New Instructions to States from CMS About EPSDT Funded BHRS

Cindy Mann at the Centers for Medicare and Medicaid Services delivered explicit instructions to State Medicaid Agencies regarding the necessity for implementing principles of “statewideness” and “comparability” when they are dealing with treatment funding via the EPSDT mandate.  Here is an excerpt from her letter:

State Plan Authorities

Under the Medicaid state plan, services to address ASD may be covered under several different section 1905(a) benefit categories. Those categories include: section 1905(a)(6) – services of other licensed practitioners; section 1905(a)(13)(c) – preventive services; and section 1905(a)(10) – therapy services. States electing these services may need to update the Medicaid state plan in order to ensure federal financial participation (FFP) is available for expenditures for these services. In addition, for children, as discussed below, states must cover services that could otherwise be covered at state option under these categories consistent with the provisions at 1905(a)(4)(B) for Early and Periodic Screening, Diagnostic and Treatment services (EPSDT). Below is information on these coverage categories for services to address ASD. Under these section 1905(a) benefit categories all other state Medicaid plan requirements such state-wideness and comparability must also be met.

Some important things to keep in mind:

1.  EPSDT is a 1905(a) benefit at 1905(a)(4)(B). 

2.  EPSDT funds BHRS (Behavioral Health Rehabilitation Services, sometimes mistakenly called “wraparound” services).

3.  BHRS is therefore a “section 1905(a) benefit” to which the Medicaid plan requirements of state-wideness and comparability (among others) must be met. 

4.  This means that BHRS has to be implemented in the same way “state-wide.” 

  • If that’s true, then how can providers (in some parts of Pennsylvania) be required by Managed Care Organizations to bill only for “face-to-face” visits with children while providers in other parts of the state have been billing for writing treatment plans and performing other necessary clinical services in offices (for the past 20 years)? 
  • If that’s true, then how (in some parts of Pennsylvania), can children be forced to be evaluated by a select group of “independent evaluators” (whose low levels of service prescription are miraculously consistent), while children in other parts of the state are allowed to be evaluated by bona-fide independent practitioners who prescribe services at much, much higher levels when the child’s presentation requires it (due to developmental delays, intellectual impairments, and/or other legitimate reasons)?

You can read Cindy’s complete July 7, 2014 Informational Bulletin here

In June of 2014, the Centers for Medicare and Medicaid Services (the people who oversee the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) mandate throughout the US)  released a terrific, thoroughly documented set of instructions about EPSDT and Behavioral Health services to children that is applicable in all fifty states.  The Substance Abuse and Mental Health Services Administration (SAMHSA) issued a joint memo on May 7th that addresses the same issues.  These two documents categorically and explicitly confirm that the information that I have been sharing throughout the US for the past seven years about EPSDT funding and the availability of Behavioral Health Rehabilitation Services (BHRS) has been complete and accurate.  Please download these two documents and you’ll see.  The EPSDT mandate remains “the greatest treatment funding secret ever concealed” but the Federal authorities are having less and less patience with government authorities and the insurance companies they support who persist in their efforts to keep it that way.

I want to thank and commend CMS and SAMHSA for recognizing the urgent need to clarify the law regarding EPSDT funding in the United States.  People who are entitled to it — AS A CIVIL RIGHT — must be allowed to access it without the unnecessary, excessive obstructions that have been created and maintained by State and other government officials for so many decades (since 1989, in fact).  CLICK HERE to review these two landmark documents from CMS and SAMHSA and learn how Behavioral Health Rehabilitation Services (BHRS) can and should be funded by the EPSDT mandate in all 50 states.

The official investigation by the US Office for Civil Rights into the Civil Rights complaint I filed in December of 2012 regarding obstructions of access to EPSDT funding for BHRS in Pennsylvania continues; you can learn about it here:

Best wishes always.




Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s