Obama Voices the Need for Access to Mental Health Care: Medicaid Recipients, Too?

Two days ago, Obama voiced that gun control and mental health care reform is on the horizon.  Since the terrible massacre at Sandy Hook Elementary School, people, especially politicians, have been talking about gun control.  The thinking behind this is that if the shooter at Sandy Hook did not have access to guns, the murders would not have happened.  Agreed.

But think of this:  If a child puts his or her finger in a light socket and gets electrocuted, do we cut off the power to the entire house forever? Or do we educate that child so he or she does not do it again?

Personally, I opt for the latter:  Educate.

If the child is incapable of understanding the concept of getting electrocuted by placing his or her finger in a light socket (i.e., the child has mental health issues), then, as a parent, I would seek mental health services for my child.  I still would not opt to cut off the power in the house.

Mental health services are vital.  Mental health services are important for all people. But since this is a Medicaid blog, I will focus on mental health services for Medicaid recipients.  Medicaid recipients need access to quality mental health services. Quite possibly, in the world of Medicaid, mental health services may be the most needed and least provided to recipients (maybe dental and specialities in medicine are also in the top most needed and least provided, but I will cover those topics in another blog).

I’m not talking about mental health services for the autistic children or children suffering from an easily diagnosed and highly recognizable mental health illness. These children obviously need mental health services.  In my opinion, most people would agree as to the need for mental health services to these children.  No, I’m talking about the thirteen year old girl who has so much anger built up inside that she begins to cut herself, torture animals and scream at her teachers. Or the 14-year-old boy, who was sexually abused by his uncle and is now exploring the sexuality of the 6 and 7-year-old boys in the school  bathroom. The 12-year-old boy who has no friends, is isolated at school, and is publicly ridiculed until he begins to think he has no reason to live and begins fantasizing about killings, both of himself and others…the ones who ridicule him.

Would wonderful access to mental health services for Medicaid recipients have stopped Sandy Hook from happening? Probably not. But future tragedies can be stopped by providing quality mental health services to all, especially to Medicaid recipients.  According to Obama’s recent speech, Obama agrees that quality mental health care needs to be accessible to all people.  But does that also mean Medicaid recipients? Medicaid recipients must meet criteria to receive therapy (after a certain number of visits).

Medicaid recipients rely on the Medicaid system for mental health services. I don’t mean to state the obvious, but think about it. People with private health insurance have choices about therapists. I can say, “I’m feel like my depression is overwhelming.” And schedule a psych visit for the next week. Not Medicaid recipients. Medicaid recipients need (for the most part) prior authorization. Which means if a Medicaid recipient feels low…really low…as in, needs a psychiatrist low, they need permission from the State.   A State-contracted agent must review the documents and determine it is medically necessary for that Medicaid recipient to receive therapy.  Although, for Outpatient Behavioral Services,

This is the criteria for a Medicaid recipient to receive Outpatient Behavioral Services:

Entrance Criteria

ALL of the following criteria are necessary for admission of a beneficiary for outpatient treatment services:

a.   A Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision (DSM-IV-TR) (or its successors) Axis I or II diagnosis.

b. Presentation with behavioral, psychological, or biological dysfunction and functional impairment, which are consistent and associated with the DSM-IV-TR (or its successors) Axis I or II diagnosis.

c. Does not require a higher level of care.

d. Capable of developing skills to manage symptoms, make behavioral changes,and respond favorably to therapeutic interventions.

e. There is no evidence to support that alternative interventions would be more effective, based on North Carolina community practice standards (e.g., Best Practice Guidelines of the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Board of Addiction Medicine).

Medicaid beneficiaries under 21 and NCHC beneficiaries are allowed 16 unmanaged visits; adults are allowed eight unmanaged visits per calendar year. All visits beyond these limitations require prior approval.

More than eliminating guns (or cutting the power off in the house), Medicaid recipients need somewhere to go to receive quality health care with no judgment and not all this criteria. If a Medicaid recipients wants to attend weekly therapy sessions, shouldn’t the Medicaid recipient be able to go to therapy without needing an Axis I or II diagnosis? Why does a Medicaid recipient need to be diagnosed with an Axis I or II diagnose in order to receive outpatient therapy?

So now Obama has publicly announced that, along with gun control measures, he plans to tackle the issue of mental health care.  I ask, “How?” and “Does this include access to therapy for Medicaid recipients?” The fact is that Medicaid recipients can see a therapist 16 (if a child) and 8 (if an adult) times. But then, the Medicaid recipient must show medical necessity in order to receive therapy. Is this quality mental health care? Is this access to quality mental health care for ALL?


About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on January 21, 2013, in Health Care Providers and Services, Medicaid, Medicaid Funds, Medicaid Recipients, Medical Necessity, Mental Illness, Obamacare, Outpatient Behavioral Health, Psychiatrists, Psychologists and tagged , , , , , , , . Bookmark the permalink. 4 Comments.

  1. As a psychologist who use to take Medicaid, I think that you are missing one important point here: it doesn’t matter if Medicaid recipients are allowed to receive mental health services if there are no providers to actually provide it. The number of Medicaid providers has decreased significantly since the move to MCOs rather than direct enrollment with Medicaid. Mental health providers do not want to deal with the micromanagement and administrative burden of the MCOs, especially when coupled with the low reimbursement. I was saddened to have to drop Medicaid, but when I stepped back and looked at what would be involved to provide services through the MCO (Mecklink, in my case), neither I nor any of the other providers in my office were interested.

  2. Knicole wrote: The fact is that Medicaid recipients can see a therapist 16 (if a child) and 8 (if an adult) times. But then, the Medicaid recipient must show medical necessity in order to receive therapy.

    These initial 8 visits for an adult and 16 for a child are when being seen with unmanaged visits, right? I’ve been wondering if there is a difference in the entrance criteria for services that are unmanaged. Would the example children you mentioned be initially eligible for outpatient treatment w/o showing medical necessity or meeting all the entrance criteria?

    I’ve read 8C and it’s still not clear if there is a difference between unmanaged and managed care, though since unmanaged visits exist, one would assume there is a difference.

    • You are completely correct. 8C is not much help.

      Yes, the initial visits (8 for an adult and 16 for a child) are unmanaged.

      As to your question, I could write a book on it. Good question! From my understanding, a valid referral is needed for the unmanaged visits. Before the end of the unmanaged visits, all the documents required for prior approval must be drafted.

      That said, during all care, both managed and unmanaged, all the documentation requirements in 8C are required. But you do not have to send the documents to anyone. The only time you really have to send the documents to an entity is during an audit. So always have documentation. But until the end of unmanaged care, no one really needs to see it, unless you are getting audited.

      Hope that helps!!

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