Key Benefits Under Medicaid and the State Childrens Health Insurance Program (SCHIP) for Children With Mental Health and Substance Abuse Problems

CRS Report for Congress
Key Benefits Under Medicaid and the State
Children’s Health Insurance Program (SCHIP) for
Children With Mental Health and
Substance Abuse Problems
April 21, 2004
Elicia J. Herz
Specialist in Social Legislation
Domestic Social Policy Division


Congressional Research Service ˜ The Library of Congress

Key Benefits Under Medicaid and the State Children’s
Health Insurance Program (SCHIP) for Children With
Mental Health and Substance Abuse Problems
Summary
About 18% of all U.S. adolescents received mental health treatment in 2000.
Almost $7 billion was spent for such services for teens in 1998. While many youth
have used alcohol or other illicit drugs, less than 2% received treatment for substance
use in 2000. In 1997, costs for such care for children under 18 totaled $604 million.
In this report, the availability of selected mental health and substance abuse
services under Medicaid and SCHIP for low and moderate income children is
explored. Under SCHIP, states may provide coverage by expanding Medicaid or
creating a separate SCHIP program or both. Data from two CRS-sponsored surveys,
documenting general limits placed on such services as of June, 2000, are presented.
For Medicaid, including Medicaid expansions under SCHIP, survey results were
reported for all 50 states and the District of Columbia. For separate SCHIP
programs, survey results were reported for all 41 programs operating in 33 states.
Nearly all Medicaid and SCHIP programs covered inpatient and outpatient
mental health services for children, and most also covered inpatient detoxification
and outpatient substance abuse treatment. Such benefits were more frequently
unlimited under Medicaid than under SCHIP. While the majority of Medicaid
programs covered residential treatment centers, most SCHIP programs did not. In
many cases, expressing benefit limits as a simple quantity (e.g., days of care,
admissions per year, visits/hours per year) did not address the full scope of
restrictions on coverage. Other means of limiting benefits were also reported (e.g.,
use of prior authorization, thresholds specific to condition/diagnosis, and treatment
plan requirements). Under SCHIP, but not Medicaid, a single quantity limit was
often applied to two or more related benefits combined rather than separately for each
benefit category.
Coverage policies and benefit limits for children under Medicaid are seldom
absolute in part because of special provisions in the law requiring that children
receive all medically necessary services authorized in federal statute. This guarantee
does not exist in SCHIP. Instead, SCHIP children have access to similar types of
benefit packages available in the private sector.
Facing declining revenues and increased expenses, some states are
implementing a number of Medicaid cost containment strategies focused on
reductions in provider payments, and reductions in and/or elimination of optional
services and populations, mostly affecting adults. Under SCHIP, some states are also
capping enrollment and increasing beneficiary cost-sharing. While these proposed
strategies appear to leave mental health and substance abuse benefits for children
largely intact, they could effectively limit access to care.
Finally, this report also describes mental health parity and its application to
Medicaid and SCHIP under current federal law, and related, pending legislation in
the 108th Congress.



Contents
Background ......................................................2
What are Mental Health And Substance Abuse Services?..............2
The Role of Medicaid and SCHIP.................................3
Medicaid ................................................3
Eligibility for Medicaid.....................................3
Mental Health and Substance Abuse Benefits Under Medicaid......5
SCHIP ......................................................7
Eligibility for SCHIP.......................................7
Mental Health and Substance Abuse Benefits Under SCHIP........7
Scope of Mental Health And Substance Abuse Benefits for Children — A
Snapshot of Selected Medicaid and SCHIP Coverage Policies in FY2000.9
Survey Design and Implementation................................9
General Coverage Policies......................................11
Methods for Limiting Benefits...................................18
Inpatient Mental Health Services.............................18
Outpatient Mental Health Services...........................18
Outpatient Substance Abuse Services.........................19
Inpatient Detoxification....................................19
Residential Treatment Center Services........................19
The Nature of Coverage and Benefit Limits for Children Under Medicaid and
S C HIP ....................................................20
Changes in Benefits Under Medicaid and SCHIP Today..............22
Mental Health Parity..........................................23
Appendix F. Notes and Abbreviations Used in Appendix A Through E......57
List of Tables
Table 1. Coverage of, and Limits for/Monitoring of Inpatient Mental Health
Services for Children Under Medicaid and SCHIP..................13
Table 2. Coverage of, and Limits for/Monitoring of Outpatient Mental
Health Services for Children Under Medicaid and SCHIP ............14
Table 3. Coverage of, and Limits for/Monitoring of Inpatient Detoxification
Services for Children Under Medicaid and SCHIP ..................15
Table 4. Coverage of, and Limits for/Monitoring of Outpatient Substance
Abuse Services for Children Under Medicaid and SCHIP.............16
Table 5. Coverage of, and Limits for/Monitoring of Residential Treatment
Center (RTC) Services for Children under Medicaid and SCHIP.......17
Appendix A. Specified Limits and/or Monitoring of Inpatient Mental
Health Services for Children Under Medicaid and SCHIP.............25
Appendix B. Specified Limits and/or Monitoring of Outpatient Mental
Health Services for Children Under Medicaid and SCHIP.............31
Appendix C. Specified Limits and/or Monitoring of Inpatient
Detoxification Services for Children Under Medicaid and SCHIP.......38



Appendix D. Specified Limits and/or Monitoring of Outpatient Substance
Abuse Services for Children Under Medicaid and SCHIP.............44
Appendix E. Specified Limits and/or Monitoring of Residential Treatment
Center Services for Children Under Medicaid and SCHIP.............51



Key Benefits Under Medicaid and the State
Children’s Health Insurance Program
(SCHIP) for Children With Mental Health
and Substance Abuse Problems
A small, but significant proportion of youth in this country have mental health
problems. Some studies estimate that only about one-fourth of those in need of1
mental health services receive treatment. According to the National Household
Survey on Drug Abuse (NHSDA),2 about 18% of adolescents ages 12 to 17 received
mental health treatment or counseling in 2000. In 1998 (the latest available figures),
the estimated annual expenditures for mental health care delivered to all youth ages
1 to 17 was nearly $12 billion, of which adolescents accounted for almost $7 billion
of that total.3 The majority of these costs were covered by private insurance (48%)
and state and local payers (24%). Medicaid financed almost 19% of these
expenditures.
A relatively large portion of adolescents have experimented with alcohol and
illicit drugs. According to the NHSDA, in 2000, one-third of teenagers reported
using alcohol, and about 21% had used an illicit drug. However, only 4.9% of
adolescents were classified as needing treatment for an illicit drug problem. An even
smaller proportion, just 1.5%, received treatment. Expenditures for substance abuse
services for children under 18 years of age totaled just $604 million nationwide in
19974 which is consistent with the very small proportion of youth who report
receiving treatment for alcohol or illicit drug use. The primary sources of payment
for substance abuse treatment services included family members (35%), private
health insurance (28%), and own savings or earnings (21%). Medicaid covered about


1 The Rand Corporation, Mental Health Care for Youth: Who Gets It? How Much Does It
Cost? Who Pays? Where Does the Money Go? Research Highlights (no date).
2 The annual NHSDA (now known as the National Survey on Drug Use and Health) is the
primary source of information on the use of illicit drugs, alcohol and tobacco by the civilian,
noninstitutionalized population in the United States. It also includes a series of questions
for respondents ages 12 through 17 on their mental health status and use of related services.
See Department of Health and Human Services, Substance Abuse and Mental Health
Services Administration, Office of Applied Studies, Results from the 2001 National
Household Survey on Drug Abuse: Volume III, Sept. 2002.
3 Jeanne Ringel and Roland Sturm, “National Estimates of Mental Health Utilization and
Expenditures for Children in 1998,” Journal of Behavioral Health Services and Research,
vol. 28, no. 3 (2001), pp. 319-333.
4 Henrick Harwood, Tami Mark, David McKusick, Rosanna Coffey, Edward King, and
James Genuardi, “National Spending on Mental Health and Substance Abuse Treatment by
Age of Clients, 1997,” Journal of Behavioral Health Services and Research, (forthcoming).

14% of these costs. SCHIP programs were first implemented in 1998, and thus,


would not have accounted for much of the spending on either mental health or
substance abuse services in the late 1990s.
In this report, the availability of mental health and substance abuse services
offered to low and moderate income children under Medicaid and SCHIP is explored.
Data from two CRS-sponsored state surveys on selected benefits and general limits
placed on the amount, duration and scope of such services is presented.5 Specifically,
this analysis compares the methods states use in their Medicaid versus SCHIP
programs to define the breadth of children’s mental health and substance abuse
services. To provide a context for this discussion, this report also gives a basic
overview of who is eligible for Medicaid and SCHIP. Then mental health and
substance abuse benefits available under each program are described. Differences
in the design and nature of benefits for children under Medicaid and SCHIP are
delineated. Other strategies states use to contain costs under these programs, and
how those strategies may affect access to care apart from setting limits on benefits,
is presented. Finally, mental health parity is discussed.
Background
What are Mental Health And Substance Abuse Services?
Mental health and substance abuse services are designed to ameliorate the
negative effects of mental illness and use of, or addiction to, illicit drugs,
respectively.6 According to the 1999 Surgeon General’s report on mental health,7
mental illness refers to all diagnosable mental disorders, which are conditions
characterized by alterations in thinking, mood or behavior (or combinations thereof).
Among children, for example, attention-deficit/hyperactivity disorder is primarily
marked by alterations in behavior (overactivity) and/or thinking (inability to
concentrate). Depression is characterized by alterations in mood. In general, mental
disorders can lead to distress, impaired functioning in daily life, and increased risk
of pain, disability, death or loss of freedom. Treatment for mental illness is generally
of three types–psychosocial (various types of individual, family and group therapies),
pharmacological (prescription drugs), or a combination of both.
The Surgeon General’s report also describes a patchwork of mental health
services that have come to form a de facto mental health system over the past three
centuries. This system has distinct sectors, two of which are most relevant to the


5 CRS gratefully acknowledges the valuable input of Neva Kaye with the National Academy
for State Health Policy for her extensive assistance in analyzing and interpreting the survey
data presented in this report.
6 This report excludes a discussion of children with mental retardation or developmental
disabilities and the services provided to them.
7 U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon
General, 1999.

purpose of this report — the specialty mental health sector and the general
medical/primary care sector.
Speciality mental health services include services provided by specialized
mental health professionals (e.g., psychologists, psychiatric nurses, psychiatrists, and
psychiatric social workers), expressly for the provision of mental health care. The
general medical/primary care sector consists of health professionals (e.g., family
practitioners, nurse practitioners, internists, pediatricians, etc.) who provide the full
range of medical and health services, including but not exclusively for mental health
care.
Various types of mental health treatment are also defined by their duration and
setting. Duration of care is divided into services for the treatment of acute conditions
versus long-term chronic care. Settings of care include institutional (e.g., hospital,
nursing facility, residential treatment facilities), community-based (e.g., in public and
private schools, services provided by mental health professionals in an office), and
home-based.
While a recent comprehensive analysis of the current system of care for
substance abuse in this country is lacking, the Surgeon General’s description of the
patchwork nature of the mental health care system likely applies in this context as
well. Substance abuse treatment services are generally of two types: (1)
detoxification (i.e., to rid the body of the toxic substance) and medication
management (i.e., to control withdrawal symptoms and drug craving, and to block
the effects of drugs), and (2) education, counseling and rehabilitation. All these
services are designed to reduce or eliminate use of and dependence on alcohol or
illicit drugs, to improve the individual’s ability to function, and to minimize other
medical and social complications of drug abuse.8 Care is provided in both inpatient
and outpatient settings, including community- and home-based services, with varying
levels of intensity in response to the individual’s acute or chronic care needs. And
as with mental health care, there are substance abuse specialty practitioners as well
as general medical/primary care providers that treat individuals with alcohol and drug
problems.
The Role of Medicaid and SCHIP
Medicaid. Medicaid is a federal-state entitlement program that pays for
medical services on behalf of certain low-income individuals. Medicaid provided
access to medical services for 44.3 million people in FY2000 (the latest official
enrollment figure) at a cost to the federal government of $116.9 billion, representing

57% of total program costs, the remainder of which was covered by state and local9


governments. In FY2002, federal payments rose to $146.2 billion.
Eligibility for Medicaid. To qualify for Medicaid, applicants’ income and
resources (also called assets) must be within program financial standards. These


8 See [http://www.nida.nih.gov/infofax/treatmeth.html] for additional information.
9 See CRS Report RS20245, Medicaid: A Fact Sheet, by Jean Hearne.

standards vary considerably among states, and different standards apply to different
population groups within a state. Medicaid eligibility is also subject to categorical
restrictions — generally, it is available only to low-income persons who are aged,
blind, disabled, members of families with dependent children, and certain other
pregnant women and children. In addition, certain individuals within these categories
and with higher income, especially those facing high costs for medical care, may also
be eligible. (This latter group is sometimes referred to as the medically needy; see
below for more details).
The Medicaid statute defines over 50 distinct population groups as potentially
eligible, including those who must be covered and those for whom coverage is
optional. Eligibility groups have traditionally been divided into two classifications
— the “categorically needy” and the “medically needy.” For the purposes of this
report, this distinction is important because the scope of services that states must
provide to categorically needy individuals is much broader than that required for the
medically needy.
In addition to financial requirements, for some eligibility groups, disability
status is also considered. For example, the mandatory categorically needy coverage
group of recipients of Supplemental Security Income (SSI)10 requires the presence of
a disability. For children, the SSI disability criteria are defined by types of functional
impairments affecting daily life and may include mental illness. Substance abuse is
not considered to be a disability for SSI purposes, and hence, for Medicaid.
Examples of other major mandatory categorically needy groups relevant to
children and for which no disability criteria apply include: (1) members of families
who meet the requirements of the former Aid to Families with Dependent Children
(AFDC) program as in effect on July 16, 1996, (2) pregnant women and children
under six years of age living in families with income up to 133% of the federal
poverty level (FPL),11 and (3) children ages 6 to 19 living in families with income up
to 100% of the FPL. Children with mental illness and/or substance abuse problems
may qualify for coverage under these latter groups if the financial criteria, which in
some cases are more generous than the SSI pathway into Medicaid, are met.
The medically needy are persons who fit the definition of a categorical group
(e.g., they are aged, disabled, children or members of families), but who do not meet
applicable income and/or resource standards. States may establish higher income and
resource standards for the medically needy.12 Also, such persons may “spend down”
to the medically needy income standard by incurring medical expenses. That is, net
income after subtracting medical expenses is used to determine eligibility.


10 SSI is a means-tested federal cash assistance program for persons who are aged or with
disabilities that meet certain criteria. The income standard for an individual is about 74%
of the federal poverty level (FPL) and the resource standard is $2,000.
11 100% of the FPL is equal to $15,260 and 133% of the FPL is equal to $20,256 for a
family of three in 2003.
12 The income standard for medically needy coverage can be up to one-third higher than the
state-specific AFDC standards as of July 16, 1996. The median level for the AFDC standard
is roughly 44% of the FPL across states.

States have the option of covering the medically needy, and if they choose to do
so, they must include children under 18 who would qualify under a mandatory
categorically needy group, and pregnant women who would qualify under a
mandatory or optional categorically needy group, except that their income and/or
resources are too high. States may also offer medically needy coverage to otherwise
ineligible individuals under 21 who meet the applicable financial criteria. States may
cover all such individuals or reasonable subclassifications (e.g., those in publically
subsidized foster care or adoptions, those receiving active treatment as inpatients in
psychiatric facilities or programs). In 2002, 36 states had medically needy
programs. 13
There were 24.2 million children under the age of 21 enrolled in Medicaid in
FY2000 (the latest official enrollment information), accounting for nearly 55% of the
total Medicaid population nationwide. Total Medicaid expenditures for these
children was $38.5 billion, representing 22.9% of all Medicaid spending in that year.
Mental Health and Substance Abuse Benefits Under Medicaid. As
with eligibility, some benefits under Medicaid are mandatory and others may be
covered at state option. Some categories of service, by virtue of their label, have an
obvious connection to mental health care or substance abuse treatment, while others
do not.
The mandatory benefits relevant to children that all states must offer to their
categorically needy groups, and that are likely to or may include mental health and
substance abuse services, are:
!inpatient hospital services (other than in an institution for mental
diseases or IMD),14
!outpatient hospital services,
!rural health clinic services,
!federally-qualified health center services,
!early and periodic screening, diagnosis and treatment (EPSDT) for
persons under age 21 years (more on this benefit below),
!physician services (e.g., psychiatrists), and
!home health services for persons entitled to nursing facility care.
The EPSDT program provides screening and preventive care to nearly all groups
of Medicaid beneficiaries under 21 years old, as well as services necessary to correct
a health problem identified through screening, including mental illness and substance
abuse as well as conditions caused by drug use or addiction. That is (with the


13 Centers for Medicare and Medicaid Services, Medicaid At-A-Glance, 2002, Publication
No. CMS-11024-02, (no date).
14 An IMD is a hospital, nursing facility or other institution of more than 16 beds that is
primarily engaged in diagnosis and treatment of persons with mental disease, including
medical attention, nursing care, and related services. Medicaid statute includes two optional
IMD benefits, one for individuals age 65 years and older residing in an IMD, and one
covering inpatient psychiatric services for persons under age 21 years (see text for further
information).

exceptions noted below), states are required to provide all federally-allowed
treatment to correct identified problems, even if the specific treatment needed is not
otherwise covered under a state’s Medicaid plan. Thus, states may be required to
cover some services for children that would be optional or not covered at all for
adults. EPSDT is not a mandatory benefit for the medically needy, although states
may choose to make this benefit available to this group.
There are a wide variety of optional Medicaid benefits relevant to children
which states may offer to their categorically needy groups that could include mental
health and substance abuse services. These are:
!medical care provided by other licensed practitioners (e.g.,
psychologists, social workers),
!other clinic services,
!prescribed drugs,
!other diagnostic, screening, preventive, and rehabilitative services
for the maximum reduction of physical or mental disability and
restoration to the best possible functional level,
!inpatient psychiatric services for persons under age 21 years
(including psychiatric residential treatment facilities15), and
!case management services.16
States that cover the medically needy may offer a more restricted set of benefits
to these individuals than is offered to the categorically needy. For medically needy
beneficiaries, at a minimum, states must cover the following benefits that may
include mental health and substance abuse services:
!ambulatory services for those under 18 and persons entitled to
institutional services, and
!home health services for persons entitled to nursing facility care.
There are additional benefit requirements for those states that cover IMD
services (see footnote 14) or services in intermediate care facilities for the mentally
retarded (ICF/MR)17 for any group of medically needy beneficiaries. In these cases,


15 Psychiatric residential treatment facilities (or centers) are non-hospital settings that
provide a wide range of mental health services to children and adolescents with severe
mental illness who require a residential environment offering 24-hour care, but for whom
the acute nature of their condition does not warrant more intensive hospitalization. Services
may include psychosocial therapy, behavior management, substance abuse counseling, and
medication management. Length of stay may be brief (e.g., one month) or long-term (e.g.,
one year).
16 Case management includes services which assist eligible individuals with access to, and
coordination of, needed medical, social, educational and other services. If states choose to
provide targeted case management services, they must specify the applicable “target group”
which can defined in terms of age, type or degree of disability, illness or condition (e.g.,
chronic mental illness) or any other identifiable characteristic or combination thereof.
17 An ICF/MR is a facility (or a distinct part of a facility such as a wing, floor, or building)
(continued...)

states must cover either the mandatory services available to the categorically needy
(except services provided by pediatric and family nurse practitioners), or
alternatively, any seven categories of care and services listed in Medicaid law
defining covered benefits. Again, such coverage may include mental health care and
substance abuse treatment.
Finally, states may apply for waivers of program rules to establish special
programs to accommodate unique needs. Many states have such waivers which can
be statewide or limited to certain geographic areas. Such programs may include
coverage for mental health care and substance abuse services. Three states —
Kansas, New York and Vermont — have waivers specifically to provide special
services to children with severe mental illness. Some of the services offered under
these waivers include caregiver training and respite care, crisis intervention and
support, independent living skills training, and case management. The number of
children served under these waiver programs is small (roughly 1,200 in Kansas in

2002, 375 in New York in 2000, and 240 in Vermont in 2001).


SCHIP
SCHIP was established in 1997, and provides health insurance to certain
uninsured children in families with modest income. A total of $39.7 billion has been
appropriated for SCHIP for FY1998 through FY2007. Approximately 5.3 million
children were enrolled in SCHIP during FY2002. Nationally, through June 2003,
$12.5 billion in federal funds had been spent under the program.
Eligibility for SCHIP. In general, SCHIP allows states to cover uninsured
children under age 19 in families with incomes that are above applicable Medicaid
financial standards.
States can define the group of children who may enroll in SCHIP. The law
allows states to use the following factors in determining eligibility: geography, age,
income and resources, residency, disability status, access to other health insurance,
and duration of SCHIP enrollment. Children who are eligible for Medicaid or are
covered by a group health plan or other insurance are not eligible for SCHIP.
As of FY2002, the upper income eligibility limit under SCHIP had reached
350% FPL (in one state). Nearly one-half (24) of the states and the District of
Columbia had established upper income limits at 200% FPL. Another 13 states
exceeded 200% FPL. The remaining 13 states set maximum income limits below

200% FPL.


Mental Health and Substance Abuse Benefits Under SCHIP. The
SCHIP statute defines child health assistance to include a wide range of coverable
benefits. As with Medicaid, some categories of service, by virtue of their label, have
an obvious connection to mental health care and substance abuse treatment, while


17 (...continued)
that provides health and rehabilitation services to residents with mental retardation or related
conditions.

others do not. The categories of service that may include mental health care and
substance abuse treatment are:
!inpatient hospital services,
!outpatient hospital services,
!physician services,
!clinic services (including health center services) and other
ambulatory health care services,
!prescription drugs,
!inpatient mental health services,
!outpatient mental health services,
!home and community-based health care services and related
supportive services,
!nursing care services (e.g., psychiatric nurse practitioner)
!inpatient substance abuse treatment services,
!outpatient substance abuse treatment services,
!case management services,
!care coordination services,
!any other medical, diagnostic, screening, preventive, restorative,
remedial, therapeutic, or rehabilitative services (if recognized by
state law, and prescribed, furnished or supervised by a physician or
other licensed practitioner or state- or local-government operated
health care facility), and
!any other health care services or items.
Under SCHIP, states do not simply select among these benefits in establishing
what is and is not covered. Rather, states choose from three options when designing
their SCHIP programs. They may expand their current Medicaid program, create a
new “separate state” program, or devise a combination of both approaches. These
program level choices determine the package of benefits offered. All 50 states, the
District of Columbia, and five territories have SCHIP programs in operation. As of
August, 2003, 19 had Medicaid expansions, 19 had separate state programs, and 18
used a combination approach.18
States that choose to expand Medicaid to new eligibles under SCHIP authority
must provide the full range of mandatory Medicaid benefits for the categorically
needy, as well as all optional services covered. Alternatively, states deciding to use
a separate state program may choose any of three other benefit options: (1) a
benchmark benefit package, (2) benchmark equivalent coverage, or (3) any other
benefits plan that the Secretary of Health and Human Services determines will
provide appropriate coverage to beneficiaries. The option chosen determines the set
of covered benefits under separate SCHIP programs.
A benchmark benefit package is one of the following three plans: (1) the
standard Blue Cross/Blue Shield preferred provider option offered under the Federal
Employees Health Benefits Program (FEHBP), (2) the health coverage that is offered


18 Some states classified as “separate state program states” have more than one such
program.

and generally available to state employees in the state involved, and (3) the health
coverage that is offered by a health maintenance organization (HMO) with the largest
commercial (non-Medicaid) enrollment in the state involved.
Benchmark equivalent coverage is defined as a package of benefits that has the
same actuarial value as one of the benchmark benefit packages. A state choosing to
provide benchmark equivalent coverage must cover each of the benefits in the “basic
benefits category.” The benefits in the basic benefits category are inpatient and
outpatient hospital services, physicians’ surgical and medical services, lab and x-ray
services, and well-baby and well-child care, including age-appropriate
immunizations. Benchmark equivalent coverage must also include at least 75% of
the actuarial value of coverage under the benchmark plan for each of the benefits in
the “additional service category.” These additional services include prescription
drugs, mental health services, vision services, and hearing services.
Finally, as with Medicaid, states may apply for waivers of program rules to
establish demonstration projects to accommodate unique needs. Currently, only a
few states have such waivers under SCHIP. While none of these waivers specifically
focus on mental health or substance abuse benefits, they may provide access to such
services.
Scope of Mental Health And Substance Abuse
Benefits for Children — A Snapshot of Selected
Medicaid and SCHIP Coverage Policies in FY2000
In this section, a description of the state survey data collection instruments and
implementation issues is provided, followed by important data caveats that affect
interpretation of the survey findings presented in the subsequent section.
Survey Design and Implementation
In 2000, the Congressional Research Service (CRS) contracted with the National
Academy for State Health Policy (NASHP) to collect data from Medicaid and SCHIP
state agencies on limits placed on selected benefits for children under each program.
Two parallel survey instruments19 were developed with extensive input from state
officials, one for Medicaid programs and one for separate state SCHIP programs.
The benefits data collected from these surveys represent general program policies
as of June 2000.


19 These surveys covered other topics in addition to benefits for children. In the Medicaid
survey, detailed data were also collected on eligibility rules and the extent and scope of
managed care activities for all Medicaid populations. The SCHIP survey covered many
other major aspects of program policy (e.g., eligibility rules, administrative services,
outreach activities, employer-sponsored insurance, healthcare marketplace, public input
methods, coordination with other state agencies, managed care policies, cost-sharing, and
crowd-out prevention). For information on results from these other survey components, go
to [http://www.nashp.org].

For each benefit category listed on the survey, respondents indicated the amount
of each service children could receive without special permission, that is, before prior
authorization20 was required. If there was no point at which prior authorization for
continued services was necessary, the benefit was identified as unlimited. State
officials could also indicate that limits for a specific benefit were absolute, meaning
that children could not receive more than the specified amounts even with prior
authorization.
For Medicaid, survey results were reported for all 50 states and the District of
Columbia. For SCHIP, survey results were reported for 41 separate programs in 33
states, representing the universe of such states and programs in June, 2000. Two
states (California and New Jersey) had two SCHIP programs with different benefit
plans, and three states (Connecticut, Florida, and Massachusetts) each had three
SCHIP programs with different benefit plans.
Because there was limited space available on the two survey instruments for
questions on coverage of and limitations placed on benefits, only five general mental
health and substance abuse service categories were included. These were inpatient
mental health services, outpatient mental health services, inpatient detoxification
services, outpatient substance abuse services, and residential treatment center (RTC)
services.
There is no direct one-to-one correspondence between each of the five service
categories included on the surveys and a single coverable benefit listed in Medicaid
statute. This is in part due to the fact that many of the benefit categories listed in
Medicaid statute identify a type of provider rather than a type of service. For
example, a wide variety of providers can deliver outpatient mental health and
substance abuse services. Under Medicaid, the benefit categories listed in statute
under which such care is most likely covered include outpatient hospital services,
rural health and federally qualified health center services (providers that deliver
primary medical services and mental health care), physician services (e.g.,
psychiatrists), other practitioner services (e.g., psychologists, social workers), and
other clinic services (e.g., community mental health centers and other specialty
mental health or substance abuse clinics). Inpatient mental health services and
inpatient detoxification are most likely covered as inpatient hospital services or
inpatient psychiatric services for persons under age 21. Such care is typically
delivered in general acute care hospitals with distinct psychiatric care wings or
designated psychiatric beds, or in psychiatric hospitals. Residential treatment centers


20 Prior authorization, also referred to as precertification or preadmission screening, means
that an entity other than a provider (e.g., state Medicaid agency, fiscal agent, or other
contractor) must approve the delivery of a specific service to a specific beneficiary or the
Medicaid agency will not reimburse the provider for that service. Examples of other
common utilization controls include: (1) concurrent review, which means an authorized
entity (e.g., state Medicaid agency, or a contractor) reviews services while they are being
provided to a given beneficiary; for example, hospital stays may be subject to concurrent
review when they exceed a specified length of stay, and (2) utilization review which is a
generic term encompassing all reviews of service provision, whether they happen
prospectively, concurrently, or retrospectively.

are typically covered as inpatient psychiatric services for persons under 21, or under
the rehabilitative services option.
In general, the coverable benefits listed in SCHIP statute are more closely
aligned to the service categories included on the surveys. However, there is not an
obvious, single benefit category listed in SCHIP statute that would encompass
residential treatment centers. Several could apply here (e.g., inpatient mental health
services, inpatient substance abuse services, rehabilitative services).
In sum, each of the five categories of service used in the surveys likely
corresponds to multiple benefits listed in both Medicaid and SCHIP statute. This is
an important problem for the survey design because very different limits may apply
to “outpatient mental health services,” as used on the surveys, when delivered as a
“physician service” versus an “other clinic service,” for example. For this reason, the
survey data are imprecise. Therefore, the results from the two surveys represent
general, statewide benefit limit policies for broad classifications of mental health and
substance abuse services for children under each program.
Overall, the value of the survey data presented here is not in the specific,
detailed responses that each state agency provided on benefit limits for each service
category. To further complicate the picture, both Medicaid and SCHIP programs rely
on managed care organizations (MCOs) to deliver services to most beneficiaries
(described further below). Detailed data on variations in benefit limits specific to
individual managed care contracts under each state program, which can differ from
the general criteria delineated in state plans as reported here, were not captured.
Also, states may have changed coverage policies since June, 2000 (the point in time
represented by the survey data), especially during the past few years as they began to
face growing state budget constraints and rapidly rising Medicaid costs. Instead, the
importance of these survey results lies in the identification of the different methods
states use in their Medicaid versus SCHIP programs to define the breadth of these
services for children. Also, these survey data serve as a baseline documenting
general coverage policies in place during a strong economic period when many states
were expanding their Medicaid and SCHIP programs.
General Coverage Policies
For each of the five mental health and substance abuse benefit categories
included in the CRS-sponsored surveys, Tables 1 through 5 provide a summary of
whether the service is covered, and general information about service limits and
monitoring activities for Medicaid and separate SCHIP programs across states.
As of June 2000, nearly all Medicaid and SCHIP programs covered inpatient
and outpatient mental health services for children. When covered, proportionally
more Medicaid programs (about one-third) than SCHIP programs (about one-fourth)
reported that inpatient and outpatient mental health benefits for children were
unlimited.
Most Medicaid and SCHIP programs also covered inpatient detoxification and
outpatient substance abuse services for children. Roughly one-third of Medicaid and
SCHIP programs that offered inpatient detoxification services indicated that this



benefit was unlimited. In contrast, with respect to outpatient substance abuse
services for children, about 40% of Medicaid programs covering such care identified
this benefit as unlimited, compared to approximately 22% of SCHIP programs.
The biggest discrepancies in general coverage between Medicaid and SCHIP
programs was for RTCs. Among SCHIP programs, 44% did not make RTC services
available. In contrast, only one-fourth of Medicaid programs indicated that RTC
services were not covered.
It is no surprise that SCHIP programs often exclude RTC services since this
kind of benefit is not typically available in commercial insurance products. It is more
noteworthy that some SCHIP programs do provide access to RTC services.



Table 1. Coverage of, and Limits for/Monitoring of
Inpatient Mental Health Services for Children
Under Medicaid and SCHIP
(as of June, 2000)
Medicaid (51 programs ina
50 states and DC)SCHIP
Program classifications(41 programs in 33 states)bCN onlyCN+MN
Programs that do not cover002 – CT-B and CT-C
inpatient mental health
services
Programs with unlimited3 – MO, OH,15 – AR,10 – FL-B, FL-C, IL, MA-A,
inpatient mental healthORCA, DC, IA,MA-C, ME, MI, OR, VA,
servicesIL, KS, MA,WA
ME, NJ, NY,
PA, TX, UT,
WA, WI
Programs with specified13 – AK,20 – CT, FL,28 – AL, AZ, CA-A, CA-B,
limits and/or monitoring ofAL, AZ, CO,GA, HI, KY,CO, CT-A, DE, FL-A, GA,
inpatient mental healthDE, ID, IN,LA, MD, MI,IA, IN, KS, KY, MA-B, MT,
servicesMS, NM,MN, MT,NC, ND, NH, NJ-A, NJ-B,
NV, SC, SD,NC, ND,NV, NY, PA, TX, UT, VT,
WYNE, NH,WV, WY
OK, RI, TN,
VA, VT,
WV
Programs for which limits001 MS
were not specified
Source: Congressional Research Service (CRS) analysis of benefits data collected in two 2000
surveys, one for state Medicaid programs and the other for separate state SCHIP programs, conducted
by the National Academy for State Health Policy under contract to CRS. State abbreviations are used
in this table.
a. In the Medicaid column, the sub-column labeledCN only”means that coverage, limitations and
monitoring of inpatient mental health services apply only to beneficiaries classified as
categorically needy, and the sub-column labeled “CN+MN” means that coverage, limitations
and monitoring of such services apply to both categorically needy and medically needy
beneficiaries.
As of Oct. 2000, 36 states had medically needy programs that covered at least some groups
under Medicaid. These 36 states may be shown in either the “CN Only” or the “CN+MN” sub-
columns, depending on benefit coverage policies for categorically needy versus medically needy
beneficiaries. Those states WITHOUT medically needy programs were AK, AL, AZ, CO, DE,
ID, IN, MO, MS, NM, NV, OH, SC, SD, and WY. These 15 states are always listed in the “CN
Only” sub-column.
b. In the SCHIP column, 28 states had a single separate SCHIP program represented by the state
abbreviation. The remaining five states with separate SCHIP programs each had more than one
such program with different benefit plans. Two states (California and New Jersey) each had two
separate SCHIP programs. In this case, an A or B extension was added to the state abbreviation
to distinguish these programs (e.g., CA-A, CA-B). Three states (Connecticut, Florida, and
Massachusetts) each had three separate SCHIP programs. In this case, an A, B, or C extension
was added to the state abbreviation to distinguish these multiple programs (e.g., CT-A, CT-B,
CT -C) .



Table 2. Coverage of, and Limits for/Monitoring of Outpatient
Mental Health Services for Children Under Medicaid and SCHIP
(as of June, 2000)
Medicaid (51 programs ina
50 states and DC)
SCH IP b
Program characteristics(41 programs in 33 states)CN onlyCN+MN
Programs that do not cover001 CT-B
outpatient mental health
services
Programs with unlimited3 – MO, OH,14 – CA, IL,9 – FL-B, FL-C, IL, KY,
outpatient mental healthSCKS, KY, LA,MA-A, MA-C, MI, OR, WY
servicesMD, MI,
ND, OR, PA,
RI, UT, WA,
WV
Programs with specified12 – AK,22 – AR,28 – AL, AZ, CA-A, CA-B,
limits and/or monitoring ofAL, AZ, CO,CT, DC, FL,CO, DE, FL-A, GA, IA, IN,
outpatient mental healthDE, ID, IN,GA, HI, IA,KS, MA-B, ME, MT, NC,
servicesMS, NM,MA, ME,ND, NH, NJ-A, NJ-B, NV,
NV, SD, WYMN, MT,NY, PA, TX, UT, VA, VT,
NC, NE,WA, WV
NH, NJ, NY,
OK, TN, TX,
VA, VT, WI
Programs for which limits003 – CT-A, CT-C, MS
were not specified
Source: Congressional Research Service (CRS) analysis of benefits data collected in two 2000
surveys, one for state Medicaid programs and the other for separate state SCHIP programs, conducted
by the National Academy for State Health Policy under contract to CRS. State abbreviations are used
in this table.
a. In the Medicaid column, the sub-column labeledCN only”means that coverage, limitations and
monitoring of inpatient mental health services apply only to beneficiaries classified as
categorically needy, and the sub-column labeled “CN+MN” means that coverage, limitations
and monitoring of such services apply to both categorically needy and medically needy
beneficiaries.
As of Oct. 2000, 36 states had medically needy programs that covered at least some groups
under Medicaid. These 36 states may be shown in either the “CN Only” or the CN+MN” sub-
columns, depending on benefit coverage policies for categorically needy versus medically needy
beneficiaries. Those states WITHOUT medically needy programs were AK, AL, AZ, CO, DE,
ID, IN, MO, MS, NM, NV, OH, SC, SD, and WY. These 15 states are always listed in the “CN
Only” sub-column.
b. In the SCHIP column, 28 states had a single separate SCHIP program represented by the state
abbreviation. The remaining five states with separate SCHIP programs each had more than one
such program with different benefit plans. Two states (California and New Jersey) each had two
separate SCHIP programs. In this case, an A or B extension was added to the state abbreviation
to distinguish these programs (e.g., CA-A, CA-B). Three states (Connecticut, Florida, and
Massachusetts) each had three separate SCHIP programs. In this case, an A, B, or C extension
was added to the state abbreviation to distinguish these multiple programs (e.g., CT-A, CT-B,
CT -C) .



Table 3. Coverage of, and Limits for/Monitoring of Inpatient
Detoxification Services for Children Under Medicaid and SCHIP
(as of June, 2000)
Medicaid (51 programs ina
50 states and DC)
SCH IP b
Program classification(41 programs in 33 states)CN OnlyCN+MN
Programs that do not cover2 – ID, MS6 – AR, GA, 4 – CT-B, CT-C, WA, WY
inpatient detoxificationLA, NH, TX,
services WA
Programs with unlimited2 – OH, OR12–CA, CT,11 – FL-B, FL-C, IL, MA-A,
inpatient detoxificationIA, IL, KS,MA-B, MA-C, ME, MI, MT,
servicesME, MI, NJ,NH, OR
NY, OK,
PA, WI
Programs with specified12 – AK,17 – DC, FL,24 – AL, AZ, CA-A, CA-B,
limits and/or monitoring ofAL, AZ, CO,HI, KY, MA,CO, CT-A, DE, FL-A, GA,
inpatient detoxificationDE, IN, MO,MD, MN,IA, IN, KS, KY, NC, ND,
servicesNM, NV,MT, NC,NJ-A, NJ-B, NV, PA, TX,
SC, SD, WYND, NE, RI, UT, VA, VT, WV
TN, UT, VA,
VT, WV
Programs for which limits002 – MS, NY
were not specified
Source: Congressional Research Service (CRS) analysis of benefits data collected in two 2000
surveys, one for state Medicaid programs and the other for separate state SCHIP programs, conducted
by the National Academy for State Health Policy under contract to CRS. State abbreviations are used
in this table.
a. In the Medicaid column, the sub-column labeledCN only”means that coverage, limitations and
monitoring of inpatient mental health services apply only to beneficiaries classified as
categorically needy, and the sub-column labeled CN+MN” means that coverage, limitations
and monitoring of such services apply to both categorically needy and medically needy
beneficiaries.
As of Oct. 2000, 36 states had medically needy programs that covered at least some groups
under Medicaid. These 36 states may be shown in either the “CN Only” or the “CN+MN” sub-
columns, depending on benefit coverage policies for categorically needy versus medically needy
beneficiaries. Those states WITHOUT medically needy programs were AK, AL, AZ, CO, DE,
ID, IN, MO, MS, NM, NV, OH, SC, SD, and WY. These 15 states are always listed in the CN
Only” sub-column.
b. In the SCHIP column, 28 states had a single separate SCHIP program represented by the state
abbreviation. The remaining five states with separate SCHIP programs each had more than one
such program with different benefit plans. Two states (California and New Jersey) each had two
separate SCHIP programs. In this case, an A or B extension was added to the state abbreviation
to distinguish these programs (e.g., CA-A, CA-B). Three states (Connecticut, Florida, and
Massachusetts) each had three separate SCHIP programs. In this case, an A, B, or C extension
was added to the state abbreviation to distinguish these multiple programs (e.g., CT-A, CT-B,
CT -C) .



Table 4. Coverage of, and Limits for/Monitoring of
Outpatient Substance Abuse Services for Children
Under Medicaid and SCHIP
(as of June, 2000)
Medicaid (51 programs ina
50 states and DC)SCHIP
Program characteristics(41 programs in 33 states)bCN OnlyCN+MN
Programs that do not cover3 – CO, ID,3 – AR, TX,1 – CT-B
outpatient substance abuseSDVA
services
Programs with unlimited4 – IN, MO,14 – CA, IL,9 – FL-B, FL-C, IL, MA-A,
outpatient substance abuseMS, OHKS, LA,MA-C, MI, OR, WA, WY
servicesMD, MI,
MT, ND,
OR, PA, RI,
UT, WA,
WV
Programs with specified8 – AK, AL,19 – CT,28 – AL, AZ, CA-A, CA-B,
limits and/or monitoring ofAZ, DE,DC, FL, GA,CO, DE, FL-A, GA, IA, IN,
outpatient substance abuseNM, NV,HI, IA, KY,KS, KY, MA-B, ME, MT,
servicesSC, WYMA, ME,NC, ND, NH, NJ-A, NJ-B,
MN, NC,NV, NY, PA, TX, UT, VA,
NE, NH, NJ,VT, WV
NY, OK,
TN, VT, WI
Programs for which limits003 – CT-A, CT-C, MS
were not specified
Source: Congressional Research Service (CRS) analysis of benefits data collected in two 2000
surveys, one for state Medicaid programs and the other for separate state SCHIP programs, conducted
by the National Academy for State Health Policy under contract to CRS. State abbreviations are used
in this table.
a. In the Medicaid column, the sub-column labeledCN only”means that coverage, limitations and
monitoring of inpatient mental health services apply only to beneficiaries classified as
categorically needy, and the sub-column labeled CN+MN” means that coverage, limitations
and monitoring of such services apply to both categorically needy and medically needy
beneficiaries.
As of Oct. 2000, 36 states had medically needy programs that covered at least some groups
under Medicaid. These 36 states may be shown in either the CN Only” or the “CN+MN” sub-
columns, depending on benefit coverage policies for categorically needy versus medically needy
beneficiaries. Those states WITHOUT medically needy programs were AK, AL, AZ, CO, DE,
ID, IN, MO, MS, NM, NV, OH, SC, SD, and WY. These 15 states are always listed in the “CN
Only” sub-column.
b. In the SCHIP column, 28 states had a single separate SCHIP program represented by the state
abbreviation. The remaining five states with separate SCHIP programs each had more than one
such program with different benefit plans. Two states (California and New Jersey) each had two
separate SCHIP programs. In this case, an A or B extension was added to the state abbreviation
to distinguish these programs (e.g., CA-A, CA-B). Three states (Connecticut, Florida, and
Massachusetts) each had three separate SCHIP programs. In this case, an A, B, or C extension
was added to the state abbreviation to distinguish these multiple programs (e.g., CT-A, CT-B,
CT -C) .



Table 5. Coverage of, and Limits for/Monitoring of
Residential Treatment Center (RTC) Services for
Children under Medicaid and SCHIP
(as of June, 2000)
Medicaid (51 programs ina
50 states and DC)
SCH IP b
Program classifications(41 programs in 33 states)CN onlyCN+MN
Programs that do not cover5 – AL, ID,8 – FL, HI, 18 – AZ, CA-A, CA-B, CO,
RTC servicesIN, OH, WYIA, LA, NH,CT-A, CT-B, CT-C, FL-B,
TX, UT, WIFL-C, IA, IN, MA-A, MA-B,
MA-C, NH, NJ-B, WA, WY
Programs with unlimited1 – OR10 – AR,4 – IL, ME, MI, OR
RTC servicesCA, IL, KS,
MD, ME,
NJ, NY, PA,
WA
Programs with specified10 – AK,16 – CT,18 – AL, DE, FL-A, GA, KS,
limits and/or monitoring ofAZ, CO, DE, GA, KY,KY, MT, NC, ND, NJ-A,
RTC servicesMO, MS,MA, MI,NV, NY, PA, TX, UT, VA,
NM, NV, MN, MT,VT, WV
SC, SD NC, ND,
NE, OK, RI,
TN, VA, VT,
WV
Programs for which limits01 – DC1 – MS
were not specified
Source: Congressional Research Service (CRS) analysis of benefits data collected in two 2000
surveys, one for state Medicaid programs and the other for separate state SCHIP programs, conducted
by the National Academy for State Health Policy under contract to CRS. State abbreviations are used
in this table.
a. In the Medicaid column, the sub-column labeledCN only”means that coverage, limitations and
monitoring of inpatient mental health services apply only to beneficiaries classified as
categorically needy, and the sub-column labeled “CN+MN” means that coverage, limitations
and monitoring of such services apply to both categorically needy and medically needy
beneficiaries.
As of Oct. 2000, 36 states had medically needy programs that covered at least some groups
under Medicaid. These 36 states may be shown in either the “CN Only” or the CN+MN” sub-
columns, depending on benefit coverage policies for categorically needy versus medically needy
beneficiaries. Those states WITHOUT medically needy programs were AK, AL, AZ, CO, DE,
ID, IN, MO, MS, NM, NV, OH, SC, SD, and WY. These 15 states are always listed in the “CN
Only” sub-column.
b. In the SCHIP column, 28 states had a single separate SCHIP program represented by the state
abbreviation. The remaining five states with separate SCHIP programs each had more than one
such program with different benefit plans. Two states (California and New Jersey) each had two
separate SCHIP programs. In this case, an A or B extension was added to the state abbreviation
to distinguish these programs (e.g., CA-A, CA-B). Three states (Connecticut, Florida, and
Massachusetts) each had three separate SCHIP programs. In this case, an A, B, or C extension
was added to the state abbreviation to distinguish these multiple programs (e.g., CT-A, CT-B,
CT -C) .



Methods for Limiting Benefits
For each of the five mental health and substance abuse benefit categories,
Appendices A through E provide information on the specific limits and monitoring
activities identified by states for their Medicaid and SCHIP programs (when
applicable) as of June, 2000. The methods for limiting benefits are summarized
below.
Inpatient Mental Health Services. With respect to limits on inpatient21
mental health services under Medicaid, many states (23 of 51) reported using prior
authorization or other types of review only. A few states specified other kinds of
limits in addition to or in lieu of prior authorization or other review, usually in the
form of a quantity limit on the number of inpatient mental health days per year or per
admission.
In contrast, few separate SCHIP programs relied exclusively on prior
authorization or other review only for inpatient mental health services. Nearly one-
half of these programs (17 of 39) indicated that specific quantity limits applied to
inpatient mental health services. Some of these programs (9 of 17) set a single
overall quantity limit, usually expressed in terms of days per year, on inpatient mental
health services in combination with other related benefits, such as inpatient substance
abuse treatment or other residential care, and in some cases, outpatient mental health
and/or substance abuse services, or partial hospitalization programs.22 This practice
of applying a single quantity limit to a combination of related services may facilitate
the tailoring of benefits to ever changing individual needs, especially for persons with
both mental health and substance abuse problems, while at the same time controlling
utilization, and hence costs, for services that tend to be expensive.
For several programs (8 of 39), state respondents highlighted that quantity limits
for inpatient mental health care varied by managed care organization, while others
established thresholds that varied by type of provider (e.g., general acute care versus
psychiatric hospitals; 3 of 39) or beneficiary diagnosis or condition (e.g., unlimited
care only for children with severe emotional disturbances enrolled in a behavioral
health plan; 1 of 39).
Outpatient Mental Health Services. Other types of thresholds were used
by states to define the breadth of outpatient mental health services. Under Medicaid,
a few states (4 of 51) reported that dollar-based limits were used. More often, other
non-dollar quantity limits applied, expressed in units or hours of service, or in visits,
typically per year (14 of 51). In a few cases, limits varied by type of outpatient
mental health service (e.g., individual versus group versus family therapy; 2 of 51)


21 In this section, counts in parentheses are derived from Appendices A through E and
represent the number of programs with the identified limitation compared to the total
number of programs that covered the benefit in question. Appendix F provides a definition
of abbreviations used in the other appendices.
22 For example, the limit may be defined as a total of 21 days per year for all inpatient
mental health and substance abuse treatment, for which 2 partial hospitalization program
days may be substituted (exchanged) for one inpatient day.

or by whether the provider was a physician versus other practitioner (4 of 51). A few
states (4 of 51) required an initial evaluation and development of a treatment plan for
each beneficiary which would determine what the Medicaid agency would pay for on
behalf of such individuals.
In general, the types of limits placed on outpatient mental health services under
SCHIP were similiar to those under Medicaid. Non-dollar quantity limits were
applied in over one-half of separate SCHIP programs (22 of 40). In several cases (6
of 40), a single overall quantity limit for outpatient mental health services, in
combination with related benefits, was used. Few programs (2 of 40) used dollar-
based limits. And a handful of programs had provider-specific, type of service-
specific or condition-specific restrictions on outpatient mental health services (4 of

40).


Outpatient Substance Abuse Services. In general, under both Medicaid
and SCHIP, the methods used to limit outpatient substance abuse services were
similar to those used to define restrictions on outpatient mental health care (see
above).
Inpatient Detoxification. The immediate purpose of hospitalizations for
detoxification is to rid the body of the toxic substance. Under Medicaid, one-half of
the states (22 of 43) used prior authorization or other types of review to monitor such
care. In a few cases (3 of 43), day limits for inpatient detoxification tended to be
short (e.g., three to five days) probably reflecting per admission/episode limits.
Otherwise, such stays were treated in the same way as any other acute care
hospitalization, and thus, overall quantity limits (typically expressed as total
admissions and/or total inpatient days per year) on general inpatient acute care
applied.
Limits placed on inpatient detoxification services under SCHIP were somewhat
different from those reported for Medicaid. For example, only three programs relied
solely on prior authorization or other review for this benefit. One-fourth of these
programs (9 of 37) used day limits per year or benefit period for such care. Some set
a single quantity limit for inpatient detoxification services in combination with other
related benefits (4 of 37). A few (3 of 37) also specified lifetime limits (e.g.,
expressed as total dollars or admissions per lifetime) on inpatient detoxification
services.
Residential Treatment Center Services. RTCs are rapidly replacing23
hospitals in treating children with psychiatric disorders. In many state Medicaid
programs (19 of 38), prior authorization or other types of reviews accompany
admissions to RTCs for children. When quantity limits were specified, they tended
to be day limits per admission or episode (4 of 38).


23 Health Care Financing Administration, “Medicaid Program; Use of Restraint and
Seclusion in Psychiatric Residential Treatment Facilities Providing Psychiatric Services to
Individuals Under Age 21; Final Rule,” 66 Federal Register 7148, Jan. 22, 2001.

As reported above, under SCHIP, most programs did not cover RTC services
at all. Among those which did, most (9 of 23) reported day limits per admission,
episode, year or benefit period. As with many of the other services included in the
CRS-sponsored surveys, some SCHIP programs (5 of 23) established a single
quantity limit applicable to RTC services in combination with other related
institutional and outpatient treatments for mental illness and/or substance abuse.
The Nature of Coverage and Benefit Limits for
Children Under Medicaid and SCHIP
Comparing benefit limits under Medicaid and SCHIP must be done with care
because the term “limits” does not have the same meaning across these two
programs. This difference in the meaning of “limits” has implications for both the
relative breadth or scope of care available under each program as well as efforts to
collect uniform, comparable data on benefit restrictions.
In addition to defining the amount, duration and scope of all covered services,
states also elect the service delivery systems under which benefits are made available
to Medicaid and SCHIP beneficiaries. There are two primary service delivery
systems under each program: fee-for-service (FFS) and managed care. Generally,
under FFS, state Medicaid and SCHIP agencies monitor and control all service
delivery. In contrast, under managed care, MCOs under contract to states monitor
and control all service delivery. These two systems of care are not entirely
independent of each other. There are hybrid models across states that combine
various features of FFS and managed care for a given population or set of interrelated
services. At any given point in time, beneficiaries may obtain all their services
under a single system or different sets of services under both systems simultaneously.
Under Medicaid, specific limits on benefits have grown out of the fee-for-
service environment in which Medicaid began. State Medicaid agencies determine
which optional services will be covered, and set limits on both mandatory and
optional services. Such agencies also establish other utilization controls (e.g., prior
authorization) to ensure that beneficiaries do not receive services they do not need
or in amounts greater than that needed to serve their medical purpose. Providers
receive payments from the state based on rates established by the state for a given
benefit or type of provider.
Under FFS, health care providers must obtain special permission or approval
from the state to continue delivery of medically necessary services beyond the pre-
defined, standard upper limit set by the state for a given benefit. For example, a state
Medicaid plan may limit coverage of outpatient mental health services to 24 visits
per year. But children who need more than 24 such visits in a year can obtain
additional visits, as long as the provider of care demonstrates the medical necessity
for more visits. Stated limits on benefits reflect what providers can generally expect
to be paid for in the absence of official clearance for more services, rather than
definitive limits on what beneficiaries may receive. The fee-for-service delivery
system is generally used by individuals whose Medicaid eligibility group (e.g., the
aged and individuals with disabilities) or geographic location (e.g., rural areas) is not



served through managed care, or for persons who opt out when managed care is
voluntary.
Most Medicaid children without disabilities receive services in the managed
care setting. Under this system of care, state Medicaid agencies negotiate different
benefit plans with one or more contracted managed care organizations (MCOs).
MCOs may be commercial plans (e.g., Kaiser Permanente) that serve private sector
beneficiaries as well as Medicaid and/or SCHIP enrollees. In some cases, states also
contract with Medicaid-only plans. State Medicaid agencies generally pay each
MCO a fixed, prospectively determined, monthly fee for each beneficiary enrolled.
In turn, the MCOs establish networks of participating providers to deliver the agreed-
upon covered services and pay those providers negotiated rates. Benefit plans may
be comprehensive or limited in scope (e.g., behavioral health services only, also
referred to as “carve out” plans). There are likely to be variations in coverage of, and
limits placed on, specific benefits across Medicaid managed care plans within a given
state. Managed care plans also employ utilization controls to monitor service
delivery and to insure that benefits provided are medically necessary (similar to the
point at which prior authorization begins in the fee-for-service delivery system in
Medicaid).
Even though most Medicaid programs provide services through managed care
plans, especially for children without disabilities and families, most states continue
to operate significant, parallel fee-for-service programs. Under a Medicaid managed
care plan, if benefit limits are met by a Medicaid child and additional services are
medically necessary beyond the contractual agreement between the MCO and the
Medicaid agency, additional funding may be provided to the MCO for extended
services, or that child may continue to receive such services in the fee-for-service
setting.
Coverage policies and benefit limits described in state Medicaid plans are
seldom absolute, especially for children, due to the medical necessity criterion, but
also because of EPSDT. Under both fee-for-service and managed care, for nearly all
Medicaid children, states are required to provide all federally-allowed treatment to
correct identified problems, even if the specific treatment needed is not otherwise
covered under a state’s Medicaid plan. As a result, when a Medicaid agency reports
that a specific benefit is not covered for children, that means the service is only
available when delivery of that service meets the EPSDT requirement. In these
circumstances, providers typically go through a prior authorization process to receive
payment for what are sometimes called “EPSDT extended benefits.”
Unlike Medicaid, but consistent with federal statute, separate SCHIP programs
are modeled after private sector, commercial insurance products. The requirement
to use benchmark plans (or actuarial equivalents of those plans), most of which are
state employee health plans or commercial HMO plans, provides the framework for
defining benefit limits.
Under SCHIP, managed care is the predominant service delivery system. At the
time of the CRS-sponsored survey (June, 2000), all but five SCHIP programs
(Alabama, North Carolina, North Dakota, West Virginia, and Wyoming) contracted
with one or more managed care or indemnity plans to deliver care to SCHIP children.



California contracted with 23 comprehensive health plans. Some states also use a
FFS delivery system. Under commercial insurance products, benefits are always
limited by medical necessity, but other limits, when applicable, vary by insurance
product, as do the points at which each insurer monitors service delivery for medical
need and appropriateness. Payments to providers participating in these plans may be
altered based on the outcome of such service utilization reviews, which can in turn
affect access to care.
In the CRS-sponsored survey, some of the benefits for which data on limits were
collected (i.e., residential treatment centers) are commonly covered under Medicaid,
but not routinely included in commercial insurance products, and hence, SCHIP.
There is no federal EPSDT requirement under SCHIP that would guarantee the
availability of uncommon, but coverable benefits.
In sum, a small, but significant proportion of children have mental health
problems. Some also suffer from the consequences of substance abuse. Medicaid
and SCHIP provide access to an array of inpatient and outpatient services that can
help such children in low to moderate income families overcome these difficulties.
However, the breadth of benefits available under these two programs likely differs
within and across states. Limits on benefits for the lowest income children under
Medicaid are seldom absolute, while restrictions on services for higher income
children under SCHIP may be. SCHIP children have access to the same types of
benefit packages available in the private sector as intended by Congress.
Changes in Benefits Under Medicaid and SCHIP Today
Given the recent economic downturn, some members of Congress and
advocates for children have raised concerns about the elimination or reduction in
benefits under state health care programs. On average, Medicaid expenditures
account for approximately 12% of the state funded portion of state budgets. Much
of the recent increases in costs have been attributed to pharmaceuticals, nursing
home, community-based long-term care services, and payments to managed care
plans. However, enrollment increases have also contributed to significant growth in
Medicaid costs in the past few years.
Faced with declining revenues and increasing expenses, states proposed or
implemented a number of Medicaid cost containment strategies for fiscal years 2003
and 2004.24 The majority of changes have focused on prescription drug costs
followed by reductions in provider reimbursement rates, and the elimination or
reduction in optional services and populations. Examples of such actions include
eliminating coverage for certain adults and non-custodial parents, and eliminating
dental, chiropractic, optometry and podiatry services. In addition, many states are
delaying or rescinding plans for expansions of services.
Some states are also facing problematic enrollment growth and limited revenues
in their SCHIP programs. About one-third of states have either implemented cost


24 National Association of State Budget Officers, Medicaid and Other State Healthcare
Issues: Current Trends, June, 2003.

containment measures in their SCHIP programs in FY2003 or plan to do so in
FY2004. Examples of such activities include eliminating dental care for adults
without children (under SCHIP waiver programs), reducing payments for providers,
capping enrollment and increasing beneficiary cost-sharing requirements. In some
states, cost containment activities under Medicaid, such as reducing pharmacy
reimbursement rates and increasing prior authorization for pharmaceuticals, carry
over to SCHIP.
Detailed state-level information on explicit plans to reduce benefits for children
under either program is not available. While the cost containment strategies
summarized above appear to leave mental health and substance abuse benefits for
children largely intact, these actions may still effectively reduce access to such care
in the near term.
Mental Health Parity
Finally, what about mental health parity?25 While the CRS-sponsored surveys
described in this report do not address this question, mental health parity is a leading
policy issue for the mental health community and providers, as well as lawmakers.
In 1996, Congress enacted the Mental Health Parity Act (MHPA), which
established new federal standards for mental health coverage offered by group health
plans. The MHPA, however, is limited in scope and does not compel group plans to
offer full-parity mental health coverage. It requires group plans that choose to
provide mental health benefits to adopt the same annual and lifetime dollar limits on
their coverage of mental and physical illnesses. Group plans may still impose more
restrictive treatment limitations and cost sharing requirements on their mental health
coverage. MHPA specifically excludes treatment of substance abuse and chemical
dependency from the definition of mental health benefits.
Both Medicaid managed care plans and SCHIP programs must comply with the
MHPA. Specifically, all prepaid Medicaid managed care contracts that cover
medical/surgical benefits and mental health benefits must comply with MHPA
without exemptions. The MHPA does not apply to fee-for-service arrangements
because state Medicaid agencies do not meet the definition of a group health plan.26
In separate SCHIP programs, to the extent that a health insurance issuer offers group
health insurance coverage, which can include, but is not limited to managed care, the
MHPA applies.
Congress has reauthorized the MHPA through December 31, 2004. Lawmakers
introduced full-parity legislation in the 107th Congress, but it failed to pass. The
legislation, which has been reintroduced in the 108th Congress (S. 486/H.R. 953),
would expand the MHPA by requiring group health plans to impose the same
treatment limitations and financial requirements on their mental health coverage as


25 For a detailed discussion of this issue, see CRS Report RL31657, Mental Health Parity,
by C. Stephen Redhead.
26 Health Care Financing Administration (now called the Centers for Medicare and Medicaid
Services), letter to State Medicaid Directors on mental health parity, Jan. 20, 1998.

they do on their medical and surgical coverage. The bills are strongly supported by
advocates for the mentally ill and have broad, bipartisan support in Congress.
Employers and health insurance organizations oppose full-parity legislation because
of concerns that it will drive up costs. As with the MHPA, both Medicaid managed
care plans and SCHIP programs would have to comply with the full-parity provisions
in S. 486/H.R. 953.



CRS-25
Appendix A. Specified Limits and/or Monitoring of Inpatient Mental Health Services for
Children Under Medicaid and SCHIP
(as of June, 2000)
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimits combined
CoveredPA or otherquantityconditionPA or otherquantity with otherProvider, service
sgroupsreviewlimitslimitsProgramsreviewlimitsbenefit(s)or condition limits
CN onlyxAKN/A
CN only> age 1 yr,No limits <ALVaries by MCO
16 days perage 1 yr
iki/CRS-RL32362 CY
g/w
s.orCN+MN U nlimited AR N /A
leakCN onlyVaries byAZ30 days/yr
://wikiMCO; no FFScombined for MH and SA
httptreatment
CN+MNUnlimitedCA-A30 daysVaries by MCO
CA-B10 daysVaries by MCO
CN onlyxCO45 days
CN+ M N Asse ssme nt CT -A sp e c i fi c
(no PA) thenconditions have
treatmentmax 60 days
follows planexchangeable
of carewith alternative
levels of care
CT-BNot Covered



CRS-26
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimits combined
CoveredPA or otherquantityconditionPA or otherquantity with otherProvider, service
sgroupsreviewlimitslimitsProgramsreviewlimitsbenefit(s)or condition limits
CT-CNot Covered
CN+MN U nlimited D C N /A
CN only30 daysCovered inDE30 daysCovered in MC
MC onlyonly
CN+MNxFL-A30 days or 20/10
split with
iki/CRS-RL32362residential care
g/w
s.or FL-B Unlimited
leak FL-C Unlimited
://wikiCN+MNx (non-GA30 days per admit
httpemerg)only for short-term
acute care in
general hospital
CN+MNx30 days perHIN/A
year
CN+MNUnlimitedIA60 days perVaries by MCO
year
CN onlyxIDN/A
CN+MN U nlimited I L U nlimited
CN onlyxINNo coverage for
IMDs with > 16
beds



CRS-27
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimits combined
CoveredPA or otherquantityconditionPA or otherquantity with otherProvider, service
sgroupsreviewlimitslimitsProgramsreviewlimitsbenefit(s)or condition limits
CN+MNUnlimitedKSVaries by MCO
CN+MN x KY x
CN + M N x LA N / A
CN+MN MA-A Unlimited
MA-B unlimited -ge ne r a l
iki/CRS-RL32362Unlimitedhospital; 60 daysper yr-psych
g/whospital; varies by
s.or MCO
leak
://wiki MA-C Unlimited
httpCN+MNx (non-MD
emerg. N/A
ad mits)
CN+MN U nlimited M E U nlimited
CN+MN30 days perMIUnlimited
admit
CN+MN x MN N/A
CN onlyUnlimitedMON/A
CN onlyx45 days perMSNot Reported


admit

CRS-28
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimits combined
CoveredPA or otherquantityconditionPA or otherquantity with otherProvider, service
sgroupsreviewlimitslimitsProgramsreviewlimitsbenefit(s)or condition limits
CN+MNxMT21 days/yrno IP limits for
combined for MHchildren with
and SA treatment;severe emotional
can exchange onedisturbances under
IP day for twoMH PHP
partial hosp. days
CN+MN x NC x
iki/CRS-RL32362CN+MNxNDx60 days per
g/w benefit
s.orperiod; 45
leakmay be used
fo r
://wiki psychiatric
http services
CN+MNxprior EPSDTNE
screen N/A
requir ed
CN+MNxpaymentsNH15 days per
limited toCY
me d ically
necessary
days
CN+MNNJ-AUnlimited in
general; varies by
Unlimited MCO
NJ-B35 days/yrVaries by MCO



CRS-29
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimits combined
CoveredPA or otherquantityconditionPA or otherquantity with otherProvider, service
sgroupsreviewlimitslimitsProgramsreviewlimitsbenefit(s)or condition limits
CN onlyx (FFSNMN/A
ad mits)
CN onlyxNVUnlimited in
general; varies by
MCO
CN+MNNY30 days/yr
combined for IP
iki/CRS-RL32362UnlimitedMH, RTC and IP
g/wSA treatment
s.or
leakCN onlyUnlimitedOHN/A
://wikiCN+MN x OK N/A
httpCN onlyUnlimitedORUnlimited
CN+MNPA90 days/yr
Unlimitedcombined for IPMH and acute
care IP
CN + M N x RI N / A
CN onlyxSCN/A
CN onlyx (non-SD
emerg. N/A
ad mits)
CN+MNvaries byNo FFSTNN/A


MCO

CRS-30
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimits combined
CoveredPA or otherquantityconditionPA or otherquantity with otherProvider, service
sgroupsreviewlimitslimitsProgramsreviewlimitsbenefit(s)or condition limits
CN+MNTX45 days/yr;
Unlimitedincludes ICF/MR
services
CN+MNUT30 days/yr
Unlimitedcombined for IPand OP MH, RTC
and SA treatment
iki/CRS-RL32362CN +MN x VA Unlimited
g/w
s.orCN+MNx (after 14VTx (after 14
leakdays; PA forall out-of-days; PA forall out-of-
://wikistate admits)state admits)
httpA CN+MN U nlimited W A U nlimited
I CN+MN U nlimited W I N /A
CN+MNxWV60 visits
including partial
hosp and day
treatme nt
programs
CN onlyxWYx
Congressional Research Service (CRS) analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs and the other for separate state SCHIP
rams, conducted by the National Academy for State Health Policy under contract to CRS.
See Appendix F for definition of abbreviations used here.



CRS-31
Appendix B. Specified Limits and/or Monitoring of Outpatient Mental Health Services for
Children Under Medicaid and SCHIP
(as of June, 2000)
Medicaid SCH IP
Provider,
RequiresGeneralRequiresGeneralservice orLimits
CoveredPA or otherquantityProvider or servicePA or otherquantityconditioncombined with
sgroupsreviewlimitstype limitsProgramsreviewlimitslimitsother benefit(s)
CN onlyx (treatmentAll services must beAKN/A
plan)in care plan
CN only3-4 hrs perAL20 visits per
iki/CRS-RL32362day; 260 hrsyear
g/wper year
s.or
leakCN+MN$2,500 perARN/A
year
://wikiCN onlyVaries by MCO; noAZ30 days per year
httpFFSfor MH and SA
treatme nt
CN+MNCA-A20 visits perVaries by
year MCO
Unlimited
CA-BVaries by
MCO
CN onlyRegional MH/SACO20 visitsneurobio-
PHP decides medicallogical
necessityillnesses not
subject to this
limit



CRS-32
Medicaid SCH IP
Provider,
RequiresGeneralRequiresGeneralservice orLimits
CoveredPA or otherquantityProvider or servicePA or otherquantityconditioncombined with
sgroupsreviewlimitstype limitsProgramsreviewlimitslimitsother benefit(s)
CN+MNAssessment (no PA);CT-ANot Reported
then services as
defined in care planCT-BNot Covered
CT-CNot Reported
CN+MN x DC N/A
CN only30 units covered in MC onlyDE30 units covered in MC
iki/CRS-RL32362 only
g/wCN+MNVaries by serviceFL-A40 visits per
s.or typ e year
leak
FL-B Unlimited
://wiki
http FL-C Unlimited
CN+MN24 hours perGApsychologist -
year24 hrs;
psychiatrist -
12 hrs
CN+MNx24 visits perHIN/A
year
CN+MNStatewide BHOIA20 visits perVaries by
year MCO
CN only12 hours perIDN/A
year
CN+MN U nlimited I L U nlimited



CRS-33
Medicaid SCH IP
Provider,
RequiresGeneralRequiresGeneralservice orLimits
CoveredPA or otherquantityProvider or servicePA or otherquantityconditioncombined with
sgroupsreviewlimitstype limitsProgramsreviewlimitslimitsother benefit(s)
CN onlyx (servicesINx (after 3050 visits per
exceedingvisits peryear
20 units peryear)
year)
CN+MNUnlimitedKSVaries by
MCO
CN+MN U nlimited K Y U nlimited
iki/CRS-RL32362
g/wCN+MN U nlimited LA N /A
s.orCN+MN B HO MA-A Unlimited
leak
://wikiMA-B20 visits or$500 perVaries byMCO
http year
MA-C Unlimited
CN+MN U nlimited M D N /A
ECN+MN2 hoursME2 hours
therapy pertherapy per
week (unlessweek (unless
emerg) emerg)
CN+MN U nlimited M I U nlimited
CN+MN160 hoursMNN/A
per year
CN onlyUnlimitedMON/A



CRS-34
Medicaid SCH IP
Provider,
RequiresGeneralRequiresGeneralservice orLimits
CoveredPA or otherquantityProvider or servicePA or otherquantityconditioncombined with
sgroupsreviewlimitstype limitsProgramsreviewlimitslimitsother benefit(s)
CN onlymed eval 144 unitsMS
per year; individual
therapy 144 units per
year; family therapyNot Reported
96 units per year;
group therapy 160
units per year (unit =
15 mins.)
iki/CRS-RL32362CN+MNxMTNo IP limit for21 days per year
g/wchildren withfor all MH and
s.orsevereSA treatment
leak emo tio na l
disturbances in
://wikiMH PHP
httpCN+MN26 visits perNo limits if mentalNCx (after 26
year withouthealth centervisits per
PA year)
CN+MNND30 hrs per
Unlimited benefit
period
CN+MNx (group1 eval perannual eval required;NE
therapy)episodemust have EPSDT
screen beforeN/A


services given; only
services in care plan
covered

CRS-35
Medicaid SCH IP
Provider,
RequiresGeneralRequiresGeneralservice orLimits
CoveredPA or otherquantityProvider or servicePA or otherquantityconditioncombined with
sgroupsreviewlimitstype limitsProgramsreviewlimitslimitsother benefit(s)
CN+MN$1,800 per12 visits if non-MDNH20 visits/yr
yearprovidercombined for
OP MH and OP
SA
CN+MNxNJ-Aunlimited in
general; varies
by MCO
iki/CRS-RL32362NJ-B20 visits perVaries by
g/w year MCO
s.or
leakCN onlyxNMN/A
://wikiCN onlypsychologist orpsychiatrist onlyNVunlimited ingeneral; varies
httpby MCO
CN+MN40 visits perNY60 days/yr for
yearOP MH and OP
SA treatment
CN onlyUnlimitedOHN/A
CN+MNx (evals afterst1st eval (no PA)OK
1 and treat-N/A
me n t )
CN+MN U nlimited O R U nlimited
CN+MNUnlimitedPA50 visits per
year



CRS-36
Medicaid SCH IP
Provider,
RequiresGeneralRequiresGeneralservice orLimits
CoveredPA or otherquantityProvider or servicePA or otherquantityconditioncombined with
sgroupsreviewlimitstype limitsProgramsreviewlimitslimitsother benefit(s)
CN+MN U nlimited RI N /A
CN onlyUnlimitedSCN/A
CN only40 hours perSDN/A
year
CN+MNVaries byNo FFSTNN/A
MCO
iki/CRS-RL32362CN+MN30 visitsTX60 visits per
g/wyear for crisis;
s.or60 days per
leakyear per
://wikidiagnosis forrehab
http
CN+MNUT30 days/yr for IP
Unlimitedand OP MH,RTC and SA
treatme nt
CN+MN26 visits perVA26 visits (no
year (no PA)PA)
CN+MN$500 beforeVT$500 before
autho r i- autho r i-
zatio n zatio n
needed needed



CRS-37
Medicaid SCH IP
Provider,
RequiresGeneralRequiresGeneralservice orLimits
CoveredPA or otherquantityProvider or servicePA or otherquantityconditioncombined with
sgroupsreviewlimitstype limitsProgramsreviewlimitslimitsother benefit(s)
CN+MNWACan self-Psyc testing as
refer toneeded if
Re gio na l problem
Supportidentified by
UnlimitedNetworksEPSDT screen;
(paid FFS)no limits on
or obtain 12med
hrs/yr inmanagement
iki/CRS-RL32362 plan
g/wCN+MN15 hours orWIN/A
s.or $500
leak
CN+MNWV60 visits
://wikiUnlimitedincluding day
http programs
YCN onlycommunity MHWYUnlimited
centers only
Congressional Research Service (CRS) analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs and the other for separate state SCHIP
rams, conducted by the National Academy for State Health Policy under contract to CRS.
See Appendix F for definition of abbreviations used here.



CRS-38
Appendix C. Specified Limits and/or Monitoring of Inpatient Detoxification Services for
Children Under Medicaid and SCHIP
(as of June, 2000)
Medicaid SCH IP
Provider,
RequiresService, orRequiresGeneralLimits combinedProvider, service,
CoveredPA or otherGeneralConditionPA or otherquantitywith otheror condition
sgroupsreviewquantity limitsLimitsProgramsreviewlimitsbenefit(s)limits
CN onlyxAKN/A
CN onlyNo limits <AL3 days per
age 1 yr;episode; 20
iki/CRS-RL32362 > age 1 yr,days per
g/w16 days/yryear
s.or counted
leakagainst 16
days/yr IP
://wiki limit
httpNot CoveredARN/A
CN onlyVaries byAZ30 days/yracute care only
MCO; no FFScombined for MH
and SA treatment
CN+MNCA-AVaries by MCO
Unlimited
CA-BVaries by MCO
CN only40 daysCO3 daysmedical detox only
CN+MNCT-AMH parity
Unlimited
CT-BNot Covered



CRS-39
Medicaid SCH IP
Provider,
RequiresService, orRequiresGeneralLimits combinedProvider, service,
CoveredPA or otherGeneralConditionPA or otherquantitywith otheror condition
sgroupsreviewquantity limitsLimitsProgramsreviewlimitsbenefit(s)limits
CT-CNot Covered
CN+MNCovers onlyDC
removal ofN/A
toxic matter
CN only30 daysCoveredDE30 daysCovered under MC
under MConly
only
iki/CRS-RL32362
g/wCN+MNxFL-A7 days
s.or FL-B Unlimited
leak
://wiki FL-C Unlimited
httpNot CoveredGAshort-term, acute
care only
CN+MNx (non-10 days perHI
emerge.admit; 30 daysN/A
admits)per year
CN+MNIA$9,000 per year;Varies by MCO
Unlimited$39,000 perlifetime for both IP
and OP care
Not CoveredIDN/A
CN+MN U nlimited I L U nlimited



CRS-40
Medicaid SCH IP
Provider,
RequiresService, orRequiresGeneralLimits combinedProvider, service,
CoveredPA or otherGeneralConditionPA or otherquantitywith otheror condition
sgroupsreviewquantity limitsLimitsProgramsreviewlimitsbenefit(s)limits
CN onlyxINexcludes IMDs >
16 beds
CN+MNUnlimitedKSVaries by MCO
CN+MNxKYAcute phase of
medical detox only
Not CoveredLAN/A
iki/CRS-RL32362CN+MNBHO MA-AUnlimited
g/w
s.orMA-Bunlimited in
leakgeneral; varies by
://wiki MCO
http MA-C Unlimited
CN+MNx (non-MD
emerg. N/A
ad mits)
CN+MN U nlimited M E U nlimited
CN+MN U nlimited M I U nlimited
CN+MN x MN N/A
CN onlyx (for 4+3 daysMON/A
days)
Not CoveredMSNot Reported



CRS-41
Medicaid SCH IP
Provider,
RequiresService, orRequiresGeneralLimits combinedProvider, service,
CoveredPA or otherGeneralConditionPA or otherquantitywith otheror condition
sgroupsreviewquantity limitsLimitsProgramsreviewlimitsbenefit(s)limits
CN+MNx (for 5+4 daysMTUnlimited
days)
CN+MNxonly inNCx
ge ne r a l
ho sp ital
CN+MNxND5 days per
ad mit;
iki/CRS-RL32362 counted
g/wagainst IP
s.or limit
leakCN+MNx (staysNE
://wikilonger than5 days)N/A
http
Not CoveredNHUnlimited
CN+MNNJ-AUnlimited in
general; varies by
Unlimited MCO
NJ-BVaries by MCO
CN onlyx (FFSNMN/A
ad mits)
CN onlyxNVUnlimited in
general; varies by
MCO



CRS-42
Medicaid SCH IP
Provider,
RequiresService, orRequiresGeneralLimits combinedProvider, service,
CoveredPA or otherGeneralConditionPA or otherquantitywith otheror condition
sgroupsreviewquantity limitsLimitsProgramsreviewlimitsbenefit(s)limits
CN+MNUnlimitedNYNot Reported
CN onlyUnlimitedOHN/A
CN+MN U nlimited O K N /A
CN onlyUnlimitedORUnlimited
CN+MNPA7 days per
iki/CRS-RL32362Unlimitedadmit; 4admits per
g/w lifetime
s.or
leakCN + M N x RI N / A
://wikiCN onlyxSCN/A
http
CN onlyx (non-SD
emerg. N/A
ad mits)
CN+MNvaries byNo FFSTNN/A
MCO
TX14 days per year
Not Coveredfor detox and crisis
stab ilizatio n
CN+MN3 days perUT30 days per year
episodecombined for IP
detox, plus IP and
OP MH, RTC and
SA treatment



CRS-43
Medicaid SCH IP
Provider,
RequiresService, orRequiresGeneralLimits combinedProvider, service,
CoveredPA or otherGeneralConditionPA or otherquantitywith otheror condition
sgroupsreviewquantity limitsLimitsProgramsreviewlimitsbenefit(s)limits
CN+MNxVAfor pregnant
women, 1 course
of treatment per
lifetime
CN+MNx (after 14VTx (after 14
days) days)
ANot CoveredWANot Covered
iki/CRS-RL32362
g/wI CN+MN U nlimited W I N /A
s.orCN+MN x WV x
leak
://wikiCN onlyxWYNot Covered
http Congressional Research Service (CRS) analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs and the other for separate state SCHIP
rams, conducted by the National Academy for State Health Policy under contract to CRS.
See Appendix F for definition of abbreviations used here.



CRS-44
Appendix D. Specified Limits and/or Monitoring of Outpatient Substance Abuse Services for
Children Under Medicaid and SCHIP
(as of June, 2000)
Medicaid SCH IP
Provider, Provider, Limi t s
Requires PAGeneralservice, orRequires PAGeneralservice, orcombined
Coveredor otherquantityconditionor otherquantityconditionwith other
s groups review limit s limit s P ro g r a ms review limit s limit s benefit(s)
CN onlyx (treatmentAll servicesAK
plan)must be in
care plan;N/A
extend if
iki/CRS-RL32362 me d ically
g/w necessary
s.or
leakCN only6 hours perAL20 visits per
day; 1,040year
://wikihours per year
httpNot CoveredARN/A
CN onlyvaries byAZ30 days per
MCO; no FFSyear for MH
and SA
treatme nt
CN+MNCA-A20 visits perVaries by
year MCO
Unlimited
CA-BVaries by
MCO
Not CoveredCO20 visits



CRS-45
Medicaid SCH IP
Provider, Provider, Limi t s
Requires PAGeneralservice, orRequires PAGeneralservice, orcombined
Coveredor otherquantityconditionor otherquantityconditionwith other
s groups review limit s limit s P ro g r a ms review limit s limit s benefit(s)
CN+MNAssessmentCT-ANot Reported
(no PA);
services asCT-BNot Covered
specified in
care planCT-CNot Reported
CN+MN x DC N/A
CN only30 unitscovered inDE30 unitscovered in
iki/CRS-RL32362MC onlyMC only
g/w
s.orCN+MNdepends onFL-A40 visits per
leakspecific typeof serviceyear
://wiki FL-B Unlimited
http FL-C Unlimited
CN+MNxGASome services
covered; some
limits
CN+MNx24 visits perHIN/A
year
CN+MNstatewideIA$1,500 for$39,000
BHOtreatment;lifetime limit
$2,500 forfor IP and OP
c o unse l i ng; services


varies by
MCO

CRS-46
Medicaid SCH IP
Provider, Provider, Limi t s
Requires PAGeneralservice, orRequires PAGeneralservice, orcombined
Coveredor otherquantityconditionor otherquantityconditionwith other
s groups review limit s limit s P ro g r a ms review limit s limit s benefit(s)
Not CoveredIDN/A
CN+MN U nlimited I L U nlimited
CN onlyUnlimitedINx (after 3050 visits per
visits per year)year
CN+MNUnlimitedKSVaries by
MCO
iki/CRS-RL32362CN+MNxonly forKYonly for those
g/w p r e gna nt with
s.orwomen andconcurrent
leakthose withMH disorder
://wikiconcurrentMH disorder
http
CN+MN U nlimited LA N /A
CN+MN B HO MA-A Unlimited
MA-B20 visits orVaries by
$500 per yearMCO
MA-C Unlimited
CN+MN U nlimited M D N /A
ECN+MNthree hoursMEthree hours
therapy perper week
week
CN+MN U nlimited M I U nlimited



CRS-47
Medicaid SCH IP
Provider, Provider, Limi t s
Requires PAGeneralservice, orRequires PAGeneralservice, orcombined
Coveredor otherquantityconditionor otherquantityconditionwith other
s groups review limit s limit s P ro g r a ms review limit s limit s benefit(s)
CN+MNcovered onlyMN
t hr o ugh N/A
special fund
CN onlyUnlimitedMON/A
CN onlyUnlimitedMSNot Reported
CN+MNMT21 days per
iki/CRS-RL32362Unlimitedyear for MH
g/wand SA
s.or services
leakCN+MNxNCx (after 26
://wiki vi sits/yr )
httpCN+MNUnlimitedND20 visits per
benefit period
CN+MNx (group1 eval perannual evalNE
therapy)episoderequired; must
have EPSDT
screen beforeN/A


services given;
only services
in care plan
covered

CRS-48
Medicaid SCH IP
Provider, Provider, Limi t s
Requires PAGeneralservice, orRequires PAGeneralservice, orcombined
Coveredor otherquantityconditionor otherquantityconditionwith other
s groups review limit s limit s P ro g r a ms review limit s limit s benefit(s)
CN+MN$1,800 per12 visits ifNH20 visits/yr
yearnon-MDcombined for
providerOP MH and
OP SA
treatme nt
CN+MNxNJ-AUnlimited in
general; varies
by MCO
iki/CRS-RL32362
g/wNJ-Brehab not
s.or covered;
leakvaries by
MCO
://wikiCN onlyxNMN/A
http
CN onlypsychologistNVUnlimited in
or psychiatristgeneral; varies
onlyby MCO
CN+MN40 visits perNY60 days/yr for
yearOP MH and
OP SA
services
CN onlyUnlimitedOHN/A
CN+MNx (evals afterfirst eval (noOK
first andPA)N/A


treatme nt)

CRS-49
Medicaid SCH IP
Provider, Provider, Limi t s
Requires PAGeneralservice, orRequires PAGeneralservice, orcombined
Coveredor otherquantityconditionor otherquantityconditionwith other
s groups review limit s limit s P ro g r a ms review limit s limit s benefit(s)
CN+MN U nlimited O R U nlimited
CN+MNPA30 full visits
or equal
Unlimitedpartial visitsper year; 120
days lifetime
limit
iki/CRS-RL32362CN+MN U nlimited RI N /A
g/w
s.orCN onlyxSCN/A
leakNot CoveredSDN/A
://wikiCN+MNVaries byNo FFSTN
httpMCO N/A
TX12 weeks per
episode for
intensive OP
Not Coveredprog; OP
services up to
6 months per
episode
CN+MNUT30 days/yr for
UnlimitedIP and OPMH, RTC and
SA services



CRS-50
Medicaid SCH IP
Provider, Provider, Limi t s
Requires PAGeneralservice, orRequires PAGeneralservice, orcombined
Coveredor otherquantityconditionor otherquantityconditionwith other
s groups review limit s limit s P ro g r a ms review limit s limit s benefit(s)
Not CoveredVA26 visits (noPA)
CN+MN90 hours perVT90 hours per
episode episode
A CN+MN U nlimited W A U nlimited
CN+MN15 hours orWIN/A
iki/CRS-RL32362 $500
g/wCN+MNWVx (after 2626 visits per
s.or Unlimited vi sits) year
leak
://wikiYCN onlycommunityMH centersWYUnlimited
http only
Congressional Research Service (CRS) analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs and the other for separate state SCHIP
rams, conducted by the National Academy for State Health Policy under contract to CRS.
See Appendix F for definition of abbreviations used here.



CRS-51
Appendix E. Specified Limits and/or Monitoring of Residential Treatment Center Services for
Children Under Medicaid and SCHIP
(as of June, 2000)
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimitsProvider, service, or
GroupsPA or otherquantityconditionPA or otherquantity combined withcondition
Programscoveredreviewlimits limitsProgramsreviewlimitsother benefit(s)limits
CN onlyxAKN/A
Not CoveredALvaries by MCO
iki/CRS-RL32362CN+MN U nlimited AR N /A
g/wCN onlyvaries byAZ
s.orMCO; no FFSNot Covered
leak
://wikiCN+MNUnlimitedCA-ANot Covered
httpCA-BNot Covered
xno limits -
CN onlyfoster careCONot Covered
only
AssessmentCT-ANot Covered
(no PA);
CN+MNtreatmentfollowsCT-BNot Covered
approved plan
of careCT-CNot Covered
CN+MNNot ReportedDCN/A



CRS-52
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimitsProvider, service, or
GroupsPA or otherquantityconditionPA or otherquantity combined withcondition
Programscoveredreviewlimits limitsProgramsreviewlimitsother benefit(s)limits
CN only30 days covered inDE30 days covered in managed
managed carecare only
only
30 days RTS
FL-A(SA) or 20 days
RTS and 10
Not Covereddays behavioral
iki/CRS-RL32362FL-BNot Covered
g/w
s.orFL-CNot Covered
leakCN+MNxGAshort-term, acute care
://wiki only
httpNot CoveredHIN/A
Not CoveredIANot Covered
Not CoveredIDN/A
CN+MN U nlimited I L U nlimited
Not CoveredINNot Covered
CN+MNUnlimitedKSvaries by MCO
CN+MN x KY x
Not CoveredLAN/A



CRS-53
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimitsProvider, service, or
GroupsPA or otherquantityconditionPA or otherquantity combined withcondition
Programscoveredreviewlimits limitsProgramsreviewlimitsother benefit(s)limits
CN+MN B HO
MA-ANot Covered
MA-BNot Covered
MA-CNot Covered
CN+MN U nlimited M D N /A
iki/CRS-RL32362CN+MN U nlimited M E U nlimited
g/wCN+MN30 days per
s.or admit MI Unlimited
leak
CN+MN x MN N/A
://wiki
httpCN onlyTreatment
only; roomMON/A
and board not
covered
CN onlyx40 days peradmitMSNot Reported
21 days per yearNo IP limits for
for MH and SA;children with certain
CN+MNxMTcan exchangeone IP day forMH diagnoses
two partial hosp.
days
CN+MN x NC x



CRS-54
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimitsProvider, service, or
GroupsPA or otherquantityconditionPA or otherquantity combined withcondition
Programscoveredreviewlimits limitsProgramsreviewlimitsother benefit(s)limits
CN+MNxNDx120 days per
benefit period
CN+MN x NE N/A
Not CoveredNHNot Covered
unlimited in general;
CN+MNUnlimitedNJ-Avaries by MCO
iki/CRS-RL32362NJ-BNot Covered
g/w
s.orCN onlyx (FFS
leakad mits) NM N/A
://wikiCN onlyxNVx
http
30 days/year
CN+MNUnlimitedNYcombined for IPMH, RTC and
IP SA treatment
Not CoveredOHN/A
CN+MN x OK N/A
CN onlyUnlimitedORUnlimited
PA30 days per
CN+MNUnlimitedyear; 90 days
lifetime limit
CN + M N x RI N / A



CRS-55
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimitsProvider, service, or
GroupsPA or otherquantityconditionPA or otherquantity combined withcondition
Programscoveredreviewlimits limitsProgramsreviewlimitsother benefit(s)limits
CN onlyxSCN/A
CN onlyx (non-
emergency SDN/A
ad mits)
CN+MNx (varies byNo FFSTNN/A
MCO)
iki/CRS-RL3236225 days per year
g/wcounted against
s.orNot CoveredTX45 available for
leakIP MH andICF/MR
://wiki30 days per year
httpfor IP and OP
Not CoveredUTMH, RTC, and
SA services
CN+MNxVAPregnant women only
CN+MN21 days perVT21 days per
episode; twoepisode; two
admits andadmits and 30
30 days perdays per year
year
ACN+MNUnlimitedWANot Covered
INot CoveredWIN/A



CRS-56
Medicaid SCH IP
Provider,
RequiresGeneralservice, orRequiresGeneralLimitsProvider, service, or
GroupsPA or otherquantityconditionPA or otherquantity combined withcondition
Programscoveredreviewlimits limitsProgramsreviewlimitsother benefit(s)limits
CN+MN x WV x
YNot CoveredWYNot Covered
Congressional Research Service (CRS) analysis of benefits data collected in two 2000 surveys, one for state Medicaid programs and the other for separate state SCHIP
rams, conducted by the National Academy for State Health Policy under contract to CRS.
See Appendix F for definition of abbreviations used here.


iki/CRS-RL32362
g/w
s.or
leak
://wiki
http

Appendix F. Notes and Abbreviations
Used in Appendix A Through E
Notes: In the two “Programs” columns (one for Medicaid and one for SCHIP), state
abbreviations are used. For SCHIP, 28 states had a single separate SCHIP program
represented by the state abbreviation. The remaining five states with separate SCHIP
programs each had two or three such programs with different benefit plans. In this
case, an A, B, or C extension was added to the state abbreviation (e.g., CT-A, CT-B,
CT-C) to distinguish multiple programs as needed.
In the “Covered groups” column for Medicaid, “CN only” means this benefit is
covered for categorically needy beneficiaries only, and “CN+MN” means this benefit
is covered for both categorically needy and medically needy beneficiaries.
Under the SCHIP columns, N/A means that the state had no separate SCHIP program
at the time of the survey, and thus, coverage of this benefit is not applicable.
Definition of other terms (in alphabetical order):
BHO — behavioral health organization (also see PHP below)
CY — calendar year
day treatment — see partial hosp (below)
eval — evaluation
FFS — fee-for-service
ICF/MR — intermediate care facilities for the mentally retarded
IMDs — institutions for mental disease
IP — inpatient
MC — managed care
MCO — managed care organization
MD — physician
med eval — medical evaluation
med management — medication management (e.g., monitoring use of prescribed
drugs to treat mental illness or substance abuse)
MH — mental health
OP — outpatient
PA — prior authorization
partial hosp — also called day treatment or partial care; is a structured environment
for youth during the day that does not involve an overnight stay; may include an
integrated curriculum that includes education, counseling and family interventions;
setting of care may be a hospital, school or clinic; may be a transitional service after
inpatient psychiatric or RTC care for youth who no longer require institutionalization
but who are not ready to be placed back in the school system due to on-going needs
for extensive treatment and supervision.
PHP — prepaid health plan; typically these are managed care plans that provide less
than a comprehensive set of benefits (such as behavioral health services that may
include only mental health care or mental health and substance abuse services only)
RTC — residential treatment centers (facilities)
SA — substance abuse