Appendix 5

Materials for Ohio Leadership Workshop

I. Planning and Financing for Child Development Services

Promoting Early Childhood Development in Medicaid and Medicaid Managed Care

While child health professionals agree about the importance of early childhood development services,^{1 2 3}
financing child development services through Medicaid is not simple. One reason is that current Federal
guidance does not specifically define "child development services."^{4 5} Despite overlaps between coverage
for young children in Medicaid’s Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program
and early child development services, the final determination as to whether Federal Medicaid matching
funds are allowable for a particular service is made by the Centers for Medicare and Medicaid Services
(CMS). A second reason is that Medicaid was designed to finance health care, while child development
services often are provided by education or social service agencies. Third, each State has flexibility to
make rules about which providers are qualified. Finally, because some child development services also
are funded by other public programs (e.g., early intervention, mental health, or children with special
health needs), it may be difficult to understand which eligibility rules apply and who should pay for what
services.

At the same time, Medicaid managed care offers clear opportunities to promote early childhood
development. Medicaid managed care contracts typically include prevention and early intervention
through EPSDT, as well as treatment. States can work with MCOs to improve care, using their power as
purchasers to ensure the quality and appropriateness of services provided. Researchers at the George
Washington University have prepared purchasing specifications to assist States in efforts to finance child
development services through Medicaid managed care. (This work was financed by the Commonwealth
Fund. See http://www.gwumc.edu/sphhs/healthpolicy/chsrp/newsps/child/)

Benefits and Services to Promote Early Childhood Development

• Use the GWU purchasing specifications on child development to develop contract
  language that clearly communicates policies on developmental services to managed care
  plans. While Medicaid has over 30 benefit categories, no category is labeled "child development
  services.” The purchasing specifications identify a range of covered services linked to child
  development
• Improve and clarify the description of developmental assessment under EPSDT. For
  example, States may distinguish a routine developmental screening conducted as part of an EPSDT
  screen from developmental exams or diagnostic assessment (evaluation) conducted by a medical
  social worker, public health nurse, or developmental pediatrician. States also could encourage use of
  professionally recommended screening tools appropriate for young children.
• Encourage pediatric provider sites to promote healthy development. State Medicaid
  agencies could reimburse primary pediatric practitioners for providing preventive mental health care
  and development services (see Bright Futures). Medicaid also might pay for developmental services
  provided by social workers and child psychologists co-located in pediatric practices.
• Clarify rules on Medicaid payment for services delivered through other public
  programs, such as IDEA Part C Early Intervention, children’s mental health, child welfare, and
  Head Start. For example, Medicaid can finance early childhood mental health consultation for
  children in child care settings. Many contracts require MCOs to sign memoranda of understanding
  with public agencies.

Opportunities identified by NASHP

With the support of the Commonwealth Fund, the National Academy of State Health Policy (NASHP)
has defined some examples of activities that a State might use to improve the health, mental health,
development, and well being of young children and their families.⁶ These included the following:

• Managed care contract provisions that specify coverage of child development services and parent
  education, as well as require local interagency coordination agreements;
• Incentives (in pay-for-performance or other arrangements) for pediatric providers to screen children
  and families for risk factors and provide appropriate guidance and counseling;
• Structured capitation payments to plans, enhanced primary care case management (PCCM) fees,
  and/or payment to providers for the inclusion of certain child development services; and
• Adopt benefits definitions and billing codes for diagnostic assessment and intervention services
  to reduce risk factors that can impede healthy development, such as family depression or other
  mental illness, smoking, substance abuse, potential for child abuse and neglect, injury hazards, lead
  poisoning, inadequate nutrition, developmental delays, or behavioral problems.
  

Other no cost / low cost opportunities

• Collaborative planning – States that have established more comprehensive and/or coordinated
  approaches appear to do a better job at serving vulnerable and at-risk children (e.g., FL, HI, IN, MI,
  MN, and NC). In 2003-04, States have used Title V discretionary grant funds, called Comprehensive
  Early Childhood Care Systems (CECCS), to support planning efforts (e.g., CT, IL, MA, and NM).
• Maximize use of Federal entitlement funds and State/local dollars available for matching –
  Whether Medicaid, SCHIP, CCDBG, or IDEA, designation of State and local dollars is an essential
  step for drawing down available Federal funding.
• Clarify the definitions of children at risk – While no State can afford to extend eligibility to all
  children at-risk, use of broader and clearer definitions can help include more young children in need
  of early interventions to help them achieve school readiness.

Clarify and Adopt Billing Codes for Early Childhood Development Services

Without clear billing codes and payment rates, providers are less likely to deliver developmental services.
Some States have found that billing codes tailored to young children’s conditions (using the Diagnostic
Classification for Children 0 – 3 - DC:0-3)⁷ helped to reduce unnecessary spending, minimize fraud, and
maximize early intervention. For example:

• In North Carolina, Child Service Coordination is case management services to children at risk for or
  diagnosed with special needs. Diagnosis codes that support medical necessity for Coordination
  include: V11.9 -Unspecified mental disorders; V15.86 - Exposure to lead; V15.9 - Unspecified
  personal history presenting hazards to health; V17.2 - Other neurological diseases.
• A workgroup report from King County (WA) studied the potential role of the DC:0-3 and emphasized
  the importance of training and a standardized “crosswalk” between the two sets of codes.
• Florida has developed guidelines and a tool for professionals to use with the DC:0-3. For example, in
  a “crosswalk” between the two codes: DSM-IV 700 “Disorders of Relating and Communicating” is
  clarified in DC:0-3 as “Psychoses with origin specific to childhood (299.0 – 299.9)” and/or
  “Developmental disorder NOS (319.5).”

II. Screening and Assessment for Young Children

In clinical practice, the terms screening, assessment, and evaluation have general, but not precise
meanings. Professionals do not use these terms consistently. Because these terms are confused in
Medicaid/EPSDT guidance to States, it is important to reach agreement on what they mean in this
context.

Screening is used to identify possible problems and presumes follow-up with additional tests if a problem
is suspected. Screening tools can be general, be specific to a disorder or be focused on an area of
development (e.g., language or motor skills).⁸ Ideally, developmental screening tools should: identify
children with or at risk of problems, be quick and inexpensive to administer, be of demonstrated value to
the patient, provide information leading to follow-up, and be sensitive and specific enough to avoid
mislabeling many children.^{9 10} Screening does not result in diagnoses.

When a possible problem is identified through screening, the next step is assessment (also sometimes
called evaluation). Assessment is more in depth and helps child health professionals to determine the
nature of the condition and to consider possible treatments. Assessment tools or (more often) processes
might be considered diagnostic. An assessment may be comprehensive or measure a child’s condition on
an area such as physical, cognitive, or behavioral development.¹¹

How does this fit with Medicaid and EPSDT/ screening?

In this context, the word “screening” also reflects the definition in Medicaid’s Early Periodic, Screening,
Diagnosis, and Treatment (EPSDT) program.¹² EPSDT screening (a comprehensive well-child checkup),
diagnostic assessment, and treatment for any health problems found during the checkup including
medical care, mental health services, vision, hearing, and dental care. By law, an EPSDT screen is
comprehensive and includes age-appropriate: health history, physical exam, developmental tests, blood
and urine lab tests, immunizations, and health education/anticipatory guidance. Screening visits may be
based on the State established (periodicity) schedule or on an interperiodic basis, as necessary. Hearing,
vision, and dental screening also are required and have their own periodicity schedule. Children age three
and older must be referred to a dentist.¹³

Developmental screening is a basic component of an EPSDT screen for a child or adolescent of any age
and, thus, should be part of a comprehensive screen. If developmental problems are suspected or detected
as part of a screen, a more thorough developmental assessment by a trained professional should occur as
soon as possible. While measurement tools vary, developmental screening and diagnostic
assessment/evaluation should include measurement using standardized tools of the following domains:
gross and fine motor, cognitive, language, psycho-social, and activities of daily living skills.

III. Early Childhood Mental Health Services

Research has shown that early child health and development services can effectively address the needs of
many children who are considered at risk of cognitive, social, or emotional problems. ^{14 15} While
effective early interventions and treatments do exist once a child is identified, the challenge is to identify
those children in need. Surveys indicate that care for the social-emotional-behavioral development of
children lags behind that of other preventive and developmental services recommended by the AAP.¹⁶
Financing early childhood mental health services poses particular challenges.¹⁷

Challenges related to Serving Young Children

• Definitions of eligibility for the child – Our silo approach to programs for children and families
  creates gaps and overlapping authority. This particularly affects IDEA Part C, Part B Preschool, Head
  Start, child welfare, and Medicaid/SCHIP programs.
• Lack of eligibility for parents –Promoting or repairing a child-to-caregiver relationship is
  fundamental for child mental health, especially if the parent is battered, abusing substances, or
  depressed. This requires treating parent and young child together.
• Difficulties in distinctly diagnosing conditions among young children – Can the child’s
  condition be specifically diagnosed? Is the condition considered a medical, social, or educational
  problem? Is the appropriate provider trained in medicine, social work, mental health, or child
  development?
• Dilemmas of primary care providers about where to refer children for diagnostic
  assessment and treatment. Surveys of pediatricians indicate problems with the number of
  referrals, the willingness to refer, and the linkages to referral resources. These data suggest systemic
  barriers for children.¹⁸

Opportunities to Promote and Protect Socio-Emotional Development

• Clarify State Medicaid guidance on screening, assessment, and treatment related to early
  childhood mental health development. Specifically, States might clarify benefits covered, better
  define developmental screening and assessment, put protocols into place for developmental services,
  and define a set of providers qualified to receive reimbursement.
• Encourage pediatric provider sites to promote healthy mental development. State Medicaid
  agencies might reimburse primary pediatric practitioners for providing preventive mental health care
  and development services as defined under the Bright Futures Mental Health Guidelines.¹⁹
  Alternatively, Medicaid might designate specific payment rates for social workers and child
  psychologists co-located in pediatric practices and clinics to promote healthy emotional development
  through assessment, referrals, and treatment.
• Eliminate treatment barriers created by requiring providers to diagnose young children as
  having a mental or behavioral health condition in order to obtain intervention and
  treatment. Such requirements are established at the State level. States might review State mental
  health or Medicaid mental health rules that require a diagnosis prior to Medicaid mental health
  financing and identify opportunities to finance early interventions that promote healthy mental
  development.
• Use the revised Child Abuse Prevention and Treatment (CAPTA) law as a stimulus.
  Congress revised the CAPTA legislation, which now requires each State to submit a plan for early
  intervention referrals among children ages birth to three with confirmed cases of child abuse and
  neglect. Some States are using this opportunity to restructure the linkages between child welfare, Part
  C early intervention, and Medicaid.
  • New protocols for screening. One starting point is to provide more uniform and
    appropriate early childhood assessment for children entering foster care based on
    protocols developed by professionals, as well as approved for financing by Medicaid.
    Such protocols could be used as the basis for enhanced EPSDT screening.
  • New professionals in Part C. In most States, the sites conducting early intervention
    assessments are not well equipped or trained in providing assessments/evaluations for
    children with a history of abuse and neglect or in providing treatment for infants and
    toddlers with high levels of social-emotional need.
  • New referral patterns. For staff in local child welfare agency, TANF, Medicaid, and
    Part C programs, an aggressive response to the intent of new CAPTA rules will be a big
    change in practice. The State agencies can help by providing suggestions or guidance
    about how and when children should be referred between programs.
• Target other at-risk populations already eligible for Medicaid benefits. This includes groups
  such as children in protective services/foster care or in IDEA Part C Early Intervention Programs.
  Specific efforts might involve activities such as:
  • Better linking EPSDT and IDEA. Some Medicaid agencies require the signature of a
    primary care provider, as prior approval on each child’s IFSP under the IDEA Part C
    program. Since these populations already use services, this is an opportunity to reduce
    long-term costs and improve children’s mental health outcomes.
  • Focusing on children with special health care needs. Children with special health
    care needs (CSHCN) can be defined as children under 21 who have or are at risk for a
    chronic physical, developmental, behavioral, or emotional condition, and require health
    and related services of a type or amount beyond that which is required by children
    generally. However, not all CSHCN programs include children with social-emotionalbehavioral
    needs.

Other no cost / low cost opportunities

• Conduct joint training of professionals - Facing shortages of professionals trained to provide
  appropriate mental health services to young children and their caregivers, some States – such as
  Florida, Indiana, Louisiana, Michigan, and Vermont – have aimed to provide training to “grow their
  own” crop of professionals. Training dollars are available in many programs.
• Monitoring children at risk - Children at-risk are more likely to fall into the cracks between
  various service systems (and associated eligibility definitions). Several existing mechanisms could be
  used by States to monitor or track children at risk. Children whose EPSDT periodic screening exams
  indicate high risk for social-emotional or developmental delays may receive more frequent
  “interperiodic” screening to assess their progress and need for treatment.²⁰

IV. Financing for home visiting – Medicaid and funding streams

Home visiting is a long-standing, well-known prevention strategy used by States and communities to
improve the health and well-being of women, children, and families, particularly those who are at risk.
One home visitation program evaluation found that children in participating families made 35 percent
fewer visits to the emergency department, had 40 percent fewer injuries, and 45 percent fewer behavioral
and parental coping problems noted in their physicians’ records than children in the comparison group.²¹
Mothers visited by nurses provided home environments that were more conducive to child development.²²
Overall, comprehensive home visitation or pediatric programs can save society money in the long run,
due to reduced welfare dependency, teen parenthood, and violence.²³

Characteristics of effective home visiting projects

• Provide specific services, social supports, and referrals. States are using home visiting to help
  transition families from welfare to work, strengthen early childhood development programs, and
  provide support to first-time families. Matching services to goals is essential.
• Quality services. Recent national evaluation research underscores the importance of improving the
  implementation and quality of home visiting services. Staff training is a fundamental element of
  quality. Ongoing monitoring and evaluation helps to ensure that quality is maintained.
• Integrated strategy. Effective home visiting efforts must be connected to other child and family
  services and supports. For the many home visiting programs designed to provide care coordination
  and social support linkages, this is a critical aspect of the program.
• Maximize Federal funding streams. A variety of Federal funding streams are available to support
  home visiting - including Medicaid, the State Children's Health Insurance Program (SCHIP), the Title
  V Maternal and Child Health Services Block Grant (Title V), and Temporary Assistance to Needy
  Families (TANF) - some of the largest and most common sources of Federal support. Blended
  funding is associated with long-term program survival.

The Status of Home Visiting Policies

From Alaska to Florida, States have advanced home visiting programs and policies. At the beginning of
Fiscal Year 2003, a total of 21 States had laws establishing home visiting programs. Among these 21
States, 31 laws were in effect, with the authority typically assigned to Departments of Public Health (33
percent) or to Departments of Education (23 percent). Just over half of these laws mentioned a specific
program model, and nearly half specified a funding source.²⁴ Other States operate home visiting
programs without specific legislative authority. Most State home visiting programs are adaptations of preexisting
program models, including Healthy Families America (HFA), the Nurse-Family Partnership
(Olds model), Early Head Start, Home Instructional Program for Preschool Youngsters (HIPPY), and
Parents as Teachers (PAT).²⁵

Home Visiting Policies and Financing

• A survey of 30 State-based home visiting programs conducted in 1999-2000 found that: ²⁶
  • State dollars were used to fund home visiting programs by virtually all of these 30 States,
    with nearly half using State general revenue funds and others using categorical funding
    streams.
  • Both large and small States have made substantial public investments in home visiting.
    The largest reported State spending was in Florida, Illinois, Michigan, New York, Ohio,
    Oklahoma, and Washington; however, on a per capita basis, small States such as
    Delaware, Hawaii, and Rhode Island are spending well above the average.
• A more recent survey of home visiting programs in 37 States found that: ¹
  • State funds were the primary source of funding for home visiting programs.
  • Federal dollars accounted for about 45 percent of home visiting budgets.
  • Local public and private dollars also were being used as matching and supporting funds.
• Leading sources of funding from specific Federal programs include the following:
  • Medicaid State-Federal matching funds, particularly to finance targeted case
    management and care coordination delivered through home visits.
  • States have found a fit between home visiting and Title IVB (of the Social Security Act)
    program, with goals to address child abuse and neglect and promote safe and stable
    families.
  • Temporary Assistance for Needy Families (TANF) Federal dollars and State
    maintenance of effort dollars have been used to fund home visiting, which fits with
    program purposes.
  • Early Head Start has launched a major initiative to enhance home visiting.
  • Maternal and Child Health Block Grant dollars from Federal set-aside funds, Federal
    block grant allocations to States, and State matching funds are being used to support
    home visiting.
  • Part C Early Intervention Program of the Individuals with Disabilities Education Act
    (IDEA) Federal, State, and local dollars for children birth to age three with disabilities.
  • Other Federal grant dollars from various programs such as the Social Services Block
    Grant, Adolescent Family Life Grant, Americorps, and domestic violence prevention.

Opportunities through Medicaid and Medicaid Managed Care

Medicaid is used to finance home visits in more than a dozen States. A number of States -- including
Illinois, Michigan, Kentucky, Oklahoma, and Wisconsin -- are using some version of Medicaid case
management to finance home visiting services to at-risk families. Medicaid may finance all or part of the
cost of home visiting services. Some States are using "target case management", which would require
Federal approval and is matched as a medical assistance service. Others are using "Administrative Case
Management", which does not require special Federal approval and is matched at the 50/50 administrative
rate. A few States use fee-for-service payments for various services. States use various resources for
matching; for example, Kentucky uses a combination of Medicaid and tobacco dollars.

• The Illinois Medicaid Family Case Management program provides intensive service coordination
  for pregnant women and infants, using Medicaid's administrative case management approach. The
  target group includes pregnant women and mothers with infants. Local agencies under contract
  include health departments and community-based organizations. Program guidelines are set out in
  State regulations.
• In Michigan, the Medicaid Maternal and Infant Health Advocacy Services (MIHAS) program
  provides outreach, health education, and care coordination to pregnant women and their infants. To
  qualify for services, a pregnant woman must be Medicaid eligible and have one or more risk factors
  (i.e., single marital status, social isolation, younger than age 20, history of abuse or neglect, maternal
  depression, low intellectual functioning or educational level, and HIV/AIDS risk). Services include
  case management and assistance with making and keeping prenatal care appointments, referrals to
  other needed services, transportation assistance, needs/risk assessments, and health education related
  to pregnancy and parenting.

1 Institute of Medicine. From Neurons to Neighborhoods: The Science of Early Childhood Development. Jack P.
Shonkoff and Deborah A. Phillips, (Eds), Washington, DC: National Academy Press, 2000.
2 Brown B, Weitzman M, et al. Developmental Needs of Many Children Not Being Met Early Child Development in Social Context: A Chartbook. New York, NY: Commonwealth Fund, 2004.
3 VanLandeghem K, Curtis D, and Abrams M. Reasons and Strategies for Strengthening Childhood Development Services in the Healthcare System. Portland, ME: National Academy for State Health Policy, 2002.
4 Rosenbaum S, Proser M, Schneider A, and Sonosky C. Room to Grow: Promoting Child Development Through
Medicaid and CHIP. New York, NY: Commonwealth Fund, 2001.
5 Perkins J. Medicaid Early and Periodic Screening, Diagnosis and Treatment as a Source of Funding Early
Intervention Services. Los Angeles: National Health Law Program, 2002.
6 Johnson K and Kaye N, Using Medicaid to Support Children’s Health Mental Development. Portland, ME:
National Academy for State Health Policy, 2003.
7 Zero to Three: National Center for Infants, and Toddlers and Families. Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3) (1994) and DC:0-3 Casebook.
Washington, DC: Zero to Three Publications, 1997.
8 Centers for Disease Control and Prevention, National Center for Birth Defects, Developmental Disability, and Disability Health.
9 Bergman D. Screening for Young Children. Portland, ME: National Academy of State Health Policy, 2004.
10 Glascoe FP and Shapiro HL. “Developmental Screening,” from the web site of Developmental-Behavioral
Pediatrics Online Community, 5/5/2004
11 American Academy of Pediatrics Committee on Children with Disabilities “Developmental Surveillance and
Screening of Infants and Young Children” Pediatrics 2001;108:192-196.
12 Rosenbaum S and Sonosky C. Federal EPSDT Coverage Policy. Prepared by the George Washington University Center under contract to the Health Care Finance Administration, 2000.
13 States’ Medicaid Manual Part 5: Early and Periodic Screening, Diagnosis, and Treatment. Centers for Medicare and Medicaid Services (CMS).
14 U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General, 1999.
15 Op cit. Neurons to Neighborhoods. Washington, DC: National Academy of Sciences, 2002.
16 Bethell C, Peck C, Abrams M, Halfon N, Sareen H, and Scott-Collins K. Partnering with Parents to Promote the Healthy Development of Young Children Enrolled in Medicaid: Results from a Survey Assessing the Quality of
Preventive and Developmental Services for Young Children Enrolled in Medicaid in Three States. New York, NY:
The Commonwealth Fund, 2002.
17 Johnson K, Knitzer J, and Kaufmann R. Making Dollars Follow Sense: Financing early childhood mental health services to promote healthy social and emotional development in young children. New York, NY: National Center for Children in Poverty, 2002.
18 Rushton J, Bruckman D; Kelleher K. “Primary Care Referral of Children with Psychosocial Problems,” Archives of Pediatric and Adolescent Medicine 2002;156:592-598
19 Jellinek M, Patel BP, and Froehle MC. eds, Bright Futures in Practice: Mental Health. Arlington, VA: National
Center for Education in maternal and Child Health, 2002.
20 Johnson K and Knitzer J. Finance and Policy Strategies to Promote Socio-Emotional Development for School
Success. New York, NY: National Center for Children in Poverty. In press. November 2004.
21 Olds, D.H., Henderson C., and Kitzman H., “Does Prenatal and Infancy Nurse Home Visitation Have Enduring
Effects on Quality of Parent Caregiving and Child Health at 25 to 50 Months of Life?” Pediatrics 1994;93: 89-98.
22 Kitzman et al., “Effect of Prenatal and Infancy Home Visitation by Nurses on Pregnancy Outcomes, Childhood
Injuries and Repeated Childbearing,” Journal of the American Medical Association 1997;278: 637-643.
23 Karoly, L.A., Greenwood, P.W., Everingham, S.S. et al, Investing in Our Children: What We Know and Don’t
Know About the Costs and Benefits of Early Childhood Interventions, Santa Monica, CA: RAND, 1998.
24 Home Visiting Legislation and Funding: Lessons from Healthy Families America. Healthy Families America, April, 2003.
25 Home Visiting Forum, 2003.
26 Johnson K. No Place Like Home. New York, NY: Commonwealth Fund, 2000.