By: Sheila Smith, Maribel R. Granja, Elisabeth Wright Burak, Kay Johnson, and Daniel Ferguson; Representing the National Center for Children in Poverty, Georgetown University Center for Children and Families, and Johnson Policy Consulting

Full report available here.

INTRODUCTION

Young children covered by Medicaid are growing up in low-income households and are more likely to experience multiple sources of stress related to financial insecurity.^[i] This report shows how Medicaid infant-early childhood mental health (IECMH)-related policies can be leveraged to offer families with infants and young children equitable access to supports that are essential to children’s healthy development in the early years and beyond.

Medicaid, and its smaller companion, Children’s Health Insurance Program (CHIP), have unparalleled reach to young children and their families. At least three-fourths of low-income children under age 6 rely on Medicaid or CHIP for health coverage.^[ii] The program’s reach to historically marginalized children and families also helps promote health equity: Medicaid is the predominant payer in US births, including 65 percent of births to Black women and 60 percent of births to Hispanic women in 2019.^[iii] More than half of Black, Hispanic, and American Indian or Alaska Native children in the United States are covered by Medicaid or CHIP.^[iv]

This 50-state policy survey asked state Medicaid agency leaders about policies related to screenings and services designed to identify, prevent, and treat infant-early childhood mental health (IECMH) problems. Five states (DE, FL, NE, NH, and WI) did not complete any part of the survey. Select findings are summarized below. The full report, including methodology, state examples, and policy recommendations is available here.

SCREENING

Most states use the Bright Futures Guidelines for preventive care visits, the guidance on children’s preventive services provided by the American Academy of Pediatrics and federal Health Resources and Services Administration. These guidelines include a periodicity schedule that calls for regular child social-emotional screening for children beginning in early infancy and  a series of maternal depression screenings in the first year. The schedule also indicates that a social-emotional screening may include questions about social determinants of health.

The survey asked whether Medicaid provides a supplemental payment for three types of screening: child social-emotional, maternal depression, and social determinants of health screening. Supplemental payments offer one way to incentivize particular screenings. Survey respondents could indicate that they offer a supplemental payment or that the screening is considered part of a well-child visit payment.

Child Social-Emotional Screening

The early identification of possible IECMH problems that may require evaluation and treatment is now widely viewed as a pillar of best practice in pediatrics. Bright Futures calls for regular social-emotional (SE) screens of children in the first five years (separate from broad developmental screens) and the use of validated SE screening tools.

Maternal or Parental Depression Screening

Screening for maternal depression (MD) can help identify mothers or other caregivers who may need further evaluation and treatment to improve the mother’s well-being and to prevent or help address impairment in the mother-child relationship and the child’s mental health and development. In 2016, CMS issued guidance encouraging state Medicaid agencies to promote maternal depression screening and allow billing for this screening under the child’s EPSDT Medicaid benefit. CMS highlighted the benefits of early identification of maternal depression and provision of needed interventions to children, citing this condition’s potential for causing serious, long-lasting harm to children’s development.

Screening for Social Determinants of Health 

Social determinants of health (SDOH), such as severe financial problems and food insecurity, pose a significant risk to parent and child well-being. Recognition that pediatric health care providers can play a role in identifying and addressing social-determinants of health (SDOH) has grown in recent years.^[v]  SDOH, such as housing instability, severe financial hardship, and food insecurity, create family stress and risk of harm to parents’ and children’s health and mental health.^[vi]  The American Academy of Pediatrics added a recommendation to Bright Futures to include questions about SDOH in 2017.

ASSESSMENT AND DIAGNOSIS

Young children stand the best chance of receiving appropriate services and treatment to address their mental health needs when Medicaid policies support effective, developmentally based assessments and diagnostic services. State’s use of the DC:0-5™ (or DC:0-3R) diagnostic system and payment for multiple visits, which can be used for assessment or brief interventions without a diagnosis, are still not universal.

State administrators were asked if their state’s Medicaid policy or guidance “require” or “recommend” the use of DC:0-5™ or DC:0-3R (Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood) for diagnosis of infant and early childhood mental health conditions. The DC:0-5 is the only system designed to provide age-appropriate assessment the mental health of children under age 5.

IECMH TREATMENT OR SERVICES

Parent-Child Dyadic Treatment

Parent-child dyadic treatment seeks to improve very young children’s mental health and strengthen the parent-child relationship.^[vii] In parent-child dyadic treatment, a clinician treats a parent and infant/young child together using methods to reduce mental health and behavior difficulties that include interventions to help the parent respond to the child’s needs and interact with the child in ways that promote a healthy, nurturing parent-child relationship. The survey asked about whether the state’s Medicaid program pays for dyadic treatment (also referred to as family therapy and eligibility criteria for coverage).

IECMH-focused Group Parenting Programs

Group parenting programs can provide both social support and guidance about parenting practices that benefit young children’s development and mental health.^[viii]  Several research-informed parenting programs have been designed to promote close, nurturing parent-child relationships and positive child behavior in the first five years.^[ix]

RECOMMENDATIONS

The survey’s results show that Medicaid policies supporting infants’ and young children’s access to high-quality IECMH services can be found in a growing number of states in every region of the country. Yet, the actual impact of these policies depends on many factors, including a shared understanding among Medicaid leaders and providers about these policies, guidance to foster this understanding, and workforce capacity. The use of payment incentives and data showing the provision of IECMH services may also affect whether and how providers deliver IECMH services. Moreover, many states still have Medicaid policies that fall short of promoting high-quality IECMH screening and services for children 0-6 (e.g., rules that do not recognize payment for certain services or that fail to encourage or require the use of evidence-based services and a developmentally based diagnostic system). Recognizing that Medicaid policy is an important but not sufficient driver of IECMH supports for infants and young children, we offer the following recommendations for using the results presented in this brief.

Use results in stakeholder meetings with cross-sector representatives, including Medicaid, pediatricians and mental health specialists, Part C Early Intervention, Child Welfare, and Home Visiting, to address the following questions:

1. Is there a shared understanding of how Infant-Early Childhood Mental Health (IECMH) services for infants and young children are reimbursed and what criteria qualify a child for coverage (e.g., risk factors, medical necessity)?
2. Are services under the policy available and being used? What information is available about the receipt of services (e.g., rates of social-emotional screening of infants and young children, use of dyadic treatment)?
3. How can implementation be strengthened (e.g., through provisions of managed care contracts, guidance for providers, incentive payments, recommendations to use evidence-based or research-informed models, training and workforce development)? For example, Washington State Health Care Authority developed detailed billing implementation guides on DC:0-5™ and hosts trainings and office hours for Medicaid providers.
4. How can gaps in coverage or policy be addressed? Consider evidence about the benefits of services, examples from other states and leveraging Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) rules.

Strengthen policies to help identify children who may need IECMH services and ensure access to mental health and related services for young children and parents. For example:

• Use guidance and incentives to encourage the use of specialized social-emotional screening tools and standardized parent depression and social-determinants of health screening tools
• Broaden criteria for access to IECMH services beyond a requirement for a child diagnosis; consider child and family risk factors that could qualify a child for IECMH services
• Expand the use of inter-professional IECMH consultation to build providers’ capacity to address IECMH needs and access specialized supports (e.g., diagnostic assessment and treatment)
• Reimburse and provide guidance on preventive services that help ensure the identification of infants and young children in need of IECMH assessment and treatment services, and connect families to supports for mental health and basic needs (e.g., services provided by Healthy Steps, Doulas, and Community Health Workers)

Prioritize IECMH in broader system reform efforts, including improvements in coverage for maternal health care and mental health care, and in payment and delivery systems.    

Medicaid is often at the center of federal and state health reform efforts due to its prominent role as a healthcare payer. National and state-level reforms in the following areas are only a few examples of areas where IECMH should be represented at decision-making tables.

• Maternal health. Federal and state Medicaid leaders have made addressing the persistent maternal health crisis a priority, making changes in Medicaid coverage, benefits, and providers to more effectively reach and serve low-income pregnant and postpartum mothers. States now have the option to extend Medicaid coverage for pregnant women to 12 months postpartum, increased from the previous 60-day cap. With more than half of states implementing extended postpartum coverage, many are identifying new ways to help address postpartum mental health.^[x] The relationship between parent mental health and infant-early childhood mental health and development point to the value of a robust IECMH system that serves postpartum mothers and their infants together.^[xi]
• Mental health. National and state policymakers are actively working on ways to improve access to mental health services for children. Without explicit attention to infants’ and young children’s development, there is a risk that state policies designed to improve access to mental health services will miss opportunities to strengthen prevention and intervention services that support parent-child relationships in the early years that are critical to healthy development and mental health.^[xii]
• Payment or delivery system reforms. Within broad federal rules, states set the parameters for Medicaid reimbursements, including payment rates, qualified service providers, and eligibility rules for receipt of services. With most children served in Medicaid managed care, states should explicitly include IECMH services in the contracts with managed care companies responsible for furnishing health care and making EPSDT work as intended. Without attention to the unique developmental and mental health needs of young children, reforms targeting adults and near-term cost savings may fail to include critical IECMH services that can prevent or lesson the impacts of serious, costly conditions children may experience as they grow older.

Monitor and report on the use and quality of IECMH services.

The capacity of state Medicaid agencies to collect and publish data on providers’ delivery of IECMH-related services is critical to ensuring equitable access to high-quality mental health care for infants and young children. For example, data on rates of child social-emotional and parent depression screening and the provision of services, such as evidence-based dyadic treatment, can show the extent to which preventive care and treatment of young children are being used at expected levels under IECMH policies, or the extent to which they appear to be under-used. Disaggregated data by plan, region, race/ethnicity, or other factors can help states identify gaps in care in specific locations or for sub-groups of families and can inform efforts to improve health equity. Apart from billing data, provider surveys and interviews can be helpful in learning about both the provision of IECMH-related services and the barriers providers face in delivering mental health care to infants and young children. The collection, analysis, and public reporting of data by race/ethnicity is critical to ongoing monitoring and improvement of equitable access to IECMH and related services.

[i] Duncan, G., & Le Menestrel, S. (2019). A roadmap to reducing child poverty. Consensus Study Report. 500 Fifth Street NW, Washington, DC: National Academies Press; Masarik, A. S., & Conger, R. D. (2017). Stress and child development: A review of the family stress model. Current Opinion in Psychology, 13, 85-90.

[ii] Georgetown University Center for Children and Families analysis of US Census Bureau 2021 American Community Survey (ACS) Public Use Microdata Sample (PUMS).

[iii] Kaiser Family Foundation. (2021). Births financed by Medicaid. https://www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/; Martin, J. A., Hamilton, B. E., & Osterman, M. J. K. (2020). Births in the United States, 2019. NCHS DataBrief, 387, 1–8.; National Center for Health Statistics. (2023). Health, United States, 2020–2021: Annual perspective. Hyattsville, Maryland. DOI: https://dx.doi.org/10.15620/cdc:122044

[iv] Guth, M., & Artiga, S. (2022). Medicaid and racial health equity. Kaiser Family Foundation. https://www.kff.org/medicaid/issue-brief/medicaid-and-racial-health-.equity

[v]  Nerlinger, A. L., & Kopsombut, G. (2023). Social determinants of health screening in pediatric healthcare settings. Current Opinion in Pediatrics, 35(1), 14-21.

[vi] Cutts, D. B., Meyers, A. F., Black, M. M., Casey, P. H., Chilton, M., Cook, J. T., ... & Frank, D. A. (2011). US housing insecurity and the health of very young children. American Journal of Public Health, 101(8), 1508-1514.; Johnson, A. D., & Markowitz, A. J. (2018). Food insecurity and family well-being outcomes among households with young children. The Journal of Pediatrics, 196, 275-282.

[vii] Shafi, R. M., Bieber, E. D., Shekunov, J., Croarkin, P. E., & Romanowicz, M. (2019). Evidence based dyadic therapies for 0-to 5-year-old children with emotional and behavioral difficulties. Frontiers in Psychiatry, 10, 677.

[viii] Taylor, Z. E., & Conger, R. D. (2017). Promoting strengths and resilience in single‐mother families. Child Development, 88(2), 350-358.; Morris, A. S., Robinson, L. R., Hays‐Grudo, J., Claussen, A. H., Hartwig, S. A., & Treat, A. E. (2017). Targeting parenting in early childhood: A public health approach to improve outcomes for children living in poverty. Child Development, 88(2), 388-397.

[ix] Webster-Stratton, C., & Reid, M. J. (2018). The Incredible Years parents, teachers, and children training series: A multifaceted treatment approach for young children with conduct problems. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 122–141). The Guilford Press.; National Academies of Sciences, Engineering, and Medicine. (2016). Parenting matters: Supporting parents of children ages 0-8.

[x] Kaiser Family Foundation. (2021). Medicaid postpartum coverage extension tracker.  https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/; Clark, M. (2023). State trends to leverage Medicaid extended postpartum coverage, benefits and payment policies to improve maternal health. Center for Children and Families.  https://ccf.georgetown.edu/2023/03/20/state-trends-to-leverage-medicaid-extended-postpartum-coverage-benefits-and-payment-policies-to-improve-maternal-health/

[xi] Clark, M. & Burak, E.W. (2022). Opportunities to support maternal and child health through Medicaid’s new postpartum coverage Extension. Center for Children and Families. Available at: https://ccf.georgetown.edu/2022/07/15/opportunities-to-support-maternal-and-child-health-through-medicaids-new-postpartum-coverage-extension/

[xii] Burak, E. W., Rolfes-Haase, K. (2018). Using Medicaid to ensure the healthy social and emotional development of infants and toddlers. Center For Children and Families. https://ccf.georgetown.edu/2018/11/21/using-medicaid-to-ensure-the-healthy-social-and-emotional-development-of-infants-and-toddlers/