Kossor Steven NEW Autism One 2009.pdf - The Institute for ...

MEDICAID
EPSDT and BHRS
The Greatest Treatment
Funding Secret
Ever Concealed
Steven Kossor, Licensed Psychologist
Executive Director, The Institute for Behavior Change
The title of today’s presentation is “Medicaid, EPSDT and BHRS -- The
Greatest Treatment Funding Secret Ever Concealed.”
Further information about the EPSDT system and “wraparound” service
philosophy can be found at the website of the Institute for Behavior Change:
www.ibc-pa.org where the presenter of today’s program, Licensed
Psychologist and Certified School Psychologist Steven Kossor, is the founder
and Executive Director.
1

The short version….
Will this information be useful to you? Read the press release above. It
describes a research-based (nonexperimental) treatment program for children
between the ages of birth and 21 with autism, ADHD, and other conditions
that:
•is absolutely free to parents in at least 37 states (it is funded by the federal
Medicaid program), regardless of family income and that
•has been collecting treatment outcome data for the past decade that has
been subjected to rigorous, independent statistical analysis – documenting its
impact.
This presentation describes “the greatest treatment secret ever concealed.”
You will learn how to access its secrets, as I have, since 1997.
Steve Kossor
Licensed Psychologist
Certified School Psychologist
Executive Director, The Institute for Behavior Change
2

A word of
thanks….
US Congressman Jim Gerlach
has been a strong supporter
of the Institute for Behavior
Change and of my efforts to
bring quality mental health
treatment services to people,
especially those who have
developmental disabilities,
for many years. I deeply
appreciate his consistent and
enthusiastic endorsement of
my work and look forward to
future opportunities to share
new ideas with others.
Steve Kossor
The Institute for Behavior Change is proud to have received this Congressional
citation, and the recognition of the Pennsylvania House of Representatives and
the Pennsylvania Senate on the occasion of its eleventh year of operation,
which we celebrated in a Conference at the Eden Resort in Lancaster,
Pennsylvania on November 21 st , 2008. The first snowfall of the year came
earlier than expected and had an effect on attendance, but the participants all
expressed their appreciation for the information we presented. The two
recipients of the IBC Parent Award for Advocacy were especially warm in their
praise for the influence that the Institute has had on the lives of their children
and the Comcast videographer captured the program in its entirety for future
distribution as a DVD set. The following is one of the seven presentations
made to the audience on 11/21/2008.
3

July 9, 1868
(the first Johnson Administration)
14 th Amendment to the Constitution
All US citizens [of any age] shall have
equal protection under the law.
rich or poor
rich or poor
rich or poor
rich or poor
rich or poor
The EPSDT system grew out of the American belief that all citizens are entitled
to “certain inalienable rights,” conferred by our Constitution.
Among these are life, liberty and the pursuit of happiness, for example.
When federal legislators create new programs for US citizens, they must do so
within the boundaries set by the Constitution. One of the rights conferred by
the US Constitution through the 14 th Amendment is the right to “equal
protection under the law.”
In the United States, we have a legislative history and a philosophy of
government, dating all the way back to 1868. saying that all US citizens,
regardless of their age, and regardless of their level of income, are
entitled to receive equal benefit and equal protection under the laws created
by the United States government.
It’s up to the Supreme Court to interpret the meaning of the 14 th Amendment,
but the concepts behind it are alive and well throughout the EPSDT
regulations, as we shall see.
4

1965 (the second Johnson Administration)
“A great society protects its weakest members.”
Medicaid is created as a joint federal and state
program to finance health care treatment for
diagnosed, episodic illness in low-income
individuals.
It has no specific standards related to children.
In 1965, almost 100 years after the 14 th Amendment was ratified, President
Lyndon Baines Johnson was famous for declaring “A great society protects its
weakest members.” This declaration of a so-called “Great Society” was the
foundation for the creation of Medicaid. In the words of the legislators who
created it, Medicaid is created as a joint federal and state program to finance
health care treatment for diagnosed, episodic illness in low-income individuals.”
Notice that it had no specific standards related to children in 1965.
5

1965
Medicaid:
To provide Medically Necessary
treatment to those who need it.
Requires no Federal Reauthorization.
It’s forever.
▲
functionally
In 1965, Medicaid was created to provide Medically Necessary treatment to
those who need it.
It requires no Federal Reauthorization, like the Individuals with Disabilities
Education Act (IDEA) that requires periodic reauthorization by Congress.
Medicaid is [functionally] forever.
Like all federal programs, Medicaid has “expanded” over the years….
6

1965 Medicaid “Medical Necessity”
Is it Reasonable?
Is it Necessary?
Is it Appropriate, according to
evidence-based practices?
Then it’s Medically
Necessary.
In 1965, the definition of “Medical Necessity” was very simple: Is it
reasonable? Is it necessary? and Is it appropriate, according to evidencebased
practices?
If so, then it’s Medically Necessary, under the 1965 Medicaid statute.
7

1967 Height of the Vietnam war
50% of draftees
ARE UNFIT FOR MILITARY SERVICE!
(because of untreated childhood illnesses)
Who will fight our wars?
In 1967, during the height of the Vietnam war, it was discovered that half of the
children appearing at military induction centers (draft boards) were unfit for
military service.
They were unfit because of undiagnosed and untreated childhood illnesses.
This sent shock waves through the halls of Congress, as the legislators asked
Who will fight our wars?
If HALF of our children are unfit for military service, due to undiagnosed and
untreated childhood illnesses, something must be done!
And that’s the climate and rationale that EPSDT services were born into. All
the way back in 1967.
8

1967 Early and Periodic Screening, Diagnosis and Treatment
For children under 21 years of age:
Question: Is it intended to correct or
ameliorate defects & physical & mental
illnesses and conditions discovered by
the screening process?
Yes? Then it’s “Medically Necessary.”
Each state is permitted to create its own version of the “medically necessary” treatment
definition, but all states are required to comply with the federal EPSDT standard in order to
continue accessing federal Medicaid funds, so the definitions can’t stray too far…..
EPSDT services were created to provide Early, Periodic Screening, Diagnosis
and Treatment for children under 21 years of age. A very important new
definition of “Medical Necessity” was created just for the EPSDT program:
A simple question is asked: Is it intended to correct or ameliorate defects and
physical and mental illnesses and conditions discovered by the screening
process?
If the answer to that question is “yes.” then it is Medically Necessary. In other
words: If it helps, then it’s Medically Necessary, according to the EPSDT
regulations.
The word “ameliorate” means “to prevent” or “reduce,” so the new
definition for Medical Necessity that was created by the EPSDT program
includes prevention as well as corrective treatments. Although each state
can create its own version of the “medically necessary” treatment definition, all
states are required to comply with the federal EPSDT standards. These
standards require that services must be “sufficient in amount, duration and
scope to reasonably achieve their purpose” (as defined by the prescriber,
not a government employee or Managed Care Organization’s “reviewer”).
Those standards can be found in Title 42 of the Code of Federal Regulations,
Chapter IV Part 440.
9

1988 and 1989
The Medicare Catastrophic Coverage Act
of 1988, P.L.100-360
Less-restrictive Medicaid eligibility standards
The Omnibus Budget Reconciliation Act
of 1989
Mandatory EPSDT services in all 50 states
Since 1988 when the Medicare Catastrophic Coverage Act of 1988,
P.L.100-360 was enacted, states have had the option to use “less restrictive”
methodologies to measure the assets children and certain other eligibility
categories (including children with disabilities), allowing a relaxation of the
asset test or its elimination altogether, and the extension of Medicaid benefits
to a wider section of the population.
Since the Omnibus Budget Reconciliation Act of 1989 (OBRA ’89) became
law, certain Medicaid services became available to any child with a disability
whether or not such services are covered under the State plan.
Legislative events have brought about significant expansions in Medicaid over
the past 40 years.
The growth of Medicaid has been especially significant in the past decade….
10

No “Asset Test” for Medicaid Eligibility
No “Asset Test” is required for Medicaid eligibility for children in any state now.
The child’s assets (resources including bank accounts, property, etc) are not
counted to determine Medicaid eligibility, and a disabled child can be
considered “a family of one” for the purpose of determining his/her eligibility for
Medicaid in most states.
A disabled child can be found eligible for Medicaid coverage as a “Medically
Needy” person, regardless of family income, in any state in the nation, just like
Pennsylvania.
In Pennsylvania, children who are granted Medicaid eligibility under 1902(r)(2)
of the Social Security Act are sometimes referred to as “Loophole” children,
even by public officials in official documents -- as if these disabled kids are
somehow gaming the system and getting services they don’t deserve -- that is
clearly incorrect and misinformed.
The Kaiser Family Foundation (www.kff.org) is one of the most helpful
sources of facts about Medicaid in America:
http://www.statehealthfacts.org
11

Medicaid Spending in 2004 (in millions)
Rank 1995 1999 2001 2004
1 New York $22,348 $27,930 $32,140 $40,077
2 California $13,273 $18,778 $22,911 $28,957
3 Texas $8,008 $9,646 $11,218 $15,521
4 Pennsylvania $6,172 $8,805 $10,194 $12,842
5 Florida $5,285 $6,214 $8,213 $11,763
6 Ohio $5,658 $6,462 $8,555 $11,086
7 Illinois $5,702 $6,679 $8,096 $10,118
8 Georgia $3,148 $3,626 $5,178 $8,683
9 Mass $4,962 $5,977 $7,030 $8,282
10 N Carolina $3,601 $4,853 $6,206 $8,096
11 New Jersey $4,473 $5,227 $5,632 $7,346
12 Michigan $4,586 $5,400 $5,632 $7,029
13 Tennessee $2,966 $3,956 $5,140 $6,506
14 Missouri $2,451 $3,410 $4,305 $5,867
In Millions
12

Medicaid Cost Containment Efforts
Note: Most changes do not apply to “EPSDT”
Provider Payments: Provider payment rate change, which may involve a payment rate freeze
or cut. Providers include physicians, inpatient hospitals, nursing homes and managed care
organizations.
Pharmacy Controls: Pharmacy utilization or cost control initiatives including subjecting more
drugs to prior authorization, implementing or expanding preferred drug lists, and seeking new
or enhanced supplemental rebates.
Benefit Reductions: Benefits restrictions, reductions or eliminations. This does not include
EPSDT benefits.
Eligibility Cuts: Eligibility reductions or restrictions. This may involve changes to eligibility
standards, application and renewal process, or premiums. Other actions restricting eligibility
include increasing the asset transfer look-back period from three to five years, limiting
countable prior medical bills to those incurred within three months of application, increasing the
waiting period from six to nine months, and freezing enrollment. This does not include
EPSDT benefits.
Copays: New or higher copayments for services. In imposing copayments, states must comply
with Federal Medicaid law, which specifies that copayments must be "nominal", generally
defined as $3.00 or less per service. The law also provides exemptions so copayments cannot
apply to certain services or certain eligibility groups such as children or pregnant women.
Federal law requires that a provider must render a service regardless of whether the
copayment is collected.
LTC: Cost containment initiatives for long term care and home and community based services
programs.
13

Positive Changes in Medicaid
Note: Most changes do apply to “EPSDT”
Provider Payments Increases: Provider payment rate change. Providers
include physicians, inpatient hospitals, nursing homes and managed care
organizations.
Benefit Expansion: In the beginning of FY2005, a 7 states reported plans to
cut or restrict benefits. At the same time, 9 states were adopting benefit
restorations and expansions.
Eligibility Expansion: In FY2005, 20 states made eligibility expansions and/or
positive changes to the application and renewal processes.
Long Term Care (LTC) Expansions: In FY2005, more states expanded
Home & Community Based Services (HCBS) programs (11 states) than cut or
restricted Long Term Care (LTC) services (10 states). Within the 11 states that
expanded community service options, 8 states created new HCBS waivers or
expanded existing waivers, two states added additional services to existing
HCBS waivers, one state implemented or expanded a PACE program and one
state expanded LTC eligibility by restoring coverage for certain state-defined
impairment levels.
Sources: Headed for a Crunch: An Update on Medicaid Spending, Coverage
and Policy Heading into an Economic Downturn. Results from a 50-State
Medicaid Budget Survey, State Fiscal Years 2008 and 2009, Appendix A-1.
Kaiser Commission on Medicaid and the Uninsured, September 2008.
Available at http://www.kff.org/medicaid/upload/7815.pdf.
14

Key concepts in treatment funding
1. EPSDT services must be provided
to children enrolled in Medicaid
whether or not the services are
provided for in any State Plan.
2. Medicaid, not the school, must
pay for covered services to a child
if funding is in dispute.
Since 1989, Congress has affirmed that EPSDT services must be made
available to children in all 50 states, and Washington DC, Puerto Rico, the
Virgin Islands, and Samoa.
Under Medicaid Law and the Individuals with Disabilities Education Act (IDEA),
Medicaid, not the school system must pay for covered services to a child,
even when these services have been found necessary and included in the
child’s Individual Education Plan (IEP) or Individual Family Service Plan
(IFSP).
See 42 U.S.C. § 1396b(c) and §612(a)12) of the amendments of 1997 to IDEA, 20
U.S.C. §1400
Behavioral Health Rehabilitation Services (BHRS) can always be provided to a
child during school hours if they are needed and prescribed by a licensed
practitioner of the healing arts (just like medication to treat a physical or mental
illness), whether or not the child has a 1:1 aide provided by the school district.
See also the Bazelon Center for Mental Health Law Policy Analysis #5 (1997): Defining
Medically Necessary Services to Protect Children available at www.bazelon.org
15

Pending Plans for changes in Medicaid
The Centers for Medicare and Medicaid Services (CMS) is responsible for
monitoring implementation of the Medicaid statute by the various states. From
time to time, the CMS proposes changes to the Medicaid statute in an attempt
to reduce or eliminate waste and fraud. The first six proposed Medicaid
regulation changes in the table above have been placed in “moratorium” status
by the US Congress until April of 2009. After that date, the changes proposed
by the CMS will be enacted, following revisions based on public comment that
was received.
More than 400 people and organizations responded to the proposed revisions
to the Rehabilitation Services and these comments have caused the writers to
revise their original language (in the words of one CMS authority: significantly).
It is unlikely that services to developmentally disabled children will be cut, but
the need for treatment outcome measurement, professional oversight of
treatment programs and other improvements in the quality of care to children
receiving Medicaid benefits is a certainty.
The proposed revisions to the Rehabilitation Option were published in the
Federal Register volume 72 on 8/13/07 beginning at page 45201 and can also
be referenced as CMS 2261-P
16

What is the official PA DPW
stance on Behavioral Health
Rehabilitation Services
(BHRS)?
This is an excerpt from the
document submitted to the
CMS by Pennsylvania’s DPW
regarding the changes that
the CMS was proposing to
the “Rehabilitation Option.”
This response is representative of the responses submitted by more than 400
organizations and individuals, many of them state Medicaid authorities like the
PA Secretary of the Department of Public Welfare. The Institute for Behavior
Change and its outcome data was cited by two of these people – one from
Maine and one from California.
Congress placed a moratorium on proposed changes to this section of the
Medicaid statute until April 2009. Informed sources within the CMS have said
that the final form of the proposed regulations will incorporate the concerns
that were heard “loud and clear” from an enormous constituency.
There is absolutely no doubt that “Behavioral Health Rehabilitation Services”
(BHRS) cannot be removed from the EPSDT mandate, and that they are an
entitlement for any child who has a disability under the Medicaid statute. As
such, any changes to the “Rehabilitation Option” must comport with the
EPSDT mandate and cannot deny access to services based on diagnosis, or
otherwise interfere with the “amount, duration or scope” of services so that
they can reasonably achieve their intended purpose. This has grave
implications for Pennsylvania’s Act 62, as we will see….
17

Rehabilitation vs. “habilitation”
Treatment Effect
“Neurotypical”
With Treatment
Without Treatment
We all start out exactly the same. We communicate at an “age-appropriate
level.” We cry when we’re unhappy. We look around to see what’s
interesting in the world. We focus our attention on things that interest us. But
then, some of us start having delayed development.
Although we all started out having “age-appropriate” functioning ability, some
of us aren’t keeping up with the pace that most others are. As this continues,
the gap between the “neurotypical” and “developmentally delayed” children
widens. It will continue to widen as time passes, unless something is done to
REhabilitate the child who is lagging behind his/her peers.
We are not “teaching new skills” to the developmentally delayed child, we are
REhabilitating the child so he/she can resume functioning at an age
appropriate level, as he/she once did.
The hope is that, eventually, with the right amount of Rehabilitation treatment,
the “gap” between the functional capability of the “neurotypical” child and the
child who showed developmental delays earlier in life can be shrunk to the
point that it is inconsequential. That is what Rehabilitation services are for,
and this is why BHRS is a Rehabilitation service, even when it is delivered to
children who have developmental delays.
18

EPSDT Benefits
• Treatment AND Prevention services
• Physical, Speech & Related Therapies
• Hearing Services
• Eye Examinations & Eyeglasses
• Durable Medical Equipment
• Home, Residential & Inpatient Care
• Dental Care
• Other Services (including mental health care)
The remainder of this presentation will focus on the
Behavioral Health Rehabilitation Services that can be
delivered to disabled children through the EPSDT
mandate of Medicaid. See 42 USC §1396d (r) (5).
This presentation will focus now on just the “Behavioral Health Rehabilitation
Services” aspect of EPSDT, but EPSDT covers so much, much more, as you
can see.
The following text appeared on the Health Resources and Services
Administration (HRSA) website on 6/3/2007, regarding “Medical Necessity”
under EPSDT:
“In a report prepared for the federal Health Care Financing Administration
(HCFA), now known as the Centers for Medicare and Medicaid Services –
CMS), Rosenbaum and Sonosky described the EPSDT medical necessity
standard as follows: While there is no federal definition of preventive
medical necessity, federal amount, duration and scope rules require that
coverage limits must be sufficient to ensure that the purpose of a benefit
can be reasonably achieved… Since the purpose of EPSDT is to prevent
the onset or worsening of a disability and illness in children, the
standard of coverage is necessarily broad… the standard of medical
necessity used by a state must be one that ensures a sufficient level of
coverage to not merely treat an already-existing illness or injury but also,
to prevent the development or worsening of conditions, illnesses, and
disabilities.”
(See http://www.hrsa.gov/epsdt/medical.htm for the complete document)
19

2005 The Deficit Reduction Act (DRA)
Children will… “still be entitled to receive EPSDT
benefits in addition to the benefits provided by the
benchmark coverage...”
The Centers for Medicare and Medicaid Services (CMS)
“will not approve any state Medicaid plan that does not
include the provision of EPSDT benefits.”
CMS Administrator Mark B. McClellan, “Statement on EPSDT Coverage for Children Under 19,” April 2006.
Available at www.tilrc.org/Real%20Choice%20Website/epsdt0406htm.
So, let’s look at the recent history of challenges to the federal mandate of
EPSDT services. In 2005, a proposal to create “benchmark” coverage was
advanced, but Congress warned that the EPSDT benefits must not be deleted
if “benchmark” coverage is enacted in any state. The Centers for Medicare
and Medicaid Services (CMS) specifically prohibited, in writing, any
interference with EPSDT services.
The “track record” of challenges to the EPSDT statutes since 1967 is clear:
The mandate for EPSDT services has always been upheld, and
strengthened. That applies to Behavioral Health Rehabilitation (BHR)
Services as well.
In 2005 another proposal was made (unsuccessfully) to place all BHR services
under the control only of licensed professionals, who would be obligated to
collect outcome data regarding treatment progress. Great idea!
The Institute for Behavior Change has been doing both of these things since
1997 and supports legislative efforts like this that are aimed at improving the
quality of services delivered under the EPSDT regulations. There is no doubt
that these are good ideas that will, hopefully soon, find their way into the
EPSDT regulations.
20

42 CFR Chapter VII Subchapter XIX §1396d
[Sec. 1905(a)] “The Social Security Act”
Definitions
For purposes of this subchapter—
(a) Medical assistance
The term “medical assistance” means payment of part or all
of the cost of the following care and services …
(if provided in or after the third month before the
month in which the recipient makes application for
assistance) …
for individuals who are—
(i) under the age of 21, or, at the option of the State,
under the age of 20, 19, or 18 as the State may choose,
…
Where does EPSDT “live” within the laws of the United States?
The Social Security Act is the “big umbrella” statute under which Medicaid
exists (see http://www.ssa.gov/OP_Home/ssact/title19/1902.htm to start your
review). EPSDT “Behavioral Health Rehabilitation Services” (BHRS) are
addressed at Sec. 1905(a)(13) and Sec. 1905(r)( 5). EPSDT is a mandatory
part of Medicaid. EPSDT BHRS regulations are found at 42 CFR Part
440.40 (see http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr440_02.html).
The slide shows the language of the Social Security Act (also referred to as
“42 CFR §1396a” that created “Medical Assistance” as part of the Medicaid
statute in 1967. This is the law in all 50 states.
Notice that it permits children to receive Medical Assistance benefits (funding
for necessary treatment) for up to three months before they are determined to
be eligible for Medical Assistance.
In other words, the federal Medicaid statute permits children to receive
Medical Assistance benefits for up to three months before they get official
approval for the Medicaid benefits that they are eligible for, because of a
disabling condition. Pennsylvania complies with this federal law (no surprise
there, right?). It’s called the “presumptive eligibility” standard.
21

42 CFR Chapter VII Subchapter XIX §1396d
[Sec. 1905(r)(5)] “The Social Security Act”
(r) Early and periodic screening, diagnostic, and treatment services
(5) Such other necessary health care, diagnostic services, treatment,
and other measures described in subsection (a) of this section to
correct or ameliorate defects and physical and mental illnesses and
conditions discovered by the screening services, whether or not such
services are covered under the State plan.
Nothing in this subchapter shall be construed as limiting
providers of early and periodic screening, diagnostic, and
treatment services to providers who are qualified to provide all of
the items and services described in the previous sentence or as
preventing a provider that is qualified under the plan to furnish
one or more (but not all) of such items or services from being
qualified to provide such items and services as part of early and
periodic screening, diagnostic, and treatment services.
Here is the actual language that mandates EPSDT mental health treatment
services in all 50 states. They’re called “Behavioral Health Rehabilitation”
services in Pennsylvania and are described more thoroughly at 42 USC
Chapter IV 440.130.
Notice that it specifies the definition of “Medical Necessity” and says that the
treatment services must be provided “whether or not such services are
covered under the State plan.” The term “Medical” in the Medicaid statute
refers to the services provided by a licensed practitioner of the healing arts
(psychologists and psychiatrists are always covered, and in some states,
social workers).
In other words, it doesn’t matter whether the prescribed services are part of
any “State plan” for its residents – all Medicaid recipients under the age of 21,
regardless of the state in which they live, are entitled to these EPSDT
“Behavioral Health Rehabilitation” services.
EPSDT service providers do not have to deliver the full range of EPSDT
services. This means that licensed psychologists can participate in the
EPSDT system to deliver “Behavioral Health Rehabilitation” services without
having to also provide dental, or hearing or vision or medical services.
22

42 CFR Chapter IV Part 440.130
[Sec. 1905(a)(13)] “The Social Security Act”
(a) ‘‘Diagnostic services,’’ except as otherwise provided under this subpart,
includes any medical procedures or supplies recommended by a physician or
other licensed practitioner of the healing arts, within the scope of his practice
under State law, to enable him to identify the existence, nature, or extent of
illness, injury, or other health deviation in a recipient.
(c) ‘‘Preventive services’’ means services provided by a physician or other
licensed practitioner of the healing arts within the scope of his practice under
State law to
(1) Prevent disease, disability, and other health conditions or their progression;
(2) Prolong life; and
(3) Promote physical and mental health and efficiency.
(d) ‘‘Rehabilitative services,’’ except as otherwise provided under this subpart,
includes any medical or remedial services recommended by a physician or
other licensed practitioner of the healing arts, within the scope of his practice
under State law, for maximum reduction of physical or mental disability and
restoration of a recipient to his best possible functional level.
This slide shows that Behavioral Health Rehabilitation Services MUST be available,
according to the mandatory federal Medicaid statute, in every state in the nation.
This is where Pennsylvania got the mandate and the authority to create what they call
“Behavioral Health Rehabilitation Services” (BHRS) as part of the EPSDT (Medicaid)
program. Every other state could, and should implement the exact, same BHRS program as
those implemented in Pennsylvania under this Statute because:
• They are effective and cost-efficient when implemented properly under the direct
supervision and control of licensed professional psychologists
• Licensed psychologists are “qualified practitioners of the healing arts” in every
state where Medicaid is administered.
• The “Rehabilitation Option” has been adopted in every state, according to data
published by the Human Services Research Institute in 2008
Any state that hasn’t yet implemented these BHRS programs can be compelled to with
relative ease, because BHRS programs have been implemented successfully and costefficiently
in Pennsylvania by the staff of the Institute for Behavior Change since 1997. We
have the data to prove it, and it’s available to others who need it.
23

Medicaid Eligibility:
CATEGORICALLY needy
• Qualified Medicare beneficiaries
• Pregnant women
• Low-income families with children
• Supplemental Security Income (SSI)
recipients
• Anyone under age 21 with income less
than a specified percent of the Federal
Poverty Level
Categorically Needy: As defined by the Centers for Medicare & Medicaid
Services, categorically needy individuals are those who must be covered,
which usually includes: low-income families with children; individuals receiving
Supplemental Security Income (SSI); pregnant women, infants and children
with incomes less than a specified percent of the Federal poverty level;
and qualified Medicare beneficiaries.
States have options as to how they define categorically needy. Their definition
may include individuals receiving only a state supplementation of SSI, although
their income would prohibit any SSI payment. Categorically needy individuals
must be provided with the following services: inpatient hospital services;
outpatient hospital services; rural health clinic services; laboratory and x-ray
services; nursing facility services; home health care services for individuals
age 21 or older; family planning services and supplies; early and periodic
screening, diagnosis and treatment for individuals under age 21; certified
mid-wife services and physician services; certified pediatric and family nurse
practitioner services; and Federally qualified ambulatory and health center
services. In addition, there are many other services a state may choose to
provide such as prescription drugs. For the medically needy, states have
considerably more discretion in the services they provide.
24

Medicaid Eligibility:
Medically Needy
◦ Those who, except for income and
resources (assets), would be eligible
as “categorically needy.”
• There are no “asset tests” anymore.
• How much “income” does a child have?
• Does parental income always “count?”
hint: no
The medically needy have too much money (and in some cases resources
like savings) to be eligible as categorically needy.
If a state has a medically needy program, it must include pregnant women
through a 60-day postpartum period, children under age 18, certain newborns
for one year, and certain protected blind persons. The state can include
“disabled persons” or “disabled persons under age 21” as “medically needy,”
for example. Medically Needy programs existed in 35 states in 2005. People
classified as “medically needy” are eligible to receive all of the services
provided to people classified as “categorically needy.”
In all 50 states, the family’s income (the child’s “assets”) are not counted.
There is no longer any “asset test” for Medicaid eligibility for children in
America.
25

Pennsylvania’s “Medically Necessary”
definition under Medicaid Regulations
STATEMENT OF POLICY DEPARTMENT OF PUBLIC WELFARE
OFFICE OF MEDICAL ASSISTANCE PROGRAMS
[55 Pa. Code Chapter 1101] General Provisions
§1101.21a. Clarification Regarding the Definition of “Medically Necessary” –
statement of policy.
A service, item, procedure or level of care that is necessary for the proper treatment
or management of an illness, injury or disability is one that:
(1) Will, or is reasonably expected to, prevent the onset of an illness,
condition, injury or disability.
(2) Will, or is reasonably expected to, reduce or ameliorate the physical,
mental or developmental effects of an illness, condition, injury or disability.
(3) Will assist the recipient to achieve or maintain maximum functional capacity
in performing daily activities, taking into account both the functional
capacity of the recipient and those functional capacities that are
appropriate of recipients of the same age.
Pennsylvania, like all other states, must adhere to the federally prescribed
definition of what constitutes “Medically Necessary” treatment.
In other words:
•if it probably will help to prevent the onset of a
disability, it’s medically necessary.
•if it probably will help to reduce or lessen the
effects of a disability, it’s medically necessary.
•if it probably will help a child achieve or maintain
“maximum functional capacity” in daily activities,
it’s medically necessary.
This definition applies to “Behavioral Health
Rehabilitation Services,” just like all of the
other EPSDT services.
26

Who decides if treatment is
“medically necessary”
If a licensed practitioner of the
healing arts prescribes a treatment
“to correct or ameliorate a physical
or mental defect or condition” and it
works, it is medically necessary and
Medicaid can fund it, regardless of
whether it is an “accepted medical
practice” in someone else’s opinion.
Every new treatment program or approach initially has more detractors than
champions, because scientists are inherently skeptical about new things, and
lots of doctors and other authorities fancy themselves as “scientists.” The
good news is, the opinions of the nay-sayers are all irrelevant. Lots of people
poked fun at Penicilliin (How could mold possibly produce something of value!)
It doesn’t take unanimous consent of all treatment providers, or the agreement
of “a panel of experts” created by an insurance company or a court, or any
other panel to establish that a treatment is “medically necessary.” If there is
bona-fide evidence that a treatment prescribed by a licensed practitioner of the
healing arts is “ameliorating a physical or mental defect or condition” then it is
“medically necessary” – period. That’s what the federal Medicaid statute says,
and what every implementation of the Medicaid statute in every state can be
held to.
The agreement of two licensed practitioners is all that’s necessary to find that a
treatment is working, no matter how many other “experts” disagree (even
if they have godlike credentials). See 258 GaApp. 446, 576 S.E.2d 2
Georgia Department of Community Health v Freels (No. A02A1160, November
19, 2002) for more information.
27

The Social Security
“Blue Book”
lists disabilities
that qualify a child
as a person with a
disability under
Medicaid
A person under the age of 19 (up to 21 in most states) with a condition that is
listed in the Social Security disability “Blue Book” is considered a “disabled
child” under Medicaid.
If a “licensed practitioner of the healing arts” performs an evaluation that
diagnoses a child with a disability that is listed in this book, and the child is
eligible for Medicaid, then the child’s eligibility for Medicaid funding to
diagnose the disability is assured, and the child’s eligibility to receive
Medicaid funding to begin treatment of the disability is assured under the
EPSDT mandate.
Maintaining the funding for continued treatment depends upon the collection
of treatment outcome data that shows:
1) amelioration of the condition, or
2) a reasonable probability for ameliorating the condition, or
3) a reasonable probability for preventing the worsening of the condition
(under EPSDT, prevention is a key component of treatment).
28

42 CFR Chapter IV Part 440.230
(b) Each service must be sufficient in amount, duration,
and scope to reasonably achieve its purpose.
(c) The Medicaid agency may not arbitrarily deny or
reduce the amount, duration, or scope of a required
service […] to an otherwise eligible recipient solely
because of the diagnosis, type of illness, or condition.
(d) The agency may place appropriate limits on a
service based on such criteria as medical necessity or
on utilization control procedures. Here enters the MCO
By 1997, States were awash in red ink over the Medicaid program. EPSDT
services were costing a fortune – much more than anticipated, sometimes
because of fraud and abuse.
But what to do. These services are federally mandated…. Every parent had
the legal right to choose the provider of EPSDT services for their child, and
there were some pretty unscrupulous people running around prescribing some
pretty outrageous “services” – that all had to be paid-for under the EPSDT
mandate.
In this climate, the bright idea of Managed Care to the Rescue was born. A
federal waiver of the “parental choice” provision of the Social Security Act was
created, allowing Managed Care Organizations into the EPSDT system.
Today, we all know how “Managed Care” has helped us use the health care
system more effectively. Hindsight is 20/20….
Despite all of their bluster and protest, every State and every Managed Care
Organization is obligated to comply with the federal EPSDT statutes. Period.
They just need to be shown how to do it successfully and cost-efficiently.
Putting licensed professional psychologists in charge of BHR Services is a
great way to improve quality and reduce costs, and that’s where the Institute
for Behavior Change comes in. We’ve been doing precisely that since 1997
and we want to help parents and professionals (including Licensed Clinical
Social Workers) in other States to accomplish the same things.
29

The children by numbers
15,575 children receiving Medical Assistance in the County.
(SAMHSA estimates 10% of children require MH treatment)
1,557 children on MA in the County who should be getting
MH treatment (not D&A), based on SAMHSA’s estimate.
658 children on MA in the County who are getting some
Mental Health services from any source whatsoever.
899 children on MA not getting any MH help whatsoever.
But less than 20 cases are on the MCO Waiting List…
Guess which number the MCO & County government
focuses on….
This is a good example of what parents and conscientious providers of
Behavioral Health Rehabilitation Services are up against. For every expert,
there is an equal and opposite expert.
Some of them have advanced degrees in psychology, education and medicine.
Some of them work for insurance companies and do what they’re paid to do.
Some of them are serving political agendas and advancing their own careers
by selectively attending to the research literature and dismissing anything that
deters them from their mission.
There is karma, of course, but in the mean-time, parents and conscientious
providers of treatment services have to share information and practice polite
and persistent advocacy for the children we care about.
Providers of services under Medicaid are obligated to report suspected
incidents of fraud and abuse within the Medicaid system. Most County
contracts contain explicit requirements for this advocacy, and protections
against repercussions for performing as an advocate, for EPSDT BHRS
service providers. The federal government certainly extends these
responsibilities and protections to all practitioners who receive Medicaid funds.
30

Relationship between “levels of need” and
PA DPW “medical necessity” criteria
A child who is presently at functioning at “Level I” (mild disability) can require a
great deal of professional support to prevent his/her deterioration to a greater
level of need.
Since EPSDT is supposed to be a preventive service, it may be necessary for
a licensed practitioner to prescribe a substantial amount of EPSDT BHR
service, including “TSS” service, to a child at any “level” of need. Levels of
need can change quickly and dramatically, as we all know, especially in
children. Some professionals’ opinions are highly influenced by the
preferences of their employer. Accordingly, the Pennsylvania Department of
Public Welfare (DPW) “Medical Necessity” guidelines (Appendix T of the
Health Choices RFP) do NOT specify any particular amount of “TSS” or other
EPSDT BHR service that a child can receive based on his or her “level” of
functioning.
Some people certainly disagree with this, but fortunately, they aren’t allowed to
change State or Federal Medicaid regulations to impose inappropriate,
arbitrary limits on a child’s access to EPSDT BHR services that have been
prescribed by a licensed practitioner of the healing arts in the State, especially
when the prescription is based on research (such as the Report of the
National Academy of Sciences called Educating Children with Autism, for
example) and current behavioral data.
31

Wraparound Philosophy
• Services must be “time limited” (a year or less).
• Services must be “titrated” (reduced over time).
• Services must be replaced by “naturally occurring”
[i.e., low-cost or no-cost] supports as quickly as
possible.
• Treatment skills must be “transferred” to parents
and other caretakers.
• Caretakers must be present at all times while
treatment services are being rendered.
• Services can not be delivered in a doctor’s office.
NONE of this is part of the EPSDT system!
The “wraparound” philosophy is a nice ideal to shoot toward, as long as it
doesn’t interfere with the child’s access to necessary EPSDT services.
32

…they make bullets – we make armor
Now, as a professional who has prescribed BHRS treatment, we
expect you to predict exactly what troublesome behavior the
child will be displaying between 10 and 11 am on Mondays,
Tuesdays, Wednesdays…. and use this form to do it.
Insurance companies make their money by denying or restricting service
delivery. They hire licensed practitioners of the healing arts to counteract the
influence of other licensed practitioners of the healing arts who are trying to
help children. County governments and insurance companies get paid a great
deal of money at the start of the year (or each month), and if they don’t spend
all of it, they get to keep what’s left over -- as much as 38%, according to a
recent report issued by the Office of the Inspector General.
By doing their job, they create obstacles to the delivery of treatment services,
including EPSDT services that are not supposed to be impeded in regard to
their amount, duration or scope. It’s ultimately up to the federal Medicaid
authorities to fix abuses of the Medicaid system, and they expect the state
Medicaid authority to do that, even though state and county governments have
a vested interest in keeping the amount of EPSDT spending to a minimum,
since the federal government doesn’t pay for all of it.
Sometimes, violations of the Medicaid statute result in federal court rulings, as
in the case of Kirk T. vs. the Pennsylvania Department of Public Welfare,
or the Lawrence K. decision that brought EPSDT BHRS to life in Pennsylvania
in the early 1990s.
33

T
Titration that makes sense
T
T
20 20 20 20
T
Ô
The concept of “titration” is alive and well outside of the chemistry class, where it means to
“water-down” the strength of a solution.
In the world of managed care, “titration” is seen as a necessary requirement of any treatment
program. The treatment solution has to be “watered-down” over time.
The number of hours of treatment has to be reduced – from 20 hours per week to 15, to 10, to
5 and then stopped. Usually over the course of four months. 20 hours in January, 15 hours in
February, 10 hours in March and treatment ended at 5 hours a week on April 30th.
Nostradamus would be proud.
A much more appropriate, clinically responsible method of titration is to increase the distance
between the therapist (T) and the child (Ô) over time, without reducing the total number of
hours of treatment delivered. This way, if the child regresses (that’s predictable, of course),
the therapist can immediately “close the gap” and provide the level of support necessary for the
child to recover and continue making progress. In the other system, they have to call a
meeting, get a licensed practitioner of the healing arts to increase the hours, get the
prescription approved by the Managed Care Organization and look for someone who can work
the additional hours. What sense does that make?
In this alternative titration system, when the therapist has been separated at maximum distance
from the child for a few weeks, we KNOW the treatment program has been successful and then
it makes sense to reduce or eliminate the hours – the therapist can find another child who
needs 20 hours of work every week, and doesn’t have to look for another job as soon as his
hours get cut in the “other” titration scheme.
34

Here are some other things that most
people don’t know anything about….
This is the “last word”
about what children
with Autism spectrum
disorders require in
order to have a
reasonable
probability of
reducing their
symptoms of autism.
© 2001 National Academy Press
The National Academy of Sciences is a private, nonprofit, self-perpetuating
society of distinguished scholars engage in scientific and engineering
researching dedicated to the furtherance of science and technology and to
their use for the general welfare. Upon the authority of the charter granted to it
by the Congress in 1863, the Academy has a mandate that requires it to
advise the federal government on scientific and technical matters.
Educating Children with Autism © 2001 by the National Academy of Sciences
was published by the National Academy Press Constitution Avenue, NW
Washington, DC 20418
This report is also available on-line at http://www.nap.edu
35

Here are some other things that most
people don’t know anything about….
The National Academy
of Sciences completed
this research with
funding from the US
Dept. of Education
and that’s the only
reason it’s called
“Educating” and not
“Treating” children
with Autism.
This is a “Who’s Who” of experts in the field of Autism in 2001, many of whom
continue to publish scholarly research about the TREATMENT of Autism.
Unfortunately, funding for discovery of the causes of Autism is commanding
the vast majority of financial, political and professional resources today, as if
we would rather know who to blame than how to treat this scourge.
As in everything else that is healthy, we need a little balance here. Research
describing “what works” should be valued at least as much as research into
“what caused it.”
36

Here are some other things that most
people don’t know anything about….
AT LEAST 25 hours of
“intensive, individualized
treatment” every week.
2008:
“There are no other studies
planned. This was intended
to be a definitive report
about what children on the
Autism spectrum need.”
- James P. McGee, Study Director
Dr. McGee explained to me in a telephone conversation that the National
Academy of Sciences partnered with the US Department of Education to
perform a definitive survey of treatment methods for children on the Autism
spectrum. They studied 11 modalities (Discrete Trial Training, TEACCH, DIR,
etc) and found that NO SINGLE MODALITY SHOWED A CLEAR TRACK
RECORD OF SUCCESS. They DID find, however, that:
Unless a child received at least 25 hours of intensive individualized
treatment, the child did not have a statistically significant probability of
symptom reduction.
In other words: Funding agencies have known since 2001 that they have
been denying children with Autism spectrum disorders the treatment they
require to get better.
So: Anybody who’s been saying “This study only applies to older children” or
“There are newer studies that refute these conclusions” is (let me say this
politely) misinformed.
37

For every expert, there is an equal and
opposite expert….
BHRS was never meant to
treat children with Autism
spectrum disorders.
Complete nonsense. To some people, Penicillin wasn’t meant to treat people
who are immoral.
38

PART II:
How to treat mental illness in children
We’ve explored the Medicaid statute.
We’ve explored the EPSDT mandate.
We’ve identified what is possible.
Now, we’ll look at what is working.
I think we need to spend more time focusing on what works in the treatment of
behavior disorders in children.
It’s good to study causes but we also need to spend some time and resources
studying what works right now, too, so more people can start doing it.
Medicaid provides the funding for treatment. The EPSDT mandate creates a
platform for treatment delivery that can be highly professional and costefficient.
Now, we’ll look at how to make EPSDT and the Behavioral Health
Rehabilitation Services (BHRS) platform work beautifully….
39

They Work! 300 Treatment records 2002-2006 Children ages 2-17
Overall Treatment Effectiveness
BETTER
71%
WORSE
11%
ST ABI LI ZED
18%
Once each week, the child’s parent is asked to rate their child’s level of
involvement in “target behavior” (behavior “targeted” for improvement) on a
scale from 1 to 10.
The frequency of the child’s involvement in the behavior is measured, as well
as the severity of the child’s involvement in the “target behavior” using the
same 10 point scale.
The question is posed by the child’s Behavior Specialist Consultant, who
has intimate familiarity with the child’s treatment plan and the staff who are
providing the EPSDT services.
The average of these two ratings is computed, for each “target behavior” under
study, and the result is graphed so that week-to-week changes can be seen
easily.
All of the children in treatment were showing significant behavioral problems,
with deteriorating behavioral profiles, prior to the start of EPSDT services.
The pie chart shows the results of 300 “target behavior” treatment records
between 2002 and 2006 for children between 2 and 17 years of age, with
various diagnoses including autism, disruptive behavior disorders, ADHD and
Pervasive Developmental Disorders. 71% had lower involvement in “target
behavior” and 18% more showed no worsening of “target behavior” -- an
overall success rate of 89% in four months.
40

They Work! 300 Treatment records 2002-2006 Children ages 2-17
Lack of Safety Awareness
Physical Aggression
WORSE
11%
STABILIZED
6%
WORSE
14%
STABILIZED
14%
BETTER
85%
BETTER
72%
Noncompliance with Adult Prompts
WORSE
7%
STABILIZED
11%
BETTER
82%
Physical Aggression is one of five primary areas that the staff of the Institute
for Behavior Change targets for intervention. Obviously, it is key to
establishing age-appropriate peer relationships and safety in interpersonal
relationships. The restoration and maintenance of adaptive, nonviolent
behavior (especially in response to frustration) is crucial to socialization at all
ages.
We all start out behaving “safely” – we depend on our caretakers and they
keep an eye on us to keep us safe. That’s age-appropriate. We all grow in our
awareness of environmental safety as we age, but we don’t all grow at the
same pace; some of us lag behind, and need Rehabilitation to restore an ageappropriate
level of safety awareness.
Children who have lost the ability to comply with adult prompts at an ageappropriate
level need to reacquire this ability so that they can have access to
the teaching, training and support of adults who care for them. This is a
primary focus within the EPSDT Behavioral Health Rehabilitation Services
system.
41

They Work! 300 Treatment records 2002-2006 Children ages 2-17
Communication Deficits
Socialization Deficits
WORSE
11%
WORSE
14%
BETTER
63%
STABILIZED
26%
BETTER
64%
STABILIZED
22%
Restoring the ability to communicate at an age-appropriate level is central to
the restoration of functional capacity in children. This is an area of primary
concern to parents of children with Autism spectrum disorders, and rightly so.
When approached from a behavioral perspective, communication deficits can
be addressed successfully through the EPSDT BHRS system.
Restoration of age-appropriate socialization skills in children can be one of the
most time-consuming and difficult undertakings in the field of children’s mental
health treatment. It is crucial to the treatment of children with Autism and
Pervasive Developmental Disorders. The Institute for Behavior Change
specializes in this area of Rehabilitation treatment for children with
developmental delays.
42

One of the 301 treatment records of a
child with an Autism Spectrum Disorder
TSS effect on behavior
12
10
8
6
physical aggression
socialization
noncompliance
4
2
BEFORETSS
AFTER TSS
0
1 2 3 4 5 6 7 8 9 10 11 12 13
Weeks
The downward trend shown here after the implementation of TSS service
indicates that the target behavior reduced in both frequency and severity.
This is “amelioration.” Because “amelioration” is categorically and
unequivocally documented in this 13-weektreatment period, the child’s
entitlement to the continuation of treatment services is assured, because he
hasn’t yet achieved the level set by the Treatment Team for the discontinuation
of services (scores would have to be below 2).
It is remarkable that this dramatic treatment effect was documented in less
than four months. Not all children respond so dramatically to the
implementation of TSS services. The next phases of the treatment program
will involve the TSS provider’s delivery of interventions at a greater distance
from the child, and the use of a lower level of prompting intensity. If the child
continues to display improvement, and the improvement reaches the
Discharge Criteria set by the Treatment Team, it will be professionally, ethically
and morally responsible to “titrate” the service delivery hours. Not before.
Smart behavioral scientists will recognize that hundreds of studies like this
(and we have them) spells the end of the “TSS doesn’t work” and “BHRS
doesn’t work for kids with autism” arguments.
Honest behavioral scientists and public officials will tell the truth, and admit
they exist. Responsible public officials will sponsor these, and other studies,
and the treatment programs and approaches that produce them, so that
children can get the help they need and deserve.
43

Another successful treatment record of a
child with an Autism Spectrum Disorder
TSS effect on behavior
12
10
8
6
Saf et y Awareness
Physical Aggression
Noncompliance
4
2
BEFORETSS
AFTER TSS
0
1 2 3 4 5 6 7 8 9 10 11 12 13
Weeks
The level of “amelioration” isn’t as dramatic in this case as it was in the
previous case, but it is also plainly visible, and the rationale for continuing
treatment in this case is at least as strong, and perhaps even stronger, than in
the previous case (because the child’s behavior is more problematic at the end
of the 13 week tracking period). Definitive evidence of improvement, in less
than four months.
Bear in mind that this tracking period could be 13 weeks, or 13 months, or 13
years. EPSDT services can be delivered to a child from the age of birth to the
age of 21 years, and if the treatment record shows amelioration during the
“treatment period” then the child is entitled to the continued delivery of
treatment because it is having the desired effect on the child’s disabling
condition. There is no need to stop prematurely if the treatment program is
showing “amelioration.”
Remember that, according to EPSDT regulations, the continuation of treatment
can be funded if the treatment is preventing the worsening of the child’s
condition, or if the treatment has a reasonable probability of producing
amelioration in the child’s condition. Referring to the hundreds of “Treatment
Plans that Worked” should be more than enough evidence to establish the
“reasonable probability” from a scientific perspective that a comparably
designed treatment plan will have its intended effect if it is funded….
44

They Worked!
treatmentplansthatworked.com
has more than 150 “treatment plans that
worked” available on-line for download
– with the data that documents it.
A subscription with unlimited access (including
loads of information on EPSDT and especially
“BHR” mental health treatment services) is $65
If EPSDT BHR services are mandatory in all 50 states, Washington DC, Puerto
Rico, the Virgin Islands and Samoa, and
if “Medically Necessary” treatment must be delivered under EPSDT to any
child who needs it, and
if our treatment methods work and we can prove it with data collected from
the parents of children who received our help, then
Our treatment methods (Behavioral Health Rehabilitation Services) can
become “mandatory” in all 50 states, Washington DC, Puerto Rico, etc.
Any parent or professional can download all of our “treatment plans that
worked,” with the data proving that they “worked,” and the treatments
described in those plans are therefore “medically necessary” under the
EPSDT program.
The $65 fee is a once-in-a-lifetime charge to access ALL of the “treatment
plans that worked” that we have developed and proven over the years – and all
of the new ones we’ll develop in the future, too.
45

The #1 source for information worldwide
Google “Treatment plans for children”
Our treatment plans (and the data that demonstrates their success) have been
downloaded in more than 104 countries.
A Google search for “treatment plans for children” has produced
“www.treatmentplansthatworked.com” – sponsored by the Institute for
Behavior Change – as the #1 information source in the world since May of
2007.
The average time on our site has been over two minutes per visit for more than
a year, and we are showing more than 85% new traffic every month.
46

PA Prescriptions for EPSDT services
Behavior Specialist Consultant (BSC)
• licensed or unlicensed psychologist
• Masters or Doctoral degree “in a clinical field”
• One year of experience working with children
◦ Philadelphia requires 2 years post-graduate experience
Mobile Therapist (MT)
• licensed or unlicensed psychologist
• Masters or Doctoral degree “in a clinical field”
• One year of experience working with children
BSC and MT providers are supervised closely each week by licensed
psychologists at the Institute for Behavior Change in Pennsylvania.
See http://www.ibc-pa.org/job_descriptions.htm for more information.
“Behavioral Health Rehabilitation Services” in Pennsylvania include
“Behavior Specialist Consultant” services and “Mobile Therapy” services.
These EPSDT services have become confused in the minds of many people
with so-called “wraparound” services. There are significant differences, as
we shall see.
Every state has responded to the EPSDT mandate for “preventive” and
“rehabilitation” services that is found in 42 USC Chapter IV Part 440.130 and
have created “Mobile Therapy” services (although they may call it by a different
name). However, “Behavior Specialist Consultant” and “Therapeutic Staff
Support” services can also be created in any state under EPSDT.
If a licensed psychologist (or any other “licensed practitioner of the healing
arts”) in any given state prescribes “Behavior Specialist Consultant” or
“Mobile Therapy” or “Therapeutic Staff Support” services, under the EPSDT
mandate those services must be provided in that state, and funded through
Medicaid, whether or not those services are part of the “State plan.” This
is especially true if treatment outcome data shows that these types of services
work and that they’re cost-effective.
This is precisely what the Institute for Behavior Change provides via its
website and through Treatmentplansthatworked.com.
47

TSS?
What’s that?
Therapeutic Staff Support (TSS) is provided
in Pennsylvania by a person with a Bachelors
degree (usually in psychology) who works 1:1
with the child for several hours each day, at
home, in school, and in the community.
Prescriptions for 20 or more TSS hours weekly are often
appropriate, necessary and authorized by the MCO if the
child’s behavioral data supports the need for TSS service.
Therapeutic Staff Support (TSS) providers can accompany the child to school,
to church, to youth group meetings, on shopping outings with a parent, to a
summer camp, or to any location in the child’s home, school or community
where the Treatment Plan is implemented. In the early days of TSS service in
Pennsylvania, some children received prescriptions of more than 40 hours of
TSS service per week. While it may be necessary for some children to receive
such a high level of treatment, it is not common.
The State of Pennsylvania created its own set of Medical Necessity Criteria
when it created its Proposal to bring Mandatory Managed Care into the
Pennsylvania Medicaid system in the mid 1990’s This document is called
“Appendix T” of the Request for Proposals (RFP) that the State had to submit
to the Centers for Medicare and Medicaid Services (CMS) to get permission (a
“waiver”) to implement its Mandatory Managed Care program under the Social
Security Act. The CMS granted the waiver, continues to monitor it, and reauthorizes
it periodically. The CMS is the final authority, because they “permit”
the State of Pennsylvania to implement its version of the EPSDT mandate.
48

www.ibc-pa.org
The Institute for Behavior Change was created in 1997 by licensed
psychologist and certified school psychologist Steven Kossor and celebrated
its 11 th year of successful operation in 2008. Mr. Kossor has received citations
from the President’s New Freedom Commission on Mental Health, from the US
Congress, and both houses of the Pennsylvania legislature for his visionary
leadership in creating a cost-effective, highly successful means of providing
direct support and consultative services to children with serious mental illness
symptoms in four southeastern Pennsylvania counties.
Based on our experience in the field of community-based children’s mental
health, our staff are expanding their horizons and offering their consultation
services in a much wider area….
49

If your service provider doesn’t tell the truth (because they don’t know it, or for
any other reason), you need a different service provider – no matter what field
they’re working in.
If they’re not thankful to help you and your child, they don’t deserve to work
with you.
If they aren’t helping you and your family, they shouldn’t be involved (if they
aren’t taking outcome data from you, how can they – or you – know what
they’re doing?).
If you aren’t sharing the work with them, then the system is unbalanced and
needs to be fixed (if they always do all the work, you’re always going to need
them around).
If you’re not moving forward (with a plan to address unforseen
circumstances), the plan isn’t complete and needs to be redesigned.
The staff of OurCaseManager.pro are experienced Masters-level clinicians,
working under the close supervision of licensed professional psychologists.
They “know the rules” about treatment prescription, delivery and monitoring.
They know how to get – and keep – funding until the treatment program is
finished successfully. They can help any professional do a better job. What
good is the best treatment program in the world, if it’s unavailable because it
isn’t being funded.
50

Recommendations
Ribbit…
Parents and others interested in quality mental health care for children
should look into EPSDT Behavioral Health Rehabilitation (BHR)
services. EPSDT is in your state, EPDST BHR Services work, and
they may be totally free regardless of family income.
There isn’t a private health insurance plan anywhere in America that
offers treatment options like EPSDT BHR services.
The Institute for Behavior Change is available to help any State
government, psychologist or other “licensed practitioner of the healing
arts” implement a more successful, cost-efficient, professional and
outcome-based implementation of EPSDT BHR services.
More information is available at www.ibc-pa.org
Money is important, of course. Maybe more important than ever. That’s why
it’s so important to spend it wisely:
• On treatment providers who are taking outcome data from the recipients of
services (or their parents), not just their own staff, and
• that are closely supervised by licensed mental health professionals, and
• who are implementing written treatment plans identifying specific,
measurable outcomes that incorporate evidence-based practices,
multidisciplinary input and
• are showing improvement in their clients’ behavior, or the reasonable
probability of it, and are updating the treatment program conscientiously to
achieve this goal.
The Institute for Behavior Change model of BHR Service delivery can be
implemented in all 50 states (and Guam, and other territories, too). Why not
replace wasteful, ineffective and inefficient treatment models and providers
with those who can do what is necessary to deliver Medicaid funded treatment
for children that works. I’m interested in presenting this material at locations
where parents, advocates, government officials and groups of interested
“licensed practitioners of the healing arts” are meeting.
Steve Kossor
sakossor@ibc-pa.org
51