CiMH TBS EPSDT Webcast Fiscal Training

1. CiMH TBS EPSDT Webcast Fiscal Training The California Institute for Mental Health in Collaboration With State Department of Mental Health Presents TBS EPSDT Webcast Fiscal Training Wednesday March 29, 2006 1:00 pm – 3:00 pm

2. AGENDA • 1:00-1:10 Introductions – • Cynthia Rutledge • Mary Jane Alumbaugh • 1:10-1:20 Overview of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit under Medi-Cal - Cynthia Rutledge • 1:20-1:35 EPSDT Distribution/Calculation (DMH All County Mental Health Director’s Letter dated August 15, 2005) - Mike McCourt • 1:35-1:50 Cost Settlement Calculations (Rainbow County Cost Settlement Calculation) - Germi Matsunami • 1:50-2:00 Reimbursement for Children/Youth Placed Out-of-County - Cynthia Rutledge • 2:00-2:10 Use of Service Function Code 58 for Therapeutic Behavioral Services (Service Function Code Definitions and DMH Letter No. 99-03) – Cynthia Rutledge • 2:10-2:30 Questions

3. Overview ofEarly and Periodic Screening Diagnosis and Treatment (EPSDT) Background The EPSDT benefit is a required service under the federal Medicaid (Medi-Cal) program to provide comprehensive health care for eligible persons under 21 years of age. Included in this benefit are screening services that provide initial, periodic or additional health assessments under the Child Health and Disability Prevention (CHDP) Program. Sections 124025 through 124110 of the Health and Safety Code provide the enabling legislation for the CHDP Program.  The Department of Health Services was empowered under this code of law to adopt standards for screening evaluation and diagnostic procedures for CHDP pediatric providers throughout the state who were then able to refer Medi-Cal eligible children for treatment under EPSDT. EPSDT services were expanded in 1995 by the Department of Health Services (DHS) in accordance with federal regulations and statutes that require states to not only provide any medically necessary health treatment services but also provide any mental health treatment services needed to correct or ameliorate the mental health condition of a full-scope Medi-Cal eligible beneficiary under the age of 21. Part of the impetus for the change was a lawsuit, T.L. vs. Belshé, which put forth the position that California had not fully complied with these federal regulations and statutes. DHS concluded that, in order to meet the needs of children and youth with serious emotional disturbances (SED), the logical providers for these expanded EPSDT services to this population were the county mental health departments.

4. Overview ofEarly and Periodic Screening Diagnosis and Treatment (EPSDT) Upon implementation of a federal Freedom of Choice 1915 (b) Waiver and the specialty mental health managed care program in fiscal years (FYs) 1997 and 1998, EPSDT services were provided as a component of the Medi-Cal Specialty Mental Health Consolidation program that provides services in a managed care environment in counties through local mental health plans (MHPs). Services provided by MHPs are Short Doyle/Medi-Cal (SD/MC) services under the Rehabilitation Option. Each county implemented plans for meeting the additional demand for services and providing access to care. Services to EPSDT beneficiaries may also include services directed toward the substance abuse issues of an EPSDT beneficiary with dual diagnoses of mental illness and substance abuse if such services are necessary to the attainment of the mental health treatment goals In July 1999, following the preliminary injunction in the Emily Q. vs. Belshé lawsuit, MHPs also became responsible for providing or arranging for Therapeutic Behavioral Services (TBS) as an EPSDT supplemental specialty mental health service. TBS allows for the provision of intensive one to one services for children/youth who are SED and who are experiencing a stressful transition or life crisis. TBS may be provided to support other specialty mental health services when additional short-term support is needed to prevent placement in a group home of Rate Classification Level (RCL) 12 through 14 or a locked facility for the treatment of mental health needs. TBS may also be provided to enable a transition from any of those levels to a lower level of residential care. Fiscal Background With the expansion of EPSDT services in 1995, DHS estimated the State General Fund (SGF) dollars and Federal Financial Participation (FFP) dollars needed to provide State and local mental health agencies with the funding necessary to meet the federal mandate for the provision of medically necessary EPSDT mental health services. This funding is allotted to DMH through an Interagency Agreement between DHS and DMH.

5. Overview ofEarly and Periodic Screening Diagnosis and Treatment (EPSDT) -2- SGF amounts for counties for expanded EPSDT services were determined after a baseline was established representing the county’s responsibility to maintain their mental health services funding levels prior to EPSDT expansion. This baseline represents the FY 1994/95, SD/MC allowable cost report settlement amounts adjusted for cost of living (home health market basket indicator) and for the amount allocated to counties for Fee-for-Service Medi-Cal services to this population. Local funds are used as match for FFP up to baseline levels. It should also be noted that State funding for expanded EPSDT services is not intended to replace financial resources available from other sources i.e. grants or through shared resources at the local level. The current arrangement regarding State funding of expanded EPSDT mental health services was made with the understanding that once the financial risk for these services could be reasonably assessed, a fixed funding amount would be transferred to the MHPs. Beginning with FY 2003-04, DMH initiated a monthly distribution of 95 percent of the SGF for EPSDT based on SD/MC approved claims data for each MHP. This process replaced the previous SGF distribution process for EPSDT to MHPs through an annualized initial distribution of 75 percent of expected payments. Effective FY 2002/03, MHPs were required to provide ten percent of the State's matching requirement for growth in the cost of EPSDT services above the FY 2001/02 level. Although a monthly distribution of EPSDT SGF is made to MHPs as previously described, final SGF payment continues to be part of the cost report settlement process. DMH’s current cost settlement methodology for settling costs for SD/MC is used for all MHPs for final fiscal year SGF reimbursement for EPSDT services. For reimbursement of the FFP portion of the service, MHPs continue to submit claims for services through the SD/MC claims processing system. Federal Authority Federal definitions and requirements for EPSDT are outlined under Section 1905 of the Social Security Act and Part 05 of the Centers for Medicare and Medicaid Services’ State Medicaid Manual, and may be accessed on the internet at www.ssa.gov and http://cms.hhs.gov respectively. State Authority DMH definitions and requirements for EPSDT are outlined under Title 9, California Code of Regulations, Chapter 11, and may be accessed on the Internet at www.calregs.com. DMH policies for EPSDT are outlined in DMH Letters and Information Notices and may be accessed at www.dmh.ca.gov/infoadminprov. Additional DMH requirements are outlined in the annual DMH/MHP contract and may also be found on the DMH web site at www.dmh.ca.gov.