UNITED STATES DISTRICT COURT 
DISTRICT OF MASSACHUSETTS 


) 

ROSIE D., et al., ) 
) 
on behalf of themselves and ) 
all others similarly situated, ) 
) 
Plaintiffs ) 
) Civil Action 
v. ) No. 01-CV-30199-MAP 
) 

DEVAL PATRICK, et al., ) 
) 
Defendants ) 
__________________________________________) 


REPORT ON IMPLEMENTATION 

The Defendants hereby submit this Report on Implementation (“Report”) pursuant to 
paragraphs 37(c)(i), 38(d)(i), 39(c)(i), and 47(b) of the Judgment dated July 16, 2007 in the 
above-captioned case (“Judgment”). 

This Report details the steps that the Defendants currently have taken to implement the 
tasks in Projects One through Four in the Judgment. For this purpose, the Defendants construe 
Projects One through Four to include all tasks described in paragraphs 2 through 46 of the 
Judgment. 

Pursuant to the Judgment, the Defendants had until December 31, 2007 to complete 
Project One and have until November 30, 2008 to complete Project Two, until June 30, 2009 to 
complete Project Three, and until November 30, 2008 to complete Project Four. 

Taking paragraphs 2 through 46 of the Judgment in turn, the Defendants hereby report as 
follows: 


2



Paragraph 2: As set forth below, the Defendants will improve their methods for notifying 
Medicaid-eligible individuals enrolled in MassHealth (“MassHealth Members” or 
“Members”), MassHealth providers, public and private child-serving agencies, and other 
interested parties about the availability of behavioral health services, including the services 
described in Section I.D. below, and behavioral health screenings in primary care settings. 

This paragraph is introductory; see detailed response below. 

Paragraph 3: The Defendants will inform all EPSDT-eligible MassHealth Members 
(Members under age 21 enrolled in MassHealth Standard or CommmonHealth) and their 
families about the availability of EPSDT services (including services focused on the needs of 
children with SED) and the enhanced availability of screening services and Intensive Care 
Coordination as soon as the EPSDT-eligible child is enrolled in MassHealth. 

The Defendants have updated the three notices that MassHealth sends to MassHealth members 
under the age of 21 to notify them about preventive health-care services, including EPSDT 
services. These notices are sent to members (1) when they are first enrolled in MassHealth; (2) 
when members are reenrolled in MassHealth after any break in MassHealth coverage; and (3) 
annually, on or around the member’s birthday. 

These notices were first revised in June 2007 to specifically inform members that behavioral 
health screens are included as part of routine well-child care visits. These notices were further 
revised to include additional information about the standardized behavioral health screening 
tools. This further revised version went into distribution in February 2008. 

These notices subsequently were revised to provide members more detailed information about 
the standardized behavioral health assessment process using the Child and Adolescent Needs and 
Strengths (CANS) tool. The Defendants plan to begin distribution of the updated notices in early 
January 2009. 

The Defendants plan to revise these notices again to describe the remedy services, including how 
to access those services, in advance of their implementation. 

Paragraph 4: The Defendants will take steps to publicize the program improvements they are 
required to take under the terms of this Judgment to eligible MassHealth Members (including 
newly-eligible MassHealth Members), MassHealth providers, and the general public. As part 
of this effort, the Defendants will take the actions described below and will also provide 
intensive training to MassHealth customer service representatives, including updating scripts 
used by such representatives to facilitate timely and accurate responses to inquiries about the 
program improvements described in this Judgment. 

The Defendants executed a contract amendment with MassHealth’s customer services contractor 
in December, 2007. Pursuant to the terms of this amendment, the customer services contractor: 

¾ Conducted an initial training for all Customer Service Representatives (CSRs) about 
EPSDT services, including information about the standardized behavioral health screens. 


These trainings took place during November and December, 2007, and were completed 
by December 31, 2007. 

¾ Conducted a refresher training for all CSRs about new activities related to the behavioral 
health screens, which included information on the resources available to members and 
providers on EOHHS’ Children’s Behavioral Health Initiative page on the EOHHS 
website, and the availability of resources for primary care providers needing assistance 
with implementing the behavioral health screening requirement in their practices. These 
refresher trainings took place in April 2008 and again in September 2008. 

¾ Conducted trainings for all CSRs on the Child and Adolescent Needs and Strengths 
(CANS) tool. The training included information on the purpose of the CANS tool; when, 
where, and by whom use of the CANS tool is required; and how providers required to use 
the CANS tool become certified to use it. These trainings took place between November 
11 and 21, 2008. 

¾ Will continue to train new CSRs as they are hired and provide ongoing trainings for 
veteran CSRs about (i) EPSDT services, including information about the standardized 
behavioral health screens; (ii) the CANS tool; and (iii) the remedy services, including 
how to access those services, once those services are implemented. The Defendants must 
review and approve the training curriculum used by the contractor. 

¾ Updated its Knowledge Center, which is the library of materials accessed by CSRs, to 
include information about EPSDT services, including information about the standardized 
behavioral health screens and the standardized behavioral health assessment process 
using the CANS tool. 

¾ Will continue to update its Knowledge Center to include information about (i) EPSDT 
services, including information about the standardized behavioral health screens; (ii) the 
CANS tool; and (iii) the remedy services, including how to access those services, once 
they are implemented. 

¾ Revised the voice menu that directs members and providers with questions about services 
for children to CSRs trained to answer questions about EPSDT. 

Pursuant to contract requirements, MassHealth’s behavioral health services contractor, the 
Massachusetts Behavioral Health Partnership (MBHP), and MassHealth’s contracted Managed 
Care Organizations (MCOs), have completed intensive training for their CSRs about when, 
where and how members may obtain EPSDT screenings, diagnosis, and treatment services, and 
have established a schedule for refresher trainings on updates to the behavioral health screens. In 
addition, MBHP and the MCOs have conducted extensive CSR training on the use of the CANS 
tool as part of a standardized behavioral health assessment process. Both MBHP and the 
contracted MCOs will ensure that all new CSRs will be trained about (i) when, where and how 
members may obtain EPSDT screenings, diagnosis, and treatment services and (ii) the CANS 
tool; and (iii) the remedy services, including how to access those services, once they are 
implemented. Both MBHP and the MCOs will ensure that veteran CSRs will be trained on an 
ongoing basis about (i) when, where and how members may obtain EPSDT screenings, 
diagnosis, and treatment services, including information about the behavioral health screens; (ii) 
the CANS tool; and (iii) the remedy services, including how to access those services, once they 
are implemented. The Defendants will review and approve the training curricula used by the 
contractors. 


Further steps that EOHHS will take to publicize the program improvements to eligible 
MassHealth members, providers, and the general public are described in the paragraphs below. 

Paragraph 5: MassHealth Members -The Defendants will take the following actions to 
educate MassHealth Members about the program improvements they are required to take 
under the terms of this Judgment: 

a. Updating and distributing EPSDT notices to specifically refer to the availability of 
behavioral health screening and services and to describe other program improvements 
set forth in this Judgment. 
See the response to paragraph 3 above. 

Also, in December 2007, the Defendants mailed a new member notice to every household 
that included a MassHealth member under the age of 21 to inform these members about the 
program improvements described in the Judgment. This member notice also is being 
included in each distributed copy of the PCC Plan’s member handbook, each MCO’s 
member handbook, and MBHP’s member handbook. 

Prior to implementation of the remedy services, the Defendants will mail an updated member 
notice to every household that includes a MassHealth member under the age of 21 to inform 
these members about the program improvements described in the Judgment, including the 
remedy services and how to access those services. This member notice also will be included 
in each distributed copy of the PCC Plan’s member handbook, each MCO’s member 
handbook, and MBHP’s member handbook. 

b. Updating and distributing (in the normal course of communications with MassHealth 
Members) Member education materials, including Member handbooks created by 
MassHealth and MassHealth’s contracted managed care entities, to include 
description of these improvements, and how to access behavioral health screenings and 
services including the home-based services described in Section I.D. 
The Defendants (or, where applicable, contractors) have taken or are currently undertaking 
the steps described below to update and distribute the following materials: 

1. MassHealth Managed Care Enrollment Guide 
The MassHealth Managed Care Enrollment Guide is sent to all members newly 
determined eligible for MassHealth who are eligible for managed care enrollment. 
The Guide has been updated to include more detailed information on EPSDT 
services, including the fact that primary care providers must offer to conduct 
behavioral health screens using a standardized behavioral health screening tool during 
preventive care visits. The updated Guide went into use in January, 2008. 

The Enrollment Guide has been updated to educate members on the CANS tool, 
including information on how the tool will be used by behavioral health providers as 


part of the standardized behavioral health assessment process. The updated Guide 
will go into circulation November 30, 2008. 

The Defendants plan to further revise the Guide to include information about the 
remedy services, including information about how to access those services, when 
those services are implemented. 

2. PCC Plan Member Handbook 
The PCC Plan member handbook is sent to all members who enroll in the PCC Plan 
and additional copies are available for enrolled members upon request. 
The Handbook has been updated to include more detailed information on EPSDT 
services, including the fact that primary care providers must offer to conduct 
behavioral health screens using a standardized behavioral health screening tool during 
preventive care visits. The updated Handbook went into use in January, 2008. 

The Defendants plan to further revise the Handbook to include information about the 
standardized behavioral health assessment process using the Child and Adolescent 
Needs and Strengths (CANS) tool and the remedy services, including how to access 
them, in Spring 2009. 

3. MBHP Member Handbook 
The MBHP member handbook is for members who are enrolled with MBHP but not 
the PCC Plan (children in the care and custody of the Departments of Children and 
Families (DCF) (formerly the Department of Social Services (DSS)) or Youth 
Services (DYS)). It includes detailed information on EPSDT services, including the 
fact that primary care providers must offer to conduct behavioral health screens using 
a standardized behavioral health screening tool during preventive care visits. The 
Handbook went into use for the first time in December, 2007. Hard copies were 
distributed to DCF and DYS in December, 2007, and an electronic copy was posted 
on the DCF and DYS intranet sites. In October 2008, the Defendants mailed copies 
of the Handbook to DCF and DYS members. 
The Defendants plan to direct MBHP to further revise this Handbook to include 
information about the standardized behavioral health assessment process using the 
Child and Adolescent Needs and Strengths (CANS) tool and the remedy services, 
including how to access those services, in Spring 2009. 

4. MCO Member Handbooks 
Each MCO sends its own Member Handbook to members who enroll in that MCO 
and additional copies are available for enrolled members upon request. 
Each MCO has updated its Member Handbooks to include more detailed information 
on EPSDT services, including the fact that primary care providers must offer to 
conduct behavioral health screens using a standardized behavioral health screening 


tool during preventive care visits. Each MCO had completed updates to its member 
handbooks by February, 2008. 

The Defendants plan to direct each MCO to further revise these handbooks to include 
information about the standardized behavioral health assessment process using the 
Child and Adolescent Needs and Strengths (CANS) tool and the remedy services in 
Spring 2009. 

c. Amending Member regulations, as necessary, to describe the services described in 
Sections I.C. and D. below and other program improvements. 
The Defendants revised relevant portions of MassHealth’s regulations (130 CMR 450.000) 
to describe program improvements, effective December 31, 2007. For more information 
about these regulations, see the response to paragraph 6.a. below. 

The Defendants are in the process of revising relevant portions of the following MassHealth 
regulations to implement the use of the CANS tool during behavioral health assessment for 
MassHealth members under the age of 21: 

• Physician Services (130 CMR 433.000); 
• Mental Health Center Services (130 CMR 429.000); 
• Outpatient Services (130 CMR 410.000); 
• Acute Inpatient Hospital Services (130 CMR 415.000); 
• Chronic Disease and Rehabilitation Inpatient Hospital Services (130 CMR 
435.000); 
• Psychiatric Inpatient Hospital (130 CMR 425.000); and 
• Psychiatric Hospital Outpatient Services (130 CMR 434.000). 
The regulations will require: 

• Certain behavioral health clinicians to obtain and maintain certification in the use 
of the CANS tool; 
• Providers in outpatient settings to use the CANS as part of the comprehensive 
evaluation each member under the age of 21 receives before initiation of therapy 
and update the CANS at least once every 90 days as part of the review of the 
member’s treatment plan; 
• Providers in inpatient settings to use the CANS during the discharge planning 
process; and 
• Providers to report data collected during each CANS assessment to EOHHS. 
Defendants have published proposed revisions to each of the regulations identified above 
and will promulgate final regulations following the close of the public comment period, 
which ended on November 21, 2008. 

The Defendants plan to further revise MassHealth regulations, as needed, to implement the 
remedy services. 


d. Participating in public programs, panels, and meetings with public agencies and with 
private advocacy organizations, such as PAL, the Federation for Parents of Children 
with Special Needs and others, whose membership includes MassHealth-eligible 
children and families. 
Since the May 30, 2008 Report on Implementation, the Defendants’ Compliance 
Coordinator or her Assistant Director has held or participated in the following forums and 
meetings: 

• Youth at Risk Conference, Endicott College, Beverly. June 11, 2008. This 
conference brings together staff of youth-serving state agencies, school departments 
and private human services agencies on the North Shore. 
• Executive Office of Education (EOE) Meeting, July 3, 2008. EOHHS staff and 
EOE staff, including representatives of the Department of Early Education and Care 
and the Department of Elementary and Secondary Education. 
• Department of Public Health Central Office Staff, August 21, 2008. 
• Program in Education Afterschool and Resiliency (PEAR) Annual Conference, 
Cambridge, September 19, 2008. 

• Family Forum, Worcester, September 24, 2008. 
• Family Forum, Springfield, October 16, 2008. 
• Family Forum, Lawrence, November 20, 2008. 
Paragraph 6: MassHealth Providers – The Defendants will take the following actions to 
educate MassHealth providers about the program improvements they are required to take 
under the terms of this Judgment. 

a. Updating EPSDT regulations to reflect the program improvements described in this 
Judgment. 
The Defendants revised relevant portions of MassHealth’s regulations (130 CMR 450.000), 
which include the EPSDT regulations (130 CMR 450.140-150), effective December 31, 
2007. These amendments, among other things, mandate that primary care providers offer to 
conduct screens required in MassHealth’s EPSDT Medical Protocol and Periodicity 
Schedule (Appendix W of the MassHealth Provider Manual); refer children for treatment 
when a screen reveals the need for follow-up care; and use a standardized behavioral health 
screening tool when conducting behavioral health screens. 

b. Updating Appendix W of the MassHealth Provider Manual, which describes medical 
protocols and periodicity schedules for EPSDT services, to reflect the program 
improvements related to screenings for behavioral health described in Section I.A.2 
below. 
Effective December 31, 2007, the Defendants updated Appendix W to include a list of 
MassHealth-approved standardized behavioral health screening tools from which primary 
care providers must select a tool when administering behavioral health screens for 


MassHealth enrolled children. The Defendants published the updated Appendix W along 
with the updated EPSDT regulations described in subparagraph a. above. 

In collaboration with the Massachusetts Chapter of the American Academy of Pediatrics 
(MCAAP), the Defendants have begun the process of reviewing the menu of approved 
screening tools and the schedule for behavioral health screenings in Appendix W. In the 
event of any changes to the menu of approved screening tools or to the frequency of 
behavioral health screening, the Defendants will publish a further revised version of 
Appendix W. 

The Defendants plan to review the menu of approved screening tools and the schedule for 
behavioral health screenings on an ongoing basis, in collaboration with the MCAAP. 

c. Drafting and distributing special provider communications related to the program 
improvements described in this Judgment, including how to assist MassHealth 
Members to access the home-based services described in Section I.D. 
For more information on provider communications regarding screening, see the response to 
paragraph 10. 

For more information on provider communications regarding assessments using the CANS 
tool, see the response to paragraphs 14-16. In addition, the Defendants prepared an article on 
implementing the CANS tool that was published in the August 8, 2008 edition of “Focus”, the 
newsletter of the Massachusetts Chapter of the National Association of Social Workers. 

Prior to implementation of the remedy services, the Defendants will produce and distribute 
information for MassHealth providers describing MassHealth behavioral health services for 
children and youth and how to access them. 

d. Updating and distributing existing provider education materials to reflect the program 
improvements described in this Judgment. 
The Defendants have updated (or have required the contractor responsible for their 

publication to update) the following materials that currently are distributed to providers to 

inform providers about using standardized behavioral health screens and using the CANS 

tool during behavioral health assessments: 

1. PCC Plan Provider Newsletters – The PCC Plan Provider Newsletter is the provider 
newsletter for PCC Plan providers. The Newsletter included articles in the December, 
2007 and March, 2008 issues that provided information on the requirement for PCCs 
to use standardized behavioral health screening tools. The PCC Plan included articles 
in the Spring 2008 and Summer 2008 issues of the Newsletter that provided 
information on implementing standardized behavioral health screening and using the 
Child and Adolescent Needs and Strengths (CANS) tool. 

2. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services and 
Preventive Pediatric Health-care Screening and Diagnosis (PPHSD) Services Billing 
Guidelines for MassHealth Physicians and Mid-level Providers – The Defendants 
updated this Guide for providers who bill MassHealth directly for EPSDT and PPHSD 
screening services to explain how to bill for standardized behavioral health screens. 
The updated Guide became available in December, 2007. 
3. PCC Plan Provider Contract – The Defendants updated this contract to describe the 
standardized behavioral health screening requirement for PCCs and mailed the 
updated contract to enrolled Primary Care Clinicians in January, 2008. 
4. PCC Plan Provider Handbook – The Defendants updated this Handbook for providers 
who are enrolled as PCCs to describe the standardized behavioral health screening 
requirement. The updated Handbook was mailed to all enrolled PCCs with the 
updated PCC Plan provider contract. 
5. MCO newsletters – Each MassHealth-contracted MCO included articles in their 
respective MCO provider newsletters to inform providers about the requirement for 
using standardized behavioral health screening tools. These newsletters were 
published between November, 2007 and January, 2008. In addition, each MCO 
published newsletter articles about implementing standardized behavioral health 
screening and using the Child and Adolescent Needs and Strengths (CANS) tool 
between May and August, 2008. 
6. MassHealth “Update” article – MassHealth included articles containing information 
for providers about using standardized behavioral health screening tools in 
MassHealth “Update”, which is MassHealth’s online newsletter to all MassHealth 
providers. These articles were published in December, 2007, February, 2008, and 
August 2008. 
The Defendants will assess which materials need to be updated to inform providers about the 
remedy services, including how to access those services, once those services are 
implemented. 

e. Expanding distribution points of existing materials regarding EPSDT generally, 
including the program improvements described in this Judgment. 
The Defendants created a website for the Children’s Behavioral Health Initiative (CBHI)1 
that is available on the EOHHS website to provide information to MassHealth providers, 
MassHealth members, the broader community of human service providers, and members of 

CBHI is an EOHHS interagency initiative whose mission is to strengthen, expand and integrate 
Massachusetts state services into a comprehensive, community-based system of care, to ensure that families and 
their children with significant behavioral, emotional and mental health needs obtain the services necessary for 
success in the home, school and community. CBHI will include activities to implement the Final Judgment in this 
case. 


the general public about EPSDT generally and the program improvements that the 
Defendants are makings in response to the Judgment. 

The CBHI webpage became available in December 2007. To date, the Defendants have 
posted on this website many of the materials referenced in the paragraphs above and below 
that describe the requirements for primary care providers to use standardized behavioral 
health screening tools as well as information about the CANS tool and information about the 
remedy services, including: 

• EPSDT member notices described in paragraph 3; 
• Member notice described in paragraph 5.a; 
• PCC Plan Member Handbook described in paragraph 5.b; 
• MBHP Member Handbook described in paragraph 5.b; 
• MCO Member Handbooks described in paragraph 5.b; 
• EPSDT regulations described in paragraphs 5.c and 6.a and Appendix W described in 
paragraphs 6.b; 
• The EPSDT/PPHSD fact sheets described in paragraph 7.b; 
• EPSDT Billing Guide described in paragraph 6.d; 
• CANS-specific materials, including a CANS Frequently Asked Questions reference, 
the CANS forms, a CANS Item Glossary for scoring the CANS, CANS registration 
and training information, and CANS reference materials; and 
• Information presented at the CBHI Institute described in paragraph 6.g. 
The Defendants have also posted certain court documents and other information about the 
Defendants’ implementation efforts, including information about provider trainings on the 
behavioral health screening tools and CANS tool, as well as resources for providers 
regarding the implementation of behavioral health screening tools in their practice. The 
Defendants continue to update the website regularly with general announcements and notices 
sent to providers regarding revisions to applicable MassHealth regulations. 

The Defendants plan to update this website to include additional information about 
implementation efforts as they become available. 

f. Implementing any other operational changes required to implement the program 
improvements described in this Judgment. 
The Defendants have implemented changes to the Medicaid Management Information 
System (MMIS) to allow MassHealth primary care providers to be reimbursed for the 
administration and scoring of the standardized behavioral health screening tools, and to 
allow the Defendants to track the rate at which providers are utilizing a standardized 
behavioral health screening tool when administering behavioral health screens 

MassHealth has developed and approved a billing code with a modifier that outpatient 
behavioral health providers will use to bill for behavioral health assessments using the CANS 
tool, and also has developed and approved enhanced rates to accompany the code. MCO and 
MBHP network providers have been permitted to bill the new code since September 15, 


2008. MassHealth fee-for-service providers will be permitted to begin billing this new code 
November 30, 2008. 

The Defendants will implement other operational changes that are identified as necessary to 
implement the projects described in the Judgment. 

g. Holding special forums for providers to encourage clinical performance activities 
consistent with the principles and goals of this Judgment. 
Meetings with Primary Care Clinicians Regarding Standardized Behavioral Health 
Screening 

• Since the last court report, the Defendants have conducted three more forums to 
educate primary care clinicians about the requirement to offer to use a standardized 
behavioral health screening tool when screening children for behavioral health issues. 
These forums took place on June 18, 19 and 26, 2008 in Pittsfield, Hyannis and 
Danvers. 
• The Compliance Coordinator presented on the Judgment, the new screening 
requirement and resources to support pediatric behavioral health screening at a 
meeting for primary care clinicians sponsored by Harrington Hospital in Southbridge, 
on September 18, 2008. 
Meetings with Human Services and Behavioral Health Providers Regarding CANS 
Assessments and Remedy Services 

Since the last court report, the Defendants have participated in the following meetings: 

• Statewide Provider Meeting, Hoagland-Pincus Conference Center in Shrewsbury, 
July 16, 2008. Discussed CANS implementation and presented an introduction to the 
remedy services. 
• Meeting with Mental Health and Substance Abuse Corporations of 
Massachusetts (MHSACM), September 8, 2008. MHSACM is a trade organization 
of mental health and substance abuse providers. 
• Meeting with Behavioral Health Staff, Harrington Hospital, Southbridge, 
September 18, 2008. Discussed the Judgment, CANS implementation and the remedy 
services. 
• Statewide Provider Meeting, Hoagland-Pincus Conference Center in Shrewsbury, 
September 19, 2008. Presented an overview of the remedy services and how the 
services connect to one another. 
• Meeting with the Massachusetts Children’s League, September 22, 2008. The 
Mass League is the trade organization for child welfare providers. 
• Minority Provider Forum, One Ashburton Place, Boston, October 1, 2008. 
Presented an overview of the remedy services and how the services connect to one 
another. 
• Statewide Provider Conference Call regarding CANS Implementation, October 
10, 2008. 
• Deaf Provider Meeting, One Ashburton Place, Boston, October 15, 2008 

• “CBHI Institute”, full-day conference presented free-of-charge to over 350 
providers. The purpose of the Institute was: (1) to provide an introduction to “System 
of Care” principles and values underlying the Children’s Behavioral Health Initiative; 
(2) to provide in-depth presentations on the specifications for each of the remedy 
services; and (3) to explain the provider selection processes the managed care 
contractors will use in selecting providers for the remedy services. 
• Statewide Provider Conference Call regarding CANS Implementation, 
November 20, 2008. 
In addition, the MassHealth Behavioral Health Unit conducts regular monthly meetings 
with MHSACM at which CBHI implementation issues are discussed. Additional 
meetings are held when necessary. The Compliance Coordinator participates when 
necessary. 

The Defendants will continue to sponsor provider conference calls and meetings at 

regular intervals. 

h. Amending MassHealth’s managed care contracts to assure that all such entities 
educate the providers in their network about the program improvements described in 
this Judgment, as described in Paragraphs 6.a.-g. above. 
The Defendants have executed amendments to its contracts with MBHP and the MCOs to 
specifically require them to educate their network providers about the program 
improvements described in sections a. through g. of this paragraph. 

i. Coordinating these efforts with the “Virtual Gateway,” which is the EOHHS system for 
web-based, online access to programs, including MassHealth and related benefit 
programs such as food stamps, and which allows a wide array of hospitals, community 
health centers, health and human services providers, and other entities to assist 
children and families in enrolling in MassHealth. 
As described in paragraph 6.e, the Defendants have created a Children’s Behavioral Health 
Initiative (CBHI) webpage that is available on the EOHHS website to inform MassHealth 
providers, MassHealth members, the broader community of human services providers, and 
members of the public about EPSDT generally and the program improvements that the 
Defendants are making in response to the Judgment. The Defendants plan to update this 
website as implementation of the Judgment proceeds. 

Additionally, as more fully described in paragraph 39.b, the Defendants have developed a 
web-based training and certification application to facilitate CANS training and certification 
for behavioral health clinicians, and are developing a web-based CANS application that will 
be available through the EOHHS Virtual Gateway for behavioral health providers who are 
required to use the CANS tool to report data collected to EOHHS. 

Paragraph 7: The Public - To improve public information about the program improvements 
the Defendants are required to take under the terms of this Judgment, the Defendants will 


take the following actions to present the terms of this Judgment to public and private agencies 
that serve children and families: 

a. Presenting the Judgment to appropriate Commonwealth officials in the Executive 
Branch and the Legislature. 
The Defendants have conveyed copies of the Remedial Plan or Proposed Judgment to senior 
managers in: 

• the Executive Office of Administration and Finance; 
• the Executive Office of Health and Human Services; 
• the Office of Medicaid; and 
• the Departments of Mental Health, Mental Retardation, Public Health, Children and 
Families (formerly, Social Services), and Youth Services. 
A copy of the Judgment was included with a copy of the November 30, 2007 Report on 

Implementation and was sent to: 

• the Senate President; 
• the Speaker of the House; 
• the Chairs of the Senate and House Committees on Ways and Means and the Senate 
and House Chairs of the Joint Committees on: Health Care Financing; Mental Health 
and Substance Abuse; and Children and Families 
• the Secretary of Administration and Finance; 
• the Secretary of Health and Human Services and her senior management staff; 
• the Medicaid Director; 
• the Commissioner of the Division of Health Care Finance and Policy; and 
• the Commissioners of the Departments of: Education, Early Education and Care, 
Mental Health, Mental Retardation, Public Health, Children and Families, and Youth 
Services. 
The May 30, 2008 Report on Implementation was sent to the legislative offices listed above, 
the Secretary of Health and Human Services, the Medicaid Director, and the Commissioners 
of Children and Families, Mental Health, and Youth Services. 

b. Creating new pamphlets, informational booklets, fact sheets, and other outreach 
materials describing these improvements. 
The Defendants developed and distributed two notices, in the form of ‘fact sheets’, for the 
purposes of outreach. ‘Fact Sheet 1’ is for the general public. ‘Fact Sheet 2’ is for 
agencies/groups that work with children and whose staff are likely to help parents learn about 
and access needed screenings, assessments and services for their children. Both Fact Sheets 
contain information about EPSDT services, including standardized behavioral health 
screening services, available to children enrolled in MassHealth. 


The Defendants distributed an initial version of ‘Fact Sheet 1’ to the Massachusetts Medical 
Society, the Massachusetts League of Community Health Centers, the Massachusetts Chapter 
of the American Academy of Pediatrics, the Massachusetts Association of Family 
Practitioners, and the Mental Health and Substance Abuse Corporation of Massachusetts in 
December 2007, requesting each organization to make the materials available to their 
provider networks and to encourage their provider networks to circulate the materials to their 
patients and families. The Defendants re-distributed ‘Fact Sheet 1’ to the above named 
organizations in October 2008. The Defendants reminded the organizations that ‘Fact Sheet 
1’ describes EPSDT services available to children enrolled in MassHealth and requested each 
organization to make the materials available to their provider networks and encourage their 
provider networks to circulate the materials to their patients and families. The Defendants 
also provided updated information about the types of behavioral health providers and settings 
that will be required to use the CANS tool during the behavioral health assessment process 
and the deadlines for doing so. 

The Defendants distributed an initial version of ‘Fact Sheet 1’ and ‘Fact Sheet 2’ to staff 
working with the following agencies/groups in December 2007, requesting that each 
agency/group distribute ‘Fact Sheet 2’ to their respective staff/provider groups and encourage 
their staff/provider groups to circulate ‘Fact Sheet 1’ to their clients: 

• Department of Children and Families; 
• Department of Youth Services; 
• Department of Mental Health; 
• Department of Transitional Assistance; 
• Office for Refugees and Immigrants; 
• Department of Early Education and Care; 
• Department of Public Health; and 
• Department of Education. 
In October 2008, the Defendants re-distributed the original cover letter sent in December 
2007 along with ‘Fact Sheet 2’ to the above mentioned agencies/groups. The Defendants 
reminded the agencies that ‘Fact Sheet 2’ describes EPSDT services available to children 
enrolled in MassHealth and requested the agencies to re-circulate it to school nurses using the 
cover sheet. The Defendants also provided updated information about the types of behavioral 
health providers and settings that will be required to use the CANS tool during the behavioral 
health assessment process and the deadlines for doing so. 

The Defendants plan to update the fact sheets to include information on the remedy services, 
including information on how to access those services, when those services are implemented. 

The Defendants also are developing and will distribute, prior to implementation of the 
remedy services, a brochure for MassHealth parents describing behavioral health services for 
children and youth available through MassHealth, and how to access them. 


The Defendants prepared articles on implementing the CANS tool and the Wraparound 
Process that were published in the Summer and Fall issues of “Newsline”, the newsletter of 
the Federation for Children with Special Needs. 

c. Developing and implementing training programs for line staff at the Departments of 
Mental Health, Social Services, Youth Services, Mental Retardation, Transitional 
Assistance, and the Office for Refugees and Immigrants on how to access MassHealth 
services for children with SED. 
The Defendants distributed ‘Fact Sheet 1’ and ‘Fact Sheet 2’ to agency line staff at the 
agencies noted above. See paragraph 7.b above for more details. These fact sheets will be 
updated to include information about MassHealth services, including the new services 
required by the Judgment, as these services are implemented. 

Planning is underway with the Departments of Children and Families, Education, Early 
Education and Care, Mental Health and Public Health to produce protocols that will inform 
their staff about the remedy services, including how to access those services. Similar 
planning will commence in January 2009 with the Department of Transitional Assistance and 
the Office for Refugees and Immigrants. 

d. Distributing outreach materials in primary care settings, community health centers, 
and community mental health centers and posting electronic materials on the EOHHS 
Virtual Gateway that are designed to provide information to MassHealth Members and 
to public and private agencies that come in contact with or serve children with SED or 
their families. 
The Defendants have coordinated with the associations for these provider types, and will 
continue to do so, to ensure that updated versions of ‘Fact Sheet 1’ are made available to the 
public at provider sites. 

For more information, see the response to paragraph 7.b. above. 

For more information about the Virtual Gateway, see the response to paragraph 6.i. above. 

e. Working with the Department of Early Education and Care to educate preschools, 
childcare centers and Head Start Programs on how to access MassHealth services for 
children with SED. 
The Department of Early Education and Care (DEEC) distributed the Fact Sheets to all 
DEEC-licensed childcare providers in the Commonwealth. In October 2008, the Defendants 
requested that DEEC distribute the updated Fact Sheets to all DEEC-licensed childcare 
providers in the Commonwealth. 

The Defendants will continue to work with DEEC on strategies to inform childcare providers 
and the families and children they serve about behavioral health screenings, CANS 
assessments and services for their children. 


f. Working with the Department of Education, the Department of Public Health and 
Public School Districts to educate school nurses and other school personnel on how to 
access MassHealth services for children with SED. 
The Compliance Coordinator meets regularly with the Director of Planning and Program 
Development for the Executive Office of Education to develop strategies for communicating 
necessary information about the Judgment, the remedy services and how to access them to 
child care providers and school personnel, including superintendents, principals, special 
education directors, school counselors and school nurses. Planning for these outreach and 
education activities have recently been moved under the umbrella of Governor Patrick’s 
recently-convened “Readiness Council”, which is co-chaired by the Secretary of the 
Executive Office of Health and Human Services and the Secretary of the Executive Office of 
Education. A CBHI Implementation Working Group is being created through the Readiness 
Council to support CBHI implementation with public schools. 

The Compliance Coordinator presented at the semi-annual conference of Administrators for 
Special Education on June 6, 2008 on the Judgment, remedy services and CBHI 
implementation plans. 

Paragraph 8: The Defendants will require primary care providers who perform periodic and 
medically necessary inter-periodic screenings pursuant to 42 U.S.C. §1395d(r)(1) to select 
from a menu of standardized behavioral health screening tools. The menu of standardized 
tools will include, but not be limited to, the Pediatric Symptom Checklist (PSC) and the 
Parents’ Evaluation of Developmental Status (PEDS). Where additional screening tools may 
be needed, for instance to screen for autistic conditions, depression or substance abuse, 
primary care providers will use their best clinical judgment to determine which of the 
approved tools are appropriate for use. 

As explained in response to paragraph 6.a. above, effective December 31, 2007, the Defendants 
updated MassHealth regulations governing the EPSDT program (130 CMR 450.140-150) to 
require primary care providers who perform periodic and medically necessary inter-periodic 
screenings pursuant to 42 USC 1395d(r)(1) to select from a menu of standardized behavioral 
health screening tools. 

As explained in paragraph 6.b. above, the menu of approved screening tools, which includes the 
Pediatric Symptom Checklist (PSC) and the Parents’ Evaluation of Developmental Status 
(PEDS), as well as other tools to screen for autistic conditions, depression or substance abuse 
appears in Appendix W of the MassHealth Provider Manual, which became effective December 
31, 2007. 

Paragraph 9: The Defendants will amend pertinent MassHealth provider regulations to 
clarify that all primary care providers, whether they are paid through the managed-care or the 
fee-for-service system, are required to provide periodic and inter-periodic screens. 


As explained in paragraph 6.a. above, the Defendants have updated MassHealth regulations 
governing the EPSDT program (130 CMR 450.140-150) effective December 31, 2007 to clarify 
that all primary care providers are required to provide periodic and medically necessary inter-
periodic screens. 

Paragraph 10: There will be a renewed emphasis on screening, combined with ongoing 
training opportunities for providers and quality improvement initiatives directed at informing 
primary care providers about the most effective use of approved screening tools, how to 
evaluate behavioral health information gathered in the screening, and most particularly how 
and where to make referrals for follow-up behavioral health clinical assessment. Additional 
quality improvement initiatives will include improved tracking of delivered screenings and of 
utilization of services delivered by pediatricians or other medical providers or behavioral 
health providers following a screening and use of data collected to help improve delivery of 
EPSDT screening, including assuring that providers offer behavioral health screenings 
according to the State’s periodicity schedule and more often as requested (described in Section 
I.E.2). 

As described in paragraph 6.g, the Defendants have held a series of provider training forums to 
inform primary care providers about the most effective use of the approved screening tools, to 
educate them on how to evaluate behavioral health information gathered during the screening, 
and to provide information on how and where they can refer members needing further behavioral 
health clinical assessment. Additional provider training forums are being planned for Spring 
2009. These upcoming forums will focus on educating providers about MassHealth-approved 
screening tools and suggest strategies for implementation of behavioral health screening in the 
provider’s practice. 

Quality improvement efforts also are being implemented by the Defendants to further support the 
implementation of behavioral health screenings at all well child visits. These include: 

• In August 2008, the Defendants mailed a letter to all primary care providers that had 
submitted at least one paid claim for a well child visit to MassHealth. The letter 
included provider-specific data on the number of paid claims for well child care visits 
and the number of behavioral health screens (including the number of claims for 
behavioral health screens that used a U-modifier). The letter identified resources 
available to providers to learn more about behavioral health screening and to increase 
the number of behavioral health screens provided to members under the age of 21. 
The Defendants plan to do another mailing of such provider-specific data in early 
December 2008. 
• In collaboration with the Massachusetts Child Psychiatry Access Project (MCPAP), 
the Defendants have made Screening Tool Consultants (STCs) available, upon 
request, to help providers implement the behavioral health screening requirement. 
STCs are pediatricians who have expertise in the use of behavioral health screening 
tools, including experience using the tools in their practice. The STCs are available 
to answer questions on how to effectively implement behavioral health screening 
tools in the provider’s practice. 

• The Defendants have directed the STCs to outreach to providers who are billing only 
a few behavioral health screening codes and to discuss the provider’s need for 
assistance. 
• The Defendants and the MCOs have convened a Joint Quality Improvement 
Workgroup. The focus of this workgroup is to share successful practices, facilitate 
discussion, and generate ideas and suggestions related to quality improvement 
activities. Furthermore, through the workgroup, the Defendants are able to ensure 
that the MCOs are actively working on quality improvement activities. The group 
first met in October 2008. 
The Defendants are tracking the number of delivered behavioral health screenings and are 
developing a plan for updating existing systems and methods to allow the Defendants to track the 
utilization of services following a screening. The Defendants plan to monitor the data gathered 
from such systems and use the data to help improve delivery of EPSDT screening, including 
assuring that providers offer behavioral health screenings according to the State’s periodicity 
schedule. 

Paragraph 11: MassHealth will continue the practice of not requiring a primary care visit or 
EPSDT screening as a prerequisite for an eligible child to receive MassHealth behavioral 
health services. MassHealth-eligible children and eligible family members can be referred or 
can self-refer for Medicaid services at any time by other, including other EOHHS agencies, 
state agencies, public schools, community health centers, hospitals and community mental 
health providers. 

The Defendants do not plan to change their policy that all MassHealth members, regardless of 
their managed care enrollment status, may access behavioral health services without the need for 
a referral as a prerequisite for payment for services. MassHealth-eligible children and eligible 
family members can continue to be referred, or to self-refer, for Medicaid services at any time by 
others, including other EOHHS agencies, state agencies, public schools, community health 
centers, hospitals and community mental health providers. 

Paragraph 12: The Defendants will provide information, outreach and training activities, 
focused on such other agencies and providers. In addition, the Defendants will develop and 
distribute written guidance that establishes protocols for referrals for behavioral health 
EPSDT screenings, assessments, and services, including the home-based services described in 
Section I.D., and will work with EOHHS agencies and other providers to enhance the capacity 
of their staff to connect children with SED and their families to behavioral health EPSDT 
screenings, assessments, and medically necessary services. 

As described in the response to paragraph 7 above, the Defendants have developed and 
distributed written guidance that establishes protocols for referrals for screenings. The 
Defendants are in the process of developing written protocols with the child-serving state 
agencies to guide their staff in accessing screening services, clinical assessments and the remedy 
services. The Defendants are working with the training departments in the child-serving state 
agencies to plan for staff training in these protocols prior to June 30, 2009. 


Paragraph 13: The Defendants will ensure that EPSDT services include a clinical assessment 
process for eligible children who may need behavioral health services, and will connect those 
assessments to a treatment planning process as follows: 

This paragraph is introductory; see detailed response below. 

Paragraph 14: The Defendants will require a clinical behavioral health assessment in the 
circumstances described below by licensed clinicians and other appropriately trained and 
credentialed professionals. 

MassHealth has executed contract amendments with MBHP and the MCOs requiring them to use 
the CANS by November 30, 2008 as described below and allowing MBHP and the MCOs to use 
the CANS as part of a behavioral health assessment and pay their provider networks at an 
enhanced rate as of September 15, 2008. 

MassHealth is in the process of promulgating regulations which will require that behavioral 
health clinicians who serve MassHealth members on a fee-for-service basis to use the CANS tool 
as described below. The public comment period for these regulations ended on November 21, 
2008. The Defendants will publish the regulations accordingly. Fee-for-service providers who 
will receive an enhanced rate to perform the CANS (Physicians and Mental Health Centers) may 
begin billing the enhanced rate for services provided on or after November 30, 2008. 

The steps that the Defendants are taking to require that the assessment using the CANS tool be 
conducted by licensed clinicians and other appropriately trained and credentialed professionals is 
described in response to paragraph 16.b. below. 

Paragraph 15: In addition to the clinical assessment, the Defendants will require providers to 
use the standardized clinical information collection tool known as the Child and Adolescent 
Needs and Strengths (CANS) as an information integration and decision support tool to help 
clinicians and other staff in collaboration with families identify and assess a child’s 
behavioral health needs. Information obtained through the CANS process provides a profile of 
the child which trained clinicians use in conjunction with their clinical judgment and 
expertise to inform treatment planning and to ensure that treatment addresses identified 
needs. 

The Defendants convened a workgroup, which met regularly in 2006 and 2007 with John Lyons, 
Ph.D., developer of the CANS tool. The group included representatives from MassHealth, the 
Department of Mental Health (DMH), the Department of Youth Services (DYS), the Department 
of Children and Families (DCF), the Office of Clinical Affairs (OCA), the Commonwealth 
Medicine Division of the University of Massachusetts Medical School, the Department of Public 
Health (DPH), and a child psychiatrist. The workgroup developed a Massachusetts CANS tool in 
two forms: one form for children under the age of five and another form for children and 
adolescents ages five to 21. 


The Defendants presented draft versions of the Massachusetts CANS tool to providers, families 
and the Plaintiffs to gather their input. Both forms of the CANS tool are now complete and are 
available on the CBHI website along with explanatory and reference materials. 

In addition, EOHHS developed cover pages to accompany both forms of the CANS tool that 
requires the clinician to identify whether the member has a serious emotional disturbance. This 
cover pages were provided to the Plaintiffs for review and comment. These cover pages are part 
of the CANS forms that are available on the CBHI website. 

Paragraph 16: The Defendants will implement an assessment process that meets the following 
description: 

a. In most instances, the assessment process will be initiated when a child presents for 
treatment to a MassHealth behavioral health clinician following a referral by the 
child’s primary care physician based on the results of a behavioral health screening. 
However, there are other ways for children to be referred for mental health services. A 
parent may make a request for mental health services and assessment directly to a 
MassHealth-enrolled mental health provider, with or without a referral. A child may 
also be referred for assessment and services by a provider, a state agency, or a school 
that comes into contact with a child and identifies a potential behavioral health need. 
The Defendants are requiring managed care entities to provide MassHealth-enrolled children 
with an assessment and record the results using the Massachusetts CANS tool when a child 
presents for treatment, whether the child’s visit follows a behavioral health screening and 
referral from a primary care provider; whether the child presents following a referral from a 
provider, state agency, or school; or whether the child presents without a referral. 

Providers have been informed of this requirement through multiple channels, including 
Network Alerts from managed care entities, provider forums, and CBHI mass emails. 
MassHealth will send a transmittal letter explaining these requirements to MassHealth fee-
for-service providers when the CANS regulations become effective. 

b. Assessment typically commences with a clinical intake process. As noted, Defendants 
will require MassHealth providers to use the CANS as a standardized tool to organize 
information gathered during the assessment process. Defendants will require trained 
MassHealth behavioral health providers to offer a clinical assessment to each child 
who appears for treatment, including a diagnostic evaluation from a licensed clinician. 
MassHealth has required its managed care entities to ensure that assessments using the 
CANS tool are provided by clinicians trained and certified on the use of the CANS tool. 
MassHealth-contracted providers of behavioral health services will also be required to ensure 
that behavioral health clinicians who utilize the CANS are certified in the use of the CANS 
tool. To be certified, clinicians are required to pass a certification examination that has been 
approved by John Lyons. Clinicians who fail to attain a passing score have the opportunity 
to retake the certification examination. Recertification is required every two years. 


The Defendants executed an Interdepartmental Service Agreement (ISA) with the 
Commonwealth Medicine Division of the University of Massachusetts to assist in 
developing the CANS certification training and examination program, in collaboration and 
consultation with Dr. John Lyons. The training program includes both in-person trainings 
with continuing education unit (CEU) credits and also a web-based training opportunity. 

The Defendants started providing the in-person trainings in May, 2008. The web-based 
training became available in July, 2008. In-person training continues to be offered multiple 
times per week, including weekends, at locations across the state. Total in-person training 
sessions to date are 256, including 183 sessions at provider locations and 73 sessions at 
public locations. 

It is impossible to determine the precise, unduplicated number of behavioral health clinicians 
that will use the CANS because, among other things, contracted providers are often entities 
such as mental health centers and hospital outpatient departments rather than individual 
clinicians. However, the Defendants estimated the total number of individual clinicians 
eligible for training and certification, including those employed or under contract to entities 
to be between five and six thousand. As of November 20, 2008, the number of clinicians 
trained and certified already exceeded these estimates. As of that date, 6,606 clinicians had 
registered for training, 4,692 clinicians had received in-person training, and 1,195 clinicians 
had received training via the Web-based training. In total, 5,887 clinicians had received 
training. In addition, 4,668 have become CANS certified. 

To illustrate the intensity of current training efforts: during the one week ending November 
6, 2008, 370 clinicians were trained and 342 were certified. At the current rate, the 
Defendants will have trained close to 7,000 clinicians and certified over 5,000 clinicians 
before November 30, 2008. Defendants will continue to offer in-person and Web-based 
training as needed going forward. 

c. The assessment process leads to a clinical diagnosis and the commencement of 
treatment planning. During the assessment process, medically necessary services are 
available to the child, including, but not limited to, crisis services and short-term home 
based services, pending completion of the assessment and the development of the 
treatment plan. 
The assessment process, as described in paragraphs 15 and 16.a above, will lead to a clinical 
diagnosis and the commencement of treatment planning. While the assessment process and 
treatment planning process is underway, medically necessary MassHealth-covered services 
will be available. 

d. As described in more detail in Section I.C. below, upon referral to the Intensive Care 
Coordination process, an intensive, home-based assessment and treatment planning 
process will take place, organized by a care manager and with the involvement of the 
child’s family and other community supports. 

Providers of Intensive Care Coordination will utilize the CANS tool as part of the intensive 
home-based assessment and treatment planning process. 

e. The assessment process described here, including the use of the CANS where 
appropriate, will be required as part of discharge planning for children who have been 
identified as having behavioral health problems who are being discharged from acute 
inpatient hospitals, community based acute treatment settings (CBATS), from 
Department of Mental Health (DMH) intensive residential settings, and DMH 
continuing care programs, with the goal of identifying children for whom Intensive 
Care Coordination services may be appropriate. For those identified children, a 
referral for those services will be a component of a discharge treatment plan. 
The Defendants are requiring that MassHealth fee-for-service providers use the CANS for 
members under the age of 21 as a part of the discharge planning process from acute inpatient 
hospitals, chronic disease and rehabilitation inpatient hospitals, and psychiatric inpatient 
hospitals. 

The Defendants are requiring that MBHP and the MCOs require the use of the CANS for 
members under the age of 21 as part of the discharge planning process from psychiatric 
inpatient hospitalizations and from community-based acute treatment (CBAT) settings, 
including intensive community-based acute treatment (ICBAT) settings. 

Effective November 1, 2008, the Department of Mental Health implemented the use of the 
CANS as part of the discharge process from intensive residential and continuing care 
programs for all DMH clients under the age of 21. 

Paragraph 17: Deleted. 

Paragraph 18: Deleted. 

Paragraph 19: The Defendants will provide Intensive Care Coordination to children who 
qualify based on the criteria set forth above and who choose to have Intensive Care 
Coordination including a Care Manager, who facilitates an individualized, child-centered, 
family focused care planning team, as follows: 

This paragraph is introductory; see detailed response below. 

Paragraph 20: The role of the Care Manager is to coordinate multiple services that are 
delivered in a therapeutic manner, allowing the child to receive services in accordance with 
his or her changing needs. Additionally, the Care Manager is responsible for promoting 
integrated services, with links between child-serving agencies and programs and mechanisms 
for planning, developing, and coordinating services. 

See response to paragraph 38 below. 


Paragraph 21: The basic responsibilities of Care Managers are: (1) assisting in the 
identification of other members of the care planning team; (2) facilitating the care planning 
team in identifying the strengths of the child and family, as well as any community supports 
and other resources; (3) convening, coordinating, and communicating with the care planning 
team; (4) working directly with the child and family; (5) collecting background information 
and plans from other agencies, subject to the need to obtained informed consent; (6) 
preparing, monitoring, and modifying the individualized care plan in concert with the care 
planning team; (7) coordinating the delivery of available services; (8) collaborating with other 
caregivers on the child and family’s behalf; and (9) facilitating transition planning, including 
planning for aftercare or alternative supports when in-home support services are no longer 
needed. 

See response to paragraph 38 below. 

Paragraph 22: The Care Manager will either be a licensed mental health professional or will 
provide care management under the supervision of a licensed mental health professional. S/he 
will be trained in the “wraparound” process for providing care within a System of Care. The 
“wraparound process” refers to a planning process involving the child and family that results 
in a unique set of community services and natural supports individualized for that child to 
achieve a positive set of outcomes. The System of Care is a cross-system coordinated network 
of services and supports organized to address the complex and changing needs of the child. 
This process will be consistent with the principles and values of the Child-Adolescent Services 
System Program (CASSP) which encourages care provision to be strength-based, 
individualized, child-centered, family-focused, community-based, multi-system, and culturally 
competent. 

See response to paragraph 38 below. 

Paragraph 23: The care planning team will be family-centered and include a variety of 
interested persons and entities, as appropriate, such as family members (defined as any 
biological, kinship, foster and/or adoptive family member responsible for the care of the child), 
providers, case managers from other state agencies when a child has such involvement, and 
natural supports such as neighbors, friends, and clergy. 

See response to paragraph 38 below. 

Paragraph 24: The care planning team will use multiple tools, including a CANS 
standardized instrument, in conjunction with a comprehensive psychosocial assessment, as 
well as other clinical diagnoses, to organize and guide the development of an individualized 
plan of care that most effectively meets the child’s needs. This plan of care will be reviewed 
periodically and will be updated, as needed, to reflect the changing needs of the child. As part 
of this process, further assessments, including re-assessments using the CANS or other tools, 
may be conducted so that the changing needs of the child can be identified. 

See response to paragraph 38 below. 


Paragraph 25: 
The care planning team will exercise the authority to identify and arrange for all medically 
necessary services needed by the eligible child with SED, consistent with the overall authority 
of MassHealth to establish reasonable medical necessity criteria, set reasonable standards for 
prior authorization, and conduct other utilization management activities authorized under the 
Medicaid Act, and the obligation of all direct service providers to assure that the services they 
deliver are medically necessary. 

See response to paragraph 38 below. 

Paragraph 26: The findings of the care planning team will be used to guide the treatment 
planning process. The individualized care plan is the primary coordinating tool for therapeutic 
interventions and service planning. The care planning team, facilitated by the Care Manager, 
will be responsible for developing and updating, as needed, the individualized care plan that 
supports the strengths, needs, and goals of the child and family and incorporating information 
collected through initial and subsequent assessment. The individualized care plan will also 
include transition or discharge plans specific to the child’s needs. 

See response to paragraph 38 below. 

Paragraph 27: The care and treatment planning process will be undertaken pursuant to 
guidelines and standards developed by EOHHS, which will ensure that the process is 
methodologically consistent and appropriately individualized to meet the needs of the child 
and family. EOHHS, in consultation with DMH, will develop an operational manual that 
includes these guidelines and standards for the use of the care planning teams. 

The Defendants will develop an operations manual for providers of Intensive Care Coordination 
during the Spring of 2009. 

Paragraph 28: Each individualized care plan will: (1) describe the child’s strengths and 
needs; (2) propose treatment goals, objectives, and timetables for achieving these goals and 
objectives, including moving to less intensive levels of service; (3) set forth the specific services 
that will be provided to the child, including the frequency and intensity of each service; (4) 
incorporate the child and family’s crisis plan; and (5) identify the providers of services. 

See response to paragraph 38 below. 

Paragraph 29: Individualized care plans will be reviewed as needed, but at least monthly by 
the Care Manager and quarterly by the care planning team. In addition, such review will be 
undertaken when there is a change in another EOHHS agency’s plan for the child. 

See response to paragraph 38 below. 

Paragraph 30: Intensive care coordination services are particularly critical for children who 
are receiving services from EOHHS agencies in addition to MassHealth. In order to assure 
the success of the care planning team process and the individualized care plan for a child with 


multiple agency involvement, EOHHS will ensure that a representative of each such EOHHS 
agency will be a part of the child’s care planning team. Operating pursuant to protocols 
developed by EOHHS, EOHHS agency representatives will coordinate any agency-specific 
planning process or the content of an agency-specific treatment plan as members of the care 
planning team. EOHHS will develop a conflict-resolution process for resolving disagreements 
among members of the team. 

The Defendants are in the process of developing policies and protocols with each of EOHHS’ 
child-serving agencies covering referral to remedy services, participation by state agency staff on 
care planning teams and coordination of agency-specific planning processes with the ICC care 
planning process. 

Paragraph 31: For MassHealth Members entitled to EPSDT services, the Defendants will 
cover the following services for Members who have SED when such services are medically 
necessary, subject to the availability of Federal Financial Participation (“FFP”) under 42 

U.S.C. § 1396d(a) and other requisite federal approvals: assessments, including the CANS 
described in Section I.B above, the Intensive Care Coordination and Treatment Planning 
described in Section I.C above, and the services described in more detail below in this Section 
I.D. More detailed service descriptions will be developed later to assist in establishing billing 
codes, procedures and rates, and may be necessary or advisable for the process of seeking 
CMS approval of these services. EOHHS, in consultation with DMH, will collaborate with 
interested stakeholders (including clinical experts, child and family advocates, and managed 
care partners) in the development of clinical criteria for each of the covered services below. 
See response to paragraph 38 below. 

Paragraph 32: The components of this service category will include Mobile Crisis 
Intervention and Crisis Stabilization: 

a. Mobile Crisis Intervention -A mobile, on-site, face-to-face therapeutic response to a 
child experiencing a mental health crisis for the purpose of identifying, assessing, 
treating, and stabilizing the situation in community settings (including the child’s 
home) and reducing the immediate risk of danger to the child or others. Mobile crisis 
services may be provided by a single professional crisis worker or by a team of 
professionals trained in crisis intervention. Services are available 24 hours a day, 7 
days a week. Phone contact and consultation may be provided as part of the 
intervention. Providers are qualified licensed clinicians or, in limited circumstances, 
qualified paraprofessionals supervised by qualified, licensed clinicians. 
FN Text: Where provider qualifications appear in the description of the services in this 
section of the Judgment, the following applies: As used in this Judgment, the terms 
“qualified, licensed clinician” and “qualified paraprofessional” refer to individuals 
with specific licensure, education, training, and/or experience, as will be set forth in 
standards to be established by the Defendants. Such individuals will be authorized to 
provide specific services referred to herein. A licensed clinician is an individual 
licensed by the Commonwealth to provide clinical services within a particular scope as 


defined by the applicable licensing authority or statute, including, but not necessarily 
limited to, physicians, psychiatrists, licensed clinical psychologists, licensed 
independent clinical social workers, licensed clinical social workers, and licensed 
mental health counselors. A paraprofessional is an individual who, by virtue of 
certification, education, training, or experience is qualified to provide therapeutic 
services under the supervision of a licensed clinician. 

See response to paragraph 38 below. 

b. Crisis Stabilization - Services designed to prevent or ameliorate a crisis that may 
otherwise result in a child being hospitalized or placed outside the home as a result of 
the acuity of the child’s mental health condition. Crisis stabilization staff observe, 
monitor, and treat the child, as well as teach, support, and assist the parent or 
caretaker to better understand and manage behavior that has resulted in current or 
previous crisis situations. Crisis stabilization staff can observe and treat a child in 
his/her natural setting or in another community setting that provides crisis services, 
usually for 24-72 hours but up to 7 days. Crisis stabilization staff are qualified licensed 
clinicians and qualified paraprofessionals supervised by qualified licensed clinicians. 
Crisis stabilization in a community setting is provided by crisis stabilization staff in a 
setting other than a hospital or a Psychiatric Residential Treatment Facility (PRTF) 
and includes room and board costs. 
See response to paragraph 38 below. 

Paragraph 33: The components of this service category are In-Home Behavioral Services 
(including behavior management therapy and behavior management monitoring), In-Home 
Therapy Services (including a therapeutic clinical intervention and ongoing training and 
therapeutic support), and Mentor Services (including independent living skills mentors and 
child/family support mentors). While the services in this category may be provided where 
clinically appropriate, it is intended that they be provided in any setting where the child is 
naturally located, including, but not limited to, the home (including foster homes and 
therapeutic foster homes), child-care centers, respite settings, and other community settings. 
These services may be provided as a bundled service by a team or as a discrete clinical 
intervention depending upon the service needs of the child. 

See response to paragraph 38 below. 

a. In-home Behavioral Services - Behavioral services usually include a combination of 
behavior management therapy and behavior management monitoring, as follows: 
(i) Behavior management therapy is provided by a trained professional, who assesses, 
treats, supervises, and coordinates interventions to address specific behavioral 
objectives or performance. Behavior management therapy addresses challenging 
behaviors which interfere with the child’s successful functioning. The therapist 
develops and monitors specific behavioral objectives and interventions, including a 
crisis-response strategy, that are incorporated into the child’s treatment plan. The 

therapist may also provide short-term counseling and assistance, depending on the 
child’s performance and the level of intervention required. Behavior management 
therapy is provided by qualified licensed clinicians. 

(ii) Behavior management monitoring is provided by a trained behavioral aide, who 
implements and monitors specific behavioral objectives and interventions developed 
by the behavior management therapist. The aide may also monitor the child’s 
behavior and compliance with therapeutic expectations of the treatment plan. The 
aide assists the therapist to teach the child appropriate behaviors, monitors 
behavior and related activities, and provides informal counseling or other 
assistance, either by phone or in person. Behavior management monitoring is 
provided by qualified paraprofessionals supervised by qualified licensed clinicians. 
See response to paragraph 38 below. 

b. In-home Therapy Services – Therapy services include a therapeutic clinical 
intervention and ongoing training and therapeutic support, as follows: 
(i) A structured, consistent, therapeutic relationship between a licensed clinician and 
the family and/or child for the purpose of meeting specific emotional or social 
relationship issues. The licensed clinician, in conjunction with the care planning 
team, develops and implements therapy goals and objectives which are 
incorporated into the child’s treatment plan. Clinical services are provided by a 
qualified licensed clinician who will often work in a team that includes a qualified 
paraprofessional who is supervised by the qualified licensed clinician. 
(ii) Ongoing therapeutic training and support to the child/adolescent to enhance social 
and communication skills in a variety of community settings, including the home, 
school, recreational, and vocational environments. All services must be directly 
related to the child’s treatment plan and address the child’s emotional/social needs, 
including family issues related to the promotion of healthy functioning and 
feedback to the family. This service is provided by a qualified paraprofessional who 
is supervised by the qualified licensed clinician. This paraprofessional may also 
provide behavior monitoring as described above. 
See response to paragraph 38 below. 

c. Mentor Services – Mentor services include: 
(i) Independent Living Skills Mentors provide a structured, one-to-one relationship 
with an adolescent for the purpose of addressing daily living, social, and 
communication needs. Each adolescent who utilizes an Independent Living Skills 
Mentor will have independent living goals and objectives developed by the 
adolescent and his/her treatment team. These goals and objectives will be 
incorporated into the adolescent’s treatment plan. Mentors are qualified 
paraprofessionals and are supervised by a qualified licensed clinician. 

(ii) Child/Family Support Mentors provide a structured, one-to-one relationship with a 
parent(s) for the purpose of addressing issues directly related to the child’s 
emotional and behavioral functioning. Services may include education, support, 
and training for the parent(s) to address the treatment plan’s behavioral health 
goals and objectives for the child. Areas of need may include parent training on the 
development and implementation of behavioral plans. Child/Family Support 
Mentors are qualified paraprofessionals and are supervised by a licensed qualified 
clinician. 
See response to paragraph 38 below. 

Paragraph 34: The Defendants will systematically execute the program improvements 
described in Sections I.A-D above, including a defined scheme for monitoring success, as 
follows. The description below of the steps that Defendants will take to implement this 
Judgment is subject to modification during the course of implementation in accordance with 
Section II below. 

This paragraph is introductory; see detailed response below. 

Paragraph 35: The Defendants will implement this Judgment as a dynamic process involving 
multiple concurrent work efforts. Those efforts will be organized into four main projects, 
described below, which encompass all aspects of the program improvements contained in this 
Judgment. This Judgment assigns a timelines for implementing each project, which are 
subject to modification for good cause upon application of either party. It is important to note 
that certain elements of each project are subject to external factors that are not fully within the 
control of EOHHS. 

This paragraph is introductory; see detailed response below. 

Paragraph 36: Project 1: Behavioral Health Screening, Informing, and Noticing 
Improvements: 

a. Project Purpose: Implementation of improvements to behavioral health screening and 
clear communication of new requirements about the use of standardized screening 
tools. 
This section is a purpose statement, and requires no response. 

b. Tasks performed will include: 
(i) Developing and announcing a standardized list of behavioral health screening 
tools. 
(ii) Drafting managed-care or provider contract amendments and regulatory changes 
to conform to the new requirements. 

(iii)Improving EPSDT Member notices concerning the availability of behavioral 
health and other EPSDT screening, and the availability of behavioral health 
services. 
For a response to subparagraph i.), see in the response to paragraphs 6 and 8 above. 

For a response to subparagraph ii.), see the response to paragraphs 4, 5(b), 6(d),(g), and (h) 
above. 

For a response to subparagraph iii.), see the response to paragraph 3 above. 

c. Timelines for implementation: 
(i) Defendants will submit to the Court a written report on the implementation of 
Project 1 no later than June 30, 2007. 
(ii) Completion of this project will be by December 31, 2007. 
The Defendants submitted a report dated June 27, 2007, that fulfilled the requirement in 
subpart i. The Defendants took the steps described in paragraphs 2-12 above to complete 
this project. 

Paragraph 37: Project 2: CANS Development, Training and Development 

a. Project Purpose: To design a statewide common assessment information gathering 
tool, the CANS, for statewide use, and to train behavioral health providers in its 
appropriate use. 
This section is a purpose statement, and requires no response. 

b. Task performed will include: 
(i) developing a Massachusetts-specific short and long form CANS in conjunction 
with Developer John Lyons; 
(ii) training behavioral health providers to complete and use the CANS tool, 
including EOHHS-required data gathering techniques; and 
(iii) drafting managed-care and provider contract amendments and regulatory 
changes to conform with the new requirements. 
See the response to paragraphs 15-16 above. 

c. Timelines for implementation: 
(i) Defendants will submit to the Court a preliminary report with regard to the 
completion of Project 2 no later than November 30, 2007; and 
(ii) Completion of this project will be by November 30, 2008. 

The Defendants submitted a report dated November 30, 2007 that fulfilled the requirement in 
subpart i. 

As described in paragraphs 14-16, the Defendants will substantially complete this project by 
November 30, 2008, as required by subpart ii. The Defendants have amended managed care 
entity contracts to require the provision of assessments including the CANS effective 
November 30, 2008. The proposed regulations for fee-for-service providers were published 
and the public comment period for these regulations ended on November 21, 2008. Final 
regulations will be published accordingly. Fee-for-service providers, including mental health 
centers and psychiatrists, can begin to claim an enhanced rate for assessments that include 
the CANS provided on or after November 30, 2008. 

Paragraph 38: Development of a Service Delivery Network 

a. Project Purpose: Plan, design, and contract for a service delivery network to deliver 
the services described in this Judgment. 
This section is a purpose statement, and requires no response. 

b. Basic Project Description: EOHHS, and DMH, will engage in a process of network 
design and development that is directed and managed by EOHHS and DMH toward 
establishing a statewide network of community service agencies (“CSAs”), common 
across all MassHealth payers, to the extent feasible, and responsible for coordinating 
and providing or arranging for medically necessary home-based services. 
Although a number of mechanisms are available to EOHHS, and DMH, to design and 
approve this system, the initial, phased network development process will be 
implemented through the existing Medicaid managed care behavioral health contractor 
under the direction of EOHHS in consultation with DMH. EOHHS, and DMH, will 
establish standards for CSAs that will include provider qualifications, service delivery 
standards, training requirements, documentation requirements, utilization 
management standards, and performance measures. EOHHS will amend its managed 
care behavioral health contract to require the behavioral health contractor to procure a 
network of CSAs that meets the standards established by EOHHS, and DMH. 

CSAs will be providers included in the networks of MassHealth’s contracted managed 
care entities and its fee-for-service network. All MassHealth payers, including 
MassHealth’s managed care organizations (“MCOs”) and the managed care 
behavioral health contractor, will offer to contract with the same entities as CSAs, 
subject to successful negotiations and EOHHS’ determination that such entities have 
the capacity to serve the managed care entities’ expected MassHealth enrollment. The 
current expectation is that the Medicaid fee-for-service population will have access to 
the same providers as the Medicaid managed care population. 

CSAs will operate in service areas that will be defined by EOHHS, and DMH, with the 
following objectives in mind: that CSA service areas be generally consistent with DMH 


sites; that they promote consistency with DSS Family Networks provider areas; that 
they promote consistency, capacity, and efficiency; that they reflect linguistic or 
cultural characteristics, as appropriate; and that they reflect natural service areas. The 
current expectation is that there will be one CSA in each area so 21 defined, and that in 
total there will be no fewer than 15, and may be as many as 30, CSA service areas. The 
Defendants will consider defining regions for certain functions. 

CSAs may deliver the clinical assessment services described above in Section I.B.1 and 
the intensive care coordination services described above in Sections I.B.2 and I.C. 
CSAs will either deliver or, as a component of intensive care coordination, assist 
MassHealth Members to access the services described above in Section I.D. CSAs will 
be responsible for assisting Members to access all services described in this Judgment 
that they do not themselves provide. 

Subject to CMS approval, discussed more completely in Section c.iv, below, MassHealth 
is taking the following the following steps to implement delivery of services described in 
the Order: 

Selection of Community Service Agencies: Delivery of Intensive Care Coordination and 
Parent/Caregiver Peer-to-Peer Support 

The Massachusetts Behavioral Health Partnership (MBHP) issued a request for responses 
(RFR) for Community Service Agencies (CSAs) on October 24, 2008. The RFR was 
developed in accordance with service specifications required by EOHHS, which 
consulted with DMH and received input from the CBHI Advisory Council, the Plaintiffs, 
the Monitor and the Monitor’s consultants. 

Bidders have until January 6, 2009 to respond to the RFR. MBHP, in collaboration with 
the MCOs, will select the CSAs by the end of February 2009. MassHealth will require 
all MCOs to offer to contract with the selected CSAs. 

There will be one CSA selected for each of the 29 Department of Children and Families 
(DCF) service areas. In addition, MBHP may select up to three additional culturally- or 
linguistically-focused CSAs who will be allowed to focus on certain populations and 
enroll children and youth from an areas beyond the service area in which they are located. 

The Defendants will directly provide initial training and one year of Wraparound 
coaching to each of the CSAs. 

MassHealth is requiring its managed care entities to provide Intensive Care Coordination 
and Parent/Caregiver Peer-to-Peer Support Services through the CSAs as of June 30, 
2009, provided that CMS has approved the Defendants’ State Plan Amendment. 

Selection of Mobile Crisis Intervention Providers 


MassHealth has decided to utilize Emergency Services Providers (ESPs) to provide 
Mobile Crisis Intervention services and, for youths ages 18 through 20, Crisis 
Stabilization services. MBHP has been directed to re-procure its network of ESP 
providers and incorporate the requirements of the Judgment for Mobile Crisis 
Intervention Services and Crisis Stabilization Services. ESPs will be selected by MBHP, 
using provider qualifications established by DMH and MassHealth. MassHealth is 
requiring the MCOs to contract with MBHP’s selected network of ESPs. 

MassHealth is requiring its managed care entities to provide Mobile Crisis Intervention 
Services and, for youths ages 18 through 20, Crisis Stabilization Services as of June 30, 
2009, provided that CMS has approved the Defendants’ State Plan Amendment. 

Network Development for All Other Remedy Services 

MBHP and the MCOs will be required to provide In-Home Behavioral Services, In-
Home Therapy Services, Crisis Stabilization Services for children and youth ages 0 
through 17, and Therapeutic Mentor Services, provided CMS has approved the 
Defendants’ State Plan Amendment. 

Service Definitions and Specifications for All Remedy Services 

MassHealth requires managed care entities to provide MassHealth covered services, 
including Remedy Services in accordance with service definitions and specifications that 
MassHealth establishes. The Defendants completed service definitions and specifications 
for all of the remedy services were completed in September 2008. They were developed 
with extensive input from the Plaintiffs and the Monitor’s consultants. MassHealth will 
amend the managed care entity contracts to incorporate the required service definitions 
and specifications. 

Utilization Management, Quality Management and Network Management 
MassHealth currently requires its managed care entities to provide all services in 
accordance with MassHealth’s medical necessity regulation (130 CMR 450.204). In 
addition, MassHealth intends to require its managed care entities to utilize common 
Medical Necessity Criteria (MNC) for the remedy services. Final MNC guide providers 
as they determine the medical necessity of a remedy service for a child or youth on 
MassHealth and are used by MBHP and the MCOs to review providers’ determinations 
of medical necessity as a part of utilization management activities. MassHealth has 
developed proposed MNC for each of the remedy services with extensive input from the 
Plaintiffs and the Monitor’s consultants. The Defendants have asked for a child 
psychiatrist with System of Care experience to be added to the Monitor’s consultants. In 
addition, the Defendants will be reviewing the proposed MNC with clinicians practicing 
in the community settings. Both the child psychiatrist and the community clinicians will 
help the Defendants to evaluate the accuracy of the MNC in describing children and 
youth with a medical need for the specific remedy services. 


The Defendants hope to complete work on the MNC by the end of February 2009. 
MassHealth will work with the MCOs and MBHP throughout the Winter of 2008/2009 to 
amend contracts in order to require coordinated approaches to utilization management, 
quality management and network management. 

c. Tasks performed will include: 
i) Designing delivery system approaches that maximize access to services, taking 
into consideration the availability and willingness of providers to provide the 
services. 

As described in paragraph 6.g and in paragraph 38.c.ii, the Defendants have met with 
providers in a variety of venues to discuss many delivery system design issues, including 
those related to access such as service specifications and provider and staff 
qualifications. At the beginning of the design process, the Defendants issued a Request 
for Information, soliciting stakeholder input on a number of delivery system design 
issues. The design has been developed paying careful attention to the issues of access 
and availability of providers. Responses received through the RFI validated the basic 
design approach. Workforce availability remains a great concern for providers, 
advocates and purchasers, including MassHealth. See the response to Paragraph 38.c.iii 
below. 

ii) Engaging in a public process to involve stakeholders in the development of the 
network and services. 

The Defendants continue to rely on the Children’s Behavioral Health Advisory Council, 
a large multi-stakeholder group chaired by the Commissioner of the Department of 
Mental Health, for advice and counsel on critical design issues. The Council also has two 
sub-committees, a Clinical Sub-Committee and an Outcomes Sub-Committee. 

The Defendants also have held meetings with provider organizations and with families 
and family organizations, as described in paragraphs 5.d and 6.g, to get input on service 
design. 

iii) Planning concerning anticipated need and provider availability. 

Start-up training 

The Defendants will be providing initial group training and twelve months of staff 
coaching to providers of Intensive Care Coordination, In-Home Therapy and Mobile 
Crisis Intervention. On November 21, 2008, the Defendants released a new Request for 
Information regarding training. The Defendants currently plan to issue a Request for 
Responses (RFR) soliciting bids for portions or all of the training contract in late 
December. 

Workforce Development 


Given that staffing the current behavioral health system is an ongoing challenge for 
behavioral health provider agencies, the Defendants know that workforce availability is 
key to successful implementation of the remedy services. There are a number of 
initiatives that have take place since the last court report to address this issue, including: 

• On November 14, 2008. the Defendants convened a one-day intercollegiate Faculty 
Retreat whose goals were: (1) to provide an overview of the significant change 
process underway in the public children’s behavioral health system in Massachusetts; 
(2) to provide an in-depth introduction to the research base and “best practices” for 
Systems of Care and Wraparound Practice; and (3) to facilitate exploration of the 
potential implications for clinical education, informed by models and resources from 
other states. Over 20 schools, representing clinical preparation programs in social 
work, psychology, nursing, education and medicine, attended the retreat. The 
Defendants used the retreat to propose a Higher Education Curriculum Initiative, in 
which the state would partner with clinical programs in order to integrate into 
clinical education both research and best practices in Systems of care for youth with 
emotional disorders and their families, Wraparound practice, and the reduction of 
health care disparities. Featured speaker, Carol MacKinnon-Lewis, PhD, Director of 
the System of Care Curriculum Initiative at the University of South Florida, provided 
an overview of how other colleges/universities and states have collaborated across 
disciplines and departments to create new courses and infuse existing courses with 
Systems of Care Principles. Following her presentation, each school’s delegation of 
faculty met during breakout sessions to begin discussing how they could apply 
Systems of Care principles and CBHI values their existing curriculum and collaborate 
across disciplines and departments. The Defendants will host a follow up meeting 
with faculty in January 2009 and will convene a conference in April 2009 for both 
students and faculty. At this later conference, faculty and students will be introduced 
to career opportunities within the CBHI and child-serving state agencies, and will 
participate in experiential learning workshops on such topics as conducting a 
strengths-based assessment, exploring cultural identity, and facilitating a Wraparound 
team. The spring conference will also feature tracks for faculty in order to continue 
the work from the November 2008 faculty retreat. 
• In May 2008 the Defendants entered into an Interdepartmental Service Agreement 
with the Commonwealth Corporation (CC), a quasi-public entity that works closely 
with the Commonwealth’s Executive Office of Labor and Workforce Development. 
Through this ISA, CC is facilitating the development of a curriculum designed to 
train paraprofessionals who will be qualified, as members of a team lead by a 
clinician, to deliver In-Home Behavioral Services, In-Home Therapy Services, 
Caregiver Peer to Peer Support, and Therapeutic Mentoring. CC has been 
researching and defining competencies in consultation with a working group of 
consumers, providers, and educators. The result of this group will be a written set of 
competencies to guide the development of curriculum at the community college level 
that would count toward Associate’s and Bachelor’s degree credits. Meanwhile, CC 
has identified a core group of community colleges interested in collaborating in the 
creation of courses and/or certificates that would prepare individual to work in the 
above services. These potential partners offer Associate’s degrees in concentrations, 

such as human services, early childhood development and early intervention, in 
which the proposed courses and/or certificates could easily fit. The proposed 
outcomes of this collaboration are: (1) the creation of career pathways for individuals 
entering the behavioral health workforce at the entry level in a professional role; (2) 
the adequate preparation of a workforce who will be able to deliver services in a 
strength-based, family-driven system of care; and (3) the diversification of the 
behavioral health workforce. 

• MBHP is holding informational meetings around the state for prospective Family 
Partners (who deliver “Peer-to-Peer Caregiver Support”). MBHP is working with the 
Parent/Professional Advocacy League (PAL) to conduct these meetings. The purpose 
of these meetings is to educate parents of children with behavioral health needs 
about: the potential increase in employment opportunities for Family Partners through 
the remedy’s Family/Caregiver Peer-to-Peer Support service; the required 
competencies; and opportunities for training. In addition, it is currently anticipated 
that PAL will be contacting community organizations in minority communities to 
partner with them to explore the possibilities for Family Partners in these 
communities. 
iv) Working with CMS to obtain approval of services to be offered and of managed 
care contracting documents. 

On March 24, 2008, the Defendants submitted two State Plan Amendments (SPAs) for 
review and approval by the Centers of Medicare and Medicaid Services (CMS). One 
SPA proposes to amend the Targeted Case Management (TCM) portion of the State Plan 
(the TCM SPA) and the other proposes to amend the State Plan to add the Remedy 
services other than ICC as “EPSDT” services (the EPSDT SPA). 

Prior to submission, MassHealth requested a meeting with CMS Central Office and 
Regional Office staff to brief them on this case, the Judgment and the proposed State 
Plan Amendments. 

On June 17 and 18, CMS issued Requests for Additional Information (RAIs) on both the 
TCM SPA and the EPSDT SPA. The RAIs focused on clarifying exactly what activities 
would be performed in each of the services and who would be qualified to perform them. 

The Defendants submitted written responses to the RAIs by the deadline of September 
15 , 2008. The RAI responses were reviewed by the Plaintiffs and Monitor’s consultants 
prior to submission. 

The Defendants and CMS have had two phone calls and have additional calls scheduled. 
The calls continue to explore details of service activities, qualifications of providers and 
rate methodologies for both SPAs. 

The Defendants have responded to CMS’ clarifying questions regarding our written 
response to CMS’ RAI on the TCM SPA. We have also submitted a rate methodology 


for the TCM service. This SPA is on track for a decision within the prescribed timeframe 
of 90 days from CMS’ receipt of the Defendants RAI response. 

In follow-up telephone conferences following the Defendants’ RAI response on the 
EPSDT SPA, CMS raised a number of questions and concerns about the services 
described. In general, CMS has stated that the services appear to overlap each other and 
they have requested further explanation from the Defendants about how the services are 
different from each other. In particular, CMS has raised concerns about whether federal 
financial participation is available for the Parent/Caregiver Peer-to-Peer Support Service 
and the Crisis Stabilization Service In addition, the Defendants’ response to the RAI on 
the EPSDT SPA did not include rate methodologies for the EPSDT services because the 
rate development could not be completed until the service specifications were complete. 
CMS asked MassHealth to withdraw its written responses to the RAI, in order to “stop 
the clock” to avoid a denial of the EPSDT SPA so that discussions about both the 
services and rate methods could continue. Accordingly, MassHealth withdrew its RAI 
response on October 21, 2008. MassHealth will re-submit the RAI response once the 
discussions with CMS have concluded. It is unknown at this time whether CMS will 
approve all of the services described in the EPSDT SPA. 

Senior staff responsible for the relationship between EOHHS’ Office of Medicaid and 
CMS are supporting this process, as well as the Monitor’s consultants. 

v) Defining CSA Service Areas. 

See the response to Paragraph 38.b above. 

vi) Defining standards with respect to provider qualifications, service delivery 
standards, training requirements, documentation requirements, utilization 
management standards, and performance measures. 

See the response to Paragraph 38.b above. 

vii) For each service described in Section I.D. above, defining the following: clinical 
criteria (including admission criteria, exclusion criteria, continuing stay criteria, 
and discharge criteria); performance specifications (including service definition 
and philosophy, structural requirements, staffing requirements, service, 
community and collateral linkages, quality management, and process 
specifications); credentialing criteria (for licensed clinicians and 
paraprofessionals); and utilization management standards (prospective and 
retrospective). 

See paragraph 38.b above 

viii) Drafting contract and procurement documents, including the production of a 
detailed data set of contractors and the creation of detailed performance 
standards for contractors and providers. 


See paragraph 38.b above. 

ix) Negotiating contracts, setting rates for new services, and arranging for 
appropriate federal claiming protocols. 

Work is well underway with the Commonwealth’s rate setting agency, the Division of 
Health Care Finance and Policy (DHCFP), to develop fee for service (FFS) rates for the 
remedy services. These rates will be one of the resources used to develop MassHealth’s 
capitation payment to its MCOs and MBHP. 

x) Performing reviews of new service providers to assure readiness to perform 
contract requirements. 

This will be performed by MBHP and the MCOs pursuant to the contract amendments 
negotiated and executed in 2008. 

xi) Designing strategies to educate providers, MassHealth Members, and the general 
public about the new services offered. 

As described in paragraphs 2-7 above, the first phase of this work -- educating providers, 
members, and the general public about standardized behavioral health screening -- is 
now complete. 

The Defendants will revise all relevant communication materials, and use all of the 
communication channels, referenced in these paragraphs as each phase of the remedy is 
implemented. Updated materials will be disseminated prior to implementation of the 
remedy services, as described in paragraphs 2-7 above. 

xii) Designing a system of contract management for managed care contracts that 
includes performance standards or incentives, required reports, required quality 
improvement projects, and utilization management review, administrative 
services, and claims payment protocols. 

The design work is underway by the MassHealth Implementation Team. See the response to 
Paragraph 38.b above for additional detail. 

d. Timeline for implementation: 
i) Defendants will submit to the Court a written report with regard to completion of 
Project 3 no later than November 30, 2007. Further status reports thereafter may 
be required. 

ii) Full implementation of this project will be completed by June 30, 2009. 


The Defendants submitted a report dated November 30, 2007 that fulfilled the requirement in 
subpart i. The Defendants are taking the steps described in paragraphs 19-33 above to 
complete this project by June 30, 2009, as required by subpart ii. 

Paragraph 39: Project 4: Information Technology System Design and Development 

a. Project Purpose: The design and development of a web-based application to facilitate 
identification and monitoring of behavioral health service delivery to children with 
serious emotional disturbance. 
This section is a purpose statement, and requires no response. 

b. Tasks performed will include: 
i) Defining existing system capacities. 
ii) Gathering requirements for new functionality, including assessing whether 
development should be in-house or outsourced. 
iii) Obtaining legislative authorization and funding. 
iv) Drafting contract and procurement documents, including detailed architectural 

standards, privacy standards, and performance standards. 
v) Working with CMS to obtain necessary federal approvals of contracting


documents. 
vi) Issuing an RFR, reviewing responses, and selecting bidder(s). 
vii) Negotiating contract(s). 
viii) Confirming business requirements and technical specifications. 
ix) Performing construction and testing based upon the Unified Process 
x) Provider training development and delivery. In person training and web based 

training will be available. 

EOHHS has initiated development of two web-based applications to support the use of the 
CANS tool and to assist the Defendants to meet reporting requirements with respect to the 
CANS. The steps that the Defendants will take with respect to all other reporting 
requirements are described in Paragraph 46. 

The first CANS application is the CANS Certified Assessor Training and Certification 
Application, which will: (1) permit clinicians to register for face-to-face Certified Assessor 
Training; (2) provide web-based Certified Assessor Training for those that choose not to take 


the face-to-face training, and (3) administer the Certified Assessor Examination, and issue 
credentials to clinicians who pass the examination. 

The second application is the CANS Application, which will allow clinicians to enter client 
CANS and SED determination information into a secure EOHHS database, subject to 
necessary consent, and provide the Defendants data needed for court reporting, and for other 
clinical and administrative purposes. 

Thus far, the Defendants have taken the following steps with respect to the design and 
release of the two systems: 

CANS Certified Assessor Training and Certification Application 

The CANS Certified Assessor Training and Certification Application was developed and is 
currently being hosted through an interagency service agreement with the University of 
Massachusetts. 

The training registration function for face-to-face Certified Assessor Training and the 
Certified Assessor Examination began on May 12, 2008. The web-based Certified Assessor 
Training began in June 2008. 

Behavioral Health clinicians are currently using the Certified Assessor Application to 
register for face-to-face training and to take the Certified Assessor Examination after 
completion of that training. As described in paragraph 16.b, at the current rate, the 
Defendants will have trained close to 7,000 clinicians and certified over 5,000 clinicians 
before November 30, 2008. 

CANS Application 

Defining Existing System Capacities 

During January through March 2007, the Defendants worked with an outside consultant to 
determine whether an enterprise-wide service management (ESM) system currently under 
development for EOHHS would meet the all the reporting requirements of the Judgment. 
After consulting with program managers and IT professionals from MassHealth, EOHHS IT, 
DSS, DYS and DMH to gather high-level system requirements, it was determined that the 
ESM system would not have the required functional capacity. As a result, the Defendants 
decided to develop a web-based CANS Application that, subject to consent from the child or 
the child’s parent, guardian, or custodian, can collect CANS data from MassHealth 
behavioral health providers and providers in the network of MBHP or one of the MCOs over 
the EOHHS Virtual Gateway and share it with the child’s MCO or MBHP, if applicable. 

EOHHS IT next conducted an internal review of existing agency data systems to determine 
if any of these systems could be leveraged to meet the needs of the Judgment. It was 
determined that certain components of the DSS STARS system provide functionality that is 
similar to that which is required to administer the CANS tool. Therefore, the Defendants 
decided to take this system as the starting point for developing the IT platform for the CANS 
Application. 


System Production 

The CANS Application will be produced in two releases. The first release, which is currently 
expected to be in December, 2008, will allow users to develop familiarity with the 
application and will ask them to document certain member demographic information and to 
answer the questions that determine whether a child has a Serious Emotional Disturbance 
(SED). The second release, which is expected in the Spring of 2009, will add the rest of the 
assessment questions from the two versions of the CANS tool. The second release will 
include full reporting functionality for the Defendants and will allow EOHHS to export 
records to clinicians who have performed the CANS and the member’s managed care plan, if 
applicable. Consent from the member, the member’s custodial parent, or another authorized 
individual will be required to add any information other than demographic information and 
the SED determination into the application. 

Virtual Gateway Enrollment 

In order to access the new CANS Application, providers must be enrolled with the Virtual 
Gateway. VG personnel are currently contacting provider organizations to help them 
understand VG enrollment procedures. This process includes having the provider 
organization designate a staff person who can assign and maintain appropriate VG security 
roles. 

Authorization and Funding 

The Defendants have developed a budget for system implementation and obtained the 
necessary funding. 

Procurement and Contracting 

The Defendants are addressing the system design and development by leveraging and 
building on existing information technology resources, including existing information 
technology systems within EOHHS. The Defendants do not anticipate procuring a vendor to 
perform the activities described in this part of the Judgment. 

User Training and Support 

The Defendants are developing materials to assist providers in using the CANS Application. 
These materials will be made available to providers through a number of pathways, 
including through the CBHI website. In addition, VG personnel will provide technical user 
support. 

System Security 

The Virtual Gateway provides a secure, reliable platform that is accessible to people with 
disabilities. 

c. Timelines for implementation 
i) Defendants will submit to the Court a written status report with regard to Project 
4 no later than November 30, 2007.-Complete 


ii) Full completion of this project will be by November 30, 2008. 

The Defendants submitted a report dated November 30, 2007 that fulfilled the requirement in 

subpart i. 

The Defendants are taking the steps described in paragraphs 39-46 to complete this project by 
November 30, 2008, as required by subpart ii. At this time, the defendants anticipate that the 
CANS Application will be produced in two releases as described in paragraph 39.b. The first 
release, which will allow the Defendants to report on the number of CANS assessments 
performed and the number of SED determinations, is currently expected to be available in 
December, 2008. 

Paragraph 40: There are multiple sources of data available to the Medicaid agency and 
multiple methods for data collection. This Judgment outlines a basic data set that, based on 
sound principles of program management, will ultimately provide very useful data that will 
support the agency’s ability to track, monitor and evaluate a system of behavioral health care 
for children with SED. Some of the data points outlined here are presently available or easily 
accessible, while others are not. 

This paragraph is introductory; see response to paragraph 39 above. 

Paragraph 41: The primary source for Medicaid data is MassHealth’s claims payment system, 
known as the Medicaid Management Information System (MMIS). While MMIS can collect 
claims level data on utilization and spending, it is not a good source for much of the data 
required to evaluate the implementation beyond that otherwise necessary for providers to 
claim reimbursement from MassHealth. EOHHS is currently part way through a major multiyear project to develop a replacement MMIS (New MMIS), currently anticipated for 
implementation in August, 2007. 

This paragraph is introductory; see response to paragraph 39 above. 

Paragraph 42: A secondary means of collecting data commonly used in MassHealth program 
management originates from contract requirements, typically of managed care entities. 
MassHealth often requires managed care entities to collect data or report information in a 
particular form as an obligation of the contract. This method of collecting data is not limited 
by the capacities of the MassHealth payment system, but may be hampered by the managed 
care entities’ own system limitations. Any business requirements placed on contractors 
generally require time to make business process changes and systems modifications as well as 
some form of reimbursement of costs. 

This paragraph is introductory; see response to paragraph 39 above. 

Paragraph 43: For detailed clinical and provider performance data, MassHealth’s clinical 
staff and contracted reviewers undertake clinical record reviews. This method of collecting 
data is appropriate in very limited circumstances and is time-intensive and costly. 


This paragraph is introductory; see response to paragraph 39 above. 

Paragraph 44: For collecting and managing all of the data points associated with this 
Judgment, EOHHS will need to develop a new information technology (IT) application. 
Although the Defendants are not required by the Medicaid Act (42 U.S.C. §1396 et seq.) to 
collect this data, EOHHS believes that the data will assist in assessing its performance of the 
requirements of the Judgment, to improve the quality of Medicaid behavioral health services 
for children, and to reassure the Court of success. However, an IT systems development 
project is a significant undertaking. The Defendants will need specific legislative 
authorization and appropriation in order to proceed with an IT project of the size 
contemplated below, since it would involve a capital appropriation and expenditure 
authorization. Following that, the Defendants can engage one or more vendors through a 
competitive procurement process; design business specifications with input from the 
MassHealth provider community; allow time for the vendor to build and test the data 
collections and management system(s); amend provider agreements and contracts, as 
necessary; and train providers to report required information using the new IT application. 
Timetables for such large-scale IT projects usually range from 18-24 months from the time 
that legislative authorization and appropriation is received, and often include multiple rollouts 
of advancing sophistication and breadth to assure that providers can successfully use the 
application and that the data collected is accurate and timely. 

Provider organizations have been notified to set up their Virtual Gateway accounts and to set 
security roles that will provide access to the CANS Application for appropriate end users. A 
support structure has been developed to support the providers during this crucial setup phase. 

Paragraph 45: With these considerations in mind, the Judgment includes the following as a 
preliminary data collection strategy to assess Member access to, and utilization of, 25 EPSDT 
behavioral health screenings, clinical intake assessments, intensive care coordination, 
comprehensive assessments, and intensive home based services. Data points described below 
that are not available from MMIS are conceptual and subject to a complete inventory of the 
business requirements and data elements necessary for creating an appropriate tracking 
system or systems. 

Wherever possible, the Defendants plan to use claims data from MMIS and encounter data from 
the MCOs and MBHP. Encounter data is client- and service-specific data reported by the MCOs 
and MBHP to MassHealth. Claims data is data from the claims that providers who service 
MassHealth members on a fee for service basis submit to MassHealth for reimbursement. 

As explained in more detail in response to paragraph 46 below, there are some measures which 
will require the collection of new data or the combination of new data with existing claims and 
encounter data. 

Paragraph 46: Potential Tracking Measures 

a. EPSDT Behavioral Health Screening 

i) Number of EPSDT visits or well-child visits and other primary care visits. 

ii) Number of EPSDT behavioral health screens provided. An EPSDT behavioral 
health screen is defined as a behavioral health screen delivered by a qualified 
MassHealth primary care provider. 

iii) Number of positive EPSDT behavioral health screens. A positive screen is defined 
as one in which the provider administering the screen, in his or her professional 
judgment, identifies a child with a potential behavioral health services need. 

The Defendants will use MMIS claims data and encounter data to report on all three of these 
measures. There is a lag in time between service provision and claims payment, and also in 
the submission of MCO data to EOHHS; therefore, it is expected that the Defendants will 
have data to test the reporting function in May 2008, and will have a full data set to report to 
the Court Monitor by November 30, 2008. 

More detailed information about each of the three measures follows. 

MassHealth expanded upon an existing report on EPSDT (or well-child) visits and other 
primary care visits provided by primary care providers and added a new programming 
specification to incorporate MCO encounter data in the report. 

The Defendants are reporting on the number of EPSDT behavioral health screens provided 
by implementing a specific code that all primary care providers, including those in an MCO 
network, are using when they bill for behavioral health screens. MassHealth has made 
changes to its own systems and has required MCOs to make system changes necessary to 
report this code. The Defendants have developed the programming for the report from 
MMIS and MCO encounter data. 

The Defendants are reporting on the number of screens identifying a child with a potential 
behavioral health services need through the use of specific “modifiers” that all primary care 
providers, may use when billing the code for the behavioral health screen. MassHealth has 
amended its MCO contracts to require MCOs to utilize this billing code as well. These 
modifiers indicate both the type of provider that performed the screen, as well as whether the 
screening was positive or not. MassHealth has made changes to its own systems and has 
required the MCOs to make system changes necessary to report this code as well. The 
Defendants have developed the programming for the report from MMIS and MCO encounter 
data. 

b. Clinical Assessment 
i) Number of MassHealth clinical assessments performed. A MassHealth clinical 
assessment is defined as any diagnostic, evaluative process performed by a 
qualified MassHealth behavioral health provider that collects information on the 
mental health condition of an EPSDT-eligible MassHealth Member for the 
purposes of determining a behavioral health diagnosis and the need for treatment. 


ii) Number of clinical assessments that meet SED clinical criteria and indicate that the 
Member could benefit from intensive care coordination services. 

The Defendants plan to approach reporting on clinical assessments in two ways. 

The Defendants will first report on the number of assessments through MMIS and encounter 
data. Through work with the Division of Health Care Financing and Policy (DHCFP), the 
MCOs, and MBHP, the Defendants identified a coding strategy for billing and reporting on 
clinical assessments. The Defendants anticipate being able to report on the number of 
assessments using the CANS using claims and encounter data in the Spring of 2009. Because 
the deadline for implementing the clinical assessments is also November 30, 2008, the first 
reports from claims with any substantial amount of data will be produced later. 

In addition to reporting based on claims and encounter data, the Defendants plan to report on 
these measures through the online CANS Application described in paragraph 39.b. This will 
allow behavioral health providers to enter SED determination data and CANS data online. 
The capability to report on the number of assessments performed, and on the number of 
assessments where the child met SED criteria, are built into the CANS Application. Due to 
delays (described above) in implementation of the CANS Application system, Defendants 
anticipate that information on the number of assessments and SED determinations will begin 
to be available by the end of December, 2009. 

c. Intensive Care Coordination Services and Intensive Home-Based Assessment 
i) Number of intensive home-based assessments performed as the first step in 
intensive care coordination. Such assessment processes shall result in the 
completion of a standardized data collection instrument (i.e. the CANS tool). As 
part of the treatment planning process, that standardized tool will be used, and the 
resulting data collected on a Member level at regular intervals. 

ii) Number of Members who receive ongoing intensive care coordination services. 

The Defendants will report on ICC services delivered to new members in a given time 
period, as well as the total number of members who are receiving ongoing ICC services. 
The Defendants plan to report on both of these measures using claims and encounter data by 
using specific codes and modifiers which have been identified by DHCFP. 

Additionally, the Defendants plan to use the data collected using the online CANS 
Application described in paragraph 46.b above to report on the number of assessments 
completed by the ICC team. The Defendants currently are developing these requirements. 

The Defendants plan to have the operational capacity to report on ICC services by the Spring 
of 2009. However, data about ICC will not be available from claims until after the Remedy 
Services have been implemented. 


d. Intensive Home-Based Services Treatment 
i) Member-level utilization of services as prescribed under an individualized care 
plan, including the type, duration, frequency, and intensity of home-based services. 

ii) Provider- and system-level utilization and cost trends of intensive home-based 
services. 

The Defendants are working with the managed care entities to develop the capacity to report 
on the member-level utilization of services as prescribed under an individualized care plan 
by linking claims and encounter data to managed care entity service authorization data, 
which will include the ICC Care Plan for youth enrolled in ICC. 

The Defendants anticipate that the approach developed to meet this requirement will be 
ready for use by the time ICC and in-home services are implemented in June 2009. 

Since members will begin utilizing services only after their initial care plans are developed, 
it is likely that the first reports to contain a significant amount of actual data on utilization of 
services as prescribed, will be ready approximately six months after services are 
substantially implemented. 

e. Child and Outcome Measures - Member-level outcome measures will be established to 
track the behavioral health of an EPSDT-eligible MassHealth Member with SED who 
has been identified as needing intensive care coordination services over time. 
Defendants will consult with providers and the academic literature and develop 
methods and strategies for evaluating Member-level outcomes as well as overall 
outcomes. Member-level outcome measures would be tracked solely for the purpose of 
program improvement and would not be useable as a basis for arguing that Defendants 
are not complying with any order of the Court. 
The Defendants currently are researching potential member-level outcome measures. The 
Defendants will consult with the Children’s Behavioral Health Advisory Council, the 
Monitor and the Plaintiffs as they identify these measures. 

In addition, the Defendants are researching appropriate tools to measure the fidelity of 
clinical practice to the wraparound model. Measuring outcomes without measuring the 
service delivered limits the ability to evaluate the program. 

Because ICC is a long-term, rather than an acute care service, meaningful outcome 
measurement will require members to receive ICC for at least six months before there is any 
initial data on outcomes. Therefore, while the Defendants anticipate having a system in 
place to collect outcome data at the time that the new services for children with SED are 
implemented in June 2009, the first reports on outcomes will not be available for at least six 
months afterwards. 


f. Member Satisfaction Measures - Defendants will develop sampling methods and tools 
to measure Member satisfaction of services covered under this Judgment. Member 
satisfaction would be measured solely for the purpose of program improvement and 
would not be useable as a basis for arguing that Defendants are not complying with 
any order of the Court. 
The Defendants plan to conduct member satisfaction surveys based on a random sample of 
members who have had some experience with the services covered under the Judgment. 
The Defendants intend to contract with a vendor to develop these surveys. 

RESPECTFULLY SUBMITTED, 

MARTHA COAKLEY 
ATTORNEY GENERAL 

/s/ Daniel J. Hammond 
Daniel J. Hammond, BBO #559475 
Assistant Attorney General 
Government Bureau 
One Ashburton Place 
Boston, Massachusetts 02108 

(617) 727-2200, Ext. 2078 
Date: December 1, 2008 

I hereby certify that a true copy of this document was served electronically upon counsel of 
record through the Court’s electronic filing system on today’s date. 

/s/ Daniel J. Hammond 
Daniel J. Hammond 
Assistant Attorney General