Behavioral Health Services in Separate State CHIP Programs: Is Your State in Compliance?

Access to behavioral health services has long lagged behind physical health, despite a clear and growing need. The need has no doubt been exacerbated by the stress of the new coronavirus. Finding and ensuring health coverage for pregnant women and children’s mental health services – ones that are appropriate for their developmental stage — can be even more difficult.

The road to comprehensive coverage for behavioral health services has been a long and complicated one, and the work is far from done. The evolving patchwork of public and private health coverage has contributed to uneven access for mental health and substance abuse services. Medicaid has long provided clearer access to such services, thanks to requirements like Early and Periodic Screening, Diagnostic and Treatment (EPSDT).

Mental health parity laws more than a decade old made progress by ensuring insurance plans make behavioral health services accessible at the same levels as physical health care (called “parity”). But this parity standard was only useful if services were covered in the first place. The ACA strengthened this coverage requirement by specifying essential health benefits—including mental health and substance abuse services—for small employer, marketplace, and Medicaid alternative benefit plans. (While most large employers cover such services, federal law requires it.)

The SUPPORT Act, passed in Fall 2018, addressed the remaining public coverage gap: Children’s Health insurance Program (CHIP). Parity laws applied to CHIP, but states could get around the requirement by simply not offering behavioral health services in separate CHIP programs. (CHIP-funded Medicaid expansions for children already met this requirement under EPSDT.)

As of October 24, 2019, separate CHIP programs are now required to provide behavioral health services to children and pregnant women served. In early March, just before the pandemic public health crisis was widespread, CMS released a State Health Official letter (SHO) with direction to states on implementing new requirements in the 2018 SUPPORT ACT. From the SHO:

Section 5022 of the SUPPORT Act specifically requires that child health and pregnancy related assistance “include coverage of mental health services (including behavioral health) necessary to prevent, diagnose, and treat a broad range of mental health symptoms and disorders, including substance use disorders.” The statute also stipulates that these services must be delivered in a culturally and linguistically appropriate manner. It applies to all CHIP eligible populations regardless of the type of coverage (e.g., benchmark coverage) elected by the state under a separate CHIP under section 2103 of the Act.” (p. 1, emphasis added)

The SHO lays out the importance of behavioral health services for children and pregnant women, outlining the types of screenings, preventive services, and treatment states should detail. Notable examples include screenings and treatment for tobacco and opioid abuse, depression, and other mental health and substance abuse services.

How do states start to demonstrate compliance? The SHO specifies on page 9 that every state with a separate CHIP program must submit the State Plan Amendment (SPA) by the end of their current fiscal year that includes the SUPPORT Act effective date of October 24, 2019—for many states this would be June 30.

But is this even a problem? While no one likes the idea of CHIP programs holding out on mental health or substance abuse services, our sense has been that most states already provide mental health services in CHIP, at least to children. But the extent of behavioral health coverage is not clear, since we don’t have a recent, definitive way to know for sure. Our 2014 analysis with NASHP did show some gaps for kids, but not widespread. And it didn’t explicitly look at separate CHIP programs for pregnant women, including those covered under the unborn child option, where more opportunity may exist.

Concern about the added stress on low-income families during the pandemic only exacerbates the need to ensure these services are available to all who need them. This new requirement offers an important opportunity to check in on what children and pregnant women receive in your state. Where does your state CHIP program stand? It’s good time to check.

Elisabeth Wright Burak is a Senior Fellow at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.