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INTEGRATINGEPSDT and SYSTEM OF CARE
a Federal mandateand a great idea, too!
Steven Kossor, Licensed Psychologist
Executive Director, The Institute for Behavior Change
The short version….
A word of thanks….
US Congressman Jim Gerlach has been a strong supporter of the Institute for Behavior Change and of my efforts to bring quality mental health treatment services to people, especially those who have developmental disabilities, for many years. I deeply appreciate his consistent and enthusiastic endorsement of my work and look forward to future opportunities to share new ideas with others.
Steve Kossor
July 9, 1868 (the first Johnson Administration)
14th Amendment to the Constitution
All US citizens [of any age] shall have equal protection under the law.
rich or poorrich or poor
rich or poorrich or poor
rich or poor
1965 (the second Johnson Administration)
“A great society protects its weakest members.”
Medicaid is created as a joint federal and state program to finance health care treatment for diagnosed, episodic illness in low-income individuals.
It has no specific standards related to children.
1965
Medicaid:To provide Medically Necessary treatment to those who need it.
Requires no Federal Reauthorization.
It’s forever. ▲functionally
1965 Medicaid “Medical Necessity”
Is it Reasonable?Is it Necessary?Is it Appropriate, according to evidence-based practices?
Then it’s Medically Necessary.
1967 Height of the Vietnam war
50% of draftees
ARE UNFIT FOR MILITARY SERVICE!(because of untreated childhood illnesses)
Who will fight our wars?
1967 Early and Periodic Screening, Diagnosis and Treatment
For children under 21 years of age:
Question: Is it intended to correct or ameliorate defects & physical & mental illnesses and conditions discovered by the screening process?
Yes? Then it’s “Medically Necessary.”
Each state is permitted to create its own version of the “medically necessary” treatment definition, but all states are required to comply with the federal EPSDT standard in order to continue accessing federal Medicaid funds, so the definitions can’t stray too far…..
1988 and 1989
The Medicare Catastrophic Coverage Act of 1988, P.L.100-360
Less-restrictive Medicaid eligibility standards
The Omnibus Budget Reconciliation Act of 1989
Mandatory EPSDT services in all 50 states
Medicaid Cost Containment Efforts
Note: Most changes do not apply to “EPSDT”
Positive Changes in Medicaid
Note: Most changes do apply to “EPSDT”
Key concepts in treatment funding
1. EPSDT services must be provided to children enrolled in Medicaid whether or not the services are provided for in any State Plan.
2. Medicaid, not the school, must pay for covered services to a child if funding is in dispute.
EPSDT Benefits
Treatment AND Prevention services Physical, Speech & Related Therapies Hearing Services Eye Examinations & Eyeglasses Durable Medical Equipment Home, Residential & Inpatient Care Dental Care Other Services (including mental health care)
The remainder of this presentation will focus on the Behavioral Health Rehabilitation Services that can be delivered to disabled children through the EPSDT mandate of Medicaid. See 42 CFR §1396d (r) (5).
2005 The Deficit Reduction Act (DRA)
Children will… “still be entitled to receive EPSDT benefits in addition to the benefits provided by the benchmark coverage...”
The Centers for Medicare and Medicaid Services (CMS) “will not approve any state Medicaid plan that does not include the provision of EPSDT benefits.”
CMS Administrator Mark B. McClellan, “Statement on EPSDT Coverage for Children Under 19,” April 2006.
Available at www.tilrc.org/Real%20Choice%20Website/epsdt0406htm.
42 CFR Chapter VII Subchapter XIX §1396d[Sec. 1905(r)(5)] “The Social Security Act”
(r) Early and periodic screening, diagnostic, and treatment services
(5) Such other necessary health care, diagnostic services, treatment, and other measures described in subsection (a) of this section to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.
Nothing in this subchapter shall be construed as limiting providers of early and periodic screening, diagnostic, and treatment services to providers who are qualified to provide all of the items and services described in the previous sentence or as preventing a provider that is qualified under the plan to furnish one or more (but not all) of such items or services from being qualified to provide such items and services as part of early and periodic screening, diagnostic, and treatment services.
42 CFR Chapter IV Part 440.130 [Sec. 1905(a)(13)] “The Social Security Act”
(a) ‘‘Diagnostic services,’’ except as otherwise provided under this subpart, includes any medical procedures or supplies recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under State law, to enable him to identify the existence, nature, or extent of illness, injury, or other health deviation in a recipient.
(c) ‘‘Preventive services’’ means services provided by a physician or other licensed practitioner of the healing arts within the scope of his practice under State law to
(1) Prevent disease, disability, and other health conditions or their progression;
(2) Prolong life; and
(3) Promote physical and mental health and efficiency.
(d) ‘‘Rehabilitative services,’’ except as otherwise provided under this subpart, includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his practice under State law, for maximum reduction of physical or mental disability and restoration of a recipient to his best possible functional level.
42 CFR Chapter VII Subchapter XIX §1396d[Sec. 1905(a)] “The Social Security Act”
DefinitionsFor purposes of this subchapter—
(a) Medical assistance
The term “medical assistance” means payment of part or all of the cost of the following care and services …
(if provided in or after the third month before the month in which the recipient makes application for assistance) …
for individuals who are—
(i) under the age of 21, or, at the option of the State, under the age of 20, 19, or 18 as the State may choose,
…
Medicaid Eligibility:CATEGORICALLY needy
Qualified Medicare beneficiaries Pregnant women Low-income families with children Supplemental Security Income (SSI)
recipients Anyone under age 21 with income less
than a specified percent of the Federal Poverty Level
Medicaid Eligibility:
Medically Needy
Those who, except for income and resources (assets), would be eligible as “categorically needy.”
There are no “asset tests” anymore.
How much “income” does a child have?
Does parental income always “count?”
hint: no
Pennsylvania’s “Medically Necessary” definition under Medicaid Regulations
STATEMENT OF POLICY DEPARTMENT OF PUBLIC WELFAREOFFICE OF MEDICAL ASSISTANCE PROGRAMS
[55 Pa. Code Chapter 1101] General Provisions
§1101.21a. Clarification Regarding the Definition of “Medically Necessary” – statement of policy.
A service, item, procedure or level of care that is necessary for the proper treatment or management of an illness, injury or disability is one that:
(1) Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability.
(2) Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.
(3) Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age.
Who decides if treatment is “medically necessary”
If a licensed practitioner of the healing arts prescribes a treatment “to correct or ameliorate a physical or mental defect or condition” and it works, it is medically necessary and Medicaid can fund it, regardless of whether it is an “accepted medical practice” in someone else’s opinion.
The Social Security “Blue Book”
lists disabilities that qualify a child as a person with a
disability under Medicaid
42 CFR Chapter IV Part 440.230
(b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.
(c) The Medicaid agency may not arbitrarily deny or reduce the amount, duration, or scope of a required service […] to an otherwise eligible recipient solely because of the diagnosis, type of illness, or condition.
(d) The agency may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures. Here enters the MCO
PART II:How to treat mental illness in children
We’ve explored the Medicaid statute.
We’ve explored the EPSDT mandate.
We’ve identified what is possible.
Now, we’ll look at what is working.
We intervene “in” children’s lives, not “on” them. Every plan is completely individualized for the child who receives services through it and is developed with the full collaboration of the parent and with the cooperation of the teachers, counselors and other adults active in the child’s life. To the maximum extent possible, the child himself/herself is involved in the plan’s development and revision.
The Plan could address behavior at home, in school or anywhere else in the community.
They Work! 300 Treatment records 2002-2006 Children ages 2-17
Overall Treatment Effectiveness
BETTER71%
WORSE
11%
STABILIZED
18%
They Work! 300 Treatment records 2002-2006 Children ages 2-17
Lack of Safety Awareness
BETTER85%
WORSE11%
STABILIZED6%
Physical Aggression
BETTER72%
WORSE14%
STABILIZED14%
Noncompliance with Adult Prompts
BETTER82%
STABILIZED11%
WORSE7%
They Work! 300 Treatment records 2002-2006 Children ages 2-17
Communication Deficits
BETTER
63%
WORSE
11%
ST ABILIZE D
26%
Socialization Deficits
BETTER64%
WORSE14%
STABILIZED22%
They Worked!
treatmentplansthatworked.com
has more than 150 “treatment plans that worked” available on-line for download
– with the data that documents it.
A subscription with unlimited access (including loads of information on EPSDT and especially “BHR” mental health treatment services) is $65
The #1 source for information worldwideGoogle “Treatment plans for children”
PA Prescriptions for EPSDT services
Behavior Specialist Consultant (BSC) licensed or unlicensed psychologist Masters or Doctoral degree “in a clinical field” One year of experience working with children
Philadelphia requires 2 years post-graduate experience
Mobile Therapist (MT) licensed or unlicensed psychologist Masters or Doctoral degree “in a clinical field” One year of experience working with children
BSC and MT providers are supervised closely each week by licensed psychologists at the Institute for Behavior Change in Pennsylvania.
See http://www.ibc-pa.org/job_descriptions.htm for more information.
TSS? What’s that?
Therapeutic Staff Support (TSS) is provided in Pennsylvania by a person with a Bachelors degree (usually in psychology) who works 1:1 with the child for several hours each day, at home, in school, and in the community.
Prescriptions for 20 or more TSS hours weekly are often appropriate, necessary and authorized by the MCO if the child’s behavioral data supports the need for TSS service.
One of the 301 treatment records of a child with an Autism Spectrum Disorder
TSS effect on behavior
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13
Weeks
physical aggression
socialization
noncompliance
AFTER TSSBEFORE TSS
Another successful treatment record of a child with an Autism Spectrum Disorder
TSS effect on behavior
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13
Weeks
Safety Awareness
Physical Aggression
Noncompliance
AFTER TSSBEFORE TSS
Community
Support
Team(page B-9)
Community
Support
Individual,
Group(page B-7)
TEAM
Individual, Group
Positive Behavior Support (PBS)
University of Kansas
CollaborationCollaboration
Referral and identification process is in place in building to identify students in need of tertiary interventions, including those who may need wraparound supports, using data on student behaviors
Team-based individualized support/tertiary intervention planning (including at least one member with behavioral expertise), problem-solving, continuous progress monitoring, and data-based decision making
Comprehensive person-centered planning approaches Function-based behavioral interventions and supports based on
testable hypotheses for problem behaviors Multi-component Behavior Intervention Plans identify
interventions and supports designed to prevent, teach, and reinforce/correct behaviors
Targeted social skills training and self-management instruction emphasized
Individualized instructional and curricular accommodations made to address problem behavior
Single domain (i.e., school-only) Behavior Intervention Plans, or multi-domain plans (i.e., school, home and community), based on the student's needs
Wraparound process for the 1-2% of students who require even more intensive individualized planning across multiple settings; i.e., school, home, community
Community resources identified and collaborative relationships developed with agencies (e.g., meeting with teams, serving as referral sources to access services)
The Illinois PBIS Model
Knowledgeshifts the balance of Power
Control
Capitulate
Compromise
Collaborate
Pleading
Reasoning
Copyright © 2009 Steven Kossor visit www.OurCaseManager.pro for more information All Rights Reserved
Superior Knowledgeshifts the balance of Power
Control
Capitulate
Knowledge myth & lies
KNOWLEDGE facts & data
Reasoning
Pleading
Knowledgeshifts the balance of Power
Control
Knowledge myth & lies
Capitulate
KNOWLEDGE facts & data
DELAY
Superior Knowledgeshifts the balance of Power
Capitulate
KNOWLEDGE facts & data
Control
Knowledge myth & lies
DELAY
Appeal to Higher Authority
Knowledgeshifts the balance of Power
Control
Knowledge myth & lies
DELAY
$$$$ Capitulate
KNOWLEDGE facts & data
Appeal to Higher Authority
Superior Knowledgeshifts the balance of Power
Capitulate
KNOWLEDGE facts & data
Control
Knowledge myth & lies
DELAY
Appeal to Higher Authority
$$$$ AccountabiliAccountabilityty and and
StandardsStandards
w w w . i b c - p a . o r g
Copyright © 2009 Steven Kossor visit www.OurCaseManager.pro for more information All Rights Reserved
401-A Gordon Drive
Exton, PA 19341-1276 Secure phone/fax: 610-383-1432
www.ibc-pa.org
