In less than 100 days the Ohio Department of Medicaid (ODM) is poised to end a special funding arrangement for a 27-year-old program in Cuyahoga County called Positive Education Program (PEP) Connections. Each year, PEP Connections serves nearly 900 high-risk youth with autism, and or other intensive mental health needs who are also at risk of out-of-home placement. The termination of the funding is the result of ODM and the Ohio Department of Mental Health and Addiction Services’ (OhioMHAS) efforts to move behavioral health into their existing system of Medicaid managed care. But Greater Cleveland health, education, child welfare and juvenile court officials are increasingly raising concerns about how ending the special funding arrangement will impact these very ill children and their families. They’ve expressed concern that neither they, the Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Board of Cuyahoga County, or PEP have been contacted by the Medicaid managed care health plans to discuss how the care of these high need children will be transitioned or managed going forward. Program advocates are suggesting alternatives which would either maintain funding for the existing program, develop a new Medicaid benefit for the children, or at least allow adequate time to develop a transition plan for the hundreds of youth currently served, and to develop a system for new children who need these intensive services.
Greater Cleveland health, education, child welfare and juvenile court officials…have expressed concern that neither they, the Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Board of Cuyahoga County, or PEP have been contacted by the Medicaid managed care health plans to discuss how the care of these high need children will be transitioned or managed going forward
PEP Connections and the 1915(a) Waiver
PEP Connections is primarily financed through a Medicaid “1915(a)” waiver, as well as through a smaller pool of funds from the ADAMHS Board of Cuyahoga County (to serve non-Medicaid eligible children). Under the waiver, ODM provides the ADAMHS Board of Cuyahoga County with a monthly capitated payment of $1,604 for children served through the 1915(a) waiver – in effect acting as the managed care plan for the children’s behavioral health care needs. This arrangement gives PEP the ability to “act on behalf” of the ADAMHS Board of Cuyahoga County, in particular when cross-system planning is necessary, and or to authorize residential placements for the county’s most high risk youth. The ADAMHS Board’s contract allows PEP to provide intensive case management and care coordination services to develop creative plans, with a goal of preventing out-of-home placements, and diverting mandated system involvement, for high-risk youth with intensive mental health needs.
The U.S. Centers for Medicare and Medicaid Services are granted authority under the Social Security Act to create 19159(a) waiver programs that require certain categories of Medicaid beneficiaries to voluntarily enroll in managed care entities. In order to do this, Ohio Medicaid cannot be out of compliance with provisions related to being statewide, provider choice and the requirement that medical assistance made available to any enrolled individual cannot be less in amount, duration or scope than the medical assistance made available to any other enrolled individual. According to the Medicaid and CHIP Payment and Access Commission, Ohio is one of only a small number of states who use the 1915(a) authority to operate comprehensive and specialty (e.g., behavioral health) managed care programs on a voluntary basis.
On average, 500 youth are served each day and require an average of 18 months of service.
Ohio’s program and waiver were created in 1991 as a partnership between the then Cuyahoga County Mental Health Board, the Ohio Department of Mental Health and the Robert Wood Johnson Foundation. The purpose was to better provide services for kids served by multiple public systems (multi-system youth). Before the 1915(a) waiver was granted, the program was funded by the Robert Wood Johnson Foundation. Originally the program was limited to children in the high poverty communities of Cleveland and East Cleveland but, as poverty spread, program eligibility expanded to all of Cuyahoga County.
Between July 1, 2016 and June 30, 2017, PEP Connections served 853 youth – approximately two thirds of whom were between 13 and 18 years of age. Roughly half are from single parent families, 67 percent are male and 33 percent female. On average, 500 youth are served each day and require an average of 18 months of service. The largest source of referrals are hospitals, doctors and medical providers, but 14 percent are referred by families themselves.
Why is the Waiver Being Terminated?
The termination of the program is an outgrowth of the ODM and OhioMHAS multi-year effort to modernize and move Ohio’s behavioral health system into Medicaid managed care. The state argues that the current 1915(a) waiver is antiquated and inconsistent with the move towards a unified system of managed care that includes both physical and behavioral health care. For example, how could children whose behavioral health care is managed by one managed care program (PEP Connections) be simultaneously enrolled in another managed care program managed by one of the Medicaid managed care organizations. It isn’t clear whether Ohio Medicaid’s current claims payment and eligibility systems could support an arrangement where youth are enrolled in both the 1915(a) waiver and the broader Medicaid managed care program. The state also argues that the care coordination and services now provided by PEP could be adequately provided by Ohio’s Medicaid managed care health plans going forward. The ADAMHS Board of Cuyahoga County also believes that many of these children will have a service plan through their Medicaid managed care health plan that mirrors many of the services provided via the 1915(a) waiver.
The state also argues that the care coordination and services now provided by PEP could be adequately provided by Ohio’s Medicaid managed care health plans going forward.
Greater Cleveland’s Response to Termination of the Waiver
PEP Connections’ relatively small size and limited geographic scope has most likely allowed the debate over the future of the program to go largely unnoticed by policy makers and others. This could be changing as Cleveland community leaders have grown increasingly outspoken about the program’s June 30 ending date. Nearly 100 have written and or communicated with ODM about the impending change.
Medical leadership from the Cleveland Clinic, the MetroHealth System and the University Hospitals Rainbow Babies & Children’s Hospital recently wrote a joint letter to ODM Director Barbara Sears, and Ohio Department of Mental Health & Addiction Services Director Tracy Plouck, saying that “ending funding for this critically important program without first creating a reasonable, sustainable replacement service will have devastating impacts for children, families, and our systems of care.”
Educational and justice leaders have expressed concern that ending the program could result in these young people ending up in the criminal justice system. Eric Gordon, Cleveland Metropolitan School District CEO, wrote that “PEP Connections keeps our families together and delivers cost effective care that reduces involvement with the courts and juvenile justice systems.” Judge Kristen Sweeney, Administrative Judge for the Cuyahoga County Court of Common Pleas Juvenile Division, wrote that “these children will end up in the juvenile justice system if desperate parents, police, schools and emergency rooms have nowhere else to turn.” Finally, Mark Singer, PhD, Deputy Director of the Begun Center for Violence Prevention Research and Education, writes that ”no good will come of this potential change, and much harm will result.”
Early Periodic Screening Diagnosis and Treatment (ESPDT) Implications
Every state Medicaid program is required by federal law to provide an Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, providing comprehensive and preventive health care services for children under age 21. Ohio Medicaid’s EPSDT program is known as Healthchek. According to the U.S. Centers for Medicare and Medicaid Services this means that states are “required to provide comprehensive services and furnish all Medicaid coverable, appropriate and medically necessary services needed to correct and ameliorate health conditions.” So, one question to consider is whether the state would be meeting its EPSDT obligations if the waiver were terminated, and the youth served by the program were unable to get the type of health services that they had previously received. The question of whether state Medicaid programs are meeting their EPSDT obligations is regularly the subject of litigation. Jane Perkins, the Legal Director of The National Health Law Program, has said that the “subject matter of EPSDT litigation has shifted over time, with the current emphasis on protecting children’s access to home and community-based treatment services.”
The Future of the 1915(a) Waiver and the PEP-Connections
ODM has previously indicated that they intended to add a dedicated discrete service that would be equivalent to a high-fidelity wraparound. In fact, at the completion of the state’s behavioral health redesign process in July 2017, it was stated that a work group of state agency staff, stakeholders and providers would begin work on developing the service immediately following the completion of the 2018-2019 Biennial Budget. No meetings of this group were ever scheduled. ODM now seems to have backed away from their previous commitment to developing a high-fidelity wraparound service, and has said they have no plan to pursue it in the immediate future. Instead they’ve suggested that the newly designed behavioral health service menu contains adequate services to assist the affected children. But, PEP-Connections, and its community allies, argue that without the high-fidelity wraparound benefit the re-designed behavioral health service menu isn’t adequate to continue the unique services that these children need.
PEP-Connections, and its community allies, argue that without the high-fidelity wraparound benefit the re-designed behavioral health service menu isn’t adequate to continue the unique services that these children need.
With so little time remaining before the 1915(a) waiver expires there probably isn’t time to sort out whether the behavioral health service menu is adequate or not, and it appears that little has been done to prepare for transitioning these children out of the waiver and into some new kind of arrangement that preserves their existing levels of behavioral health services. So how might this situation be resolved?
One, the state could move the 1915(a) into their larger managed care system. This would mean that instead of the ADAMHS Board of Cuyahoga County managing the waiver, the managed care organization with the largest share of these children could manage the waiver (PEP reports that approximately 75 percent of these children are enrolled in a CareSource Medicaid managed care plan for their physical health services).
Two, ODM could issue guidance to its managed care plans requiring them to provide enhanced care services, like those offered by PEP-Connections, to youth meeting the 1915(a) waiver criteria. The department could provide additional funding to the managed care plans through the rates they pay. ODM has done something similar with the managed care plans for limited geographic areas of the state that have high infant mortality rates, and the managed care plans have then invested those additional dollars into a variety of community based activities and care.
Three, ODM could add high-fidelity wraparound services as a Medicaid service (a number of state Medicaid programs include this as part of their state plan) as it had communicated earlier; in the meantime, the department could allow children in PEP-Connections to remain in behavioral health fee for service, or provide a small amount of state funding to PEP-Connections, to supplement the normal managed care reimbursement.
Private philanthropic resources could be used in the short term to assist in planning or transition activities, or to support advocacy around encouraging the ODM to incorporate a dedicated discrete service equivalent to high-fidelity wraparound into the overall menu of services for these youth.
Private philanthropic resources could be used in the short term to assist in planning or transition activities, or to support advocacy around encouraging the ODM to incorporate a dedicated discrete service equivalent to high-fidelity wraparound into the overall menu of services for these youth. This latter option would have the added benefit of helping similar children outside of Cuyahoga County. PEP-Connections and the ADAMHS Board of Cuyahoga County may also want to approach public systems (school systems, child welfare, juvenile court, etc.) who benefit from the program through the avoidance of costly out-of-home placements to see if they might contribute in some way to its continuation.
ODM, jointly with the ADAMHS Board of Cuyahoga County, should convene a meeting of the Medicaid managed care plans, and PEP to figure out a way forward that protects the health of these very vulnerable young people and their families who are currently enrolled in the waiver.
At a minimum, ODM, jointly with the ADAMHS Board of Cuyahoga County, should convene a meeting of the Medicaid managed care plans, and PEP to figure out a way forward that protects the health of these very vulnerable young people and their families who are currently enrolled in the waiver. According to Linda J. Torbert, Children’s Behavioral Health Administrator, The ADAMHS Board of Cuyahoga County, in conjunction with Begun Center at Case Western Reserve University, will be conducting a comprehensive community needs assessment of Cuyahoga County’s crisis system for both youth and adults to identify strengths and challenges. The results of this assessment may also be helpful in terms of longer term planning.