EPSDT Background

EPSDT services are often confused with a treatment philosophy called “wrap-around” services.  They are not the same.  EPSDT services are mandated by the Federal government for children in all 50 states, are not “time limited” (except by the child’s attaining the age of 21 years), do not need to be “titrated” according to some preordained schedule (as if any mortal professional could possibly predict the future of a child’s need for services four months hence), and can be delivered anywhere (including a doctor’s office), whether or not the skills and expertise of the professionals providing treatment are “transferred” to the child, his or her parents, teachers or other adults. 

Click here to view a video that comprehensively explains EPSDT, how it funds Behavioral Health Rehabilitation Services in Pennsylvania, and how to advocate for the Civil Rights of children with disabilities.

EPSDT services are, after all, treatment services that are necessary, as defined by a licensed professional prescribing them, and cannot be denied to a child just because the “state plan” doesn’t include them.  That’s Federal Law.  On the other hand, the “wrap-around” philosophy, while a worthy ideal for treatment providers to aspire to (striving to replace professional service providers with no-cost “naturally occurring supports” in the child’s home, school and community), can be misapplied to create barriers to treatment and impose unnecessary restrictions and limitations on access to EPSDT services.  To the best of our ability to discover (since each state has implemented it’s own version of the EPSDT mandate), obedience or fidelity to the wrap-around philosophy, while it may be admirable, is not mandated anywhere, although some will argue quite forcefully as if that were the case. 

At the Institute for Behavior Change, we are dedicated to the encouragement of responsible professionals, practicing in the mental health field to better the lives of children and their families, to explore the opportunities provided by the EPSDT system to deliver state-of-the-art and evidence-based treatment services to children in their homes, schools and communities.  No other treatment modality has shown such promise in the treatment of children with developmental delays, behavioral disorders or mental illnesses. Fidelity to the wrap-around philosophy is a worthy goal for any professional or treatment provider to aspire to, so long as it does not interfere with the delivery of necessary treatment services.

Key Benefits of EPSDT “Behavioral Health Rehabilitation” (BHR) services

  1. Provides expert professional intervention directly to the child, right in the child’s own home, school and community
  2. Ongoing staff training and supervision, and total service monitoring, by licensed professional psychologists
  3. Treatment is available to all children in PA who need EPSDT services, regardless of family income

The Best Practices Newsletter of the Interdisciplinary Council on Developmental and Learning Disorders (ICDL), citing the work of Stanley Greenspan, MD and other world-renowned experts in the treatment of children with autistic spectrum disorders, has published an article written by the Executive Director of the Institute for Behavior Change explaining how parents should be able to access funding for treatment services throughout the USA, based on our experiences in Pennsylvania. The article appeared in Volume 5, Number 3 of the ICDL Newsletter.

Statement of IBC Founder and Executive Director, Steven Kossor

As a licensed psychologist working with children in Southeastern Pennsylvania since 1977, I have been a dedicated advocate of community-based psychological and behavioral support services, and an EPSDT service provider since 1993. No other mental health treatment system allows therapists to work more closely with children, right where they live and go to school. When the right Therapeutic Staff Support (TSS) person is matched with a child in need of guidance and support at home or in school, and the TSS person is closely supervised and trained by a licensed psychologist and other mental health professionals, wonderful things can happen in the life of the child. There is no substitute for a therapist who visits the child’s home, attends school with the child if necessary, who works with the parents and the child collaboratively, and who simultaneously helps the child to be a more successful family member and student. The cost-free nature of EPSDT service makes it truly available for every child.EPSDT services can be delivered for up to one year at a time without re-authorization (four months is the more typical duration, but reauthorization is a relatively simple and easy process if accurate service delivery data is being collected to show the need for services continues to exist).

Treatment planning always involves the child and the parent(s), and includes the child’s teacher(s) if services are needed in school, and others in the home or community who have an interest in helping the child. Parents are always involved in the planning and oversight of the treatment program, and are actively instructed and encouraged to implement the treatment program themselves so that the TSS and other EPSDT providers can finish their work as quickly as possible.In 30 years of clinical practice, I have never seen a more cost-effective, efficient means of treating mental illness symptoms in children, but only if the responsibility for the treatment program delivery rests firmly in the hands of a licensed professional psychologist, as it does in The Institute for Behavior Change model of EPSDT service delivery.

We have worked with several Managed Care Organizations to deliver EPSDT services cost-efficiently since 1997 and have consistently been complimented for delivering exemplary diagnostic evaluations and other EPSDT services. Our staff regularly receive the highest praise from parents. We are continually expanding the Institute for Behavior Change in Pennsylvania. We created the Children’s Behavioral Health Center to meet the desperate need of parents to obtain diagnostic evaluations of their children rapidly so that necessary treatment can get started. We would like to increase awareness of our success so that psychologists elsewhere could join the Network for Behavior Change, which received a commendation from the President’s New Freedom Commission on Mental Health, and reproduce our success.

EPSDT history

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services were created in the 1960’s and expanded by the Congressional Omnibus Budget Reconciliation Act of 1989 (OBRA’89) to provide “necessary health care, diagnostic services, treatment, and other measures described in [the statute] to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.” 42 U.S.C. § 1396d(r) (5).

These services are available to children up to 21 years of age throughout the United States. In July of 1999, the Supreme Court issued its Olmstead v L.C.decision clearly challenging federal, state, and local governments to develop more opportunities for individuals with disabilities through more accessible systems of cost-effective community-based services. These services are available to any child who has a condition discovered during the diagnostic screening process, at no cost to families, regardless of family income. States continue to improve and expand their EPSDT capacity.  

 If you live in Pennsylvania, you should contact the CASSP coordinator in your County’s Mental Health office for further information about BHR Services. If you live in Chester, Delaware, Montgomery or Philadelphia counties in Pennsylvania, you can also contact The Network for Behavior Change at 610-383-1432, which has had agreements with the Managed Care Organizations in these areas to provide BHR Services to children since 1997. The Network also offers private consultations and assistance in obtaining advocacy services to facilitate greater cooperation from school districts, other sources of behavioral support, and funding for education, treatment, respite care and other services. 

Click here to view additional information about how you can get an MA eligibility evaluation and BHR Services in Pennsylvania.

In Pennsylvania, the “medical necessity” of EPSDT services is determined by a licensed psychologist or a licensed medical doctor or psychiatrist, based on a face-to-face evaluation of the child and an assessment of the child’s strengths, weaknesses and needs. The “core principles” of the Child and Adolescent Services System Program (CASSP) are used to guide treatment: Services must be child centered, family focused, community based, culturally competent, least-restrictive, least intrusive and involve the collaboration between service systems (school, family, medical services, etc) – all working to address the needs of the child in a collaborative, cooperative effort to prevent long-term hospitalization, institutionalization, incarceration, psychiatric medical treatment, or other highly restrictive interventions.“Therapeutic Staff Support” (TSS) services were created in Pennsylvania as part of the OBRA ’89 implementation of the EPSDT entitlement. The most qualified TSS providers have Bachelors degrees, and can deliver all sorts of intensive behavioral treatments including the Developmental, Individual difference, Relationship based (DIR) treatment model developed by Stanley Greenspan, and a wide variety of other intensive behavioral treatment programs, including “Discrete Trial Training” or “Applied Behavior Analysis” behavioral methodologies. All EPSDT services are delivered in the child’s home or school, at no cost whatsoever to the child and family receiving the services, regardless of parental income in Pennsylvania.

Since the 14th Amendment — guaranteeing the right to “equal protection under the law” for all citizens (regardless of income) exists in all 50 states, it is reasonable to conclude that Pennsylvania should not be alone in offering free EPSDT treatment services (with its documented history of effectiveness) to all children who are disabled and under the age of 21 regardless of family income. At this writing, the “TSS” service component appears to exist only in Pennsylvania, although its benefits would certainly be appreciated by parents and children elsewhere.  New Jersey has implemented a similar service.

In Pennsylvania, Mobile Therapy and Behavior Specialist Services are also available under the EPSDT entitlement. Through these services, a child and/or members of the child’s family can receive psychological counseling, psychotherapy, behavioral counseling and assistance with the implementation of the child’s treatment program in the home, a school or other community setting. Any adults who interact with the child can be brought into consultations with one or both of these professionals (a Masters degree is required to perform either Mobile Therapy or Behavior Specialist services), and the child’s treatment program can be enhanced and expanded to include the child’s school teacher and classroom, day care provider, church youth group, or any other community resource.Every state is responsible for implementing the OBRA ’89 legislation in its own way, and no other state has implemented it with the vigor and scope that Pennsylvania has. 

In Pennsylvania, substantial assistance was obtained from the Robert Wood Johnson Foundation via a grant. Through this grant, the CASSP principles were used as the basis for developing the EPSDT system. The Pennsylvania Departments of Public Welfare and Education collaborated to an unprecedented extent to create a system whereby EPSDT services could be delivered by school districts themselves.Whether it is advisable or permissible in the context of compulsory education laws for school districts to also deliver Mental Health services to children, and bill Medicaid privately for reimbursement, is a pointed question. Nevertheless, Pennsylvania school districts became eligible to enroll as Medicaid providers, along with licensed psychologists, community mental health centers, and other entities, and can submit claims for Medicaid reimbursement. 

In 1989 it was projected that $4 million to $20 million dollars could be reimbursed to Pennsylvania via the Medicaid program, and the program has grown tremendously since then. In order to manage this huge financial responsibility, Pennsylvania’s governor signed an Executive Order in 1996 mandating Managed Care for all recipients of EPSDT services, and that Order will soon be fully implemented throughout Pennsylvania. Other states have managed Medicaid reimbursement for EPSDT services in other ways. It is suggested that you contact your State office of Mental Health to inquire about the OBRA ’89 legislation and how it is being implemented to make EPSDT services available to children in your state. The Robert Wood Johnson Foundation (609-452-8701) might also be helpful in assisting you with a search for individuals within your state through which achievements comparable to Pennsylvania’s might be accomplished.  EPSDT services were re-named “Behavioral Health Rehabilitation” (BHR) Services in Pennsylvania in 2002 and categorized under the “Rehabilitation Option” of EPSDT services. 

In Pennsylvania, applying for Medical Assistance benefits for a disabled child is easily accomplished by contacting the County Assistance Office to request an application for Medical Assistance benefits. By indicating on the Medical Assistance application that the application is for a “disabled child only” (writing those three, specific words on the front of the application) the OBRA ’89 legislation makes it possible for a disabled child in Pennsylvania to receive BHR Services without any cost to the family whatsoever, regardless of the family’s level of income. An application for Social Security (SSI) benefits must be made, and if the family’s level of income is above the minimum cut-off for SSI benefits, then the Medical Assistance benefits must be granted if the child has a need for treatment for a mental disorder.Although a “school” psychologist can produce the documentation necessary for a child to receive Medical Assistance benefits, a “school” psychologist can not prescribe any form of treatment, so the evaluation of a “school” psychologist is good ONLY to seek eligibility for Medical Assistance benefits — but cannot be used to determine the need for any specific services. 

Some county governments have created policies that create “Designated Providers” that they would prefer to do all of the initial evaluations to determine a child’s eligibility for Medical Assistance benefits. However, these providers never start delivering the prescribed BHR Services immediately after the evaluation is completed, and they often have long waiting times before a licensed professional’s evaluation can even be scheduled. As a result, many parents believe (or are actually told) that they must wait until their child’s Medical Assistance benefits have been granted before any BHR Services can be delivered, and this is simply and categorically incorrect.  Actually, any licensed practitioner enrolled in the Medical Assistance program (like the members of The Network for Behavior Change, for example) can perform these evaluations, which must comply with a strict set of content standards.  

By working closely with the Institute for Behavior Change, however, the Network for Behavior Change psychologists can usually complete an evaluation in less than 30 days, and, depending on the availability of qualified staff, can begin delivery of necessary, prescribed BHR Services (Behavior Specialist consultations and Mobile Therapy) within hours after the evaluation is completed if the child lives in a county where we are allowed to provide services!  In fact, for about 90 days before a child’s application for Medical Assistance benefits is delivered to the state Medicaid agency — long before the child becomes a client of any Managed Care Organization (MCO) — the state funds the delivery of these necessary, prescribed BHR Services for the child!  If the child begins to receive BHR Services in this way, the MCO in the county where the child lives is required to continue to fund the delivery of those services until the initial authorization expires (usually a period of four months, but initial authorizations for 12 months are permissible for children with developmental disorders).  After this initial authorization period, any subsequent reauthorizations of services must be done in accordance with that MCO’s policies and procedures. 

Therapeutic Staff Support (TSS) services require prior authorization and this can be obtained only from the MCO that is responsible for the child, so an inevitable delay in the delivery of TSS services (until the MCO assumes responsibility for funding the child’s treatment) is unavoidable. However, during the time that Behavior Specialist and Mobile Therapy services are available, data collection that is necessary to support the child’s need for TSS services can be undertaken, which may make it easier to convince the MCO that TSS services are positively necessary. 

Nevertheless, schemes periodically come to light that seek to undermine these services (charging “premiums” to service recipients, cutting the rates for billable for services below the rates established in 1992, etc). These tactics obviously conflict with the intent of the 1989 Congressional EPSDT legislation and the 1999 Olmstead Supreme Court decision. For example, although it would be fiscally irresponsible to charge recipients of these services a “premium,” according to a recent Pennsylvania press release: “School districts can receive federal reimbursement for providing approved medical services to children with disabilities in special education programs. “Many families will likely drop their Medical Assistance coverage because of the premium. If they do, school districts will not get that federal funding, and that will create an ‘$82 million hole’ in funding for the state’s school districts.” the proponents of such efforts remain in positions of authority and their actions must be monitored very carefully.

The 1999 Olmstead decision interpreted Title II of the Americans with Disabilities Act (ADA) and its implementing regulation, requiring States to administer their services, programs and activities “in the most integrated setting appropriate to the needs of qualified individuals with disabilities” [i.e., for children, in their homes and schools], and the EPSDT service delivery system can be an important resource to assist States in meeting these goals. The Gaskin Settlement in Federal Court in Philadelphia recently re-emphasized this right to education in the least-restrictive setting. Children with developmental disabilities, mental retardation, mental illnesses, behavioral disorders, autistic spectrum disorders, ADHD and many other conditions are eligible to receive these services in “regular” classroom settings. Since The Institute for Behavior Change has been providing these services to children in Pennsylvania since 1997, in association with The Network for Behavior Change, a licensed professional Psychologist practice, we are among the most experienced, qualified, successful providers of in-school behavior support services. 

Among the measures cited in the OBRA ’89 legislation are psychological outpatient services and behavioral rehabiliton services.  If a child has an “Axis I diagnosis” such as Autism or PDD via the most recent edition of the Diagnostic and Statistical Manual of the American Psycyiatric Association (DSM IV), and it can be shown that the child can benefit from behavioral habilitation or rehabilitation services, then that child is entitled to these services, even if the necessary services are not part of any “State Plan.”  The OBRA ’89 legislation created a legal entitlement to early and periodic diagnosis and treatment to any person under age 21 who has a “medical necessity” for such services.  It is applicabel throughout the United States adn its territories.  Federal lawsuits in Massachusetts and North Carolina in late 2006 mandated these services, just like Pennsylvania did in the early ’90s and New Jersey did at the start of the 21st century.

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