Lawmakers and stakeholders discussed how gaps in behavioral healthcare services covered by Medicaid and the Children’s Health Insurance Plan (CHIP) in Texas impact the state’s children at a House Youth Health and Safety Select Committee hearing last week.
Jamie Dudensing, CEO of the Texas Association of Health Plans, said while Medicaid-covered behavioral healthcare is available in the state, Texas is missing many vital services along the continuum of care.
“When it comes to the Texas Medicaid program, there is a huge gap in coverage,” Dudensing said. “Medicaid basically covers it as a standard benefit, just a traditional benefit—like psychiatric and drug services, and inpatient hospital stay—but none of those things in between.”
A robust continuum of care includes things like inpatient hospitals, outpatient services, residential treatment, crisis services, and early intervention services, Dudensing said, which Medicaid-covered children often do not have access to.
“These are services that do not exist as a standard covered item like we cover with diabetes or asthma in the Medicaid program,” Dudensing said.
As a result of the gaps, the foster care system is being used as a “first resort” for children who are experiencing more severe behavioral health issues, Dudensing said. She has worked with many parents who are trying to figure out how to help their Medicaid-covered child who has just been released from an inpatient stay.
“Their child has been in the hospital, they are now going to be forced to be discharged, [and] they do not feel like it is safe or appropriate for their child to be home,” Dudensing said. “The only place they can go is our foster care system.”
If more services were covered by Medicaid, children would be able to receive the treatment they need without having to remove them from their home. Outpatient services, for example, allow youths to receive intensive therapy while remaining with their family.
While Medicaid in Texas does not cover a lot of adults, it does cover a lot of children, Dudensing said. Almost half of Texas children are enrolled, she added, which is why it is so important to address the gaps in coverage.
“When we’re talking about small percentages, things may not be that big of a deal, but when we’re talking about Medicaid mental health coverage, you’re talking about impacting 50 percent of Texas kids.”
— Dudensing
The state determines what medically-necessary benefits are covered by Medicaid and CHIP. Dudensing said there are four services the state should prioritize to add as standard Medicaid benefits: step-down services such as intensive outpatient and partial hospitalization, at-risk youth services like multi systemic therapy (MST) and functional family therapy (FFT), crisis services, and psychiatric residential treatment.
Texas has invested in these services over the years, but not in a comprehensive, state-wide way, Dudensing said.
“While we have invested dollars in these and we have tried to find a patchwork system to provide these services, it is not the ideal solution and we believe there is a better way,” she said. “The Texas Health and Human Services Commission (HHSC) has already determined these services are evidence-based, they’re cost effective, and there is no reason to not just add them as a standard benefit.”
If the state were to add all four services, the legislature would have to contend with some licensing issues for psychiatric residential treatment facilities. As it stands, the state does not have the proper licensing requirements for facilities to meet Medicaid standards, Dudensing said.
Dudensing highlighted legislation passed two sessions ago addressing a voluntary licensure, but the recently-released draft rules from that legislation still do not meet the Medicaid standards.
“We do think there is an opportunity right now to take that voluntary licensure up to the Medicaid level, so the only next decision that has to be made is covering those benefits,” she said.
Dudensing said a complete review of licensure would be best, however. Updating licensure requirements would also benefit the private market because, as the laws stand, many Texans have to be sent out of state to receive the care they need. Dudensing added that 30 states already cover psychiatric residential treatment in Medicaid.
Dudensing also addressed the fiscal impact if the legislature were to consider adding these additional benefits to Medicaid. Last year, there were bills in the legislature aiming to cover all four of these services, and the fiscal impact totaled around $75 million per year.
“This is almost nothing compared to the session-over-session investment the legislature has been making in mental health,” Dudensing said. “When you talk about the fact that the legislature increased mental health dollars (by) $2.8 billion last session, spending $75 million to add these benefits for kids to make sure you have comprehensive coverage that is reliable, and that providers know they can build that base for it.”
The state would receive 60 cents for every dollar it spends on the additional services through a federal match.
Rep. Ann Johnson (D-Houston), said the House has been supportive of bills advancing the necessary legislation to implement these services, but they do not get past the finish line in the Senate. Without them, she added, the state pays for it in ways one might not expect.
“From having been in juvenile justice and criminal justice for 20 years, and having seen the cost of not addressing the mental health issues with juveniles at a time where you have a better rate of return, you are going to pay for it significantly, either financially, in incarceration, in victim crimes, [or] in public safety,” Johnson said.