This Is a Summary of EPSDT Regulations Relating Specifically to Referrals, As Adopted By

This is a summary of EPSDT regulations relating specifically to referrals, as adopted by various states. You can see that a great deal of commonality exists, but also some significant differences, as each state attempts to implement its own “flavors” of the EPSDT mandate.

In these listings, “BH” following a state’s initials appears to stand for “Behavioral Health,” and “MH” appears to stand for “Mental Health,” indicating that the state has its own “Behavioral Health” or “Mental Health” policy that addresses EPSDT services there as well as in the general laws of the state. I have separated each state’s policy from another state’s with a horizontal line; where a “BH” or “MH” policy exists within a given state, I put no line between the two.

You can contact the Governor’s office in your state to find out which office in your state’s government is responsible for EPSDT services (Medicaid). That office goes by different names in different states, but every state MUST implement the EPSDT service Federal mandate.

Referrals

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AZ | AZBH | CA | FLMH | HIBH | IA | MD | MABH | MO | NEBH | OH | ORMH | TX | UTMH | WA

“SECTION D: PROGRAM REQUIREMENTS

1. SCOPE OF SERVICES…

Early and Periodic Screening, Diagnosis and Treatment (EPSDT): ...

Because the behavioral health benefit for Title XIX and Title XXI is provided through the ADHS/RBHA system, the Contractor shall ensure the initiation and coordination of the referral of these members to the RBHA and shall follow up with the RBHA to monitor whether members have received behavioral health services...” Arizona Contract, pages 10-11.

“2. BEHAVIORAL HEALTH SERVICES...

Referrals: As specified in Section D, Paragraph 1, the Contractor must provide developmental/ behavioral health screenings in compliance with the AHCCCS periodicity schedule. The Contractor shall ensure the initiation and coordination of behavioral health referrals of these members to the RBHA when determined necessary through the screening process.

The Contractor is responsible for referring other Title XIX and Title XXI members identified as needing behavioral health treatment services to the RBHA for evaluation and provision of covered services…” Arizona Contract, page 16.

AZBH

“6. REFERRALS

ADHS shall establish written criteria and procedures for subcontracted RBHCs and providers to promptly handle referrals, including emergency referrals, from AHCCCS acute care contractors, hospitals, courts, tribes, HIS, schools, other state agencies, self referrals, family members, guardians, and other referral sources. Emergency referrals shall be accepted and emergency services shall be made available on a twenty-four (24) hours seven (7) day a week basis…

ADHS shall ensure the transition of Title XIX non-SMI 18, 19 and 20 year old members and Title XXI 18 year old members from the Health Plans to the ADHS/RBHA system per Laws of 1999, Chapter 313 in a manner that is least disruptive and promotes continuity of care for the member.” Arizona Behavioral Health Contract, page 14.

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“6.7.3.4 Alcohol and Drug Treatment Services...

The Contractor will arrange and coordinate Medically Necessary services, including referral of Members requiring alcohol and drug treatment to SD/MC alcohol and drug treatment programs including outpatient heroin detoxification providers. The Contractor will assist Members in locating available treatment Service Sites.” California Contract, page 118.

“6.7.3.3 Mental Health

All Specialty Mental Health Services (inpatient and outpatient) are excluded from the Contract.

A. Contractor shall provide outpatient mental health services within the Primary Care Physician’s scope of practice. Contractor shall provide assistance to Members needing Specialty Mental Health Services by referring such Members, whose mental health diagnosis is covered by the local Medi-Cal mental health plan or whose diagnosis is uncertain, to the local Medi-Cal mental health plan, if operational. If the Medi-Cal mental health plan is not operational or if the Member’s diagnosis is not covered by the local Medi-Cal mental health plan, Contractor shall refer such Members to an appropriate fee-for-service Medi-Cal mental health provider accepting Medi-Cal patients, if known to the Contractor, or shall refer such Members to the County Mental Health Department, or other community resources that may be able to assist the Member to locate mental health services, including the local CHDP program, regional centers for the developmentally disabled, and provider referral services.” California Contract, page 116.

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FLMH

“2.4 Additional Service Requirements...

C. Evaluation and Treatment Services for Children...

The plan will refer children to the department when residential treatment is medically necessary...” Florida Mental Health RFP, page 26.

“2.7 Institutional Services...

The contractor is responsible for transition and referral to appropriate service providers...” Florida Mental Health RFP, page 31.

“2.10 Care Coordination and Management...

B. Providing appropriate referral to the enrollees’ MediPass primary care case managers (or other physician, for non-MediPass enrollees) and scheduling of assistance for enrollees needing physical health care and mental health care services...

I. Providing appropriate referral of the enrollee for non-covered services to the appropriate service setting, and requesting referral assistance, as needed, from the Area Medicaid Program Office.” Florida Mental Health RFP, page 32.

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HIBH

“30.900 Other Services to be Provided

In addition to the behavioral health services listed in Subsection 30.710 the plan shall provide certain specialized services. This section lists the required other services...

* Appointment follow-up

When the BHMC plan refers the member to another practitioner or service provider for behavioral health services, the BHMC plan shall follow-up to verify that the member received the needed services…When the BHMC plan member requires services provided by a health plan specialist or other practitioner, the BHMC plan’s BHP or CC/CM shall coordinate the referral with the health plan PCP. The health plan shall follow-up with the specialist or other practitioner to verify that the member received the required services.” Hawaii Behavioral Health RFP, pages 31 and 33.

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“4.8 Mental Health Services

The HMO shall refer Enrollees who are found to need mental health services to the Iowa Plan. The primary diagnosis shall be determined based on clinical criteria. Applicable ICD-9 Codes are 290-302.9, 306-309.9, and 314.9...

4.9 Substance Abuse Services

The HMO shall refer Enrollees who are found to need substance abuse services to the Iowa Plan. The primary diagnosis shall be determined based on clinical criteria. Applicable ICD-9 Codes are 303.00 through 305.99.” Iowa Contract, page 27.

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“10.09.67.10...

C. Referrals of TCA Recipients Who Are 21 Years Old of Older for Residential Substance Abuse Treatment Services.

(1) In addition to providing the substance abuse treatment services described in §§A and B of this regulation, an MCO also has the responsibility of making appropriate referrals:

(a) For TCA recipients who are 21 years old or older for the following treatment modalities:

(i) Intermediate care substance abuse treatment in an intermediate care facility-alcoholic (ICF-A), and (ii) Substance abuse treatment in a halfway house or residential drug-free treatment program;

(b) For TCA recipients who are 18 through 20 years old and are parents, substance abuse treatment in a halfway house or residential drug-free treatment program; and

(c) For TCA recipients who are younger than 18 years old and are parents, substance abuse treatment in a long-term residential care program.” Maryland COMAR 10.09.67.10.

MABH

“5.0 UTILIZATION MANAGEMENT

5.01 Department Structure and Staffing The Contractor shall:

5.01.01 Develop a Utilization Management Department that shall be operational on the Full Service Start Date and shall be responsible for the following:

a. referrals and coordination of services...

g. discharge planning…” Massachusetts MH/SAP Contract, Appendix B, page 29.

“SECTION 5.6: Free Care Reimbursement to Former Replacement Units

(a) For the period from July 1, 1996 through the date the Contractor implements a new inpatient provider network pursuant to the Contract, the Contractor shall maintain an agreement (‘Free Care Agreement’) with certain of the Replacement Units (‘Selected RUN’) providing for the following: i) The Selected RUN will accept for expedited admission all patient referrals from ESPs regardless of the status of the patient’s payer...” Massachusetts MH/SAP Contract, Amendment 1, page 21.

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“2.11.7 Mental Health Benefits: ...

b. Mental Health Out-of-Network Referrals: If the health plan believes that a child or youth may require residential care in order to receive appropriate care and treatment for a serious emotional disorder, the health plan may apply to the Missouri Division of Comprehensive Psychiatric Services which shall determine whether the individual is eligible for placement by the Division, and whether an appropriate placement is not currently available, or funding is not currently available to support the placement, the individual may be placed on a waiting list by the Division of Comprehensive Psychiatric Services.” Missouri RFP, page 62.

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NEBH

“11.11.3 MH/SA Provider Qualifications and Responsibilities: Pursuant to the PHP’s contractual responsibilities, the PHP shall ensure that the MH/SA provider complies with the following: ...

(b) Signing a contract with the PHP as a MH/SA provider which explains the provider’s responsibilities and compliance with the following NHC requirements:

(3) Coordinating appropriate referrals to MH/SA services, and when necessary with medical/surgical services...

(5) Ensuring or providing continuous access to MH/SA services and necessary referrals of urgent or emergent nature available 24-hour, 7 days per week…” Nebraska Behavioral Health Contract, pages 54-55.

“11.42 Care Management Requirement: The PHP shall maintain Care Management Function for the purpose of establishing a diagnosis, formulating a treatment plan, determining the level, duration, and intensity of services to be delivered with responsibility for: ...

11.44 Referrals/Prior Authorization: The PHP shall be responsible for all required referrals and prior-authorizations.”

Nebraska Behavioral Health Contract, page 61.

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“5101:3-26-032 Managed care plan: Substance abuse screening and referral procedures for managed care plans and prenatal medical service providers in mandatory managed care counties.

(A) General provisions.

(1) Any pregnant OHIO WORKS FIRST (OWF) or healthy start recipient enrolled in an MCP in those counties designated by ODHS as mandatory managed care counties shall be screened for the possible abuse of alcohol and/or other drugs. Any such pregnant enrollee who is identified as possibly abusing alcohol and/or other drugs shall be referred to an alcohol and other drug addiction (AOD) provider which is certified by ODADAS and which has a current medicaid contract, for a clinical assessment and treatment, if necessary and not medically contraindicated by the prenatal medical services provider (PMSP) physician...

(B) Responsibilities of PMSPs...

(3) If the PMSP administering the screen determines that the enrollee has indications of alcohol and/or other drug abuse, the PMSP or other practitioner designated in paragraph (A)(2) of this rule shall refer the enrollee to an AOD provider...” Ohio RFP, Appendix E, OAC 5101:3-26-032, page 1.

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ORMH

“2. Components of the Delivery Services

a. Services Coordination...

(2) Contractor shall manage all Covered Services for its OMAP Members and shall help OMAP Members gain access to needed mental health, physical health, and social support services which are Not Covered Services. Contractor shall identify barriers to such access and help remove barriers if possible…” Oregon Mental Health Contract, page 12.

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“6.6 BEHAVIORAL HEALTH CARE SERVICES - SPECIFIC REQUIREMENTS…

6.6.7 HMO must require, through contract provisions, that PCPs have screening and evaluation procedures for detection and treatment of, or referral for, any known or suspected behavioral health problems and disorders. PCPs may provide any clinically appropriate behavioral health care services within the scope of their practice.

6.6.8 HMO must require that behavioral health providers refer Members with known or suspected physical health problems or disorders to their PCP for examination and treatment…” Texas Contract, pages 38-39.

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UTMH

“Article III

SCOPE OF SERVICES...

A. Covered Services

The CONTRACTOR will provide, at a minimum, all Medically Necessary Covered Services in accordance with the scope of services in the Utah State Plan and the Utah Medicaid Mental Health Centers Provider Manual, incorporated by reference. These manuals are available from the Department upon request. Covered services include the following services: ...

2. Mental health outpatient services including: ...

i. Targeted case management for chronically mentally ill adults and children who need case management due to mental or behavioral problems and who are not otherwise receiving similar services under another program authority, unless mutually agreed and approved by the CONTRACTOR and The Department.” Utah Mental Health Contract, page 4.

“B Clarification of Covered Services...

14. If the CONTRACTOR admits an Enrollee for inpatient hospital psychiatric care, the CONTRACTOR has the responsibility for all services needed by the Enrollee during the hospital stay that are ordered by the CONTRACTOR…If diagnostic tests conducted during the inpatient stay reveal that the Enrollee’s condition is outside the scope of the CONTRACTOR’s responsibility, the CONTRACTOR who admitted the Enrollee remains responsible for the Enrollee until the enrollee is discharged or until responsibility, including negotiating a payment for services. If the enrollee is discharged and needs further services, the admitting CONTRACTOR must coordinate with the other appropriate entity to ensure continued care is provided…” Utah Mental Health Contract, pages 6-7.

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“Outpatient Mental Health...

The Contractor shall cover: ...

4) Coordinate with the providers of outpatient community mental health services to assure members receive needed care.” Washington Contract, Exhibit 6, Attachment 1, pages 2-3.