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Cañizares M, Unnerstall A, Graaf G. COVID-19 Modifications in Public Home- and Community-Based Services for Children with Mental Health Needs. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2024; 51:85-102. [PMID: 37976019 PMCID: PMC10962056 DOI: 10.1007/s10488-023-01315-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 11/19/2023]
Abstract
Eleven states offer 1915(c) Home and Community Based Services (HCBS) Medicaid waivers to organize and fund programs that provide in-home and community support services to address the unique needs of children and youth with complex mental health concerns and their families. However, as the COVID-19 pandemic-imposed restrictions on community movement and school engagement were enacted, these children and youth lost in-person access to needed supports through school-based programs and professional community providers. The well documented mental health impacts of the pandemic on children and youth necessitates understanding how behavioral health programs and policies were adapted to the constraints of pandemic life for this uniquely at-risk population. This study examines and characterizes trends in modifications made to these programs. Appendix K applications amending HCBS waiver programs targeting children with serious emotional disturbances (SED) were collected from the Center for Medicaid & Medicare Services (CMS) website. In total, 33 applications from 10 states were included in the study. Utilizing a policy mapping approach, applications were coded by hand comparing text from elements in the applications across all 10 states. A summary of program changes reported in applications was created and changes were tracked over the course of the federal public health emergency. States modified programs by adding services for waiver participants, changing the service settings allowed, removing service limit restrictions, and offering electronic/remote service delivery. All states also issued measures to either expand or retain their provider workforce, adding family members as providers, modifying experience requirements, and offering financial incentives via increased payment rates or retainer payments. Modifications to mental health assessment processes ranged from changing the evaluation tools or documentation requirements, extending deadlines, and allowing for remote evaluations. Service plan development processes were adapted by allowing virtual service plan development meetings, allowing participants or representatives to electronically sign plans of care, and permitting verbal consent to begin receiving services. Documenting programmatic adjustments provides a context for further research to understand the experiences of youth, families, and providers in navigating these changes and the relative success or failures of these policies.
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Affiliation(s)
- Monica Cañizares
- School of Social Work, The University of Texas at Arlington, 501 W. Mitchell Street, Box 19129, Arlington, TX, 76019, USA
| | - Anna Unnerstall
- School of Social Work, The University of Texas at Arlington, 501 W. Mitchell Street, Box 19129, Arlington, TX, 76019, USA
| | - Genevieve Graaf
- School of Social Work, The University of Texas at Arlington, 501 W. Mitchell Street, Box 19129, Arlington, TX, 76019, USA.
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Graaf G, Snowden L, Keyes L. Medicaid Waivers for Youth with Severe Emotional Disturbance: Associations with Public Health Coverage, Unmet Mental Health Needs & Adequacy of Health Coverage. Community Ment Health J 2021; 57:1449-1463. [PMID: 33492561 DOI: 10.1007/s10597-020-00759-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 12/11/2020] [Indexed: 11/24/2022]
Abstract
Home and Community-Based Services (HCBS) Medicaid waivers for Serious Emotional Disturbance (SED) extend Medicaid eligibility to youth who otherwise would be financially ineligible and finance a broad array of highly specialized mental health services specific to the needs of youth with SED. This study examines whether these policies are associated with greater public health insurance coverage among youth with severe mental health diagnoses. It also assesses, among youth with severe mental health diagnoses who have public health coverage, whether waiver policies are associated with reduced reports of unmet mental health treatment need and increased reports of adequate mental health coverage. Analysis uses CMS reported data on state HCBS Medicaid waivers in conjunction with data from the National Survey of Children's Health for the years 2016 through 2018. Multi-level, fixed-effects logistic regression models demonstrate that living in a state with an HCBS Medicaid waiver is associated with significantly increased odds of having public insurance among children with concurrent private health coverage (OR 1.89), reduced odds of unmet mental health needs among youth with public coverage (OR 0.45), but not significantly associated with reported adequacy of mental health insurance coverage.
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Affiliation(s)
- Genevieve Graaf
- School of Social Work, University of Texas at Arlington, Social Work Complex - A, 112D, 211 South Cooper Street, Box 19129, Arlington, TX, 76019, USA.
| | - Lonnie Snowden
- School of Public Health, University of California, Berkeley, USA
| | - Latocia Keyes
- School of Social Work, University of Texas at Arlington, Social Work Complex - A, 112D, 211 South Cooper Street, Box 19129, Arlington, TX, 76019, USA
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Beauregard LK, Miller EA. A comparative analysis of state adoption of the Community First Choice program. Home Health Care Serv Q 2021; 40:177-191. [PMID: 34311673 DOI: 10.1080/01621424.2021.1947926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Over the last several decades, policymakers have focused on rebalancing Medicaid-funded long-term services and supports toward home and community-based services (HCBS). The Patient Protection and Affordable Care Act (ACA) included several opportunities for states to further promote HCBS options. One optional opportunity for states to expand Medicaid HCBS was the 1915(k) Community First Choice (CFC) program. To date, eight states have elected to add CFC as a Medicaid benefit. This study utilized comparative case studies to identify the factors that influenced states' adoption of CFC. Results highlight the important role that state bureaucrats, economic concerns, and existing HCBS programs had on states' decisions to adopt CFC.
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Affiliation(s)
- Lisa Kalimon Beauregard
- Massachusetts Executive Office of Elder Affairs Massachusetts Executive Office of Elder Affairs, Boston, Massachusetts, USA
| | - Edward Alan Miller
- Department of Gerontology, and Gerontology Institute, John W. McCormack Graduate School of Policy & Global Studies, University of Massachusetts Boston, Boston, Massachusetts, USA.,Department of Health Services Policy & Practice, and Faculty, School of Public Health, Brown University Providence, Rhode Island, USA
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Liu G, Velott DL, Kong L, Dick AW, Mandell DS, Stein BD, Murray MJ, Ba DM, Cidav Z, Leslie DL. The Association of the Medicaid 1915(c) Home and Community-Based Services Waivers with Emergency Department Utilization among Youth with Autism Spectrum Disorder. J Autism Dev Disord 2021; 52:1587-1597. [PMID: 33966133 DOI: 10.1007/s10803-021-05060-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 11/30/2022]
Abstract
Using the 2008-2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58-0.66]) and IDD waivers (0.65; [0.64-0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.
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Affiliation(s)
- Guodong Liu
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, 90 Hope Drive, Hershey, PA, 17033, USA.
| | - Diana L Velott
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, 90 Hope Drive, Hershey, PA, 17033, USA
| | - Lan Kong
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, 90 Hope Drive, Hershey, PA, 17033, USA
| | - Andrew W Dick
- The RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - David S Mandell
- Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market Street, Philadelphia, PA, 19104, USA
| | - Bradley D Stein
- The RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - Michael J Murray
- Department of Psychiatry, College of Medicine, Pennsylvania State University, 500 University Drive, Hershey, PA, 17033, USA
| | - Djibril M Ba
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, 90 Hope Drive, Hershey, PA, 17033, USA
| | - Zuleyha Cidav
- Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market Street, Philadelphia, PA, 19104, USA
| | - Douglas L Leslie
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, 90 Hope Drive, Hershey, PA, 17033, USA
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Characterization of Family-Directed Care Coordination and Involvement in Behavioral Treatments in an Autism-Specific Medicaid Waiver. J Autism Dev Disord 2020; 51:715-724. [PMID: 32617794 DOI: 10.1007/s10803-020-04583-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Services for children with autism spectrum disorder (ASD) and their families have evolved with the advent of the Medicaid waiver, leading to more family-based coordination of care. Evaluating family involvement, the current investigation compared 230 families of children with ASD receiving Medicaid waiver services to a propensity-score matched group of 230 families who were waiting for such services (i.e., registry families). Compared to the registry, waiver families reported more involvement in service planning tasks, but not activities related to future-planning, managing crisis situations, or searching for and securing funding. Additional analyses characterize waiver families as engaging in high levels of coordinating and delivering behavioral interventions for their child. Implications for family burden and future programming for waiver programs are discussed.
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State Approaches to Funding Home and Community-Based Mental Health Care for Non-Medicaid Youth: Alternatives to Medicaid Waivers. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 46:530-541. [PMID: 30941529 DOI: 10.1007/s10488-019-00933-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Home and Community-Based Services (HCBS) Medicaid waivers for children increase the availability of public funding for HCBS by waiving or expanding the means tests for parents' income, basing child eligibility for Medicaid coverage primarily on clinical need. But many states provide mechanisms apart from HCBS waivers to increase coverage for youth with significant mental health needs. Through interviews with public mental health officials from 37 states, this study identifies and explains non-waiver funding strategies for HCBS services for otherwise ineligible youth. Results demonstrate that states expand Medicaid-eligibility through CHIP or use state general revenue funds to pay for medically necessary HCBS for non-Medicaid youth.
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LaClair M, Mandell DS, Dick AW, Iskandarani K, Stein BD, Leslie DL. The effect of Medicaid waivers on ameliorating racial/ethnic disparities among children with autism. Health Serv Res 2019; 54:912-919. [PMID: 31132161 PMCID: PMC6606603 DOI: 10.1111/1475-6773.13176] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine the effects of Medicaid Home and Community-based Services (HCBS) waivers on reducing racial/ethnic disparities in unmet need for services among families of children with autism spectrum disorder (ASD). DATA SOURCES Data from the 2003, 2007, and 2011 waves of the National Survey of Children's Health and the 2005 and 2010 waves of the National Survey of Children with Special Health Care Needs were used. Data on waiver characteristics were collected from source materials that were submitted in support of each state's waiver application. Waiver characteristics were combined to create a single waiver generosity variable. STUDY DESIGN Quasi-difference-in-difference-in-difference models were used to determine the effect of waiver generosity on racial/ethnic disparities in unmet need among children with ASD. PRINCIPAL FINDINGS Increased waiver generosity was associated with significantly reduced odds of having unmet need for black children with ASD compared with white children with ASD. Unmet needs among black children with ASD were roughly cut in half, a 13 percentage point decrease, with the implementation of an average generosity waiver. No significant differences were seen for Hispanic ethnicity. CONCLUSION These findings suggest that Medicaid HCBS waivers have the potential to ameliorate disparities in unmet need among children with ASD. Future policy development should focus on replicating the most effective characteristics of these waivers.
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Affiliation(s)
- Michelle LaClair
- Department of Public Health SciencesPenn State College of MedicineHersheyPennsylvania
| | - David S. Mandell
- Department of PsychiatryUniversity of PennsylvaniaPhiladelphiaPennsylvania
| | | | - Khaled Iskandarani
- Department of Public Health SciencesPenn State College of MedicineHersheyPennsylvania
| | - Bradley D. Stein
- RAND CorporationPittsburghPennsylvania
- University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Douglas L. Leslie
- Department of Public Health SciencesPenn State College of MedicineHersheyPennsylvania
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Wang L, Ma J, Dholakia R, Howells C, Lu Y, Chen C, Li R, Murray M, Leslie D. Changes in Healthcare Expenditures After the Autism Insurance Mandate. RESEARCH IN AUTISM SPECTRUM DISORDERS 2019; 57:97-104. [PMID: 31440305 PMCID: PMC6706245 DOI: 10.1016/j.rasd.2018.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND In recent years, most U.S. states have passed autism mandates requiring private insurers to cover autism spectrum disorders (ASD). Little is known about the post-mandate changes in healthcare expenditures. METHOD This study utilized 2006-2012 de-identified insurance claims data from the largest insurer in Pennsylvania (PA), where the mandate went into effect in 2009. Healthcare expenditures were defined as the amount the insurer paid for healthcare services and were adjusted to 2012 price level. A mixed model approach was used to analyze the expenditures. RESULTS A total of 9,471 children with ASD were included in the study. Although the pre-mandate total expenditures per child with ASD were similar, the post-mandate expenditures significantly increased for groups subject to the autism mandate (87% increase from $7,754 in 2008 to $14,486 in 2010) compared to the exempt groups (27% increase from $7,238 to $9,171). By insurance type, the change from 2008 to 2010 in ASD-related expenditures per child with ASD was $8,439 for fully insured large employer sponsored plans and $43 for the Children's Health Insurance Program (CHIP), both subject to the PA mandate; and $2,631 for the self-insured, $980 for small-employers, and $-92 for individual plans, all of which are exempt from the mandate. These increases were due to outpatient services but not inpatient or drug costs. CONCLUSIONS Healthcare expenditures increased significantly following the PA autism mandate. Nonexempt, large employer groups had the largest increase in spending. Some exempt, self-insured companies may have voluntarily covered ASD services, leading to a moderate increase.
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Affiliation(s)
- Li Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
- Department of Statistics, Penn State University, University Park, PA
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA
| | - Junyi Ma
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Ruchita Dholakia
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Callie Howells
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Yun Lu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Chen Chen
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Runze Li
- Department of Statistics, Penn State University, University Park, PA
| | - Michael Murray
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA
| | - Douglas Leslie
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
- Department of Psychiatry, Penn State College of Medicine, Hershey, PA
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Goldrich Eskow K, Ann Summers J, Chasson GS, Mitchell R. The Association Between Family-Teacher Partnership Satisfaction and Outcomes of Academic Progress and Quality of Life for Children/Youth With Autism. JOURNAL OF POLICY AND PRACTICE IN INTELLECTUAL DISABILITIES 2018. [DOI: 10.1111/jppi.12221] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Eskow KG, Chasson GS, Summers JA. A cross-sectional cohort study of a large, statewide Medicaid home and community-based services autism waiver program. J Autism Dev Disord 2015; 45:626-35. [PMID: 25183656 PMCID: PMC4339692 DOI: 10.1007/s10803-014-2217-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
State-specific 1915(c) Medicaid Home and Community-Based Services waiver programs have become central in the provision of services specifically tailored to children with autism spectrum disorders (ASD). Using propensity score matching, 130 families receiving waiver services for a child with ASD were matched with and compared to 130 families waiting on the registry (i.e., control group). Results indicate that participants in the waiver group reported more improvement in independent living skills and family quality of life over the last year compared to those on the registry. More frequent intensive individual support services and therapeutic integration were statistically predictive of improvement in a variety of domains. The results suggest that the waiver program may be promising for improving child and family functioning.
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Affiliation(s)
- Karen Goldrich Eskow
- Department of Family Studies and Community Development, Towson University, 8000 York Road, Towson, MD, 21252, USA,
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