Behavioral Health Screening Policies in Medicaid Programs Nationwide

To determine current behavioral health screening policies in Medicaid programs, EPSDT screening tools were collected from Medicaid agencies and state mental health authorities in all 50 states and the District of Columbia between June 2000 and January 2001. All states responded.

The screening tools were categorized into two types. The first type included specialized behavioral health screening tools consisting of extensive questions about mental health or substance abuse to be asked during visits for EPSDT screening. Typically, these are stand-alone tools, separate from the comprehensive screening tools that are used to identify physical health problems. The second type includes comprehensive screening tools for physical and developmental issues that may or may not include prompts or brief questions about behavioral health. When included in comprehensive tools, behavioral health is usually briefly addressed.

For the purposes of this study we did not consider developmental screening or mental health diagnostic tools to be mental health screening tools. Although several states recommend instruments for assessing developmental issues, particularly for young children aged zero to six years, none of these instruments were found to adequately identify mental health problems. In addition, one state recommends the use of the Child Behavioral Checklist, but this instrument is more appropriate for the diagnosis of mental health conditions than for general screening.

States vary considerably in their behavioral health screening policies (Table 1). More than half the states (a total of 28) recommend screening tools that reference behavioral health to some degree, either in specialized behavioral health tools or in comprehensive EPSDT screening tools. The remaining 23 states (45 percent) have no specialized behavioral health screening tools and no behavioral health questions or prompts in their comprehensive screening tools.

States appear to have no preference between specialized tools and comprehensive ones. About the same number of states reference behavioral health in specialized tools (16 states) as in comprehensive screening tools (18 states).

States are more likely to reference mental health than substance use disorders. Fifteen states have specialized mental health tools, compared with four states with specialized substance abuse tools. Eighteen states have comprehensive screening tools that reference mental health, compared with 11 that reference substance abuse.

Most states recommend, rather than require, that primary care providers use specific tools. Although 15 states (31 percent) have specialized mental health screening tools, only one state (West Virginia) and some counties in another state (California) mandate that providers use the specified tool. The other states that recommend a specialized mental health tool allow providers to decide whether to use that tool. None of the states require the use of a specialized substance abuse tool. Most states recommend or require their own mental health or substance abuse tools rather than standardized tools. About one-third of the states (five of 16) recommend or require a standardized mental health tool. One-quarter of the states (one of four) recommend or require a standardized substance abuse tool. Of the standardized mental health screening tools, the most commonly recommended is the Pediatric Symptom Checklist. For substance abuse screening, states recommend the CAGE Questionnaire and the Michigan Alcohol Screening Test.

The 31 specialized tools used by states to screen for behavioral health were assessed on three criteria that are important for providers using them and for families answering and completing them: rapid administration, clear referral criteria, and the individual who completes them. All the screening tools can be administered quickly and efficiently, with most being one or two pages in length. A total of 23 (74 percent) of the 31 specialized behavioral health screening tools provided clear referral criteria for identifying children in need of diagnosis and behavioral health services.

Most tools list risks, behaviors, and symptoms that identify the need for an immediate referral or treatment. Only a few are scored numerically. Providers administer nearly half (48 percent) of the screening tools. Most of the remaining tools are completed by the child (42 percent) or the parent (39 percent). Tools completed by the patient or the patient's family are more likely to be used in a busy office or clinic, because parents and older patients can complete the screening tool while waiting for the provider. (A complete list of the specialized behavioral health screening tools and the criteria assessment is available from the Bazelon Center.)

This review of Medicaid behavioral screening policies found that states vary considerably in their policies and that very few have policies in place that are likely to result in accurate identification of children with behavioral health disorders. Although more states address mental health than substance use disorders, nearly half the states (a total of 23) have not addressed behavioral health issues in their EPSDT screening tools at all.

Primary care providers in many states receive no guidance from Medicaid agencies on screening tools that accurately identify behavioral health problems. Studies have found that primary care providers lack mental health and substance abuse training (6) and that those who rely on their professional judgment alone fail to identify between 40 and 50 percent of children and adolescents who have mental health and substance use disorders (7,8). The use of specialized tools has been found to considerably increase rates of identification of behavioral health problems (9).

This article is based in part on information obtained by R.O.W. Sciences under contract with the Substance Abuse and Mental Health Services Administration. The writing of this article was supported by contributions of the Public Welfare Foundation and the John D. and Catherine T. MacArthur Foundation, which provides generous core support for the Bazelon Center's overall program.

Mr. Semansky is senior policy analyst and Ms. Koyanagi is policy director at the Bazelon Center for Mental Health Law, 1101 Fifteenth Street, N.W., Suite 1212, Washington, D.C. 20005 (e-mail, [email protected]). Ms. Vandivort-Warren is senior public health analyst in the organization and financing branch of the Substance Abuse and Mental Health Services Administration in Rockville, Maryland. Versions of this paper were presented at the annual research conference—A System of Care for Children's Mental Health: Expanding the Research Base—held March 3 to 6, 2002, in Tampa, Florida, and at the annual conference of the American Public Health Association held November 12 to 16, 2000, in Boston.