What is required?
Within the revised EPSDT/PPHSD regulations (130 CMR 450.140 through 450.150), MassHealth requires primary-care providers (PCPs) to offer to EPSDT and PPHSD screens for members under the age of 21 according to the EPSDT Services Medical Protocol and Periodicity Schedule found in Appendix W of the MassHealth provider manuals, and provide or refer members to assessment, diagnosis, and treatment services, as necessary. These screens include behavioral-health screening. Behavioral-health screening must be conducted using one of the standardized screening tools listed in Appendix W of the MassHealth provider manuals. Providers choose a clinically appropriate tool from the list, based on the age of the child.
Collectively, EPSDT and PPHSD services are the preventive care and treatment services that MassHealth covers for members under the age of 21. MassHealth pays for these members to see their PCPs on a periodic schedule (at least once every year and more often when they are under the age of two). At these visits, PCPs perform a series of health screens. If the screens show that there might be a problem, MassHealth pays for certain further assessment, diagnosis, and treatment services.
Periodic visits are visits to assess a child's health at key points in life to ensure continued healthy development. Appendix W recommends a schedule of visits at the following ages:
- 1-2 weeks;
- at 1, 2, 4, 6, 9, 12, 18, and 24 months; and
- every year afterward until the member turns 21
Interperiodic visits are medically necessary visits between the ages for a periodic visit to determine if a child has an illness or condition or if a child is experiencing a change in a preexisting condition. Interperiodic visits are medically necessary whenever a parent, guardian, PCP, or other clinician (such as a school nurse) thinks that there might be something wrong. These visits may include the full range of components for a periodic visit or a portion of the components that are indicated by the suspected illness, condition, or change in preexisting condition.
What the requirement means for MassHealth members
If members agree to be screened, possible benefits include
- earlier identification of behavioral-health issues;
- earlier diagnosis and treatment of behavioral-health issues;
- increased coordination of care and access to community services; and
- decreased stigmatization of behavioral-health issues.
What the requirement means for primary-care providers
MassHealth requires PCPs to offer to use a standardized behavioral-health screening tool from the list in Appendix W at every EPSDT/PPHSD visit. PCPs choose a clinically appropriate tool from the list, based on the age of the child.
What is a PCP?
PCPs include the following, whether they practice in an individual or group practice, in the outpatient department of a hospital (acute or chronic disease and rehabilitation hospital), or in a community health center.
- physicians: pediatricians, family practitioners, internists, OB/GYNs, and general practitioners;
- independent nurse practitioners; and
- independent nurse midwives.
Physician assistants and nonindependent nurse practitioners and midwives
Nonindependent nurse practitioners, nonindependent nurse midwives, and physician assistants are permitted to conduct screens when they are under a physician's supervision. When they provide screening visits according to Appendix W (EPSDT Periodicity Schedule), the visits are payable to the physician under whose supervision they work.
If a condition is discovered that requires further assessment, diagnosis, or treatment during a visit, the PCP must either:
- provide the necessary follow-up services; or
- refer the member to a specialist.
It is important to note that screening is voluntary; while it must be offered, the family is free to refuse the screening.
What to do when a behavioral-health need is identified
PCP's role when a behavioral-health need is identified
Here you'll find information about what PCPs should do once they have identified a child with a behavioral health need.
Behavioral health needs are identified by providers using a screening tool. If a behavioral health need is discovered that requires further assessment, diagnosis, or treatment during a visit, the PCP must either
- provide the necessary follow-up services; or
- refer the member to a specialist.
The PCP must help the family and member find the recommended services. Assistance is available through the Managed Care Organizations (MCOs), or the Massachusetts Behavioral Health Partnership (MBHP) if the member is enrolled with one of these plans or through the MassHealth Customer Service Center. MassHealth will track visits, screens delivered, and screens with a behavioral-health need identified.
Follow-up in the primary-care setting
- Counseling can be provided "on the spot" during the well-child visit.
- A "second-stage" screening can be conducted for specific issues such as ADHD, anxiety, or depression.
- Written information can be given to patients and families. Many good sources are available, for example, from the:
- Substance-abuse information and assistance can be provided at
Massachusetts Substance Abuse Information and Education or by calling 1-800-327-5050.
- Counseling can be done at a follow-up appointment with the PCP or another clinical staff member.
When a referral is indicated
- Continue to refer to other MassHealth behavioral-health resources.
- If you need assistance, call Massachusetts Child Psychiatry Access Project (MCPAP). The goal of this program is to make child-psychiatry services accessible to PCPs throughout the Commonwealth.
- The MCPAP team consists of a child psychiatrist, a licensed social worker, and a care coordinator.
- A MCPAP team member is accessible by pager from 9 A.M. to 5 P.M., Monday through Friday, and generally returns pages within 30 minutes.
- Services consist of consultation to the PCP and, when indicated, transitional services.
- MCPAP serves all children regardless of insurance status, in six regions across the Commonwealth.
- More information is available on their Web site: www.mcpap.org.
- Other behavioral-health resources can be located by calling the Customer Service office of the Managed Care Organizations (MCO), the Massachusetts Behavioral Health Partnership (MBHP), or MassHealth.
Assistance with managing follow-up of screening results is available from the following.
Suggestions for implementing standardized behavioral-health screening in your practice
The Massachusetts Child Psychiatry Access Project (MCPAP) provides a helpful toolkit for Primary Care Providers on implementing behavioral health screening, which you can access here https://www.mcpap.com/pdf/PCCScreeningToolkitFINAL331909.pdf
Primary-care providers across the nation are using standardized tools to screen for developmental, and behavioral/mental-health concerns, including autism. In Massachusetts, other provider settings are also implementing screening and intervention. Both Early Intervention (birth to 3 years) and Early Education and Care (for children up to 12 years old in preschool, Head Start, or day care) conduct social/emotional screens.
Experience implementing screening using the standardized tools has been documented and shared extensively across the country. The following are the general steps needed to get started:
- Meet as an entire office group to plan for implementation. This is not a project one person can handle alone.
- Identify at least two "screening champions" on staff. One should be a clinician and the other an administrator. They can serve as point persons when others have questions.
- Select the standardized tools you want to use.
- Identify a starting point. You might consider having one clinician start, or start with one particular age group. Or, you might decide to identify one day of the week when all clinicians screen. Expand as staff become accustomed to the process. Alternatively, you may decide it is best to start with all providers.
- Use an implementation guide (suggestions to follow) to identify who is involved in each step of the plan.
- Centralize the community resource information in your office setting so it is readily available to all staff. You might also consider centralizing the screening tools.
- Launch the screening.
- Monitor your progress.
Prepare parents and patients for behavioral-health screening
It is a good idea to prepare parents and patients in advance. A simple way to do this is to put pamphlets in the waiting area and exam rooms to expose parents to the concept of behavioral-health screening. Pamphlets that address the issue of behavioral and mental health are available from the American Academy of Pediatrics (AAP). Inform parents and patients that the screening is voluntary.