Action Steps

• Identify key stakeholders from advocacy groups, youth- and family-led groups and other community-based organizations to partner with on advocacy efforts
• Identify “champions” in the state legislature and state agencies to support child and youth behavioral health priorities
• Build or participate in coalitions of cross-sector partners to drive policy change
• Engage with partners on an ongoing basis to identify top priorities for advocacy efforts

Box 2. Advocacy Partners

When advocating to strengthen the child and youth behavioral health system, hospitals have a long history of working successfully with advocacy partners. Key stakeholders to partner with include, but are not limited to:

• Children, youth and families with lived experience. While hospitals work with young people and their families living with behavioral health issues every day, it can be important to engage them in intentional ways outside of the clinical setting. Hospitals and their partners can operate focus groups, leverage existing youth and family advisory councils, and partner with youth and family advocacy groups to learn from individuals with lived experience what is working and not working and what they would like to see changed. By creating and participating in platforms for young people and families to share their stories and experiences, such as CHA’s campaign, children’s hospitals can help to translate their lived experience into a powerful advocacy tool.
• Family and youth advocacy groups. There are a wide range of national and state-specific groups that have experience engaging directly with state Medicaid programs but also work directly with youth and families and help them navigate the behavioral health system. Hospitals can partner with organizations like Youth MOVE National and local chapters and the National Federation of Families and local chapters to further understand the issues facing young people and identify potential solutions. Family advocacy groups can also be an important partner in developing advocacy campaigns, identifying specific meetings or avenues for engaging in advocacy, and building a coalition of like-minded, cross-sector partners.
• Other behavioral health providers. Children’s hospitals are one component of the broader provider ecosystem that also includes community mental health centers, federally qualified health centers, pediatric primary care practices, and individual clinicians, social workers, and non-licensed providers. These providers often have longstanding relationships with the young people and families they serve and deep knowledge of local system gaps.^* Children’s hospitals can engage with other providers through state associations, coalitions, and task forces to build a unified advocacy voice that reflects the full range of settings where young people and families access care.
• Cross-state learning efforts. Hospitals and partners in other states can be an important resource for hospitals to identify gaps in their own programs and lift up emerging best practices that their state can consider. Joining a cross-state collaborative like the CHA BHLC and identifying other opportunities to hear from national and state experts can help drive cross-state learning and ensure hospitals are working together to the extent possible.
• Legislators and representatives from state and national agencies. Hospitals can focus advocacy efforts on all three branches of state government. The legislature can propose new laws or budget changes that would drive Medicaid program or policy changes, while the Governor can be a spokesperson for state priorities, and state agencies are responsible for implementing the Medicaid program. Hospitals can build relationships with key partners in every branch of government and identify legislators and agency staff who have a personal connection to strengthening the child and youth behavioral health system. These individuals can serve as a “champion” and work alongside hospitals and other partners in advocating for specific program changes.
• Legal representatives. The legal system often ends up serving as a backstop when EPSDT obligations are not being met and other advocacy efforts are not working. Hospitals can work with organizations such as the National Health Law Program and Disability Rights who often take the lead in pursuing litigation related to EPSDT, the ADA and/or Section 504. They can also serve as experts in the child and youth behavioral health system when litigation is already underway, including through filing amicus briefs, and by advising on and supporting implementation of the provisions in EPSDT-related settlement agreements and consent decrees. In Massachusetts, for example, clinicians from Boston Children’s Hospital served as key clinical partners during implementation of the Rosie D. v. Romney settlement agreement, a landmark EPSDT class action case that resulted in Massachusetts overhauling its Medicaid behavioral health system for young people with significant behavioral health needs, including the creation of new home- and community-based services.
• Cross-sector partners. The child and youth behavioral health crisis extends far beyond state Medicaid programs and behavioral health provider organizations. Hospitals can partner with cross-sector partners, such as organizations that support children and youth in child welfare and the juvenile justice system; providers that work with children with neurodevelopmental disabilities; and housing providers and social service organizations to drive comprehensive, cross-systems change. Some states including New Jersey have established a statewide “” with a single point of entry for families seeking services for their children and connects them to appropriate supports across physical health, behavioral health, education and social services.

Action Steps

• Review state documentation to identify covered behavioral health services
• Identify coverage gaps by comparing the state’s Medicaid-covered services for children and youth to CHA’s continuum
• Work with family advocacy groups and other partners to identify top priority services that are not currently covered and should be the focus of advocacy efforts
• Identify how other states are covering high priority services
• Advocate to cover critical behavioral health services and supports for young people and families

A Note on Services for Children and Youth Without a Behavioral Health Diagnosis

As described in the EPSDT section above, all Medicaid-covered services can be provided to a young person under age 21 when clinically appropriate even if they do not have a behavioral health diagnosis. When reviewing covered behavioral health services, hospitals and their partners can also assess if their state has a diagnosis requirement for receipt of certain behavioral health services, and advocate to remove such a requirement. This is particularly important for services that might help prevent a behavioral health condition from developing or worsening, and to ensure very young children are able to access services without being unnecessarily labeled. California, for example, necessary specialty behavioral health services for children and youth who meet certain conditions, such as exposure to significant trauma or involvement in the child welfare or juvenile justice system, even if they don’t have a behavioral health diagnosis.

Box 3. Common Coverage Gaps

When reviewing their states’ continuums of Medicaid-covered behavioral health services for children, youth and families, priority services hospitals can focus on key services that frequently are required as a result of EPSDT-related litigation. These are services which must be provided when necessary and are critical to ensuring children and youth have access to treatment in the least restrictive setting (see Appendix 1 for details about past litigation that includes these services). Moreover, there is evidence that they are more cost-effective than inpatient and residential care while effectively treating young people in their homes and communities.^* Key services that are often missing include, but are not limited to:

• Intensive care coordination (ICC). ICC provides team-based, wraparound supports to youth and their families to ensure they are connected to the child-serving systems and service providers they need. High Fidelity Wraparound is a time-limited, evidence-based model of ICC that brings together a team of behavioral health practitioners and natural supports to work with youth and family to develop and implement an individualized plan that builds on strengths, responds to culture and preferences, and helps keep the youth in their home and community.
• Intensive home-based services (IHBS). IHBS are a model of intensive therapeutic support that supports a young person in their home and community. IBHS is often delivered in concert with ICC and leverages a team of behavioral health practitioners that work in partnership with youth and families. IBHS models typically integrate peer support services, crisis services, and skill-building activities in addition to therapy and other intensive behavioral supports.
• Mobile Response and Stabilization Services (MRSS). An effective crisis system can prevent unnecessary emergency department visits and hospitalizations and minimize encounters with law enforcement. MRSS is an evidence-based crisis model for children and youth that allows families and young people to define when they are experiencing a crisis (instead of requiring a professional’s determination); offers timely community-based support; integrates peers into the response team; relies on staff with specialized expertise in working with children, youth, and their families; and offers ongoing stabilization support after the immediate crisis. MRSS can also be integrated and coordinated with ICC and IHBS programs to ensure children and youth with complex needs receive comprehensive support.
• Youth and family/caregiver peer support services. Young people and family members or caregivers with lived experience with the behavioral health system and shared identities (e.g., race, sexual orientation, gender identity), or “peers,” can offer support to other young people and families who share similar experiences and identities. Peers are also often incorporated in the delivery of intensive care coordination, intensive home-based services, and crisis services. While 40 states cover peer support services under Medicaid, a subset of states ensure there are peers available to specifically support young people with behavioral health needs and their families.^*

Outside of EPSDT litigation, members of CHA’s BHLC have identified additional services as often missing in their state service arrays: IOPs and PHPs; outpatient and residential treatment for young people with substance use disorders; crisis services, including both mobile crisis geared to the unique needs of children, youth and families, and transitional stabilization and assessment treatment options; and, as discussed further in Strategy 4, specialized services for children and youth with neurodevelopmental disabilities, eating disorders or other complex needs. Finally, even when services are covered, there may be insufficient treatment spots for those who are considered more challenging or resource-intensive to serve, such as older adolescent males, young people who exhibit violent or aggressive behaviors, and gender diverse youth. ^*

Box 4. Key State Coverage Documents

Every state Medicaid program is structured differently, and covered services may “show up” in different ways. Key state documents to review to assess the current continuum of covered behavioral health services for children, youth and families include:

• Medicaid State Plan. Every state has a Medicaid state plan, or a written agreement between the state and the federal government that describes how the state administers its Medicaid program. The state plan includes all mandatory Medicaid benefits listed in Section 1905(a) and optional benefits the state has determined to cover for adults. The state plan provides assurances the state will abide by federal Medicaid rules; indicates which optional groups, services, or programs the state will cover or implement; and describes how the state determines Medicaid eligibility, reimburses providers, and deploys other processes to administer the Medicaid program. ^* The state plan is organized into seven sections: the third section and relevant supplements or attachments describe a state’s covered services, and often includes information about the EPSDT benefit and other optional covered services. In particular, hospitals may wish to review the clinic services, inpatient hospital services, rehabilitative services and targeted case management state plan sections of their state plan. SPAs are used to add benefits to the Medicaid state plan.

Example: Nevada uses an to cover adult, youth and family peer support services.

• MCO Contracts. In states with Medicaid managed care, the Medicaid program will have contracts with all Medicaid MCOs. While managed care plan contracts vary by state, they typically include a “Covered Services” or “Scope of Benefits” section that will list covered behavioral health services. The contract may also include an EPSDT section that expands or clarifies coverage requirements for children and youth that go above and beyond standard adult benefits.

Example: Exhibit M of Oregon’s Coordinated Care Organization specifies what behavioral health services plans are required to administer, including family and youth peer support specialists, Wraparound, crisis care, respite care, ICC and intensive in-home behavioral health treatment.

• Provider Manuals. State Medicaid programs and MCOs also issue policy documents directed at their contracted providers to further clarify expectations related to covered services, documentation and payment for Medicaid-covered services.

Example: Ohio’s for the OhioRISE program includes a section describing “OhioRISE Services,” including three tiers of care coordination, including ICC, intensive home-based treatment, PRTF services, respite, flex funds, and MRSS.

• Informational Bulletins or Other State Guidance Documents. States may also issue information bulletins or other guidance documents directed at their MCOs, providers or other stakeholders clarifying service standards.

Example: California issues “Behavioral Health Information Notices” (BHINs) for their county behavioral health plans responsible for delivery of intensive “specialty” behavioral health services. BHINs describe state requirements for behavioral health service delivery, such as coverage of and .

• Legislative or State Agency Reports and Strategic Plans. States may publish legislative reports, task force recommendations, or other strategic plans that describe planned reforms to the children’s behavioral health system. While these are not binding coverage authorities like the Medicaid state plan or MCO contracts, they can provide important insight into how states intend to improve behavioral health services for children and youth.

Example: In 2025, Maryland’s Behavioral Health Authority issued a , which outlines strategies the state is pursuing to strengthen youth behavioral health.

Action Steps

• Review other Medicaid authorities to identify covered behavioral health services for children, youth and families that exceed the scope of EPSDT
• Work with family advocacy groups and other partners to identify which non-EPSDT community-based services and supports that are not currently covered by Medicaid are highest priority to advocate to the state to cover
• Identify how other states are covering high priority non-EPSDT services in their Medicaid programs
• Advocate to state Medicaid programs to pursue coverage of behavioral health services and supports for young people and families that use Medicaid authorities other than 1905(a) state plan authority.

Box 5. Other Medicaid Authorities

As described above, EPSDT requires states to provide any service that could be covered under Section 1905(a) when necessary. However, there are important behavioral health services that are not part of Section 1905(a) and that states can cover using other federal Medicaid authorities. Some of these authorities allow states to waive standard Medicaid rules and provide services on a more targeted basis. For example, Medicaid state plan services provided under Section 1905(a) generally must be available to all eligible individuals throughout the state (“statewideness”), and provided in the same amount, duration and scope to all individuals within an eligibility category (“comparability”). When using other federal Medicaid authorities such as those described below, states can often make services available to just a subset of Medicaid enrollees, such as a select group of children and youth with complex behavioral health needs.

Other Medicaid authorities that states can use to cover behavioral health services for children and youth include, but are not limited to:

• Targeted Case Management (TCM) SPA. States use TCM SPAs to provide case management to a specifically defined set of members and does not require that the service be provided on a statewide basis. For example, states can leverage a TCM SPA to authorize ICC to be targeted specifically at children and youth living with complex behavioral health needs. Having a TCM SPA does not, however, allow a state to sidestep their obligation to provide an EPSDT-coverable service (like ICC) to any child or youth who needs it.

Example: As part of the Rosie D. v. Romney settlement agreement, Massachusetts covered ICC using the wraparound model for youth with serious emotional disturbance who are under the age of 21 using a .

• Home- and Community-Based Services Waiver. Section 1915(c) of the Social Security Act allows states to provide home- and community-based services to a specifically defined set of members who would otherwise require an institutional level of care. States can use a 1915(c) waiver, for example, to extend coverage of intensive behavioral health services to children and youth whose family income exceeds traditional Medicaid eligibility levels, and to provide additional services that are not coverable under 1905(a) state plan authority like respite care and supported employment and education.

Example: New York operates a program for children with serious mental health and children with physical or medical disabilities that includes respite, caregiver and family supports, habilitation, and other home- and community-based services. When determining eligibility, New York excludes parental income, counting only the child’s income.

• 1915(i) SPA. States can also use 1915(i) SPAs to provide home- and community-based services to a specifically defined set of members. Unlike 1915(c) programs, to be eligible for services authorized under 1915(i) individuals do not need to otherwise require an institutional level of care, and enrollment in 1915(i) programs cannot be capped. 1915(i) programs may include ICC and IHBS for a specific group of children and youth, as well as respite care, supported employment and education, and family supports. Like TCM SPAs, if a service is also EPSDT-coverable (like ICC or IHBS), states must make it available to any child who needs it.

Example: Illinois uses a to cover ICC, family peer support, IHBS, respite, and other therapeutic services for eligible children and youth when necessary to support recovery.

• Use of Managed Care Savings. Section 1915(b) of the Social Security Act allows states to establish mandatory Medicaid MCOs. Under 1915(b)(3), states can use savings generated from managed care to provide additional cost-effective services to Medicaid enrollees, such as flex funds for children and youth with behavioral health needs; housing, food, and other community-based services and supports; respite care; and supported employment and education. States may limit 1915(b)(3) services to MCO enrollees and they do not need to be made available statewide.

Example: Ohio uses 1915(b)(3) authority to cover respite care for parents and caretakers of children and youth living with complex behavioral health needs, as well as for flex funds that can be used to pay for school and community-based activities.

• In-Lieu-Of Services Flexibility in Managed Care. Under 1915(a) authority, states can also allow MCOs to provide in-lieu-of services, meaning that a MCO can cover an alternative service or setting instead of a traditional Medicaid benefit if it is cost-effective and clinically appropriate. States define which in-lieu-of-services are allowable in its MCO contracts, and MCOs can elect which, if any, ILOS identified by the state that they want to cover. This flexibility enables coverage of services and supports not otherwise included in the Medicaid state plan, such as respite and housing services. In-lieu-of services are limited to MCO enrollees, which can be an issue if many children and youth with complex behavioral health conditions remain in the fee-for-service system. Federal law includes protections to minimize the mandatory enrollment into Medicaid managed care of children with special health care needs (such as those receiving Supplemental Security Income), foster children, children receiving adoption assistance, and American Indians/Alaska Natives.

Example: California provides “” including caregiver respite, housing transition and tenancy supports, and personal care services as in-lieu-of services to enrollees in participating Medicaid managed care plans.

• Health Homes. Under Section 1945 of the Social Security Act, states can establish Medicaid Health Homes for individuals with chronic conditions, including serious behavioral health conditions. Health Homes provide enhanced case management and integrate physical health, behavioral health and social services. States may target Health Homes to specific populations, including children and youth with serious emotional disturbance or co-occurring conditions. Similar to 1915(i) SPAs, children and youth do not need to otherwise require an institutional level of care to be eligible for a Health Home.

Example: Maine operates a for children with behavioral health conditions or intellectual and developmental disabilities, which coordinates their physical and behavioral health services, connects families to community resources and youth and family peer supports, and supports care planning and family education.

• Section 1115 Demonstration. States use Section 1115 demonstration waivers to use federal Medicaid funds in ways that promote the objectives of Medicaid but are not otherwise allowed under the federal rules. Section 1115 demonstrations can be used to make broad changes in Medicaid eligibility, benefits, and cost-sharing, and/or provider payments. In most instances, Section 1115 demonstrations are time-limited and used when no other Medicaid authority is appropriate, including for services to address health-related social needs. In the past, some states have used Section 1115 demonstrations for investments in workforce and behavioral health system infrastructure; however, in July 2025 CMS issued a letter indicating CMS does not anticipate approving new state proposals for workforce initiatives at this time.^* .

Example: Oregon uses a to provide housing-related services (e.g., tenancy support, utility assistance), nutrition support (e.g., nutrition education, medically tailored meals) and other social services to children and youth who meet specific criteria, including those involved in child welfare, homeless or at risk of homelessness, or transitioning from incarceration or an IMD.

• CHIP Health Services Initiatives (HSIs). While not a Medicaid authority, states can use CHIP HSIs to use a small portion of their federal CHIP funding ^* to pay for health-related services or supports for low-income children, regardless of their insurance status. States have broad discretion to define the allowable uses of HSI funds. Some states use CHIP HSIs to address health-related social needs, including to provide housing supports or legal services to children and youth with behavioral health needs.

Example: Wisconsin uses a to provide housing support for low-income families with children under age 19.

Action Steps

• Engage with families with lived experience, advocacy groups, schools and other behavioral health providers in the state to understand which Medicaid-enrolled children, youth and families do not have sufficient specialized services and supports to meet their needs
• Work with other states and cross-state entities to identify what leading states and hospitals are doing to better support young people with complex behavioral health and co-occurring needs
• Identify specific investments that are most needed to better support children and youth with complex needs at different levels of the behavioral health continuum of care
• Establish a coalition of cross-sector partners to work together to advocate to their state Medicaid programs for investments in specialized services and supports

Box 6. Who Are Some of the Children and Youth With Complex Needs?

Young people with complex needs require tailored behavioral health services and supports at every level of the continuum of care. These children and youth may include, but are not limited to, those living with:

• Co-Occurring Behavioral Health and Neurodevelopmental Disabilities, such as Autism Spectrum Disorder and Intellectual and Developmental Disabilities. Children and youth living with behavioral health conditions and neurodevelopmental disabilities often require skill-building programs and coordinated care across public systems that extends beyond traditional behavioral health services. Young people living with neurodevelopmental disabilities and their families often face barriers in accessing appropriate behavioral health services, including insufficient providers with specific training or expertise to meet their individualized needs.^* Even in cases where specific services – such as Applied Behavior Analysis, specialized IHBS, supported education and respite – are technically covered under a state’s Medicaid program, families may face lengthy waitlists and other access barriers.^*

Example Intervention: In Maryland, the Kennedy Krieger Institute’s provides evidence-based assessment and treatment for children with intellectual and developmental disabilities who exhibit severe, treatment-resistant behaviors. The specialized program reports strong outcomes: over the last five years, 85 percent of discharged patients reduced problem behaviors by at least 80 percent.

• Co-Occurring Behavioral Health and Complex Physical Health Needs, including Eating Disorders. Behavioral health services often are not set up to support young people with complex behavioral and physical health needs. In children’s hospitals, medical and psychiatric units are typically separated. However, a child with an eating disorder, for example, needs simultaneous monitoring and interventions for their physical health as well as mental health treatment. The lack of capacity to treat both issues simultaneously can lead to extended inpatient stays and delays in getting the appropriate level of care.

Example Intervention: In an of access to behavioral health services for children and youth, Washington identified a gap in specialized treatment for children and youth with eating disorders. In Colorado, some Medicaid have PHPs and IOPs specifically for eating disorders, including for children and adolescents.

• Co-Occurring Mental Health and SUD Needs. Even within the behavioral health system, there are often limited treatment options for children and youth with both mental health needs and a SUD. Programs are often siloed into “mental health” or “SUD” programs, and practitioners are not equipped to treat both issues in an integrated way. At the same time, children and youth often have primary mental health and SUD conditions occurring at the same time with symptoms that may overlap.^* This makes it crucial to assess a young person for the presence of both mental health and SUD conditions and connect them with appropriate treatment. Without this, children and youth with co-occurring needs may overly rely on the crisis and emergency systems, rather than being able to comprehensively address their needs in lower levels of care.

Example Intervention: In Maryland, the serves adolescents and young adults with co-occurring needs, including comprehensive assessment, outpatient care, and dual diagnosis treatment.

• Aggressive or Violent Behavior. Youth who exhibit aggressive or violent behaviors, including sexually aggressive behaviors, face challenges in getting safe, effective care. Outpatient behavioral health programs may not accept young people who pose safety risks to other children, and youth with these issues and their families and caretakers will face stigma and over-reliance on the crisis and juvenile justice systems. When no specialized treatment options are available, the child or youth may be frequently transferred between programs, and have their care focused on containing the child, rather than on addressing underlying behavioral health issues.

Example Intervention: California has developed to support Medicaid behavioral health providers in implementing Multisystemic Therapy and Functional Family Therapy, which can be key resources for young people with aggressive, violent or externalizing behaviors and their families.

• Multi-System Involvement. Children and youth who are engaged in multiple systems – like child welfare, juvenile justice and behavioral health – face both structural and practical barriers in getting the care they need. A child may have to go through multiple assessments and repeat their history to multiple caseworkers and agencies. There may also be data sharing issues, resulting in a lack of integrated, unstable care. To address this issue and with the backing of funding from the Substance Abuse and Mental Health Services Administration (SAMHSA), numerous states have created a “system of care” for all children and youth with complex needs with a single point of entry that requires ongoing, deliberate coordination across different state system partners.

Example Intervention: New Jersey created a statewide, cross-agency to support children and youth involved in multiple systems, including behavioral health, child welfare, juvenile justice, and intellectual and developmental disabilities.

Action Steps

• Compile relevant data from the hospital, the state Medicaid program, and national resources
• Analyze data to identify trends in service utilization and provider networks that indicate access barriers
• Supplement quantitative data with stories and experiences of youth, families and other stakeholders
• Bring data and personal stories to state Medicaid agencies to advocate for changes to address identified access challenges

Box 7. Data Sources

Hospitals can use a variety of data sources to identify utilization trends that reflect systemic access barriers.

• Hospital data. Children’s hospitals can use their own data to see if there are barriers to accessing hospital-based emergency, inpatient and outpatient behavioral health services, and if there are specific populations that face disproportionate challenges in accessing services or transitioning to other levels of care. For example, hospitals can look at length of stays in their emergency department and inpatient units stratified by diagnoses or key demographic factors to see if there are specific groups of children and youth who are most frequently experiencing extended emergency or inpatient stays or have repeat hospitalizations. As described in Strategy 4, Ohio children’s hospitals conducted an analysis of children who required acute psychiatric hospitalization to identify which children most often had extended stays, which informed recommendations to hospital leadership to better support those young people.
• Utilization data. Hospitals can use available Medicaid data to identify trends in utilization of Medicaid-covered services. In some cases, states will make such data available publicly, like California’s specialty mental health services . States often are also required to gather and publish such data as part of settlements in EPSDT-related litigation. ^* Key data points that children’s hospitals can use may include, but are not limited to:
• The number of children and youth engaged in inpatient or residential treatment compared to the number of children and youth receiving IHBS or ICC; and
• The number of children placed out-of-state compared to the number of children and youth receiving IHBS, ICC, inpatient, or residential treatment in their own state.

While there is no widely agreed upon metric to assess if a state has the “right” ratio of young people in inpatient or residential treatment compared to ICC or IHBS, or an appropriate number of children placed out-of-state, data can help hospitals and partners identify concerning trends. For example, in Maryland in 2022, nearly 6,300 children and young adults received inpatient or residential, compared to 34 children and youth enrolled in the state’s IHBS program. This data prompted the state to identify strengthening IHBS as a top priority in its .

• Network adequacy data. States are required to ensure plans responsible for behavioral health services have sufficient capacity to serve Medicaid enrollees within a reasonable amount of time. States collect data that includes information about the supply of behavioral health providers in the state and compliance with time and distance standards and appointment wait time standards. Network adequacy data may be available publicly in or or . Like claims data, when network adequacy data is not available, a hospital or other stakeholder can make a public records request for data. While claims data can demonstrate where there may be over-use or under-use of specific services, network adequacy data can help illustrate where there may be a shortage of specific provider types, or in what parts of the state providers are not regularly meeting time and distance requirements.
• Data on authorizations, grievances and appeals. States also collect data related to prior authorizations for behavioral health services, as well as on grievances and appeals from Medicaid members. States are required to collect this data from MCOs annually, and starting in June 2026, all states must report plan-level information on the number of prior authorization requests, denial and approval rates, and decision times. ^* States also collect MCO data on reasons for grievances and appeals and resolutions of those appeals. Hospitals can review public MCO reports for this information as well as EQR reports and can also submit public records requests for more detailed data, including information for children and youth and for specific behavioral health services. This data can indicate if there are any barriers or delays in accessing services that require prior authorization and how any grievances related to child and youth behavioral health have been resolved. Data can illustrate if MCOs are potentially violating parity requirements under MHPAEA, such as imposing limits for behavioral health services that are more restrictive than limitations applied to substantially all medical/surgical services in the same benefit classification.^*
• State reports and roadmaps. Legislative reports, task force recommendations, state roadmaps or other strategic plans often also include data regarding why specific recommendations were made or how planned reforms were identified. Reviewing legislative reports and other state reports and roadmaps can also help hospitals understand what specific gaps the state has already identified in their behavioral health system and where data may have already been collected and analyzed for this purpose.
• Qualitative data. Hospital data and data from state Medicaid programs and their MCOs can be supplemented by personal stories and experiences about how the system works in practice. Talking directly to youth, families, advocates and other stakeholders can further illustrate what data points are important to focus on, and where data does not tell the full story. For example, the data may indicate that very few children are utilizing a specific intensive in-home service. However, after talking to young people, families, or other stakeholders, it may become clear that utilization for a specific service is low because the state also offers a similar evidence-based model for that service that is claimed and tracked differently. For example, when Maryland developed a to strengthen the public behavioral health system for children and youth, the state partnered with the Maryland Coalition of Families to ensure families with lived experience informed the roadmap goals and strategies.

Action Steps

• Use data to identify the largest gaps in the supply and distribution of behavioral health providers
• Work with peer states to identify shared challenges and opportunities to address provider network gaps
• Identify options for targeted workforce investments
• Advocate to state Medicaid agencies for workforce investments

Action Steps

• Identify services with especially low utilization and/or provider types with the most significant gaps
• Review the state’s Medicaid behavioral health rates for those services and/or provider types, and compare them to rates in other states or programs
• Identify where updated rates or other innovative financing strategies may be needed to improve access to care
• Identify where new services are being covered and there are stakeholder opportunities to engage in rate development
• Advocate to state Medicaid agencies for rate updates

Action Steps

• Partner with youth and families with lived experience to understand the information gaps around EPSDT behavioral health services
• Advocate to state Medicaid agencies to develop easy-to-understand EPSDT behavioral health education materials and launch messaging campaigns
• Partner with trusted community partners to share EPSDT behavioral health education materials with families
• Advocate to state Medicaid agencies to provide education to families on what to do if their child’s care is denied

Action Steps

• Review continuum of covered services and supports to ensure sufficient stepdown options are available
• Review Medicaid MCO contracts, performance measures and other state documents to identify existing policies related to transitions of care for children and youth leaving inpatient or residential behavioral health treatment
• Review data to identify if there are any specific children and youth with most frequent re-admissions or crisis events following discharge
• Advocate to state Medicaid agencies to strengthen policies related to discharge planning and transitions of care

Box 8. Opportunities to Strengthen Transitions of Care

• Establish clear policies related to discharge planning and ensure community-based behavioral health providers are included in planning. Without a clear transition plan, a child or youth can fall through the cracks after being discharged from a higher level of care. While federal Medicaid rules that children and youth have discharge plans in place before leaving inpatient or residential treatment, states can establish policies to better prepare young people and their families for successful transitions to community-based bare. For example, states can require discharge planning to involve the young person, their family, inpatient or residential treatment providers, and care coordinators or outpatient providers so that immediate next steps are clearly defined before discharge. States can also require closed-loop referral processes, in which referrals must be sent, received, acted on, and confirmed back to the referring provider, to ensure the young person actually connects with community-based services. States can also establish data processes to understand which children and youth are most likely to be lost to follow up or have frequent readmissions and design policies to better support those groups.

Example: After identifying that Medicaid-enrolled youth frequently experienced housing instability following discharge from psychiatric facilities, Washington State enacted establishing a rapid response team to participate in transition and housing planning for youth and young adults exiting a publicly funded system of care to ensure they are not discharged into homelessness.

• Allow transitional reimbursement of High Fidelity Wraparound, Coordinated Specialty Care, or other team-based services while a young person is still in a residential or inpatient treatment setting. Case managers, peers and other practitioners that deliver team-based services can be an important resource to a child or youth when they are transitioning between levels of care. Initiating these relationships early – before discharge – can improve trust, improve engagement in treatment after discharge, and strengthen continuity of care. States can support these transitions by allowing intensive community-based providers to be paid for initial services provided to a young person prior to discharge from a facility-based setting. For children and youth engaged in intensive services prior to intake, states can also permit ongoing engagement and reimbursement for ICC or other team-based services while the child is in a higher level of care.

Example: permits initiation of ICC, Coordinated Specialty Care and High Fidelity Wraparound prior to discharge from a residential or inpatient treatment facility.

• Require and track rapid follow-up after discharge. Timely follow-up after discharge from a residential or inpatient facility – within a few days or even a few hours – can help ensure a young person is safely transitioning to a lower level of care and mitigate crises. State Medicaid programs can require timely follow-up and establish quality measures to track and hold MCOs and providers accountable for meeting specified standards.

Example: The CMS Core Set includes quality measures to track follow-up within 7 days of discharge from psychiatric hospital stays (see Strategy 10). Some states establish state-specific follow-up metrics. For example, requires 72-hour follow up for some behavioral health events, including discharge from an inpatient psychiatric facility.

Action Steps

• Review the state’s required child and youth behavioral health quality measures
• Identify where there are gaps with a state’s current quality measures for assessing the quality of children’s and youth behavioral health and opportunities to establish additional quality measures
• Advocate for the state Medicaid program to create a stakeholder process for developing new behavioral health quality measures for children and youth and offer the children’s hospital’s behavioral health expertise
• Encourage the state Medicaid program to make current and any new quality measure data publicly available
• Encourage the state Medicaid program to hold Medicaid managed care plans accountable for specific performance targets

Box 9. Mandatory Behavioral Health Child Core Set Measures

CMS requires states to report data annually on their performance on Child Core Set measures, which include the following behavioral health-specific measures.

• Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH)
• Screening for Depression and Follow-Up Plan: Ages 12 to 17 (CDF-CH)
• Follow-Up after Hospitalization for Mental Illness: Ages 6 to 17 (FUH-CH)
• Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM-CH)
• Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)

Box 10. State Improvements in Child/Youth Behavioral Health Data Transparency and Public Accountability

States’ efforts to gather and publish children’s behavioral health data have emerged through a combination of court-mandated reforms and state legislation. These include, but are not limited to:

• Washington. Washington has developed a Quality Management Plan as a commitment of its settlement agreement (T.R. v Quigley) focused on improving children’s intensive home and community-based mental health services. The state publishes annual reports on a variety of measures that examine access to care, engagement in care, provision of appropriate and effective services, and linkage to ancillary and follow-up services, which are examined across different levels of the system (e.g., individual-level, caseload-level and state-level).^*
• Massachusetts. Through its Children’s Behavioral Health Initiative (as a result of Rosie D. v Romney), the state Medicaid program has developed several service utilization and outcome measures that are publicly available, including for behavioral health screenings, mobile crisis intervention services, high-fidelity wraparound services, and referrals to community service agencies.^*
• Michigan. As a requirement of its settlement agreement (K. B. v Michigan Department of Health and Human Service), Michigan is developing a public-facing dashboard with metrics on delivery of ICC, IHBS, crisis, respite, and peer support services, broken out by MCO.^* The dashboard will include metrics on the need for these services based on a new statewide standardized assessment tool; service utilization, including the timely receipt of services and rate of service denials; and out-of-home placements (e.g., foster home, juvenile justice settings, psychiatric and residential care facilities). For several metrics, the state will provide data by race/ethnicity and region. The state also created a dedicated unit for monitoring and quality improvement that will oversee data collection, data evaluation, and analytics to examine Michigan’s progress.
• California. Through the state’s Behavioral Health Transformation and in consultation with behavioral health stakeholders and subject matter experts, the state is developing a new set of quality and equity performance measures – many of which are focused on children and youth – for MCOs and counties (in California, counties administer specialty behavioral health services). These measures related to 14 statewide behavioral health goals to improve wellbeing (e.g., care experience, access to care, treating co-occurring physical health conditions, and engagement in school) and decrease adverse outcomes (e.g., suicide, homelessness, child removal from their home). The State Medicaid program plans to publish these measures annually for the public, stratified by county and MCO and by age and key demographics. For the first three years, the measures will be used to support transparency, population health efforts, and MCO and county behavioral health plan efforts for addressing statewide behavioral health goals. (In California Medicaid, counties operate the specialty mental health system.) Starting in the fourth year of implementation, the State will use these performance measures for MCO and county behavioral health plan accountability.^*