Have you ever felt that your child or adolescent is not getting the behavioral health services he or she needs to facilitate appropriate, day-to-day functioning? Did you know that your household’s primary, employer-provided insurance may not be enough? To access more comprehensive services, your child or teen may require the added benefit of Medical Assistance (MA).

Sometimes called Medicaid, MA is a government benefit program that provides individuals with public health insurance. Importantly, MA also provides access to health services that can be delivered at home, in the school and in the community. These services are sometimes called “wraparound” services. Usually, MA beneficiaries must fall below a certain income level; however, some states, including Pennsylvania, have an eligibility exception. That is, in Pennsylvania, children and adolescents with significantly impairing mental or physical health disabilities may be eligible for MA regardless of their parent/guardian’s economic status. Conditions that may cause significant, serious impairment include: Autism, Pervasive Developmental Disorder, ADD/ADHD, Generalized Anxiety Disorder, substance abuse, and serious mental illnesses.

In 2013, in response to an awareness of the growing need among children and teens for more comprehensive mental health services, the Centers for Medicare & Medicaid Services revised its website to include a special section, Services for Children and Youth with Mental Health and Substance Use Conditions (https://www.medicaid.gov/medicaid/benefits/bhs/index.html). A special bulletin (https://www.medicaid.gov/federal-policy-guidance/downloads/CIB-05-07-2013.pdf) was also designed to help educate the nation’s state governments and the public about the benefits of enrolling children and teens with mental health needs in Medicaid. In part, the bulletin reports that services available through Medicaid have been proven to:

  • reduce overall costs of care in the health care system;
  • improve school attendance and performance;
  • increase in behavioral and emotional strengths;
  • improve clinical and functional outcomes;
  • improve attendance at work for caregivers;
  • reduce suicide attempts; and
  • decrease contacts with law enforcement.

Due to the perception that Medicaid or MA is strictly a welfare program, some families of children who would be eligible for coverage under the exception do not apply or even consider applying. Families may feel it is taking advantage of the system to qualify via the exception. (This problem may be exacerbated because this important exception to the economic criteria for MA, technically PH-95, is sometimes referred to as the “loophole”.) However, families of a child or teen with serious mental health needs should know that MA for their child:

  • offers coverage that extends beyond what is ordinarily covered through employer-based insurance and can help children access services that are often inaccessible through employer-offered insurance;
  • is essential to obtain “wraparound” or Behavioral Health Rehabilitative Services (an explanation of BHRS is available at https://www.phlp.org/uploads/attachments/ck33h5j3h06zv51u8tvkn9saf-wraparound-services-guide-2011.pdf.
  • can serve as secondary insurance to the parent/guardian employer-healthcare program; and
  • can help local school districts receive additional monies from the federal and state governments to help subsidize the costs to individual communities (school districts) of providing a free and appropriate public education.

Additional information, including the eligibility of adults disabled since childhood, can be found at https://www.nami.org/Blogs/NAMI-Blog/January-2016/Social-Security-for-Disabled-Children-Benefits-Yo.

If you think your child or teen would benefit from improved access to behavioral health services via MA, consider completing the relevant screening tool, available via the table the follows, and then discussing the results with your child’s primary care physician or therapist:

Children and Adolescents Recommended Screens Purpose Links
Birth through 5.5 years
(66 months)
Ages and Stages Questionnaire: Social Emotional (ASQ:SE) Any mental Health Condition The ASQ varies based on age. The complete range of ASQs is available via the link that follows. Find the questionnaire that corresponds to your child’s age: http://hacstxs.org/wp-content/uploads/2013/12/Master-Set.pdf
Birth through 8 years Pediatric Symptoms Checklist
Any Mental Health Condition http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf
Ages 6 through 18 CRAFFT
(Note: CRAFFT stands for key words in the assessment tool – car, relax, forget, friends and trouble)
Substance Use https://crafft.org/
Ages 4-17 Pediatric Symptoms Checklist Any Mental Health Condition http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf
Adolescents Only
Ages 12 through 18 years Patient Health Questionnaire- 9 Depression http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf
  Center for Epidemiological Studies Depression Scale for Children
Depression http://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf
Ages 10-18 Global Assessment of Individual Needs—Short Screener
Substance Use http://dpi.wi.gov/sites/default/files/imce/sspw/pdf/gainssmanual.pdf

(adapted from: https://www.medicaid.gov/federal-policy-guidance/downloads/CIB-03-27-2013.pdf)

If you make the determination that your child/teen would benefit from MA, here are some resources (also used to compile the information in this article) that will help you get started with the application: