Rosie D. and Mental Health Screening 
A Case Study in Providing Mental Health Screening at the Medicaid EPSDT Visit 

1775 Broadway, Suite 610 | New York, NY 10019 | 1-866-TEENSCREEN (1-866-833-
6727) Fall 2010 
E-mail: TeenScreenInfo@childpsych.columbia.edu | www.teenscreen.org Case Study 

Abstract — Rosie D. v. Patrick 

The 2006 court ruling in Rosie D. v. Patrick resulted in the establishment of a 
requirement to use standardized screening tools in the implementation of a long-
standing federal Medicaid directive to provide mental health screening at well-
child visits. As part of the remedial plan drafted by the Commonwealth of 
Massachusetts and accepted by the federal District Court in Rosie D., it was 
agreed that the Massachusetts Medicaid program (MassHealth) would take steps to 
ensure that mental health screening was offered at all well-child visits and 
that the rate of screening would be monitored and reported. In the first quarter 
of reporting in 2008, just 14 percent of well-child visits reported including a 
mental health screen; by the fourth quarter of 2009, 58 percent of all well-
child visits did. MassHealth’s success in improving reported mental health 
screening rates was due to several key factors, including: 

Establishing clear implementation polices; 

Approving separate reimbursement for mental health screens; 

Offering a resource for clinical consultation and referral assistance in child 
psychiatry; and 

Engaging primary care providers and advocacy groups in the planning and 
implementation process. 

As expert consensus and quality guidelines nationally have begun to place 
greater emphasis on the importance of mental health screening, other health 
plans and provider organizations can benefit from the lessons learned in 
Massachusetts. 

Acknowledgments 

This case study was prepared by Julianna Belelieu, director of health policy at 
the TeenScreen National Center for Mental Health Checkups at Columbia 
University, a national policy and resource center devoted to increasing youth 
access to regular mental health checkups. The TeenScreen National Center for 
Mental Health Checkups at Columbia University acknowledges and thanks the 
following individuals and organizations, who contributed to the preparation of 
this case study through published materials, meetings, interviews and 
correspondence. While the feedback of these individuals was crucial to 
completing the case study, the views expressed in this case study are those of 
the TeenScreen National Center and do not necessarily represent the views of 
those acknowledged below, except where specifically noted in the text. 

Emily Sherwood, director of the Children’s Behavioral Health Inter-Agency 
Initiative in the Massachusetts Executive Office of Health and Human Services; 

Barbara Leadholm, MS, MBA, commissioner of the Massachusetts Department of 
Mental Health; 

Joan Mikula, assistant commissioner for Children’s Services in the Massachusetts 
Department of Mental Health; 

John Straus, MD, vice president of Medical Affairs at the Massachusetts 
Behavioral Health Partnership; 

Irene Tanzman, Massachusetts Child Psychiatry Access Project data analyst at the 
Massachusetts Behavioral Health Partnership; 

Karen Hacker, MD, MPH, executive director of the Institute for Community Health; 

Michael Yogman, MD, chair of the Children’s Mental Health Task Force at the 
Massachusetts Chapter of the American Academy of Pediatrics; 

Lisa Lambert, executive director of the Parent/Professional Advocacy League; 

Karen Darcy, RN, MSN, director of Child and Adolescent Mental Health Advocacy at 
Children’s Hospital Boston. 

Key Published Resources Included 

The Center for Public Representation: website and document library at 
www.rosied.org; 

The Commonwealth Fund Report The Massachusetts Child Psychiatry Access Project: 
Supporting Mental Health Treatment in Primary Care — Case Study: High Performing 
Health Care Organization prepared by Wendy Holt of DMA Health Strategies; 

Rosie D. and Me: a blog by David Keller, MD available at 
http://olddockeller.blogspot.com. 

Introduction: Medicaid, Mental Health Screening and Rosie D. 

The 2006 court ruling in Rosie D. v. Patrick* resulted in the establishment of a 
requirement to use standardized screening tools in the enforcement of a long-
standing federal Medicaid directive to provide mental health screening at well-
child visits. More than 40 years ago, the United States Congress and President 
Lyndon B. Johnson recognized that comprehensive preventive care was needed to 
improve outcomes for children enrolled in the Medicaid program. As a result, 
federal Medicaid law has provided for coverage of regular well-child visits to 
assess both physical and mental health since the establishment of the Early and 
Periodic, Screening, Diagnostic and Treatment (epsdt) benefit in 1967. The 
Omnibus Reconciliation Act (obra) of 1989 later strengthened this benefit by 
establishing participation goals and reporting requirements for epsdt visits by 
state Medicaid programs. Together, these statutes have provided a long-standing 
directive to state Medicaid programs to offer regular well-child screenings, 
diagnostic and assessment services, and any medically necessary care, services 
or treatment (within the definition of covered Medical Assistance under the 
federal Medicaid Act) to correct or ameliorate problems uncovered in the course 
of screening and diagnosed through a clinical assessment. 

Despite data showing that publicly insured children are at elevated risk for 
mental, emotional and behavioral disorders1 and overwhelming evidence affirming 
the value of preventive care, many state Medicaid programs have failed to take 
any steps to ensure that a mental health assessment is offered at the well-child 
visit. Available evidence indicates that this service is frequently overlooked: 
a quality review of Minnesota’s epsdt services in 2000 found that just 27 
percent of children received a developmental or mental health screening,2 and a 
2001 survey of state Medicaid programs found that 23 states did not include a 
single prompt or question addressing mental health in their epsdt tools for 
primary care providers.3 More recently, a 2010 report from the Department of 
Health and Human Services Office of Inspector General found that nearly 60 
percent of children across nine states who attended a Medicaid well-child visit 
were not offered a complete screening.4 Unfortunately, it is the case today that 
many children with mental health disorders are never screened, diagnosed or 
offered the treatment services to which they are entitled under the Medicaid 
epsdt benefit. 

The 2006 decision in Rosie D. v. Patrick (hereafter referred to as Rosie D.) was 
a watershed. It marked the first instance of a court-ordered requirement for a 
state Medicaid program to ensure that mental health screening is offered at all 
well-child visits as required by the epsdt benefit, as well as to record and 
report the rate of screening. The ruling in Rosie D. also required that 
Massachusetts’ Medicaid program, MassHealth, offer a specific set of home and 
community-based services for children with serious mental illness. Mental health 
screening rates as reported through provider billing practices have risen from 
just over 14 percent when reporting began to 58 percent by the fourth quarter of 
2009.5 This is a considerable accomplishment, and actual screening rates may be 
higher than reported since, while providers do not receive additional 
reimbursement without reporting the screen on the claim form, they are not 
otherwise penalized at this point for failing to report screenings. MassHealth’s 
experience can provide valuable insight to other state Medicaid programs and 
provider groups, as they seek to fulfill the obligation to provide required 
epsdt services and comply with the standard of care. 

In addition to the legal obligation, there will be growing pressure on other 
state Medicaid programs and providers to offer mental health screening using an 
evidence-based screening tool as the standard of care. In 2009, the U.S. 
Preventive Services Task Force (uspstf) recommended that annual depression 
screening begin at age 12, and the American Academy of Pediatrics’ (aap) Bright 
Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents 
recommends a psychosocial and behavioral assessment at every well-child visit. 
The aap Task Force on Mental Health strengthened this recommendation in June 
2010 with the release of new guidelines and tools to improve the incorporation 
of mental health screening tools into pediatric practice. The uspstf and aap 
guidelines are the gold-standard in pediatric preventive care. The new federal 
health reform laws — the Patient Protection and Affordable Care Act of 2010 and 
the Health Care and Education Reconciliation Act of 2010, together referred to 
as the Affordable Care Act (aca) — give special recognition to these guidelines 
by requiring that all new health plans provide preventive services recommended 
by these groups at no cost to enrollees for plans years beginning on or after 
September 2010.

* Between the date the suit was filed and its resolution, there were a number of 
turnovers in the Governor’s Office and Executive Administration. Consequently, 
the lawsuit has been variously titled, Rosie D. v. Swift, Rosie D. v. Romney, 
and Rosie D. v. Patrick. 

More than 40 years ago, the United States Congress and President Lyndon B. 
Johnson recognized that comprehensive preventive care was needed to improve 
outcomes for children enrolled in the Medicaid program. 

Growing agreement on the need for providers and health plans participating in 
federal health care programs to report clinical quality measures also will make 
it increasingly important to ensure that medical practice is aligned with 
recommendations for quality care. The Children’s Health Insurance Program 
Reauthorization Act of 2009 (chipra), the Health Information Technology for 
Economic and Clinical Health (hitech) Act, and aca include provisions to both 
ensure the development of appropriate quality measure sets and expand quality 
measure reporting. Given the expert consensus on the need to provide a mental 
health assessment at the annual well-child visit, state Medicaid programs, 
health plans, and even individual providers may soon find that they are required 
to report the rate at which this service is provided. 

Finally, state Medicaid programs would do well to implement mental health 
screening proactively, rather than pursuant to a court order. Historically, 
successful lawsuits brought against states for failure to provide required 
services under the epsdt benefit often have led to the imposition of a greater 
financial and regulatory burden than would have been required by voluntary 
compliance. 

In short, the need to comply with quality care recommendations and to provide 
federally mandated services will result in growing pressure for state Medicaid 
programs and other health providers to offer mental health screening using a 
standardized tool at the well-child visit. Massachusetts has set a new standard 
for comprehensive mental health screening and follow-up services. Their 
experience can offer valuable lessons and insight for other state Medicaid 
programs, health care plans, and providers as they consider ways to improve upon 
the mental health assessment component of the well-child visit. 



Despite data showing that publicly insured children are at elevated risk for 
mental, emotional and behavioral disorders and overwhelming evidence affirming 
the value of preventive care, many state Medicaid programs have failed to take 
any steps to ensure that a mental health assessment is offered at the well-child 
visit. 


The Lawsuit 

Filed in U.S. District Court in 2001, Rosie D. was brought against the 
Commonwealth of Massachusetts by the Center for Public Representation, the law 
firm of Wilmer Cutler Pickering Hale and Dorr, and the Mental Health Legal 
Advisors Committee on behalf of eight children who were seeking home and 
community-based mental health services from the Massachusetts Medicaid program. 
The Plaintiffs were ultimately deemed to be representative of a class of 
approximately 15,000 children in the Commonwealth, who were eligible for and in 
need of mental health services under Medicaid, but unable to access services. 

According to the complaint in Rosie D., the Plaintiffs had been screened and 
diagnosed with behavioral, emotional, or psychiatric disabilities, but were not 
being provided with the preventive and rehabilitative treatment required by the 
federal Medicaid program. The complaint further asserted that the small group of 
named Plaintiffs were part of a class that included “thousands of children who 
[had been] hospitalized or [were] at risk of hospitalization because of the 
absence of intensive home-based services. The individual plaintiffs and those 
like them [were] either forced to leave their families and communities in order 
to obtain the very limited, episodic mental health services which [had been] 
made available by the defendants, or [were] compelled to forego these limited 
and unduly restrictive services altogether, leaving them with inadequate 
treatment and supports.”6 

Rosie D. sought to help redress this situation by ensuring that all children 
covered by the Massachusetts Medicaid program would have access to medically 
necessary mental health services in home and community-based settings, in 
addition to the inpatient, outpatient, emergency and diversionary mental health 
services available at the time the suit was filed. The Plaintiffs brought the 
suit on the 

The Two-Fold Value of Mental Health Screening: Improved Outcomes and Lower Costs 
As many as 20 percent of young people suffer from a diagnosable mental disorder, 
and one in 10 suffers significant impairment due to mental illness.7 
Epidemiological research has found that three-quarters of all lifetime mental 
illnesses begin by age 24, with half beginning by age 14.8 Yet, in the United 
States today, fewer than 20 percent of all youth with a diagnosable mental 
disorder receive evaluation or treatment services.9 
The costs of this failure are substantial. According to a 2009 report from the 
Institute of Medicine (iom), the annual quantifiable cost of mental illness 
among young people is more than $247 billion annually.10 While the financial 
toll is staggering, the human toll is far more compelling. Suicide is the third 
leading cause of death for youth ages 10 to 24,11 and mental illness accounted 
for more hospitalizations among young people ages 13 to 17 than any other 
condition in 2000.12 Mental illness in adolescence also has been demonstrated to 
result in significantly poorer long-term outcomes across a range of quality-of-
life indicators, including physical health,13,14 educational attainment15,16 and 
socio-economic status.17,18 
Mental health screening using validated tools provides an effective, evidence-
based approach to increasing early identification and intervention,19,20 which 
can both improve outcomes and reduce the costs of mental illness. The iom and 
World Health Organization hold that early intervention in adolescence can reduce 
or even eliminate the manifestations of some mental disorders.21,22 Studies also 
have shown treatment of mental health disorders in youth to be effective at 
reducing rates of substance abuse;23 improving school performance;24 decreasing 
physical or somatic health complaints;25 and reducing morbidity and mortality.26 
According to data cited by the National Institute of Mental Health, covering 
mental illness on the same basis as medical illness would cost $6.5 billion, but 
this spending would result in savings of $8.7 billion to U.S. taxpayers.27 By 
expanding access to mental health screening as a routine component of preventive 
care, the United States could significantly improve access to early intervention 
and reduce both the human and financial toll exacted by mental illness. 

grounds that the state had failed to provide the preventive and rehabilitative 
services required by federal Medicaid law establishing the epsdt benefit (Title 
42, Chapter 7, Subchapter 19 of the U.S. Code, §1396a et seq.). 
As described by the statutes in §1396d(r)1-2, the epsdt well-child visit is 
required to take place at intervals meeting reasonable standards of medical 
practice and shall include “a comprehensive health and developmental history 
(including assessment of both physical and mental health development).” The 
epsdt benefit also requires that coverage for Medicaid-eligible children up to 
age 21 include “such other necessary health care, diagnostic services, 
treatment, and other measures described in subsection (a) of this section to 
correct or ameliorate defects and physical and mental illnesses and conditions 
discovered by the screening services, whether or not such services are covered 
under the State plan” in §1396d(r)5. These sections of the Medicaid statute 
provided grounds for suing the Commonwealth for the alleged failure to provide 
mental health screening and medically necessary follow-up services. Provisions 
of Medicaid law requiring reasonable promptness for access to services were also 
important to the Plaintiffs’ suit. 
The Plaintiffs proposed that the Defendants be required to take a number of 
specific actions to improve the identification of children in need of mental 
health services and to improve access to those services. Very broadly, the 
lawsuit sought to ensure that the Defendants be required to: 
Enhance activities to inform eligible Medicaid beneficiaries and their families 
of their right to services under the epsdt benefit. 
Require primary care providers to offer mental health screening* to all eligible 
Medicaid beneficiaries and provide MassHealth coverage for any medically 
necessary services described in the remedial plan, including case management, 
mobile crisis intervention and intensive home-based services within a reasonably 
prompt timeframe. 
Require mental health specialists to utilize a standardized assessment tool to 
assist with diagnosis and treatment planning. 
* The term behavioral health screening was used in the Rosie D. proceedings. For 
the purposes of this case study, the terms mental health screen and behavioral 
health screen can be used interchangeably and both refer to the administration 
of an evidence-based, standardized screening questionnaire such as the Pediatric 
Symptom Checklist (psc), Parents’ Evaluation of Developmental Status (peds), 
Patient Health Questionnaire 9 (phq-9), etc. 

Provide reimbursement rates adequate to ensure a sufficient number of available 
providers and eliminate the dmh waiting list for case management services for 
Medicaid eligible children.* 
Report on implementation of the remedy on a semi­annual basis to allow the Court 
to monitor compliance. 
Meet with the Plaintiffs quarterly to discuss the implementation of the judgment 
and any obstacles to its full and timely implementation. 
After a six-week trial, Judge Michael A. Ponsor issued a decision in the Rosie 
D. case in January 2006 stating, “the court finds that Plaintiffs have proved, 
by far more than a fair preponderance of the evidence, that Defendants have 
failed to comply with the epsdt and ‘reasonable promptness’ provisions of the 
Medicaid Act.” In the decision, the court clearly reinforced that the 
Commonwealth is responsible for informing Medicaid-eligible children of their 
epsdt rights, as well as arranging for screening and medically necessary follow-
up services, including home and community-base services, in a reasonably prompt 
manner. 
As noted earlier, the impetus for the creation of the epsdt benefit in 1967 was 
the desire to eradicate preventable diseases that had their roots in childhood. 
In a message to Congress that year, President Johnson described the importance 
of Medicaid’s preventive care provisions saying: “The problem is to discover, as 
early as possible, the ills that handicap our children. There must be a 
continuing follow-up and treatment so that handicaps do not go neglected . . . 
Ignorance, ill health, personality disorder — these are disabilities often 
contracted in childhood: afflictions which linger to cripple the man and damage 
the next generation. Our nation must rid itself of this bitter inheritance. Our 
goal must be clear — to give every child the chance to fulfill his promise.”28 
Judge Ponsor stressed the inadequacy of MassHealth’s efforts to fulfill this 
promise in his decision. He noted that a large number of children suffering from 
serious emotional disturbance (sed) had never received an assessment of their 
mental health, and concluded that it was difficult to characterize this as an 
entirely unintentional failing stating: “The simplest way to escape 
* It should be noted that the Court did not find that MassHealth had violated 
the “equal access” provision, which requires MassHealth to pay providers an 
amount sufficient to ensure that these providers are as available to MassHealth 
members as they are to the general public. 
“The court finds that Plaintiffs have proved, by far 
more than a fair preponderance of the evidence, 
that Defendants have failed to comply with the 
EPSDT and ‘reasonable promptness’ provisions of 
the Medicaid Act.” 
—Judge Michael A. Ponsor 
the challenge of serving an sed child is to avoid conducting the sort of in-
depth, comprehensive assessment that will reveal the extent of the child’s 
medical needs. Whether conscious or unconscious, this is the strategy being 
employed by the current system as regards many of the sed children in the 
Commonwealth at this time.” Because early identification and intervention are 
key to improving outcomes, the legal remedy stressed the need to improve mental 
health screening and assessment. 
Consequently, this case study will focus on the introduction of mental health 
screening and referral services by MassHealth, rather than the establishment of 
the intensive home and community-based mental health services mandated by the 
court. Reforming a mental health services system is acomplexandtime-
consumingchallenge,whereas mental health screening and referral are 
comparatively simple, yet significant steps toward improving care. As the 
implementation timeline in the Massachusetts case will demonstrate, the 
introduction of mental health screening can improve the rates of early 
identification and intervention for mental illness in the absence of a complete 
overhaul of the existing mental health services system. 





The Legal Remedy: A Blueprint for Comprehensive EPSDT Services 
To assure that the court judgment resulted in effective changes to MassHealth’s 
provision of epsdt services going forward, both the Plaintiffs and Defendants 
were asked to work together to submit a proposed remedial plan. Unable to agree 
on a joint proposal, the Defendants and Plaintiffs submitted separate remedial 
plans in late 2006. Judge Ponsor ultimately accepted the remedial plan submitted 
by the Defendants with several stipulations in July 2007. This plan laid out a 
blueprint for how the Commonwealth would provide mental health screening and 
follow-up services to Medicaid-eligible children, and included provisions to 
monitor compliance. 

The first section of the remedial plan listed a number of steps to be taken by 
MassHealth to comply with the epsdt mandated benefit: 
All Medicaid recipients, providers and the public must be notified of the 
availability of mental health screening and other services under Medicaid. 
Mental health screening using one of a menu of standardized tools must be 
offered to all Medicaid beneficiaries at well-child visits, and providers must 
be offered training in the use of these tools. 
Children screening positive can be evaluated and, if necessary, treated by the 
primary care physician or referred to a specialist for a mental health 
assessment using the Child and Adolescent Needs and Strengths (cans) tool. 
Referrals remain unnecessary in order to access Medicaid mental health services. 
Children diagnosed with sed will be offered intensive care coordination and 
covered treatments including home and community-based services and crisis 
management. 
A community service agency (csa) must deliver “intensive care coordination” 
using the Wraparound model of care planning and delivery for each region as 
defined by the Executive Office of Health and Human Services, with a minimum of 
15 regions. 
Screening and assessment services are required by the remedy to be offered to 
all Medicaid-eligible children. For children referred to behavioral health 
services, the remedy requires MassHealth to ensure that these children receive a 
mental health assessment using the Child and Adolescent Needs and Strengths 
(cans) tool, a standardized clinical information collection tool. Mental health 
services do not require a referral and are a covered service when medically 
necessary.* Each of the new home and community-based services outlined by Rosie 
D., however, has specific Medical Necessity Criteria, developed by MassHealth 
and used by MassHealth’s contracted health plans. Eligibility for intensive care 
coordination requires that children meet the definition of sed** provided by the 
Individuals with Disabilities Education Act, the Substance Abuse and Mental 
Health Services Administration, or both. Intensive care coordination is provided 
according to the Wraparound model of care planning and implementation, in which 
a care coordinator works with the child and their family, caregivers, health 
care providers, and others to form a care planning team and develop a strengths-
based, comprehensive and individualized plan of care. 
The remedial plan also set out a timeline for implementing each component of the 
remedy. Implementation was divided into four main projects, which were phased in 
over time: 
Behavioral health screening, informing and noticing improvements; 
cans development, training and deployment; 
Development of a service delivery network; and 
Information technology system design and development. 
Mental health screening was the first service to be implemented, beginning on 
December 31, 2007. The introduction of screening preceded the implementation of 
the other service components by nearly a year; cans assessments were implemented 
on November 30, 2008 and intensive care coordination, family mentoring, in-home 
therapy and in-home behavioral services, therapeutic mentoring, and mobile 
crisis intervention were implemented over a four month period between 
* Massachusetts defines medically necessary services, in part, as “reasonably 
calculated to prevent, diagnose, prevent the worsening of, alleviate, correct or 
cure conditions in the members that endanger life, cause suffering or pain, 
cause physical deformity or malfunction, threaten to cause or aggravate a 
handicap, or result in illness and infirmity.” A full definition is available in 
130 C.M.R. §450.204. 
** samhsa defines sed as follows: “Pursuant to section 1912(c) of the Public 
Health Service Act “children with a serious emotional disturbance” are persons: 
(1) from birth up to age 18 and (2) who currently have, or at any time during 
the last year, had a diagnosable mental, behavioral, or emotional disorder of 
sufficient duration to meet diagnostic criteria specified within dsm-iii-r. 
Federal Register Volume 58 No. 96 published Thursday May 20, 1993 pages 29422 
through 29425.” 
idea defines sed as: “Emotional disturbance is defined as follows: 
(i) The term means a condition exhibiting one or more of the following 
characteristics over a long period of time and to a marked degree that adversely 
affects a child’s educational performance: (A) An inability to learn that cannot 
be explained by intellectual, sensory, or health factors. (B) An inability to 
build or maintain satisfactory interpersonal relationships with peers and 
teachers. (C) Inappropriate types of behavior or feelings under normal 
circumstances. (D) A general pervasive mood of unhappiness or depression. (E) A 
tendency to develop physical symptoms or fears associated with personal or 
school problems. (ii) The term includes schizophrenia. The term does not apply 
to children who are socially maladjusted, unless it is determined that they have 
an emotional disturbance.” (34 C.F.R. §300.7). 

July and October 2009. All components except crisis stabilization are now 
operational; the Commonwealth sought state plan approval for this service from 
the Centers for Medicare and Medicaid Services (cms), which was denied. The 
Commonwealth has requested that cms approve, and therefore participate in 
payment for the service, through a waiver.29 
To ensure that the services outlined by the remedial plan were provided to 
eligible beneficiaries, a number of measures on screening, evaluation and 
follow-up services were designated for collection and reporting. The remedial 
plan also required the designation of a Compliance Coordinator for the 
Commonwealth and an impartial court-appointed Monitor, who would work with the 
Plaintiffs and with the Commonwealth during the implementation of the remedy. 
Taken together, these components of the remedial plan were designed to ensure 
that MassHealth provides comprehensive mental health screening and follow-up 
services to eligible Medicaid beneficiaries. 


MassHealth: Implementation Policy 
While the court judgment and remedial plan provided a blueprint for implementing 
mental health screening and medically necessary follow-up services, they did not 
provide a detailed plan for implementation. A significant amount of decision-
making about how to implement the various components of the remedy was left to 
MassHealth and the executive administration of the Commonwealth. 
Complicating the start of the implementation work was the change in executive 
administration following the 2006 elections. The preliminary judgment in the 
case was issued at the end of 2006, shortly after the election of Deval Patrick 
as Governor. Following his inauguration in January 2007, Governor Patrick 
appointed JudyAnn Bigby, md as secretary of the Executive Office of Health and 
Human Services (eohhs). Recognizing the risk that the remedial plan might create 
yet another separate “silo” of children’s services, Secretary Bigby created an 
interagency eohhs initiative, the Children’s Behavioral Health Initiative 
(cbhi), to provide a broader, cross-agency policy context to implementation of 
the remedial plan. As specified in the remedial plan, Secretary Bigby designated 
a Compliance Coordinator for the Commonwealth. She appointed Emily Sherwood, who 
she had chosen to act as director of the Children’s Behavioral Health Inter-
Agency Initiative and who reports directly to the Secretary. Ms. Sherwood was 
able to hire four staff members for cbhi. Key staff vacancies at MassHealth were 
also filled in summer and fall of 2007, including the hiring of Suzanne Fields, 
msw, licsw to serve as director of the Office of Behavioral Health. These two 
staff groups at the Office of Behavioral Health and cbhi, working as a joint 
team, have had primary responsibility for designing and implementing the 
remedial plan. 
Secretary Bigby asked her Commissioner of Mental Health, Barbara A. Leadholm, 
ms, mba to convene an Executive Committee to oversee cbhi. The Executive 
Committee includes the Medicaid Director, the Commissioners of the Departments 
of Children and Families, Public Health, and Youth Services, as well as senior 
program and legal staff. Additional input was obtained from the court-appointed 
Monitor and the public. For example, a Request for Information was issued in the 
fall of 2007 to solicit suggestions from families, advocates, health care 
professionals and others, and a series of stakeholder meetings were held across 
the state. Karen Snyder, court monitor in the Rosie D. case, also served as a 
critical resource in the design process for implementation, making national 
experts in each of the remedial services available to both the Commonwealth and 
the Plaintiffs. 
Screening Tools 
One of the first tasks facing MassHealth was to establish policies and 
procedures for the implementation of mental health screening by MassHealth 
primary care providers. Staff in MassHealth’s Office of Acute and Ambulatory 
Care (oaac) have had primary responsibility for implementing mental health 
screening. Working in consultation with medical professional and provider 
groups, oaac staff identified a list of approved screening tools to be added to 
the MassHealth provider manual. Feedback was solicited from the Massachusetts 
Chapter of the American Academy of Pediatrics, the Massachusetts Medical 
Society, the Massachusetts Association of Family Practitioners, the 
Massachusetts League of Community Health Centers, and the Massachusetts 
Association of Health Plans. Based on input from these organizations, the 
initial set of standardized, evidence-based screening questionnaires included 
eight tools (see appendix 1 of this document for a list). 
These mental health screening tools were added to Appendix W of the MassHealth 
provider manual, which includes information on epsdt periodicity schedules and 
services. As set forth by the court judgment, primary care providers* are 
required to offer eligible patients a mental health screening using one of the 
eight tools during well-child visits. MassHealth regulations (130 cmr 450.140 
through 450.150) and provider publications, as well as those of contracting 
Medicaid managed care organizations (mcos), were amended to reflect the policy 
changes required to implement mental health screening and referral. 

Education 
To ensure that eligible patients and their parents or guardians are made aware 
of the availability of mental health screening and follow-up services, 
MassHealth updated its member notices and handbooks to make direct reference to 
the availability of mental health screening, assessment and follow-up services. 
Member notices describing epsdt benefits are sent to members upon enrollment; 
upon re-enrollment; and annually, on or around the member’s birthday. Fact 
sheets about the new services were distributed to primary care clinics, and 
customer service agents for MassHealth and its mcos were educated about the 
availability of the new services and the necessity to inform members. 
MassHealth and its contracting mcos also held in-person training forums for 
MassHealth primary care providers across the state in the months preceding the 
mandated start date for screening. These forums provided an overview of the 
research on mental health screening, an introduction to the screening tools, and 
best administrative and clinical practices for implementing screening in primary 
care settings. Seven primary care provider training forums were held between 
fall 2007 and summer 2008 — from Taunton to Hyannis — with attendance averaging 
between 100 and 150 physicians. 
*Primary care providers are defined by MassHealth as general practitioners, 
family physicians, internal medicine physicians, obstetrician/gynecologists, 
pediatricians, independent nurse practitioners and independent nurse midwives 
practicing in an individual or group practice, in an outpatient department of an 
acute or chronic and rehabilitation hospital, or in a community health center. 
Screening requirements do not apply to these practitioners when providing 
emergency or post-stabilization services in a hospital or other setting. 
Primary care providers have professional latitude to override a positive or 
negative score on a mental health screen after discussion with the patient 
and/or family. This policy appropriately recognizes that mental health screens 
are not diagnostic tools; rather, they are a valid, effective method of 
identifying when further discussion or evaluation is indicated. 


Reimbursement and Reporting 
In order to fulfill the reporting requirements for mental health screening set 
out by the remedial plan, MassHealth chose to use Current Procedural Terminology 
(cpt) payment codes to determine the number of well-child visits; the number of 
mental health screens provided; and the number of children who were reported as 
having screened positive for a possible mental health disorder. Well-child visit 
codes were already available from payment data, but MassHealth’s decision to use 
a payment code to provide data on the number of screens and the rate of positive 
screens necessitated revised payment policies for the administration of 
standardized mental health screens. Notably, it was MassHealth’s decision to 
report data required by the remedial order using payment codes 
— and not the remedial order — that helped necessitate the policy change 
authorizing payment for this service. MassHealth also realized at the outset 
that payment would prove helpful in encouraging primary care providers to offer 
the screening, and state law would later make this reimbursement mandatory. 
To allow primary care providers to bill for mental health screening, MassHealth 
updated Appendix Z of the provider manual and designated the use of cpt code 
96110, which denotes “developmental testing; limited, with interpretation and 
report.” As determined by MassHealth, providers authorized to bill for the 
administration and scoring of a standardized mental health screen include 
physicians, independent nurse practitioners, and independent nurse midwives, as 
well as nurse practitioners, nurse midwives or physician’s assistants under the 
supervision of a physician. As of October 2009, reimbursement for this code was 
set at $9.73 and was limited to payment for the administration of one 
standardized screening per beneficiary, per day, regardless of the number of 
screenings administered. 
A series of payment modifiers were created for use with the 96110 code in order 
to allow MassHealth to report on the number of positive screens and the type of 
provider administering the screening. Odd-numbered modifiers signify that no 
behavioral health need was identified and even-numbered modifiers indicate that, 
in the professional judgment of the clinician, a behavioral health need was 
identified. In other words, primary care providers have professional latitude to 
override a positive or negative score on a mental health screen after discussion 
with the patient and/or family. This policy appropriately recognizes that mental 
health screens are not diagnostic tools; rather, they are a valid, effective 
method of identifying when further discussion or evaluation is indicated. 
To encourage the reporting of these payment modifiers, MassHealth policy 
required that they be included with the 96110 code in order for payment to be 
authorized beginning July 1, 2008. As of April 2010, claims are not yet being 
denied for lack of a payment modifier, although written communications from 
MassHealth continue to note that it is a required element. Despite the decision 
to delay the start of claims denials for lack of billing modifiers, reporting of 
the modifier with the billing code has improved markedly since the rollout of 
screening on December 31, 2007. In the first quarter of 2008, the modifiers were 
included with the 96110 code 67 percent of the time, but by the fourth quarter 
of 2009 the rate had climbed to more than 80 percent.30 

Follow-Up Services 
In contrast to the changes required to implement mental health screening, 
MassHealth policy addressing follow-up and referral by primary care providers is 
short and straightforward. MassHealth states that if a behavioral health need is 
identified, the primary care clinician must offer to either: 1) provide the 
necessary services or 2) refer the patient to a specialist. 
Primary care providers who choose to refer a MassHealth patient to a specialist 
must assist with the referral process. Resources and assistance with the 
referral process are available from MassHealth mcos, the Massachusetts 
Behavioral Health Partnership, and the MassHealth Customer Service Center. The 
cbhi website also provides links and information about outside referral 
resources, such as the Massachusetts Child Psychiatry Access Project, and 
highlights programs at Cambridge Health Alliance and Children’s Hospital Boston 
as examples of how to successfully implement mental health screening. 
The policies and procedures that MassHealth outlined in order to implement 
mental health screening set a clear path for providers and highlighted the 
benefits to patients. However, MassHealth does not directly provide services and 
its success in complying with the court mandate is dependent upon the 
cooperation of participating health care providers. 



Changing Clinical Practice: Keys to Success in the “Real World” 
From the date the remedial plan was finalized on July 16, 2007, MassHealth had 
fewer than six months to roll out mental health screening statewide on December 
31, 2007. In this short span, MassHealth was challenged to overcome widely cited 
hurdles to the implementation of mental health screening as a standard component 
of the well-child visit including: a lack of time and resources on the part of 
primary care providers; the need for additional training of primary care 
providers in mental health; and a shortage of specialty mental health providers. 
Several key factors would prove crucial to ensuring that mental health screening 
and referral services were, in fact, implemented successfully in primary care 
offices across the state. 
Initially, the court-ordered requirement to offer mental health screening at the 
well-child visit met with a cool reception from primary care providers. For the 
reasons just noted, most primary care providers in the United States do not use 
standardized screening tools to assess mental health at the well-child visit, 
despite data showing that informal interview techniques will fail to identify 
about 50 percent of all patients suffering from mental illness.31 A 2005 survey 
of pediatricians found that 71 percent always or almost always rely on a 
clinical assessment rather than using a standardized screening instrument.32 
Another survey of both pediatricians and family physicians found that just 23 
percent routinely screen their adolescent patients for mental disorders.33 The 
Rosie D. ruling, then, constituted a legally mandated, yet unwelcome, shift in 
standard operating procedure for many primary care practices in Massachusetts. 
“We have been helped immeasurably by a whole cadre of physician-leaders in 
Massachusetts who have brought their passion, commitment and expertise to the 
effort to inform, encourage and assist clinicians in adopting behavioral health 
screening in primary care.” 
—Emily Sherwood, director of the CBHI 

Engaging Providers in Decision-Making 
One of the keys to overcoming this reticence and gaining the buy-in of primary 
care providers was MassHealth’s decision to engage medical professional groups 
in the planning and implementation process. The court-mandate to offer 
standardized mental health screens was imposed on the medical community by the 
legal system, which contributed to its initial unpopularity. Recognizing the 
importance of involving the medical professional community in shaping 
implementation, MassHealth held physician-led trainings on mental health 
screening and has engaged in ongoing consultation with Massachusetts medical 
professional groups to inform its decision-making process. These groups have 
proven to be invaluable partners, that can speak credibly about the importance 
of mental health screening; assist in identifying barriers to implementation; 
and help propose solutions. Emily Sherwood, director of the Children’s 
Behavioral Health Inter-Agency Initiative states, “We have been helped 
immeasurably by a whole cadre of physician-leaders in Massachusetts who have 
brought their passion, commitment and expertise to the effort to inform, 
encourage and assist clinicians in adopting behavioral health screening in 
primary care.” 
The Massachusetts Chapter of the aap and its Children’s Mental Health Task Force 
(cmhtf) — a coalition of pediatricians, child psychiatrists, psychologists, 
social workers, nurses, policy advocates, insurance representatives, 
commissioners, legislators, employer groups, and groups from the education and 
correctional services communities — has been a particularly active and 
influential partner in helping to champion mental health screening and to 
address ongoing provider concerns. Michael Yogman, md, a pediatrician and chair 
of the cmhtf states, “Crucial to the success of pediatric screening has been the 
initial consultation and ongoing involvement in implementation by practicing 
pediatricians.” For instance, with feedback from the aap and others, MassHealth 
has made changes to the menu of approved screening tools, such as replacement of 
the Achenbach Child Behavior Checklist with the Strengths and Difficulties 
Questionnaire tool in 2009. It also has led to an ongoing discussion of whether 
the current mental health screening tools are sufficiently appropriate for use 
with infants and whether postpartum depression screening might be of greater 
utility. 

Reimbursing Providers for Mental Health Screening 
MassHealth’s decision to approve reimbursement for the use of cpt code 96110 
(developmental testing; limited) in addition to the well-child visit code was a 
crucial factor in overcoming primary care providers’ reluctance to offer mental 
health screening. While the administration of most mental health screening tools 
takes just five to 10 minutes, a 2005 survey of pediatricians found that lack of 
adequate time (83 percent); office staff (49 percent); and reimbursement (46 
percent) were the top three impediments to standardized screening.34 Increased 
demands on time and resources must be met with increased reimbursement, whether 
provided separately or in the form of an increase in a bundled payment for the 
well-child visit. 
The relative value unit (rvu) and payment assigned to the 96110 code are 
reflective of the small time and resource commitment necessary to provide 
screening, but do represent a real cost to providers. Given that Medicaid 
reimbursement rates for primary care are already low when compared with private 
insurance and Medicare 
— Medicaid averages just 66 percent of Medicare rates for primary care 
nationally and 78 percent of Medicare rates in Massachusetts35 — it was 
especially important that MassHealth adjust the payment for the well-child visit 
to ensure adequate reimbursement. Dr. Yogman explains, “Given the many valuable 
and competing priorities for time in a pediatric well child visit, insurance 
reimbursement for behavioral health screening increases the perceived value, 
importance and priority of these screens to pediatricians.” 

“. . . insurance reimbursement for behavioral health screening increases the 
perceived value, importance and priority of these screens to pediatricians.” 
— Michael Yogman, MD, chair of the Children’s Mental Health Task Force at the 
Massachusetts Chapter of the American Academy of Pediatrics 

Offering Free Clinical Consultation and Referral Resources 
Another key to MassHealth’s success was the ability to draw on an existing, 
state-funded clinical consultation and referral resource in child psychiatry for 
primary care providers. A significant proportion of primary care providers 
report that they are hesitant to offer mental health screening due to a 
shortfall in their mental health training and uncertainty about the availability 
of referral resources. A 2007 survey of pediatricians confirmed that lack of 
time (77 percent) and inadequate reimbursement (50 percent) were important 
barriers to offering mental health screening, but this survey also reported that 
many pediatricians lacked confidence in their training (65 percent) and ability 
(62 percent) to treat mental health problems in children and adolescents. 
Another 61 percent of pediatricians in this survey cited the lack of competent/ 
qualified mental health providers for referral as an impediment to the adoption 
of mental health screening.36 
The Massachusetts Child Psychiatry Access Project (mcpap)* has played a critical 
role in overcoming the hurdle posed by primary care providers’ concerns about 
their ability to administer mental health screening and provide or connect 
patients to necessary follow-up services. Originally conceived as a pilot 
project to respond to the increasing recognition and treatment of mental health 
disorders in the primary care setting, mcpap employs regional teams of 
psychiatrists offering telephone consultation and clinical guidance to primary 
care providers diagnosing and/or treating pediatric patients with mental health 
disorders. This service aims to respond to calls within 30 minutes and is free 
of charge for primary care providers regardless of a patient’s insurance status. 
Although mcpap is designed as a clinical consultation model for primary care 
providers, the service also addresses the perceived mental health provider 
shortage by providing assistance with the referral process, as well as 
transitional services when necessary. 
By the time MassHealth began mental health screening in 2008, more than 1,050 
pcps and 360 nurse practitioners in 344 practices throughout Massachusetts were 
enrolled with mcpap.37 To enroll, primary care practices complete 
*The 2010 Commonwealth Fund Report The Massachusetts Child Psychiatry Access 
Project: Supporting Mental Health Treatment in Primary Care — Case Study: High 
Performing Health Care Organization 
prepared by Wendy Holt of dma Strategies is recommended for a fuller description 
of mcpap. 
an orientation, which includes information about mcpap services and mental 
health screening. Because mcpap is organized into regional hubs based in 
academic medical centers, they are able to build relationships with the enrolled 
primary care providers. According to John Straus, md, faap, a pediatrician who 
led the design and planning of mcpap, who serves as the senior executive of the 
Project, and who is the senior vice president of medical affairs at the 
Massachusetts Behavioral Health Partnership, “Our teams have visited practically 
every pediatric practice and most family practices that treat children in the 
state. Eighty-five percent of our enrolled practices use our services within a 
given year . . . The teams’ close relationships with each primary care provider 
allow them to tailor the level and sophistication of their advice to the level 
of knowledge and comfort of the particular primary care provider.” 
During the rollout of screening pursuant to Rosie D., MassHealth recognized the 
need to address questions about mental health screening, diagnosis and referral. 
MassHealth decided to use the mcpap infrastructure to introduce four screening 
consultants to aid in the transition. These consultants helped to create the 
Primary Care Behavioral Health Screening Toolkit for MassHealth, which is 
available on the mcpap and cbhi websites and has been downloaded nearly 2,000 
times from the mcpap site alone. mcpap screening consultants also provided 
telephone, email, and in-person consultation on mental health screening. Irene 
Tanzmann, a data analyst for mcpap, states that “In the beginning of the 
screening process, primary care providers expressed reluctance to screen. They 
were worried that they would not have the referral resources to triage the 
patient with a positive screen. mcpap helped to ease that worry because we 
assured them that we would be there to help.” 
During the consultants’ employ between January 1, 2008 and June 30, 2009, they 
reported 327 encounters with primary care clinicians — 153 telephone 
consultations; 27 in-person meetings; 43 presentations to large practices; and 
48 emails. Karen Hacker, md, mph, who specializes in adolescent medicine and 
serves as executive director of the InstituteforCommunityHealth,was one of the 
consultants. She notes that: “Our role as screening consultants provided needed 
technical assistance to practices as they launched screening efforts. I think 
that this was a valuable service in which practical strategies could be shared 
and we could better understand the challenges to screening at the practice 
level.” Although the use of screening consultants was a temporary measure meant 
to ease the transition to wide-scale mental health screening for MassHealth 
patients, mcpap continues to assist with screening questions as part of their 
regular service. 
The driving force behind the creation of mcpap was a desire to offer clinical 
guidance on psychiatric issues to primary care providers serving children in the 
Commonwealth. The most frequent outcome for mcpap inquiries, approximately one-
third of all inquiries, is follow-up care provided by the primary care 
provider.38 Testifying to the success of the educational model, mcpap has noted 
that the complexity of primary care providers’ inquiries has increased over 
time. According to Dr. Straus, “Our mcpap regional hubs report that our mcpap 
enrolled primary care providers’ levels of knowledge have increased as a result 
of the help that they received through mcpap. The calls we receive now are 
rarely about a straightforward adhd [attention deficit hyperactivity disorder] 
case. Usually the calls are more complex. For instance, ‘I have a patient who 
has been diagnosed with adhd, but now I think it is possible that the patient 
also has depression.’” 
While there has been an increase in primary care providers’ willingness to 
address mental health disorders in the primary care setting, mcpap also 
continues to frequently assist with referral and care coordination. A case-study 
of mcpap published by the Commonwealth Fund shows that mcpap encounters for the 
period between July 2008 and June 2009 resulted in consultation with a care 
coordinator nearly one-third of the time, and patients were referred to a 
therapist or psychiatrist in a little more than one-fifth of cases.39 Other, 
less frequent outcomes included such services such as psycho-pharmacological 
evaluation (5.4 percent), emergency consultation (0.5 percent), or in-patient 
treatment (0.1 percent).40 
In June 2009, mcpap surveyed primary care providers about their experiences 
screening for, diagnosing and providing treatment for (either directly or via 
referral) pediatric patients both pre- and post-mcpap. The results provide a 
strong affirmation of the effectiveness of mcpap services. The number of primary 
care physicians who felt that they had adequate access to child psychiatry for 
their patients went from 5.9 percent who either “agreed” or “strongly agreed” 
before mcpap to a total of 34 percent following mcpap’s introduction.41,42 
Finally, the mcpap survey also found that a majority of primary care providers 

“We hypothesize that because MCPAP is assisting primary care providers with 
diagnosing and treating less severe behavioral health issues within primary 
care, more appointment slots may be available in the community for the more 
severely involved youth. Families also are learning that the first stop for help 
with a behavioral health issue does not need to be a child psychiatrist.” 
—John Straus, MD, vice president of Medical Affairs at the Massachusetts 
Behavioral Health Partnership 
felt better able to utilize behavioral health screening tools as a result of the 
service. Perhaps more importantly, the number of primary care providers who felt 
that “with existing resources, I am usually able to meet the needs of children 
with psychiatric problems” rose from 8.4 percent who “agreed” or “strongly 
agreed” to 63.1 percent.43,44 
This substantial increase in the proportion of primary care providers who felt 
that they had adequate access to child psychiatry and could meet the needs of 
their patients, resulted from improved coordination and use of existing 
resources — rather than from an increase in the number of specialty mental 
health providers. This suggests that the perceived shortage of mental health 
providers may partially resultfrompooraccesstoandcoordinationofresources,i.e., 
existing provider shortages are exacerbated by an inability to locate and 
connect patients to the appropriate provider. Blue Cross Blue Shield of 
Massachusetts Foundation issued a report on workforce capacity proposing that 
this may be the case in the Commonwealth, noting that they have the highest per 
capita supply of psychiatrists and social workers in the country and 
emphasizing, “the issue is not just about supply, but also the match between 
providers and clients. Parents need to find the “right” provider for their 
child’s age, need, and severity, who accepts the specific type of insurance, has 
openings during hours when the child and family are available, and is located 
conveniently for an ongoing course of treatment.” 45 
Dr. Straus at mcpap points to this improved care coordination in explaining the 
improved ability to meet patients’ needs, but also points to the role primary 
care providers have played in treating psychiatric disorders directly. He 
states, “Our mcpap care coordination teams are available to help mcpap enrolled 
primary care physicians find the right resources for families. Although mcpap 
care coordination teams do face the challenges of a system with a shortage of 
available resources, our teams are relentless in our attempts to find the right 
resource for the patients of our mcpap enrolled primary care clinicians. Because 
we are there to find the right resources, families may not perceive the 
shortages in the way they would if they were left to do the care coordination on 
their own.” However, Dr. Straus also notes the importance that primary care 
providers themselves play in easing the shortage of mental health specialists as 
they become more comfortable treating psychiatric problems. He explains: “We 
hypothesize that because mcpap is assisting primary care providers with 
diagnosing and treating less severe behavioral health issues within primary 
care, more appointment slots may be available in the community for the more 
severely involved youth. Families also are learning that the first stop for help 
with a behavioral health issue does not need to be a child psychiatrist.” 
mcpap has been exceptionally effective in overcoming the challenges of screening 
for, diagnosing and treating mental health disorders in primary care settings. 
According to Peter Kenny, md, a pediatrician enrolled with mcpap, “Access to 
mcpap child psychiatrists and services has been absolutely essential for getting 
timely professional mental health care for the children in our practice. I 
cannot imagine how we would be able to effectively serve children with emotional 
problems without the wonderful support of the mcpap Program.” This success has 
helped lead to the establishment of similar programs in New York, Illinois, 
Arkansas, Texas, Washington, and Maine, with planning underway in additional 
locations. 
“I have increased my ability to use behavioral health screening tools.” 
4% Strongly Disagree 
9% Strongly Agree 

Source: Massachusetts Child Psychiatry Access Project (mcpap) June 2009 survey 
of primary care providers in Improving Access, Pediatrics, accepted for 
publication, 2010. 


The number of primary care providers who felt that “with existing resources, I 
am usually able to meet the needs of children with psychiatric problems” rose 
from 8.4 percent who “agreed” or “strongly agreed” to 63.1 percent. 
When funded at full capacity, mcpap requires approximately $3 million in funding 
from the Commonwealth of Massachusetts annually. However, the sustainability of 
the program would be greatly improved if the model were funded by insurers on a 
proportionate basis. During the recent economic downturn, funding was cut to 
$2.5 million, resulting in a reduction in child psychiatry hours. If the service 
were reimbursed by private and public payers, the Massachusetts Behavioral 
Health Partnership estimates that it would cost just 18 cents per child, per 
month.46 


Advocates for Quality Health Care 
Finally, strong social and political support for improving children’s mental 
health services in Massachusetts also contributed to MassHealth’s success in 
implementing Rosie D. services. Patient and family advocacy groups, medical 
professional associations, and political leaders in Massachusetts have all 
played a part. 
For instance, the Children’s Mental Health Task Force at the Massachusetts’ 
Chapter of the aap and others advocated for the expanded adoption of mental 
health screening at the well-child visit well before the decision in the Rosie 
D. case. As a result, many of the private health plans in the state agreed to 
reimburse for mental health screening at the well-child visit prior to 
MassHealth’s decision to do so. Dr. Yogman, chair of the Task Force recounts 
that: “The Child Mental Health Task Force of the mcaap had long been advocating 
with insurers to reimburse for these screens. Because of budget constraints, 
MassHealth was one of the last payers to reimburse for mental health screening 
until the court mandated it.” This created an environment favorable to the 
promotion of mental health screening as a standard component of all well-child 
visits, because primary care providers can now be confident that, regardless of 
payer, they are likely to be reimbursed for providing mental health screening. 
Political support for advocates’ goals has also played a role. A coalition of 
medical professional and patient advocacy groups came together under the banner 
of the Children’s Mental Health Campaign to advocate for further improvements to 
children’s mental health care, following the successful passage of state health 
care reform in Massachusetts in 2006. Children’s Hospital Boston, Health Care 
for All, Health Law Advocates, the Massachusetts Society for the Prevention of 
Cruelty to Children, and the Parent Professional Advocacy League were all 
members of the Campaign, and the legislation that they proposed and helped to 
shape, An Act Relative to Children’s Mental Health, was passed by the 
legislature and signed into law by Governor Deval Patrick in 2008. 

Commonly referred to as Yolanda’s Law, in honor of a teenager who testified 
about her struggle with mental illness and who later died by suicide, An Act 
Relative to Children’s Mental Health was designed to expand early screening and 
treatment options for children and promote mental health consultations and 
training. Specifically, the law created new reporting requirements on the number 
of children wait-listed for mental health services; established new protections 
for individuals with private insurance; provided a statutory requirement for 
reimbursement of mental health screenings conducted by MassHealth; and 
established the Children’s Behavioral Health Advisory Council. 
This Council is charged with making legislative and regulatory recommendations 
to the Governor, the Secretary of Health and Human Services, relevant 
commissioners, and the committees of jurisdiction in the Legislature on a number 
of issues, including: 
“(i) best and promising practices for behavioral health care of children and 
their families, including practices that promote wellness and the prevention of 
behavioral health problems and that support the development of evidence-based 
interventions with children and their parents; 
(ii) implementation of interagency children’s behavioral health initiatives with 
the goal of promoting a comprehensive, coordinated, high-quality, safe, 
effective, timely, efficient, equitable, family-centered, culturally-competent 
and a linguistically and clinically appropriate continuum of behavioral health 
services for children.” 
These responsibilities intersect with the implementation of Rosie D. remedial 
services, and Yolanda’s Law has 


Yolanda’s Law has provided advocacy and medical professional groups with a 
formal role in shaping both public and private mental health services in 
Massachusetts. 
provided advocacy and medical professional groups with a formal role in shaping 
both public and private mental health services in Massachusetts. 
“Accountability is an important aspect of implementing the Rosie D. remedial 
plan and the Council provides the appropriate forum to support achievement of 
that objective,” according to Barbara A. Leadholm, ms, mba, Department of Mental 
Health Commissioner and ex-officio Chair of the Council. She continues: “The 
Council bridges the broad spectrum of interested stakeholders and the 
Administration and provides the platform to discuss, identify issues, oversee 
and forward the agenda for improving access to behavioral health services for 
children and families. The complex issues addressed by the Rosie D. remedy 
require diverse understanding of our system and the changes we need to make. The 
Council offers diversity of opinion, background and knowledge in making 
recommendations.” 
This strong representation on the Council helps to ensure accountability for 
improving mental health services, and it serves as an important complement to 
the Court’s monitoring of the Rosie D. remedial plan implementation. The 
Council’s charge to submit an annual report of legislative and regulatory 
recommendations to the Governor, the Secretary of Health and Human Services, the 
legislature, and other policymakers with jurisdiction serves as an especially 
strong mechanism for ensuring that improvements in children’s mental health 
services continue to be achieved. 


Early Results 
Given the short timeframe for implementation of the requirement to offer a 
mental health screening at all Medicaid well-child visits, MassHealth has been 
remarkably successful in increasing the rate at which this service is offered by 
primary care providers. Mental health screening was not offered universally 
beginning on the court-ordered start date of December 31, 2007, and, even today, 
not every child is offered a mental health screen at the well-child visit. 
Nevertheless, the rate of mental health screening has risen substantially, as 
has the number of young people offered early intervention services. 
Overall rates for the number of reported mental health screens provided at well-
child visits climbed from just 
14.46 percent in the first quarter of 2008 to 58 percent in the fourth quarter 
of 2009.47 In addition to reporting overall screening rates, MassHealth reports 
screening rates by age. Although overall participation in well-child visits 
drops significantly as children age — meaning that adolescent youth, the age 
group most at risk for mental illness, are most likely to miss preventive visits 
— mental health screening rates are fairly constant across age groups for those 
youth who do attend a well-child visit. However, there is a significant drop-off 
in mental health screening rates at each extreme of the age-bracket of patients 
eligible for epsdt screenings. A summary of the screening rates by age between 
January 1, 2008 and December 31, 2009 appears in the graph that follows. 
According to provider feedback, the low screening rate 
Mental Health Screening Rates by Age 
60% 50% 40% 30% 20% 10% 

<6 6 months 3 years to 7 years to 13 years to 18 years to months to 2 years 
6 years 12 years 17 years 20 years 
Source: MassHealth Quarterly Screening Data.48 
for children under six months of age can be explained by the lack of an 
appropriate screening tool. Primary care providers continue to advocate for the 
substitution of postpartum depression screening for a child mental health screen 
at visits for children less than six months of age. While the requirement to 
offer mental health screening to children in this age group remains in place, 
Massachusetts recently passed a law requiring health plans to report on the rate 
at which postpartum depression screening is provided. This law also authorized 
the creation of a commission to determine the best way to prevent, detect and 
treat postpartum depression and to recommend changes in public policy. At the 
other end of the age spectrum, screening rates are likely lower among 18 to 20 
year-olds because they are frequently seen in adult care, rather than pediatric 
settings, where providers are more often unfamiliar with the screening 
requirement. 
As screening rates have increased, the number of children who have screened 
positive for a mental health disorder has increased from 1,533 in the first 
quarter of 2008 to a cumulative total of 50,535 by the third quarter of 2009.49 
Despite this large increase in the overall number of children screening 
positive, the proportion of positive mental health screens is well within the 
expected range. According to a 1999 Report of the Surgeon General, approximately 
one in ten youth, i.e., ten percent, suffer from serious mental illness that 
causes significant impairment in their lives at home, in school and with 
peers.50 Among MassHealth epsdt beneficiaries, 9.38 percent of all screens 
provided between January 2008 and September 2009 were judged to be positive for 
a mental health disorder (this includes developmental, socio-emotional and 
behavioral health disorders).51 For children two years of age and older, the 
rate of positive mental health screens holds fairly steady at 11 or 12 percent, 
while the proportion of children screening positive is substantially smaller in 
the youngest patients; 
2.09 percent of children less than six months of age and 6.1 percent of children 
between six months and two years of age.* 
While the data show a clear increase in the number of youth who have screened 
positive for a mental disorder, good measures of outcomes or the rate at which 
these youth are connected to medically necessary follow-up services are more 
difficult to come by. MassHealth data indicate that between July 1, 2009 and 
January 31, 2010, 4,135 youth received intensive care coordination; 3,206 
received family support services; 4,029 received in-home therapy; 64 received 
in-home behavior services; 1,176 received therapeutic mentoring; and 5,504 
received mobile crisis intervention.52 However, these data only capture youth 
meeting the admission criteria for these services, and not all youth in need of 
mental health services will be reflected in these numbers. For instance, when 
looking at mcpap data, it becomes apparent that 
* The percentage of positive screens is based upon the number 96110 cpt codes 
reported to MassHealth with a positive modifier, divided by the number of 
overall 96110 codes reported with any modifier. This gives a fairly good picture 
of the overall rate, but does not take into account the approximately 20 percent 
of screens where no modifier (and thus no outcome) was reported. 
not all children who screen positive for a mental health disorder will even be 
referred for specialty mental health services; many such youth are managed in 
the primary care setting. Consequently, it is difficult to determine from 
currently available data how well the system is working to improve receipt of 
early intervention services and what kinds of outcomes are being achieved. 
For youth enrolled in the Primary Care Clinician (pcc) Plan, a Medicaid plan in 
which the primary care provider agrees to coordinate care, some data on follow-
up is being collected. Specifically, MassHealth is looking at the rate of 
follow-up on a positive screen by either the primary care provider or mental 
health provider within 60 days. However, this data has not been made publicly 
available, and the pcc plan represents a minority of MassHealth beneficiaries. 
Better data, such as referral and referral completion rates or tracking of 
mental health screening outcomes over time, would be helpful in determining the 
degree to which youth identified as in need of mental health services are 
receiving care. This need for improved reporting measures on referral and 
receipt of mental health services has been noted by the Plaintiffs in their 
status reports to the Court. Screening is obviously not an end in itself. mcpap 
screening consultant and physician Karen Hacker md, mph states: “While screening 
is an important element of child mental health care, we also need to make sure 
we are improving entrance into care and subsequent outcomes, not just 
identification.” 
Despite the lack of data showing exactly what proportion of youth who screen 
positive on a mental health screen are receiving mental health services, cost 
figures provide an indication that there has been a sizable increase in the rate 
at which youth are connected to follow-up care outside of the primary care 
setting. Officials at MassHealth have reported a significant increase in overall 
mental health care spending on youth following the introduction of the remedial 
services. This increase should be somewhat offset by decreases in the need for 
inpatient psychiatric care as home and community-based services are made more 
accessible. An earlier, small pilot program in Massachusetts that similarly 
proposed to provide “a seamless organized system of care for children and youth 
with serious emotional disturbance and behavioral problems” resulted in a 
three­fold reduction in hospital inpatient days among Medicaid managed care 
patients — from .15 days per member, per month (pmpm) in the prior 12 months to 
.05 days pmpm in the first 12 months of the program.53 This pilot also showed a 
nearly three-fold reduction in residential stays, which went from 1.29 days pmpm 
to 0.45 days pmpm.54 However, an overall increase in mental health spending may 
persist, due to the resource-intensive nature of the services required by Rosie 
D., such as home-based therapy, mobile crisis stabilization, family mentoring, 
and intensive care coordination. 
Reductions in total public spending by state and federal agencies, however, can 
be reasonably expected over the long-term. Numerous studies have shown that cost 
reductions in physical health spending can be expected following the 
introduction of mental health services, in some cases more than offsetting the 
cost of mental health services.55,56 Effective mental health interventions also 
have been repeatedly demonstrated to result in improved school performance, 
reductions in substance abuse, increased productivity, and reductions in 
involvement with the criminal justice system — all of which results in 
tremendous cost savings to both state budgets and society.57,58,59 A 2004 report 
from the Disease Control Priorities Project — a joint effort of the World Bank, 
the Fogarty International Center of the National Institutes of Health, the Bill 
& Melinda Gates Foundation, and the World Health Organization — reviewed 38 
studies on the national aggregate costs of mental illness and concluded that the 
negative economic consequences of mental illness far exceed the direct cost of 
treatment.60 So while MassHealth spending on mental health services may always 
reflect an increase over previous spending as a result of the Rosie D. services, 
overall public spending should fall. 
More importantly, MassHealth’s efforts to improve early identification and 
intervention for youth with mental illness can be expected to improve outcomes 
for thousands of children. After decades of research, we now know that there is 
a window of opportunity of two to four years between the first symptoms and the 
onset of the full-blown diagnosable disorder, when treatment is most effective 
at reducing the severity of specific disorders.61 Mental health screening holds 
the potential to intervene early, and in some cases, to prevent fully developed 
mental, emotional and behavioral disorders.62 If all children were given the 
opportunity to have a mental health checkup at the yearly well-child exam, the 
identification of mental illness at its earliest stages would be greatly 
increased and the cost to the individual and society — an estimated $247 billion 
annually — would be greatly reduced.63 



Conclusion 

Federal law has long required that Medicaid epsdt well-child visits include an 
assessment of mental health, and there is now consensus among expert panels and 
medical professional groups that well-child visits should include an age-
appropriate, evidence-based mental health assessment as the standard of care. 
The World Health Organization, the Institute of Medicine, the American Medical 
Association, the American Academy of Pediatrics (aap), the American Academy of 
Family Physicians, the National Association of Pediatric Nurse Practitioners, 
the U.S. Preventive Services Task Force (uspstf), and the Society for Adolescent 
Medicine all recommend mental health screening at preventive visits in the 
primary care setting, as do specialty mental health providers including the 
American Academy of Child and Adolescent Psychiatry and the American 
Psychological Association. 
Federal health care reform under aca has placed particular importance on the 
recommendations of the aap and the uspstf. Under aca, all preventive services 
recommended by the aap’s Bright Futures Guidelines and the uspstf must now be 
provided by new health plans at no cost to beneficiaries; both sets of 
guidelines recommend mental health screening. The uspstf recommends that 
depression screening be offered annually beginning at age 12. The aap Bright 
Futures Guidelines call for a psychosocial and behavioral health assessment at 
each well-child visit and state that “one of the most efficient ways for health 
care professionals to improve the recognition and treatment of psychosocial 
problems in children and adolescents is by using a mental health screening test 
. . .” Furthering this guidance, in 2010 the aap Task Force on Mental Health 
released algorithms to enhance pediatric mental health care that recommend the 
use of a pre-visit questionnaire, incorporating validated screening instruments, 
in order to assess mental health at each well-child visit. 
The overwhelming consensus that mental health screening should be incorporated 
into the well-child visit as the standard of care may also be reflected in 
quality reporting guidelines in the near future. The hitech Act and aca include 
provisions that will expand the use of quality reporting and measurement, and 
legislation reauthorizing chip in 2009 (chipra) established a core set of 
pediatric quality measures for voluntary use by Medicaid and chip programs. The 
initial chipra core set of pediatric quality measures will assess the rate of 
developmental screening in young children, but 
If all children were given the opportunity to have a mental health checkup at 
the yearly well-child exam, the identification of mental illness at its earliest 
stages would be greatly increased and the cost to the individual and society — 
an estimated $247 billion annually — would be greatly reduced. 
does not yet address mental health screening in older youth. However, a project 
is currently underway at the National Quality Forum (nqf) to assess measures for 
possible use in the chipra core set, and at least six separate measures that 
would assess the rate of depression screening have been nominated for 
endorsement. 
All state Medicaid and chip programs, provider groups, and health plans should 
begin taking proactive steps to meet the standard of care and improve the rate 
of mental health screening. Massachusetts’ experience in implementing mental 
health screening in their Medicaid program is the best available example of a 
large scale effort to ensure that mental health screening is offered at all 
well-child visits. Their experience offers valuable insight on both the hurdles 
to successfully implementing mental health screening and the keys to overcoming 
them. The Rosie D. remedial plan and MassHealth policy established a clear path 
for implementation. Further, MassHealth ensured success by engaging health care 
providers and advocates in the planning and implementation process; reimbursing 
for mental health screening; and providing clinical consultation and referral 
support to primary care providers. 

Appendix 1: MassHealth Approved Screening Tools 
Ages and Stages Questionnaire: Social Emotional 
(asq:se) 
Brief Infant Toddler Social-Emotional Assessment 
(bitsea) 
Modified Checklist for Autism in Toddlers (m-chat) 
Parents Evaluation of Developmental Status (peds) 
Pediatric Symptom Checklist (psc, psc-y) 
Patient Health Questionnaire-9 (phq-9) 
Strengths and Difficulties Questionnaire (sdq)* 
crafft (substance abuse risk tool) 
* Based on ongoing provider feedback, the Strengths and Difficulties 
Questionnaire (sdq) replaced the Achenbach Child Behavior Checklist Youth/ Adult 
(cbcl) on the menu of approved screening tools, effective November 1, 2009. 




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