State Medicaid Director letter (SMDL #02-008) dated May 9, 2002, specifically cover for individuals with mental illness: transitional costs from an institution to community living such as discharge planning; one-time set up expenses for individuals making a transition from institution to their own home, such as security deposits, essential furnishings and moving expenses; set up fees or deposits for utility or service access (e.g. telephone, electricity, heating); and health and safety assurances (pest eradication, allergen control or one-time cleaning prior to occupancy).

Eligibility Rules

• Issue a State Medicaid Director letter clarifying that Medicaid eligibility cannot be terminated during incarceration (unless due to loss of some other benefit, such as SSI) for either juveniles or adults
• Provide states with the option of allowing families of children with disabilities to buy into Medicaid in order to allow these children access to the intensive rehabilitative community services only available through publicly-funded systems.
• Amend federal rules to permit individuals residing in an IMD to receive Medicaid-funded physical health care services on- or off-site.

Children's Services

• CMS should permit and encourage states to switch to the Zero to Three system for children younger than four. The Zero to Three assessment system is increasingly recognized as a more appropriate system for determining the need for mental health treatment. Very young children need to be assessed for developmental delay and inappropriate behaviors or social interactions. Neither DSM nor ICD are well adapted for infants and toddlers aged 0-3.
  
  
• Provide states with greater flexibility to cover services to families of children with mental disorders. Children need to be treated in the context of their family unit. Current Medicaid rules regarding directing the delivery of all services to the identified "patient" hamper states ability to provide good care.

Administrative Issues

• Require CMS and states to report cost and utilization data for mental health services.
• CMS should conduct a study of why individuals who are eligible under their state plan do not have access to services - investigate issues of lack of appropriate billing codes, inappropriate diagnostic requirements and/or providers not available.