oversight

Medicaid: Sources of Information on Mental Health Services

Published by the Government Accountability Office on 1990-05-07.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

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    r
             United States
GAO          General Accounting  Office
             Washington, D.C. 20548

             Human Resources       Division

             B-239070

             May 7,199O
             The Honorable Daniel K. Inouye
             United States Senate

             Dear Senator Inouye:
             The availability of mental health services under Medicaid has been a
             concern to many health experts. In an earlier report, we summarized
             changesthat state Medicaid and mental health officials believe could
             improve the delivery of such services1In responseto your request, this
             report identifies sourcesof information on the types of mental health
             services offered under each state’s Medicaid program.

             Medicaid, authorized under title XIX of the,Social Security Act, is a fed-
Background   erally aided, state-administered medical assistanceprogram for low-
             income people. Generally, those receiving cash assistanceunder the Aid
             to Families With Dependent Children or Supplemental Security Income
             programs are eligible for Medicaid assistance.In addition, each state has
             the option of providing Medicaid benefits to those who cannot afford
             neededhealth care, but have income above the maximum allowable for
             public assistance.The Health Care Financing Administration (HCFA),
             within the Department of Health and Human Services(HHS), is the fed-
             eral agency responsible for developing program policies, setting stan-
             dards, and ensuring compliance with Medicaid legislation and
             regulations. Each state has considerable flexibility concerning its Med-
             icaid program. Within broad federal guidelines, states determine who
             will be eligible, what serviceswill be provided, and what limits will be
             placed on the services.As a result, between the states over the years,
             wide variations have developed in Medicaid services in general and men-
             tal health services in particular.
             Mental health services are provided to treat a variety of mental condi-
             tions including developmental, behavioral, and emotional problems, as
             well as substance abuse,schizophrenia, and depression,At a minimum,
             Medicaid mental health services cover long-term institutional care, out-
             patient hospital care, and consultations with a physician, as well as
             clinic and laboratory services.Drug therapy might also be provided.



             ‘Medicaid: Views on ChangesNeededin Mental Health Benefits(GAO/HRD-88-96FS,Sept.27,
             1988).



             Page 1                            GAO/HRD-90-100   Mental   Health   Services Under Medicaid
                        B-233070




                        Medicaid specifically excludes federal reimbursement for the care of the
                        mentally ill aged 22 through 64 in institutions for mental diseases.2
                        These are defined in Medicaid regulations as institutions primarily
                        engagedin providing diagnosis, treatment, or care (which includes medi-
                        cal attention, nursing care, and related services) for people with mental
                        diseases.States are not required, but have the option, to provide institu-
                        tional care for the mentally ill who are under 21 years of age and 65
                        years of age or older. If the states exercise this option, the federal gov-
                        ernment will pay its share of the cost of such institutional care.
                        Each state is allowed to set use and dollar limitations on the duration,
                        scope,and dollar amount of Medicaid coverage.Each state also has the
                        option of covering or not covering certain mental health services.As a
                        result, there is considerable variation acrossstates in the nature and
                        extent of mental health services available to Medicaid recipients.


Objectives, Scope,and   services offered under state Medicaid programs, we interviewed officials
Methodology             knowledgeable about mental health issuesand reviewed reports by
                        organizations concernedwith these issues.These included HCFA, HHS'S
                        National Institute of Mental Health (NIMH), the Library of Congress’s
                        CongressionalResearchService (CRS), the National Mental Health Asso-
                        ciation (NMHA), the Intergovernmental Health Policy Project (IHPP) at the
                        GeorgeWashington University, the National Alliance for the Mentally
                        Ill, the American Psychiatric Association, the National Governors Asso-
                        ciation, and the National Association of State Mental Health Program
                        Directors.


Results in Brief        As shown in table 1, several federal agenciespublish data about
                        (1) Medicaid and mental health expenditures and (2) numbers of recipi-
                        ents of services for each state. These agenciespublish relatively little
                        information, however, about the specific mental health services availa-
                        ble to Medicaid recipients in each state.




                        “The federal governmentwill not sharecostsif a personis under 66 years of age,except for a person
                        under 21. If a personreceivespsychiatric servicesjust beforereachingthe ageof 21, he or she may
                        continue to receivethem until the ageof 22.



                        Page 2                                GAO/HRD-00400     Mental   Health   Services   Under Medicaid
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                                                                B-239070




                                                                Academic, professional, and advocacy organizations publish more
                                                                detailed information than federal agenciesabout the mental health ser-
                                                                vices available to Medicaid recipients. The reports by these organiza-
                                                                tions and groups include ‘information on expenditures, eligibility criteria,
                                                                services covered, and limitations on the availability of those services.


Table 1: Summary of information Available
                                                                                                        D&a sources
information available                       ABCDEFGHIJKLMN
Document date                               6109       4109      0107      10109    1907     11/00      1990a    1907   IO/00      0109     7109      1909      l/04    1900
Periodicaiiy updated                        Yes        Yes        Yes      Yes      Yes      No         Yes      Yes    Yes        Yes      Yes       Yes      No      No
State-by-state
 ..I_.-._.._-_l
           _.._       lists:
             -.._-.._......_
                        -_- ..---..---           ---   _I_-..      --
Total mental       health    pavments       No         No         NO       No       Yes      No         No       Yesb   No         No       No        No       No      No
Medrcard       payments                     Yes        Yes        Yes      No       No       Yes        No       No     No         No       NO        No       No      Yes
Medrcard       recipients                   Yes        Yess-x-‘eNo
                                                                 .---___
                                                                                    No       Yes        No       No     No         Yes      Yesc      No       No      Yes
Medicaid eligibility cnterra                                                                            Yes      No     NO         No       NO        NO       NO
 ,.-... .__.._ .-.  .._-- ..-___.._      ..__No--_~_I_ Yes       Yes       No       No       Yes                                                                       Yes
Medicard services covered                   No         Yes        Yes      Yes      No       Yes        Yes      No     Yes        No       No        Yes      Yes     Yes
General    coveraae         limits          No         Yes        Yes      No       No       Yes        Yes      No     No         No       No        Yes      Yes     Yes
Detarls on coverage            lrmrts       No         No         No       No       No       No         Yes      No     No         No       No        No       Yes     No

                                                                Legend

                                                                A = HCFA management information svstem. unpublished data (see D. 8)
                                                                B = HCFA, Program Statistics, Medicare and Medicaid Data Book, lQ88’(see p. 8)
                                                                C = HCFA, Program Statistics, ?%ralvsis
                                                                                                     ,   of State Medicaid Proaram Characteristics. 1986 fsee D. 81
                                                                D = HCFA, Medicard Services State by State (see p. 17)
                                                                E = Natronal Institute of Mental Health, Mental Health, United States (see p. 19)
                                                                F = Congressional Research Service, Medical ‘d Source Book: Background Data and Analysis (see p. 19)




                                                                    Experience in Implementing OBRA NF [nursing facility] Reform (see p. 21)
                                                                L = American Psychiatric Association, The Coverage Catalog (see p. 21)
                                                                M = The Intergovernmental Health Policy Project, Mental Health Benefits Under Medicaid: A Survey of
                                                                     the States (see p. 22)
                                                                N = National Mental Health Association, Operation Help, A Mental Health Advocate’s Guide to Medicaid
                                                                    (see p. 22)
                                                                Y’anes by state, but kept up to date.

                                                                bExcludes data on mental retardation and substance abuse.
                                                                ‘Lists states and shows total number of people for all states.




                                                                Page 3                                        GAO/HRD4JO-100     Mental   Health   Services   Under Medicaid
B-289070




Further information on the data available from federal sources,along
with specific examples, is included in appendix I. Information on the
reports issued by academic,professional, and advocacy organizations is
included in appendix II.
We did not request written comments on a draft of this report from the
organizations consulted during our review. We discussedmatters in this
report with HCFA officials, however, and incorporated their comments
where appropriate. We are sending copies of this report to interested
parties and will make copies available to others on request. Pleasecall
me on 276-5461 if you or your staff have any questions about this
report, Other major contributors are listed in appendix III.
Sincerely yours,




Janet L. Shikles
Director, Health Financing
  and Policy Issues




Page 4                       GAO/HRD90-100   Mental   Health   Services   Under Medicaid
Y




    Page 5   GAO/HRD90-100   Mental   Health Services Under Medicaid
Contents


Letter
Appendix I                                                                                                    8
Data Available From     Health Care Financing Administration                                                  8
                        National Institute of Mental Health                                                  19
Federal Sources         CRSMedicaid SourceBook                                                               19

Appendix II                                                                                                  20
Data Published by       CommerceClearing House                                                               20
                        National Association of State Mental Health Program                                  20
Academic,                    Directors
Professional, and       American Psychiatric Association’s CoverageCatalog                                   21
Advocacy                Intergovernmental Health Policy Project                                              22
                        National Mental Health Association                                                   22
Organizations
Appendix III                                                                                                 25
Major Contributors to
This Report
Tables                  Table 1: Summary of Information Available                                                 3
                        Table I. 1: Summary of Limitations on Optional Services                                   9
                            for Intermediate Care Facility Servicesfor the
                            Mentally Retarded
                        Table 1.2:Summary of Limitations on Optional Services                                12
                            for Patients Aged 66 and Over in Mental Institutions
                        Table 1.3:Summary of Limitations on Optional Inpatient                               16
                            Psychiatric Servicesfor Patients Aged 21 and Under

Figures                 Figure I. 1: Medicaid ServicesState by State                                         18
                        Figure II. 1: Medicaid Outpatient Options by State                                   23




                        Page 6                       GAO/HRD-90-100   Mental   Health   Services Under Medicaid
    Contents




    Abbreviations

    ADP        alternative disposition plan
    CCH        CommerceClearing House
    CW         CongressionalResearchService
    HCFA       Health Care Financing Administration
Y   HHS        Department of Health and Human Services
    IHPP       Intergovernmental Health Policy Project
    NIMH       National Institute of Mental Health
    NMHA       National Mental Health Association


    Page 7                     GAO/HRD-90-100   Mental   Health   Services   Under Medicaid
Appendix I

Data Available From Federal Sources


                        The Health Care Financing Administration (HCFA) annually obtains data
Health Care Financing   from the states concerning (1) the numbers of Medicaid recipients under
Administration          17 general categoriesof services and (2) Medicaid payments for such
                        se&ices. Mental health services are included in categories such as physi-
                        cian services,clinic services,and prescribed drugs, but are generally not
                        separately identified. Only 2 of the categoriesrelate exclusively to men-
                        tal health services-inpatient mental hospital and intermediate care
                        facilities for the mentally retarded. HCFA does not publish data sepa-
                        rately on the 17 general categories,but may include them in reports on
                        Medicaid.

                        HCFA'S Medicare and Medicaid Data Book, 1988 includes (1)      overall and
                        state-by-state Medicaid eligibility criteria and (2) information on the
                        number of Medicaid recipients and payments in each state.’ Although
                        most of the information in the data book deals with the Medicaid pro-
                        gram in general, the book doesinclude, for each state, the number of
                        recipients and days of care provided in intermediate care facilities for
                        the mentally retarded. In addition, states that limit the use of outpatient
                        hospital psychiatric services and psychiatric servicesprovided by phy-
                        sicians are noted, although the limits are not specified.
                        In August 1987, HCFA published Analysis of State Medicaid Program
                        Characteristics, 1986, with information on servicesprovided and limits
                        placed on the use of those services.Intermediate care facility services
                        for the mentally retarded are shown on a state-by-state basis (seetable
                        1.1);also shown are limits placed on the services and whether prior
                        authorization,* periodic reauthorization, or both are required. In addi-
                        tion, similar information on inpatient psychiatric services in mental
                        institutions provided to patients aged 65 and older and aged 21 and
                        under is shown (seetables I.2 and 1.3).Other tables in the HCFA analysis
                        show the restrictions each state places on other services,such as outpa-
                        tient psychiatric services, and the number of psychiatric visits per year.




                        ‘A new version of the data book,a HCFArepresentativesaid,should be publishedthis spring.
                        ‘Prior authorization is a requirementto obtain approval beforeservicesare provided.



                        Page 8                                GAO/HRD-90-100     Mental   Health   Services Under Medicaid
                                                         Appendix I
                                                         Data Available   From Federal   Sources




table 1.1: Summary of Limitations on Optional Servicea for Intermediate Care Facility Services for the Mentally Retarded
                                                                                       Prior
                                                                                       authorization    Periodic         Other
State                                                         Provided     Limits      required         reauthorization  limits
Alabama .-        .-..~~ ..-..-....-.- --.                                   Yes              Yes           Yes               No                   No
Alaska .        _.            ..--.--- --~-..-                               Yes              Yes           Yes               No                   No
Arkansas                                                        --           Yes              Yes           Yes               No                   No
&iornla                                                                      Yes              Yes           Yes               Yes                  No
Colorado                                                                     Yes              Yes           Yes               Yes                  No
Connecticut                                                                  Yes              No            No                No                   No
Delaware_.       _.._ --.- . ..-.- -...- --                                  Yes              No            No                No                   No
DWlct of_  Columbia
                 .._....-.~~..- _--.-..----__                                Yes              No            No                No                   No
iiONk7J                                                                      Yes              No            No                No                   No
Georgia                                                   ~.-                Yes              Yes           Yes               No                   No
Hawall                .__- .- ^ .-__- ..__.____.                             Yes              Yes           Yes               No                   No
Idaho                                                                        Yes              No            No                No                   No
lllinols                                                                     Yes              No            No                No                   No
Indiana
,____ _. _I.“--_..-_.-- _......_-- __-.-                                     Yes              Yes           No                No                   Yes
Iowa                                ~..                                      Yes              No            No                No                   No
Kansas
.--_-_-,_.---.--____                                                         Yes              No            No                No                   No
Kentucky
    --------___-.-          _.---                                            Yes              Yes           Yes               Yes                  No
Louisiana
    ..      ...- ..- --. .~~.---.._. -_-..- .______                          Yes              No            No                No                   No
Maine                                                                        Yes              No            No                No                   No
Mar&d                                                                        Yes              No            No                No                   No
Massachusetts                                                                Yes              No            No                No                   No
Michigan                                                                     Yes              Yes           No                No                   Yes
Mlnnesoia                                                                    Yes              No            No                No                   No
Mississippi                                                                  Yes              Yes           Yes               No                   No
Mlssoun                                                                      Yes              Yes           No                No                   Yes
Montana                                                                      Yes              No            No                No                   No
Nebraska
 ._ ._ .._ --. ~--..--.-.--..--.. ___                                        Yes              Yes           No                No                   Yes
Nevada ,I,I” .        .- ..-.~-..~~------___                                 Yes              Yes           Yes               No                   No
New Hampshire                                                                Yes              Yes           Yes               Yes                  No
New Jersey                                                                   Yes              Yes           No                No                   Yes
New Mexico                                                                   Yes              No            No                No                   No
New York                                                                     Yes              Yes           Yes               No                   No
North Carolina                                                               Yes              Yes           Yes               No                   No
North Dakota                                                                 Yes              No            No                No                   No
Ohio
  . _. _. ..,-.. _----_ -----                         __--.                  Yes              Yes           No                No                   Yes
Oklahoma                          Y                                          Yes              Yes           Yes               No                   No
Oregon                                                                       Yes              Yes           Yes               No                   No
                                                                                                                                                  (continued)




                                                         Page 9                                    GAO/HRB90-100   Mental   Health   Services Under Medicaid
                                    Data Available   From Federal   Sources




                                                                                       Prior
                                                                                       authorization      Periodic             Other
State                                                   Provided         Limits        required           reauthorization      limits
 Pennsylvania                                           Yes              Yes           No                 No                   Yes
 Rhode     Island
 .-__“------..                                          Yes              Yes           Yes                No                   No
 South Carolina                                         Yes              Yes           Yes                No                   No
 South Dakota                                           Yes              Yes           No                 No                   Yes
Tennessee                                               Yes              No            No                 No                   No
Texas
_..____..- --...._...
                  - .___
                       - .___..
                            .. -.                       Yes              Yes           No                 No                   Yes
_Utah
   _-_.__-.-___._______                                 Yes              No            No                 No                   No
Vermont                                                 Yes              No            No                 No                   No
Virginia                                                Yes              No            No                 No                   No
Washington                                              Yes              No            No                 No                   No
West    Virginia
 .__----__-_._--.                                       Yes              Yes           Yes                Yes                  No
 Wisconsin                                              Yes              Yes           Yes                No                   Yes
Wyoming                                                 No               No            No                 No                   No
                                    Source: Analysis of State Medicaid Program Characteristics, 1986, Health Care Financing
                                    Administration.




                                    Page 10                                   GAO/HRD-90-100   Mental   Health Services   Under Medicaid
    Data Available   From Federal   So-




Y




    Page 11                               GAO/HRD-!I0400   Mental   Health   Services   Under Medicaid
                                         Data Available   From Federal   Sources




Table 1.2: Summary of Limitations on
Optional Services for Patients Aged 65                                                                Inpatient hospital
and Over In Mental Institutions                                                                                Prior
                                                                                                               authorization           Other
                                         State                                     Provided        Limits      required                limits
                                         Alabama                                   No              No            No                    No
                                         Alaska                                    Yes             Yes           Yes                   No
                                         Arkansas                                  Yes             Yes           No                    Yes
                                         California                                Yes             Yes           Yes                   Yes
                                         Colorado                                  Yes             Yes           No                    Yes
                                         Connecticut                               Yes             No            No                    No
                                         Delaware                                  Yes             No            No                    No
                                         District of Columbia                      Yes             Yes           No                    Yes
                                         Florida                                   Yes             No            No                    No
                                         Georaia                                   No              No            No                    No
                                         Hawaii                                    No              No            No                    No
                                         ldaho                                     No              No            No                    No
                                         Illinois                                  Yes             No            No                    No
                                         idiana                                    Yes             Yes           Yes                   No
                                         Iowa                                      Yes             No            No                    No
                                         Kansas                                    Yes             Yes           No                    Yes
                                         Kentucky                                  Yes             No            No                    No
                                         Louisiana                                 Yes             Yes           No                    Yes
                                         Maine                                     Yes             No            No                    No
                                         Maryland                                  Yes             No            No                    No
                                         Massachusetts                             Yes             No            No                    No
                                         Michiaan                                  Yes             Yes           No                    Yes
                                         Minnesota                                 Yes             No            No                    No
                                         Mississippi                               No              No            No                    No
                                         Missouri                                  Yes             Yes           No                    Yes
                                         Montana                                   Yes             No            No                    No
                                         Nebraska                                  Yes             No            No                    No
                                         Nevada                                    Yes             Yes           Yes                   Yes
                                         New Hampshire                             Yes             No            No                    No
                                         New   Jersey
                                           ..__-._
                                                --____                             Yes             Yes           No                   Yes
                                         New Mexico                                No              No            No                    No               -
                                         New York                                  Yes             Yes           Yes                   No
                                         North Carolina --_                        Yes             No            No                    No           -
                                         North Dakota                              Yes             No            No                    No
                                         Ohio                                      Yes             Yes           No                    Yes
                                         Oklahoma                                  Yes             Yes           No                    Yes
                                         Oregon                          --        Yes             No            No                    No




                                         Page 12                                   GAO/HRIHO-100      Mental   Health   Services   Under Medicaid




                                                                                          ,
  ,


                                                           Appendix I
                                                           Data Available   From Federal   Sourceo




                              Skilled nurrlnp iacilltler                                                    Intermediate care facilities
                                               Prior                                                                      Prior
                                               authorization                                                              authorization               Other
Provided                   Limit8              required              :2:              Provided              Limits        required                    limits
Yes                       Yes                  Yes                   No               Yes                   Yes           Yes                         No
No                        No                   No                    No               No                    No            No                          No
Yes                       Yes                  Yes                   No               Yes                   Yes           Yes                         No
Yes                       Yes              ---G---                   Yes              Yes                   Yes           Yes                         Yes
Yes                       Yes                  Yes                   No               Yes                   Yes           Yes                         No
No                        No                   No                    No               No                    No            No                          No
No                        No __________--.No                         No               Yes                   No            No                          No
Yes                       Yes
                         ____...____-_-        No                    Yes              Yes                   Yes           No                          Yes
No                        No                   No                    No               No                    No            No                          No
No                        No                   No                    No               No                    No            No                          No
No
 _ ___ ,__-__-..___-      No
                       -.-.-..--.              No                    No               No                    No            No                          No
No
 .__._ __.._.._-          No --
                 --. __.------                 No                    No               Yes                   Yes           No                          Yes
Yes                       No                   No                    No               Yes                   No            No                          No
No                        No                   No                    No               No                    No            No                          No
No..- ..~~.. -... .-.. ._..No                  No                    No               No                    No            No                          No
Yes                       No                   No                    No               Yes                   No            No                          No
No                        No                   No                    No               No                    No            No                          No
Yes                       No                   No                    No               Yes                   No            No                          No
Yes                       No                   No      __-___        No               Yes                   No            No                          No
Yes                       No                   No
                                            ---...---                No               Yes                   No            No                          No
Ves .- ‘.                 No                   No                    No               Yes                   No            No                          No
Yes                       Yes                  Yes                   Yes              Yes                   Yes           Yes                         Yes
                          No
Yes ._- .__--._-._---~~._-_.-..----            No
                                           ..--.-             -      No               Yes                   No            No                          No
No                        No                   No                    No               No                    No            No                          No
No                        No                   No                    No               No                    No            No                          No
Yes. .._.._-.-- ..---~ _. No                   No                    No               Yes                   No            No                          No
Yes                       No
 _. .- .._ -..--._-~-.-~.._-...--.--_-..-.-.-  No
                                                -.--    -_           No               Yes                   No            No                          No
Yes                       Yes                  Yes                   Yes              Yes                   Yes           Yes                         Yes
No                        No                   No                    No               Yes                   Yes           Yes                         Yes
Yes                       Yes                  Yes                   No               Yes                   Yes           Yes                         No
No                   _._ No ..- ._--.- __. -.-No                     No               No                    No            No                          No
No                        No                   No                    No               No                    No            No                          No
No                        No                   No                    No               Yes                   Yes           Yes                         No
No                        No
                         -..-_____             No            _       No               No                    No            No                          No
Yes
-..--_-.-_.--.--          Yes                  No                    Yes              Yes                   Yes           No                          Yes
No
~________                 NO                   No                    No               No                    No            No                          No
No                        No                   No                    No               No                    No            No                          No
                                                                                                                                                      (continued)




                                                           Page 13                                   GAO/H&D90-100   Mental   Health   Services   Under Medicaid
Appendix I
Data Available   From Federal   Sources




                                                             inpatient hospital
                                                                      Prior
                                                                      authorization         Other
State                                     Provided        Limits      required              limits
Pennsvlvania                              Yes             Yes          No                   Yes
Rhode Island                              No              No           No                   No
South Carolina                            Yes             Yes          Yes                  No
South Dakota                              Yes             Yes          No                   Yes
Tennessee                                 Yes             No           No                   No
Texas                                     No              No           No                   No
Utah                                      Yes             No           No                   No
Vermont                                   Yes             No           No                   No
Virainia                                  Yes             No           No                   No
Washington                                Yes             No           No                   No
West Virginia                             No              No           No                   No
Wisconsin                                 Yes             No           No                   No
Wvomina                                   Yes             No           No                   No




Page 14                                   GAO/HRlHO-100     Mental   Health   Services Under Medicaid
     ,
d’

                                                         Appendix I
                                                         Data Available   Prom Federal    Sources




                         Skilled nursing facilities                                                         Intermediate care facilities
                                         Prior                                                                            Prior
                                         authorization                                                                    authorization
Provided               Limits            required                  k%L               Provided               Limits        required                       EE
Yes .”                 No
                  ._~.__._._--...- --.___No                        No                Yes                    No            No                             No
No               . No  No -. ..-_-.---N~-No                        No                No                     No            No                             No
No                                                                 No                No                     No            No                             No
Yes
ves                   Yes .-.. ‘--No-No
                      No                                   -       Yes               Yes                    Yes           No                             Yes
                                                                   No                Yes                    No            No                             No
No .
ves.           _ ~.. No                  No
                      _- . - ---~. ~...--.-_                       No                No                     No            No                             No
                  ..~No _ .~- _..-- No                             No                Yes                    No            No                             No
No                   No                  No                        No                No                     No            No                             No
No                   No                  No                        No                No                     No            No                             No__-
?es .. - --          No                 No                         No                Yes                    No            No                             No
No                   No                 No
                                   ._----.                         No                No                     No            No                             No
No                   No
 .._.. . -. .._.-..---.. .--.-._-        No                        No                No                     No            No                             No
No                   No                 No                         No                No                     No            No                             No
                                                         Source: Analysis of State Medicaid Program Characteristics,   1966, Health Care Financing
                                                         Administration.




                                                         Page 15                                    GAO/HItLL!40-100   Mental   Health   Services   Under Medicaid
                                          Appendix I
                                          Data Available   From Federal   Sources




Table 1.3: Summary of Limitations on
Optional lnpatlent Psychiatric Services                                                                         Prior
for Patients Aged 21 and Under                                                                                  authorization         Other
                                          State                                     Provided     Limits         required              Limits
                                          Alabama
                                          ---                                       Yes          Yes            No                     Yes
                                          Alaska                                    Yes          No             No                     No
                                          Arkansas                                  Yes          Yes            No                     Yes
                                          California                                Yes          Yes            Yes                    Yes
                                          Colorado                                  Yes          No             No                     No
                                          Connecticut                               Yes          No             No                     No
                                          Delaware                                  No           No             No                     No
                                          District of Columbia                      Yes          No             No                     No
                                          Florida                                   No           No             No                     No
                                          Georaia                                   No           No             No                     No
                                          Hawaii                                    No           No             No                     No
                                          Idaho                                     No           No             No                     No
                                          Illinois                                  Yes          No             No                     No
                                          Indiana        -                          Yes          Yes            Yes      -             No
                                          Iowa                                      Yes          No             No                     No
                                          Kansas                                    Yes          Yes            No                     Yes
                                          Kentucky                                  Yes          No             No                     No
                                          Louisiana                                 Yes          No             No                     No
                                          Maine                                     No           No             No                     No
                                          Maryland                                  Yes          Yes            Yes                    Yes
                                          Massachusetts                             Yes          Yes            No                     Yes
                                          Michiaan                                  Yes          Yes            No                     Yes
                                          Minnesota                                 Yes          No             No                     No
                                          Mississippi                               No           No             No                     No
                                          Missouri                                  Yes          Yes            No                     Yes
                                          Montana                                   Yes          No             No                     No
                                          Nebraska                                  Yes          No             No                     No
                                          Nevada                                    No           No             No                     No
                                          New Hampshire
                                          ~-                                        No           No             No                     No
                                          New Jersev                                Yes          Yes            No                     Yes
                                          New Mexico                                No           No             No                     No
                                          New York                                  Yes          Yes            No                     Yes
                                          North Carolina                            Yes          No             No                     No
                                          North Dakota                              Yes          No             No                     No
                                          Ohio                                      Yes          Yes            No                     Yes
                                          Oklahoma
                                          --                                        Yes          No             No                     No
                                          Oreaon                                    Yes          No             No                     No
                      Y

                                          Pennsvlvania                              Yes          No             No                     No
                                                                                                                                      (continued)




                                          Page 16                                   GAO/HRD-DO-100   Mental   Health   Services   Under Medicaid
    Appendix I
    Data Available    From Federal   Soura%




                                                                               Prior
                                                                               authorization          Other
    State                                     Provided         Limits          required               Limits
    Rhode Island                              No               No              No                     No
    South Carolina                            Yes              No              No                     No
    South Dakota                              No               No              No                     No
    Tennessee                                 Yes              No              No                     No
    Texas                                     No               No              No                     No
    Utah                                      Yes              No              No                     No
    Vermont                                   Yes              No              No                     No
    Virginia                                  No               No              No                     No
    Washington                                Yes              No              No                     No
    West Virginia                             Yes              No              No                     No
    Wisconsin                                 Yes              No              No                     No
    Wvomina                                   No               No              No                     No
    Source: Analysis of State Medicaid Program Characteristics,     1986, Health Care Financing
    Administration.


    Like the data book, the primary focus of the analysis is the Medicaid
    program in general rather than specific mental health services.For
    example, nothing in the analysis indicates to what extent physician ser-
    vices, skilled nursing facility services,or outpatient hospital services are
    used for mental health needs.In addition, although states with coverage
    limits are noted, there is little information concerning the nature of the
    limits.

    HCFA also publishes a l-page summary of the optional services provided
    under each state’s Medicaid program (seefig. I. 1). Although more cur-
    rent than other HCFA publications, the summary does not provide a
    detailed description of the servicesor limitations under each category.
    In the summary, HCFA notes that the definitions of, and limitations on,
    eligibility and services vary from state to state; HCFA refers users of the
A   summary to local welfare offices and state Medicaid agenciesfor addi-
    tional details.




    Page 17                                   GAO/HRD-90-100        Mental   Health   Services   Under Medicaid
                                                           Appendix I
                                                           Data Available            From Federal   Sourcee




Figure 1.1:Medicaid Services State by State




                                 lrl           141.1           I       I       I 1
                             .         .   l     t     t   t       +       1    +




                                       +   t     I     l   1       +       1    .

                             .         .   .     *     .   +       +       .    +




                            nlrl*l*lrlnlalnln
                            * I .I I * I Y I I, I * I m I * I u




                                                           Page 18                                            GAO/HRD-SO-100   Mental   Health   Services   Under Medicaid
                        Appendix I
                        Data Available   From Federal   Sources




                        The National Institute of Mental Health (NIMH), within HHS’S Public
National Institute of   Health Service,publishes data, approximately every other year, about
Mental Health           mental health expenditures in the states. The most recent data include
                        mental health servicesbut, like earlier NIMH data, do not separately
                        break out the services funded by Medicaid.” Although the data deal pri-
                        marily with expenditures and funding, someinformation about overall
                        state services can be inferred. For example, using the data, one can infer
                        that some states rely heavily on state mental hospitals for their mental
                        health services;other states emphasizecommunity-based programs.

                        CRS’S Medicaid Source Book: Background Data and Analysis contains
CRSMedicaid Source      state-by-state listings of general eligibility criteria, coverage,limitations,
Book                    and expenditures, but limited information on mental health services4
                        Two of the book’s appendixes provide general descriptions of Medicaid
                        services for the mentally ill and for people who are mentally retarded or
                        have somerelated conditions. The appendixes contain descriptions of
                        the services used to treat these conditions and such data as numbers of
                        recipients and payments. But the appendixes do not include each state’s
                        specific mental health services.




                        “R.W.Manderscheidand S.A.Barrett, eds.,Mental Health, United States,1987,National Institute of
                        Mental Health, DHHSPub.No. (ADM)87-1618(Washington,DC.: U.S.Govt. Print. Off., 1987).
                        41ssuedto the Subcommitteeon Health and Environment,HouseCommitteeon Energy and Commerce
                        (Nov. 1988).



                        Page 19                                   GAO/HRD-90400   Mental   Health   Services Under Medicaid
                                                                                                                      ,
                                                                                                                          t
Appendix II

Data Published by Academic, Professional, and ‘-
Advocacy Organizations

CommerceClearing         CommerceClearing House(CCH) publishes its Medicare and Medicaid
                         Guide in looseleaf binders so that information can be kept up-to-date
House                    with changesin federal and state laws and regulations. In the state
                         charts section of the guide, CCH summarizes the (1) eligibility criteria
                         used by each state for Medicaid coverage,(2) types of serviceseach
                         state’s Medicaid program covers, and (3) basis used by each state to pay
                         for servicesprovided to Medicaid recipients. Included in the descriptions
                         are various limitations established by each state, such as the maximum
                         number of certain types of services,the maximum payment for selected
                         services,or the days of the week when services are provided. To facili-
                         tate collection of additional information, the CCH guide also includes the
                         names,addresses,and telephone numbers of the officials in each state
                         responsible for administering the state Medicaid programs.


National Association     The association periodically publishes reports and studies concerning
                         mental health issues.Its most extensive publication describesfunding
of State Mental Health   sourcesand expenditures.l Becausethe association is one of the sources
Program Directors        of the data used in the NIMH publication described in appendix I, the
                         association publication contains data similar to that in the NIMH
                         publication.

                         The association also conducts special studies. One of them gives infor-
                         mation, for each of the responding states2 on 10 general categories of
                         mental health services under Medicaid. For 4 of the categories,this
                         study gives information on (1) how many of the states reported provid-
                         ing such services, as well as the types of services provided, or (2) who
                         provides the servicesin each state, or (3) both. For the other services,
                         the study only indicates whether each state covers each service.




                         ’ National Associationof StateMental Health ProgramDirectors,Funding Sourcesand Expenditures
                         of StateMental Health Agencies:Revenue/ExpenditureStudy Results,Fiscal Year 1986.
                         “National Associationof StateMental Health ProgramDirectors,Medicaid:An Inventory of Commu-
                         nity Mental Health FinancingAlternatives of 38 RespondingStateMental Health Agencies,
                         Study e88-604(Oct.31,1988).



                         Page 20                             GAO/HRD-90-100    Mental   Health   Services   Under Medicaid
                       Data Publimhed by Academic, Profes&nal,
                       and Advocacy Or@mizatlo~~




                       Another association study discussesalternative disposition plans
                       (ADP).~.~ The study
                                         includes (1) which states have approved ADPS, (2) the
                       time frames allowed by the plans, and (3) state-by-state estimates of the
                       number of nursing facility residents who require transfer to alternate
                       care settings.
                       In addition, the association issued a study of (1) states reporting the use
                       of preadmission screening for mental illness among nursing facility
                       applicants and (2) the total number of people who received such screen-
                       ing during the first quarter of 1989.5,6The study also includes the costs
                       reported by the states for the screening and describeswho doesit in
                       each state.

                       The American Psychiatric Association’s The CoverageCatalog (2nd ed.
American Psychiatric   rev., 1989) is a detailed compendium of public and private sector health
Association’s          insurance plans covering mental and nervous disorders, The catalog also
Coverage Catalog       describes(1) the general types of mental health services available under
                       Medicaid and (2), briefly, each state’s Medicaid mental health coverage,
                       limitations, and prior authorization requirements for the following
                       services:

                       inpatient general hospital,
                       outpatient hospital,
                       physician services,
                       nonphysician services,
                       clinic services, and
                       inpatient psychiatric specialty hospital for patients aged 65 and over or
                       aged 21 and under.



                       “National Associationof StateMental Health ProgramDirectors,43 StatesHave HCFAApproved
                       ADPs[alternative dispositionplan] for PersonsWith Mental Illnesses(Aug. 10, 1989).
                       “The OmnibusBudgetReconciliationAct of 1987requiresthat state mental health authorities deter-
                       mine the appropriatenessof current placementsfor all nursing facility residentswith mental illness,
                       Of all inappropriately placedresidents,thosewho have not continuously lived in a nursing facility
                       for at least 30 monthsbeforethe date of the determinationmust betransferred to facilities providing
                       the appropriatecareunlessstateshave ADPs approvedby HCFA.
                       “National Associationof StateMental Health ProgramDirectors,StateMH AgenciesReportInitial
                       Experience in Implementiig OBRANF [nursing facility] Reform,Study #89-636(July 24, 1999).

                       “Preadmissionscreeningfor nursing facility applicantsis an independentreview, basedon an appli-
                       cant’s mental condition, of his or her needto be admittedinto a nursing facility. The review is done
                       beforeadmission.



                       Page 21                                 GAO/HRD9O-100      Mental   Health   Services   Under Medicaid
                        Appendix II
                        Data Pubkhed  by Academic,    Professional,
                        and Advocacy Oqanizationa




                        The Intergovernmental Health Policy Project (IHPP) at the GeorgeWash-
Intergovernmental       ington University monitors, on an ongoing basis, changesin state health
Health Policy Project   laws and programs. IHPP is funded by HCFA and Public Health Service
                        contracts, as well as by various foundation awards and corporate contri-
                        butions. IHPP produces regular newsletters (State Health Notes and State
                                                                                           --
                        Health Reports) and an annual report summarizing major legislation
                        enacted by the states concerning mental health and substanceabuse.

                        IHPP published a report in 1984 describing each state’s coverageof men-
                        tal health servicesunder Medicaid.’ It includes information concerning
                        mental health coverageand limitations for the same basic services
                        included in the American Psychiatric Association’s CoverageCatalog.
                        The primary difference is that IHPP’S descriptions are more complete and
                        detailed for many of the states. The American Psychiatric Association
                        catalog, however, is more recent.


National Mental         The National Mental.Health Association (NMHA) published a guide to
                        mental health coverageunder Medicaid.8The guide, designedto help
Health Association      mental health advocatesencouragechangesin Medicaid plans and poli-
                        cies, generally describesthe Medicaid program and mental health ser-
                        vices provided under the program. It also contains an annotated
                        bibliography of resource materials and various tables; the tables include
                        information on expenditures, eligibility criteria, and types of services
                        covered by each state’s Medicaid program. Also included is a table with
                        outpatient servicesunder the various state Medicaid programs, includ-
                        ing outpatient treatment in clinics and hospitals, as well as other ser-
                        vices, such as personal and home health care for Medicaid recipients
                        with mental health problems (seefig. 11.1).Whether states place limits
                        on psychiatrists’ servicesis shown on the table, but there are no indica-
                        tions concerning the nature or extent of the limits. Although someof the
                        information in the NMHA publication had already been published by
                        HCFA, other sourceswere also used to show a more complete picture of
                        state mental health programs.




                        7GailE. Toff, Mental Health BenefitsUnder Medicaid:A Survey of the States,Intergovernmental
                        Health PolicyProject,GeorgeWashingtonUniversity (Jan. 1984).
                        ‘Chris Koyanagi,OperationHelp: A Mental Health Advocate’sGuideto Medicaid,National Mental
                        Health Association(1988).



                        Page 22                                GAO/HRD-90400   Mental   Health   Services Under Medicaid
-----     .-..   _._.I   --~   __-   .-.   .-..   -.   ..-..   _-.._-.-.._--__                                                   _____----


                                                                                   Appendix II
                                                                                   Data Published by Academic,   Profeseional,
                                                                                   and Advocacy Organizationa




Figure 11.1:Medicaid Outpatient Options by State

                                                                                 Medicaid    Outpatient     Options        By State




                                                                                   Page 23                                GAO/HRD-90-100     Mental   Health   Services Under Medicaid
                                                                                                                                                           “ii

                                  Appendix II
                                  Data Published by Academic,            Professional,
                                  and Advocacy Organizationa




                             Medicaid           Outpatient         Options        By State
                                                        (Continued)
                                       CLINIC       ) HOSPITN.    1




‘Rural   health clinics   only.
SOIJRCES:
“Mental Health Benefits under Medicaid:         A Survey of the States, January 1984,” Intergovernmental         Health Policy
Prolect, Washington,   DC.
“State Medicaid    Plan Provisions   for Mental Health,”     Mental Health Policy Resource Center, Washington,             DC,
July 1987.
“Medicaid: An Inventory   of Community    Mental Health Financing Alternatives,” Preliminary Study - 88.604,
National Association of State Mental Health Program Directors, A Report by E. Clarke Ross, July 1988.
“Health Care Financing: Program Statistics: Analysis of State Medicaid          Program   Characteristics,”      1986, Health
Care Financing Administration, August 1987.




Y




                                  Page 24                                         GAO/HRDW-100                Mental   Health    Services Under Medicaid
Major Contributors to This l3eport


                   Jane L. Ross,Senior Assistant Director, (202) 275-6195
Human Resources    James R. Linz, Assistant Director
Division,          Donald J. Walthall, Assignment Manager
                   R. Kenneth Schmidt, Evaluator-in-Charge
Washington, D.C.   M. Lee McConico,Evaluator




(101102)           Page 25                     GAO/HRD90-100   Mental   Health   Services Under Medicaid
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