Medicaid’s Essential Role in Improving the Mental Health of America’s Most Vulnerable Youth

Since well before the COVID-19 pandemic began, the number of young people diagnosed with a mental health need has been increasing, particularly among ethnic minorities, low-income households, and those involved with the child welfare and juvenile justice systems. In response, there has been an increased focus over the past year on strengthening behavioral health services for children and adolescents. A recent report from the Surgeon General describes “a national emergency in child and adolescent mental health” and offers several recommendations, including expanding access to response teams and funding community-based care systems to connect families with evidence-based interventions in their homes, communities, and schools.

Prevention and screening are also essential to meet the needs of young people at risk of mental health challenges. Fortunately, in 2013, the Centers for Medicare and Medicaid Services (CMS) issued guidance outlining the need to provide mental health and substance use treatment to members under age 21, including behavioral health screening and preventive services. Medicaid, which covers approximately 27 million young people, addresses this priority by offering the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which requires states to provide medically necessary services to people under 21 who may be experiencing a mental health need. EPSDT is more comprehensive than commercial insurance benefits, ensuring access to physical and mental health care that promote healthy development and to treatment that addresses symptoms before they worsen. This is a powerful tool; Medicaid-eligible youth are entitled to EPSDT benefits regardless of whether the service is covered in their state’s Medicaid program.

The recent launch of the national 988 suicide and crisis hotline has spotlighted efforts to ensure the availability of behavioral health mobile crisis teams. But preventive services and behavioral health screening can prevent youth from requiring an intervention in the first place. The Center for Medicaid and CHIP Services estimates that 11 percent of youth have a mental health diagnosis, and that at least two-thirds of those youth were not identified as receiving any mental health service. Attending to the wellness of caregivers is also part of ensuring healthy children and strong attachment with caregivers. In 2016, CMS issued guidance allowing for maternal depression screens as part of the EPSDT benefit. A 2018 survey found 31 states and Washington, D.C., allow maternal depression screening to be billed under the child’s Medicaid.

Providing screening and preventive behavioral health services doesn’t save large amounts of money up front. However, when proactive screening and prevention services are implemented through Medicaid programs such as EPSDT, youth and families receive necessary supports, allowing them to gain the skills that improve long-term health outcomes. We know that the more adverse childhood experiences a young person has, the more likely it is he or she will experience poor health outcomes later in life. Preventive interventions aimed at addressing behavioral health problems earlier in life could yield significant savings, less involvement in juvenile justice, less disruption in education, and more productivity in the workforce all by the time a person enters adulthood. California, Colorado, and Massachusetts are leading the way by allowing Medicaid-eligible youth access to preventive behavioral health services without requiring a formal mental health diagnosis.

Given CMS’s recent bulletin on “leveraging” Medicaid funding to “optimize” access to behavioral health benefits for youth and the passage of the Bipartisan Safer Communities Act of 2022, which requires the U.S. Department of Health and Human Services to review each state’s implementation of EPSDT and report gaps, states should take several steps:

• Review how families are notified of all EPSDT benefits, including preventive behavioral health services
• Ensure that EPSDT benefits are accessible in a timely way
• Ensure that EPSDT benefits are equitable to all youth and families, with particular attention to those involved with child welfare and to families of color
• Incentivize both behavioral and developmental screening to occur annually through age 20
• Work across all youth-serving agencies to ensure coordination of services
• Review how local educational agencies can access and bill EPSDT services for Medicaid-eligible youth.

In additional blog posts for this series, we’ll take an in-depth look at opportunities, through Medicaid and other federal funding, to improve and sustain youth and adolescent behavioral health. Topics will include school-based Medicaid, intensive home and community-based services, and creative workforce strategies.