Systems of Care SERIES ISSUE BRIEF R E B M U 1and issues raised in this Issue Brief are intended to...

Systemsof Care

Prepared By:James A. Wotring, M.S.W.Beth A. Stroul, M.Ed.

Published By:

GEORGETOWN UNIVERSITY CENTER FORCHILD AND HUMAN DEVELOPMENT

In Partnership With:

ISSUEBRIEFSERIES N

UMBER

The Intersect of Health Reform andSystems of Care for Children and Youthwith Mental Health and Substance Use

Disorders and Their Families

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Notice on Nondiscrimination:Georgetown University provides equal opportunity in its programs, activities, and employment practices for all persons and prohibits discrimination and harassment on thebasis of age, color, disability, family responsibilities, gender identity or expression, genetic information, marital status, matriculation, national origin, personal appearance,political affiliation, race, religion, sex, sexual orientation, veteran status or any other factor prohibited by law. Inquiries regarding Georgetown University’s nondiscriminationpolicy may be addressed to the Director of Affirmative Action Programs, Institutional Diversity, Equity & Affirmative Action, 37th and O Streets, N.W., Suite M36, Darnall Hall,Georgetown University, Washington, DC 20057.

AcknowledgmentsEach of the following individuals contributed to the development of this Issue Brief by participating in discussions and byreviewing, commenting on, and editing drafts. Their insights, perspectives, and feedback are gratefully acknowledged.

Gary Blau, Ph.D.Chief, Child, Adolescent and FamilyBranchCenter for Mental Health ServicesSubstance Abuse and Mental HealthServices Administration

Joan Dodge, Ph.D.Senior Policy AssociateNational Technical Assistance Centerfor Children’s Mental HealthGeorgetown University, Center forChild and Human Development

Sybil Goldman, M.S.W.Senior AdvisorSenior Policy AssociateNational Technical Assistance Centerfor Children’s Mental HealthGeorgetown University, Center forChild and Human Development

Vivian Jackson, Ph.D.Senior Policy AdvisorNational Technical Assistance Centerfor Children’s Mental HealthGeorgetown University, Center forChild and Human Development

Teresa King, B.A.Training and Technical AssistanceResource SpecialistNational Federation of Families forChildren’s Mental Health andNational Technical Assistance Centerfor Children’s Mental HealthGeorgetown University, Center forChild and Human Development

Gary Macbeth, M.S.W., M.Ed.Senior Policy AssociateNational Technical Assistance Centerfor Children’s Mental HealthGeorgetown University, Center forChild and Human Development

Sherry Peters, M.S.W., A.C.S.W.Director of PRTF Waiver InitiativeNational Technical Assistance Centerfor Children’s Mental HealthGeorgetown University, Center forChild and Human Development

Frank Rider, M.S.Technical Assistance CoordinatorNational Federation of Families forChildren’s Mental Health

This Issue Brief is funded by a cooperative agreement among the Child, Adolescent and Family Branch of the Center forMental Health Services, Substance Abuse and Mental Health Services Administration and the Children’s Bureau of theAdministration for Children and Families in the U.S. Department of Health and Human Services. The views expressed donot necessarily reflect the views or policies of the funding agencies and should not be regarded as such.

Additional Copies of the Issue Brief are Available From:National Technical Assistance Center for Children’s Mental HealthGeorgetown University Center for Child and Human Development3300 Whitehaven Street, NW, Suite 3300Washington, DC 20007Phone: 202-687-5000Fax: 202-687-1954Website: http://gucchd.georgetown.edu

Suggested Citation:Wotring, J., & Stroul, B. (2011). Issue Brief: The intersect of health reform and systems of care for children’s behavioralhealth care. Washington, DC: Georgetown University Center for Child and Human Development, National TechnicalCenter for Children’s Mental Health.

TABLE OF CONTENTS

Introduction and Purpose ................................................4

Health Reform ................................................................................5Expanding Access to Health, Mental Health, and Substance Use Services ....................................5General Provisions ............................................................................5

System of Care Approach..................................................6Rationale ..................................................................................................6Framework, Philosophy, and Outcomes ........................7

Essential Benefits Packages ........................................10Description—Essential Benefits in Medicaid ..........................................................................................10Description—Essential Benefits in Health Insurance Exchanges and Other Insurance Plans ......................................................10Intersect with Systems of Care ............................................10Implementation Issues to Consider ..................................12Eligibility and Enrollment Issues to Consider..........13

Medicaid and Children’s Health Insurance Program (CHIP) Expansion ......................................................................14Description ..........................................................................................14Intersect with Systems of Care ............................................14Implementation Issues to Consider ..................................14

Health Homes ..............................................................................15Description ..........................................................................................15Intersect with Systems of Care ............................................16Implementation Issues to Consider ..................................16

1915(i) State Medicaid Plan Amendments ..................................................................17Description ..........................................................................................17Intersect with Systems of Care ............................................18Implementation Issues to Consider ..................................18

Money Follows the Person ..........................................19Description ..........................................................................................19Intersect with Systems of Care ............................................20Implementation Issues to Consider ..................................21

Accountable Care Organizations ..........................21Description ..........................................................................................21Intersect with Systems of Care ............................................22Implementation Issues to Consider......................................2

Conclusion ........................................................................................23

Resources ..........................................................................................24Health Reform ..................................................................................24System of Care Approach ........................................................25Health Insurance Exchanges..................................................25Essential Benefits Packages ....................................................25Medicaid and CHIP Expansion ..........................................25Health Homes....................................................................................261915(i) State Plan Amendments..........................................26Money Follows the Person......................................................26Accountable Organizations ....................................................26

References ........................................................................................27

Introduction and Purpose

This is a time of monumental change in healthsystems across the United States. With thepassage of the Patient Protection and AffordableCare Act on March 23, 2010, referred to as theAffordable Care Act (ACA), an additional 41million Americans will gain access to health careand the financing, organization, and delivery ofhealth services, including mental health andsubstance use services, will be revolutionized.Activities are underway to implement provisionsof the ACA in 47 states and the District ofColumbia, as well as at the federal level. Asstates and federal agencies plan and implementthe ACA, particular attention must focus on howmental health and substance use services(collectively referred as “behavioral health”services in this Issue Brief) will be covered andprovided and, in particular, how the needs ofchildren with serious behavioral healthchallenges and their families will be met.

This Issue Brief is intended to provide anoverview of the ACA and discuss the synergy ofhealth reform with the system of care approachfor serving children with behavioral healthchallenges and their families. Additionally, theIssue Brief will articulate how the system of careapproach can provide both a conceptualframework and specific strategies forimplementation of the ACA in ways that ensurethat the behavioral health service needs ofchildren, adolescents, young adults, and theirfamilies will be met effectively. This Issue Brief ispart of an ongoing series that is intended toinform the field about the implementation of keyaspects of the ACA and how issues related tochildren’s behavioral health can be addressed.

The system of care approach has been the majorframework for improving delivery systems,services, and outcomes for children with mentalhealth needs for the past 25 years, shaping

system reforms in many states, communities,tribes, and territories (Stroul, Blau, & Friedman,2010; Stroul, Blau, & Sondheimer, 2008).Extensive research and evaluation havedocumented the effectiveness of this approachfor improving the organization and delivery ofchildren’s mental health services, and forimproving clinical and functional outcomes forchildren and their families (Manteuffel, Stephens,Brashears, Krikelyova, & Fisher, 2008).Although the system of care approach continuesto evolve to reflect advances in research andservice delivery, the core values of community-based, family-driven, youth-guided, andculturally and linguistically competent servicesare widely accepted. In fact, the guidingprinciples calling for a broad array of effectiveservices, individualized care, and coordinationacross child-serving systems are extensively usedas the standards of care throughout the nation.

The system of care approach offers tested modelsfor implementing many provisions of the ACA inorder to address the needs of children with or atrisk for serious mental health and substance usechallenges and their families. Applying thesystem of care approach to the implementationof health reform can assist states to build on 25years of experience in system reform and, at thesame time, meet the central goals of healthreform—assisting Americans to obtainaffordable, appropriate health insurance;improving the quality of care; increasingefficiency and reducing costs; and improvinghealth outcomes. The ACA also provides anopportunity for states and communities tosustain and expand key elements of the system ofcare approach that are already a part of theirservice delivery systems.

Decisions on the shape of health reform will, for the most part, be made by states. The information and issues raised in this Issue Brief are intended to assist state policy makers to make health reformwork for children with mental health and substance use service needs and their families. The

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THE INTERSECT OF HEALTH REFORM AND SYSTEMS OF CARE

SYSTEMS OF CARE ISSUE BRIEF SERIES: #1

Issue Brief examines relevant provisions of the ACA and explores how the adoption of the system of care approach can be effective in implementing those provisions. Overviews of health reform andthe system of care approach are followed bysections that describe specific provisions of theACA. For each provision, the “intersect” withthe system of care approach is discussed, andissues and questions that should be considered inimplementing the ACA are delineated.

Health Reform

Expanding Access to Health, MentalHealth, and Substance Use ServicesThere are currently over 50.7 million uninsuredpeople in the United States, and it is estimatedthat the ACA will provide coverage for 41million of them (Congressional Budget Office[CBO], 2011; Washington Post, 2010). Coveragewill be provided by expanding Medicaid and theChildren’s Health Insurance Program (CHIP),through the implementation of Health InsuranceExchanges that will offer an opportunity forindividuals to purchase private health insurancepolicies at reduced rates, and through incentivesfor small businesses to provide health insuranceto their employees.

Medicaid will be expanded to cover individualswith incomes up to 133% of the federal povertylevel; the federal poverty is currently $22,350 fora family of four (Federal Register, 2011). CHIPwill cover approximately 6.5 million additionalchildren. It is estimated that by 2019, theexpansions in Medicaid and CHIP will increaseenrollment in these programs by 33%, coveringapproximately 17 million additional individuals(CBO, 2011; Washington Post, 2010).

The creation of Health Insurance Exchanges willfurther expand access to coverage. It is estimatedthat exchanges will provide coverage to an

additional 24 million individuals with incomesup to 400% of the poverty level. The ACA alsoincludes financial incentives for small businessesto offer insurance to their employees, penaltiesfor large businesses that do not offer insurance,and a mandate for all individuals to obtainhealth care coverage beginning in 2014. Anestimated 95 percent of U.S. citizens and otherlegal residents will have health insurance withinsix years (CBO, 2011; Washington Post, 2010).

Since behavioral health is an integral part of health, behavioral health benefits will be included in Medicaid, CHIP, and policies purchasedthrough Health Insurance Exchanges. It isestimated that between 20% and 30% of thenewly covered individuals (approximately 6 to10 million) will be persons with mental health or substance use disorders who will require specialty services from behavioral health professionals(Substance Abuse and Mental Health ServicesAdministration [SAMHSA], 2011a).

Another significant influence on access tobehavioral health services has resulted fromenactment of the Mental Health Parity andAddiction Equity Act (MHPAEA) of 2008 thatrequires health insurance plans containing behavioral health benefits to allow consumers the same number of mental health visits as for otherkinds of health care, at no greater cost, and not subject to any additional limitations. The law now will require all health plans sold through the state Health Insurance Exchanges to cover mentalhealth and substance abuse services coverage atparity with physical health coverage (MentalHealth Parity and Addiction Equity Act, 2008).

General ProvisionsThe ACA includes a number of generalprovisions that protect consumers’ rights toaccess health care (Patient Protection andAffordable Care Act [ACA], 2010). A significantprovision prohibits practices such as denial ofcoverage due to pre-existing conditions, annual

5SYSTEMS OF CARE ISSUE BRIEF SERIES: #1


and lifetime caps on coverage, and rescission ofcoverage due to health conditions. Adults deniedinsurance because of pre-existing conditions cannow access insurance through high-risk insurancepools until 2014, when insurance companies willno longer be able to deny them coverage.However, this requirement is already in force forchildren under age 18, and, therefore, they canno longer be denied coverage due to pre-existingconditions. Another provision allows youngadults to be covered under their parents’insurance plans until they reach the age of 26.

An ACA component of particular importance forchildren is the creation of a grant program tosupport Maternal, Infant, and Early ChildhoodHome Visiting Programs. These programs arenow offered in 49 states and focus on improvingthe well-being of families with infants, toddlers,and preschool children. They provide nurses,social workers, or other professionals who meetwith at-risk families in their homes, evaluatetheir needs, and connect them to services andsupports that can make a positive difference intheir child’s health, development, and ability tolearn (U.S. Department of Health and HumanServices [DHHS], 2010).

The ACA also addresses the reality that racialand ethnic minority populations aredisproportionately uninsured, often face systemicbarriers to accessing health care services, andexperience worse health outcomes. Accordingly,the act includes specific actions to address racialand ethnic health disparities and to promotecultural and linguistic competence in servicedelivery (ACA, 2010; SAMHSA, 2011a).

Other provisions of the ACA encourage states tocoordinate and integrate primary care andspecialty services for individuals with chronicproblems through the use of health homes. Statesare encouraged to experiment with new modelsof integrated behavioral health and primary carein order to improve outcomes and reduce thecosts of care. Health reform also seeks to

improve the quality of medical practices,improve health outcomes in measurable ways,reduce industry waste and duplication, preventmedical error, enhance patient safety, increase theuse of technology, and perhaps most difficult,“bend the curve” of rising costs (ACA, 2010;Washington Post, 2010).

All of these general provisions can positivelyimpact access to treatment and the quality ofcare for children, youth, and young adults withbehavioral health challenges, and their families.However, careful data collection and monitoringwill be needed to ensure that these ACAprovisions are implemented as required, and thatappropriate and sufficient services are provided.

System of CareApproach

RationaleAn estimated 20% of children in United States has a diagnosable mental health condition, and about one in ten children suffers from a serious mental health disorder that causes substantial impairment in functioning at home, at school, or in thecommunity (DHHS, 1999; Friedman, Katz-Leavy, Manderscheid,& Sondheimer, 1998; U.S.Public Health Service, 2000). The seriousness ofmental health problems for children and youthhas been well documented, confirming significantprevalence rates, persistence of these problemsover time, difficulties experienced across manyspheres of life, and high financial and social coststo families and to the nation (Friedman, Kutash,& Duschnowki, 1996; Greenbaum et al.,1998;Huang et al., 2005; Warner, 2009).

Most mental health disorders have their roots in childhood, with 50% of affected adultsmanifesting disorders by age 14 and 75% by age 24 (DHHS, 1999; Kessler, Chiu, Demier, &Walters, 2005, O’Connell, Boat, & Warner,2009). These disorders affect children of all ages,

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every socio-economic status, and every racial andethnic background. Mental health disorders inchildren are typically complex, involving multipleproblems, multiple diagnoses, and co-occurringdisorders. These disorders impact children indifferent ways throughout their development,from infancy through school years and thetransition to adulthood, and affect theirfunctioning at home, in school, and in theircommunities. Further, these children arecommonly served in more than one specializedsystem including mental health, substance abuse,primary health, education, child care, childwelfare, juvenile justice, and developmentaldisabilities. Children and youth of various racialand ethnic groups are overrepresented in childwelfare and juvenile justice systems. Thisinvolvement in multiple systems often results infragmented and inadequate care and leavesfamilies overwhelmed by having to work withmultiple child-serving agencies.

Mental health problems can lead to devastatingconsequences including poor academicachievement, dropping out of school, substanceabuse, involvement with the correctional system,lack of vocational success, inability to liveindependently, and suicide. Suicide is the thirdleading cause of death in the 15-24 year agegroup, and approximately one in five adolescentsand young adults experience suicidal ideationevery year (Huang et al., 2005).

Although these problems have been characterizedas a public health crisis, approximately 65% to80% of children with behavioral health disordersdo not receive the specialty services and supportsthey need (President’s New Freedom Commissionon Mental Health, 2003; U.S. Public HealthService, 2000). To address inadequacies in servicedelivery and poor outcomes, the federalgovernment developed the system of careapproach in 1986 (Stroul & Friedman, 1986,1996; Stroul, 2002; Stroul, Blau, & Friedman,2010; Pires, 2002a, 2008, 2010). In 1992, theSubstance Abuse and Mental Health Services

Administration (SAMHSA) began investingsubstantial federal resources to implement andevaluate the outcomes of systems of care in statesand communities across the nation through theComprehensive Community Mental Health forChildren and their Families Program (alsoknown as the Children’s Mental Health Initiative or CMHI).

Framework, Philosophy, and OutcomesThe system of care approach provides anorganizational framework and philosophy tobetter structure the delivery of mental healthservices and to improve the effectiveness of theinterventions used to meet the complex andchanging needs of children with serious mental health problems and their families. This approach has gained broad acceptance over the past 25years as states and communities have recognizedthat traditional service delivery structures andpractices are not successful, particularly forchildren and youth with serious and complexdisorders who are involved with multiple childserving systems. The system of care approachinvolves collaboration across agencies, providers,and families to improve access and expand thearray of high-quality services and supports thatare home and community-based, individualized,coordinated, family-driven and youth-guided,and culturally and linguistically competent. Thecore values and principles comprising the systemof care philosophy are shown on Table 1 (Stroul,Blau, & Friedman, 2010).

Research and evaluation results from the CMHIover the past 15 years have consistently foundthat the implementation of the system of careapproach results in positive outcomes forchildren and their families, such as improvementsin clinical and functional outcomes, increases inbehavioral and emotional strengths, reduction insuicide attempts, improvement in schoolperformance and attendance, fewer contacts withlaw enforcement, reductions in reliance oninpatient care, and more stable living situations.Data also show that caregivers of children served



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DEFINITIONA system of care is: A spectrum of effective, community-based services and supports for children and youth with or at risk for mentalhealth or other challenges and their families, that is organized into a coordinated network, builds meaningfulpartnerships with families and youth, and addresses their cultural and linguistic needs, in order to help them tofunction better at home, in school, in the community, and throughout life.

CORE VALUESSystems of care are:1. Family driven and youth guided, with the strengths and needs of the child and family determining the types andmix of services and supports provided.

2. Community based, with the locus of services as well as system management resting within a supportive, adaptiveinfrastructure of structures, processes, and relationships at the community level.

3. Culturally and linguistically competent, with agencies, programs, and services that reflect the cultural, racial,ethnic, and linguistic differences of the populations they serve to facilitate access to and utilization of appropriateservices and supports.

GUIDING PRINCIPLESSystems of care are designed to:1. Ensure availability and access to a broad, flexible array of effective, evidence-informed, community-based servicesand supports for children and their families that address their physical, emotional, social, and educational needs,including traditional and nontraditional services as well as informal and natural supports.

2. Provide individualized services in accordance with the unique potential and needs of each child and family, guidedby a strengths-based, wraparound service planning process and an individualized service plan developed in truepartnership with the child and family.

3. Deliver services and supports within the least restrictive, most normative environments that are clinically appropriate.

4. Ensure that families, other caregivers, and youth are full partners in all aspects of the planning and delivery oftheir own services and in the policies and procedures that govern care for all children and youth in theircommunity, state, territory, tribe, and nation.

5. Ensure cross-system collaboration, with linkages among child-serving systems and mechanisms for system-levelmanagement, coordination, and integrated management of service delivery and costs.

6. Provide care management or similar mechanisms to ensure that multiple services are delivered in a coordinatedand therapeutic manner and that children and their families can move through the system of services inaccordance with their changing needs.

7. Provide developmentally appropriate mental health services and supports that promote optimal social-emotionaloutcomes for young children and their families in their homes and community settings.

8. Provide developmentally appropriate services and supports to facilitate the transition of youth to adulthood and tothe adult service system as needed.

9. Incorporate or link with mental health promotion, prevention, and early identification and intervention in order toimprove long-term outcomes, including mechanisms to identify problems at an earlier stage and mental healthpromotion and prevention activities directed at all children and adolescents.

10. Incorporate continuous accountability mechanisms to track, monitor, and manage the achievement of system ofcare goals; fidelity to the system of care philosophy; and quality, effectiveness, and outcomes at the system level,practice level, and child and family level.

11. Protect the rights of children and families and promote effective advocacy efforts.

12. Provide services and supports without regard to race, religion, national origin, gender, gender expression, sexualorientation, physical disability, socio-economic status, geography, language, immigration status, or othercharacteristics, and services should be sensitive and responsive to these differences.

SYSTEM OF CARE CONCEPT AND PHILOSOPHYTABLE 1

within systems of care experience reduced strainassociated with caring for a child who has aserious mental health condition, more adequateresources, fewer missed days of work, andimprovement in overall family functioning(Manteuffel et al., 2008).

In addition, evaluation of the CMHI has shownthat the system of care approach has a positiveimpact on the structure, organization, andavailability of services and that it is a cost-effective way of investing resources, redirectingresources from deep-end services (inpatient andresidential treatment) to home and community-based services and supports (Gruttadaro, Markey, & Duckworth, 2009; Maine Department ofHealth and Human Services, 2011; Manteuffel etal., 2008; Maryland Child & AdolescentInnovations Institute, 2008). Care managemententities have been created in many states andcommunities as the locus of accountability formanaging care and costs for youth with the mostserious and complex needs, and intensive caremanagers coordinate services across multipleproviders and child-serving systems (Pires, 2010;Stroul et al., 2009). As a result of the positiveoutcomes measured and reported, the system of care approach has been widely adopted by mental health systems as well as by child welfare, juvenile justice, education, and substance abuse systems;early childhood programs; systems designed toserve youth in transition to adulthood; and evenby many adult-serving systems. In addition,SAMHSA has launched a new effort to furtherthis progress by providing funds to states,territories, and tribes to develop comprehensivestrategic plans for widespread expansion of thesystem of care approach so that more childrenand families can benefit (SAMHSA, 2011b).

These documented outcomes of systems of careat the system and service delivery levels areclosely aligned with the goals of health reform—improving access; improving the organization,management, and delivery of services; managingcosts and better investing resources; and

improving care coordination and outcomes forservice recipients. The system of care approachand health reform also share two additionalgoals. One of the central purposes of healthreform is to increase health promotion,prevention, and early identification efforts inorder to mitigate more serious health problemsand associated costs in the future. Similarly, thesystem of care philosophy entails incorporatingor linking with behavioral health promotion,prevention, and early identification andintervention activities in order to improve long-term outcomes. Particularly important is thelinkage between primary health care services andbehavioral health care and the consequentopportunity to identify behavioral healthproblems earlier in primary care settings. Theincreased access to health care resulting fromhealth reform offers new potential for screeningto detect behavioral health issues at earlier agesand at earlier stages, and for obtainingappropriate treatment in an integrated approach.

In addition, both systems of care and healthreform are characterized by a commitment tohigh-quality care, data-informed service delivery,and continuous quality improvement to ensurethat health care resources fund “what works.” The use of evidence-informed practices to improve outcomes is embraced in the system of care approach and is an explicit goal of health reform.

Given its alignment with the goals of healthreform and its positive outcomes, the system ofcare approach provides an effective frameworkand approach for implementation of the majorcomponents of the ACA. The components of theACA that have direct relevance to the system ofcare approach include:

1. Essential benefits packages in Medicaid,CHIP, Health Insurance Exchanges, andother insurance plans

2. Medicaid and CHIP expansion

3. Health homes

4. 1915(i) State Medicaid Plan Amendments



5. Money Follows the Person

6. Accountable Care Organizations

Each of these components is discussed in detailbelow, along with a discussion of the relevanceand relationship of the system of care approach,and implementation issues to consider as theyrelate to children’s behavioral health.

Essential BenefitsPackages

The ACA requires the development of essentialbenefits packages for Medicaid, for policiesoffered through Health Insurance Exchanges,and for policies offered through individual andsmall group markets outside of the exchanges.

Description—Essential Benefits in Medicaid:Work is currently underway to define a benefitplan that will be a “benchmark benefit package”for newly eligible Medicaid populations enrolledunder the ACA. All new Medicaid enrollees will be entitled to this benchmark benefit package, and states can choose to offer benefits that exceed the benchmark package. DHHS, includingSAMHSA, is undertaking activities to delineatean “essential benefits package” for behavioralhealth services to recommend for inclusion aspart of the benchmark plan in Medicaid.

Description—Essential Benefits in HealthInsurance Exchanges and Other InsurancePlans: A Health Insurance Exchange is agovernmental agency or nonprofit entityestablished by a state to offer an array ofqualified health insurance plans for purchase byindividuals with incomes from 133% to 400% ofthe federal poverty index and for smallbusinesses. States must have their exchanges inplace by January 1, 2014, or the federalgovernment will develop an exchange for thestate. States have wide discretion in setting thestandards, requirements, and rates for plans

offered in their Health Insurance Exchanges.States will determine the benefits that must beoffered by the plans and will create rules toensure that plans are transparent regarding boththe benefits provided and their costs. Nearly allstates have already received federal funds toassist in covering the costs of planning andimplementing their exchanges.

In addition to the benefit package underdevelopment for Medicaid, an essential healthbenefits package is being developed by theDepartment of Health and Human Services(DHHS) that will apply to all insurance plansoffered through Health Insurance Exchanges, aswell as to individual and small group healthinsurance markets outside of the exchanges. TheInstitute of Medicine (IOM) is charged withsubmitting recommendations to the Secretary ofDHHS, and it is anticipated that rules regarding the essential health benefits package for insurance plans will be proposed by DHHS in 2011.

The ACA requires that the essential benefitspackage be the same as a typical employer-sponsored health insurance plan. The ACA alsorequires the Secretary of DHHS to ensure thatthis benefit package is appropriate for vulnerablepopulations, which includes children withbehavioral health treatment needs. The statutelists general categories that must be covered,such as mental health and substance use disorderservices, rehabilitative and habilitative services,and preventive and wellness services. Further, theACA specifies four possible tiers of benefits. Thesilver and gold tiers are required, and as anoption, states may enrich benefits by creatingbronze and platinum plans. However, no detailsare specified under the categories of services orfor specific benefits within each tier, leavingstates with decisions to make regarding theservices to include.

Intersect with Systems of Care: By definition,systems of care include a comprehensive array ofservices to meet the multiple and changing needs

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of children with behavioral health challenges andtheir families, including many services andsupports that have not historically been includedin insurance benefit packages. The system of careapproach also emphasizes an individualizedapproach to service delivery and theincorporation of evidence-informed practices toimprove the effectiveness of services. The arrayof services and supports typically included in thesystem of care approach are shown in Table 2,with the addition of some especially relevantservices and supports that are included in therecently developed for a model “Good andModern Addictions and Mental Health ServiceSystem” (O’Brien, 2011). For many of theseservices, evidence-informed interventions, as wellas interventions created or adapted for particularcultural groups, can be applied.

Many state Medicaid plans have alreadyincorporated coverage for several of theseservices, offering a rich array of children’sbehavioral health services and supports. In manycases, incentives are incorporated to reduce theutilization of high-cost inpatient and residentialservices and to increase the use of home andcommunity-based services that have proven to be

effective. In this way, the system of careapproach has resulted in the redirection of scarceresources. Employer-based insurance plans,however, typically include only a very basicbehavioral health benefit, often limited totraditional outpatient and inpatient servicesrather than the wider range of services that isoptimal for children’s behavioral health. As aresult, children with serious and complexbehavioral health disorders do not receiveintensive services and supports, and are oftenplaced in costly residential and inpatient settingsdue to the lack of coverage for community-basedalternatives.

The comprehensive service array that is inherentin the system of care approach provides a modelfor the essential benefits packages underdevelopment for Medicaid, Health InsuranceExchanges, and other insurance policies.Adoption of this broader service array, in wholeor in part, would ensure that children withserious and complex disorders receive theservices and supports they need in a cost-effectivemanner. In addition, the system of carephilosophy of family-driven, youth-guided,individualized, coordinated, and culturally and

Non-Residential Services• Assessment and evaluation• Individualized “wraparound” service planning• Intensive care management• Outpatient therapy—individual, family, group• Medication management• Intensive home-based services• School-based behavioral health services• Substance abuse intensive outpatient services• Day treatment• Crisis services• Mobile crisis response• Therapeutic behavioral aide services• Behavior management skills training• Therapeutic nursery/preschool

(Specific evidence-informed interventions and culture-specific interventions can be included in each type of service)

Supportive Services• Peer youth support• Peer family support• Youth and family education• Respite services• Therapeutic mentoring• Mental health consultation• Supported education and employment• Supported housing• Transportation

Residential Services• Therapeutic foster care• Therapeutic group home care• Residential treatment center services• Inpatient hospital services• Inpatient medical detoxification• Crisis stabilization services

ARRAY OF SERVICES AND SUPPORTS IN THE SYSTEM OF CARE APPROACHTABLE 2

linguistically competent services provides atemplate to help both states and insurancecompanies offer state-of-the-art children’sbehavioral health services that build on thesenow widely accepted standards of care.

In crafting proposed behavioral health benefitpackages, SAMHSA has considered stakeholderinput advocating the inclusion of specific servicesin the benefit packages as part of the broad arrayof services and supports, such as intensive home-based services, crisis response and stabilizationservices, respite care, professionalized therapeuticmentoring, mental health consultation (forexample, consultation in early childhood settingsor psychiatric consultation with primary carephysicians), parent and caregiver supportpartners who provide peer-to-peer support andassist families in navigating complex servicesystems, therapeutic recreation, increased use oftechnology such as e-therapy and e-support, andothers. This provides concrete guidance to both state policy makers and insurance providers abouthow they should craft their benefit packages.

Implementation Issues to Consider: The addition of this comprehensive service array will be newfor many insurance plans and, in some cases, forstate Medicaid entities. An overriding concern is the need to be cost-conscious in developing benefit plans so as not to increase costs. UnderMedicaid, both the Psychiatric ResidentialTreatment Facility (PRTF) Waiver Demonstrationand the Money Follows the Person (MFP) initiatives are showing that the use of this broader array of services and supports can successfullymaintain children with serious disorders in theirhomes, schools, and communities, and that thisapproach is more cost effective than expensivelong-term residential treatment. On theprevention side, some states that provide earlychildhood mental health consultation in earlychild care and education settings are realizingcost savings by intervening early to addresspotential problems before they develop into moreserious problems requiring intensive and costly

interventions at a later stage. The CMHI hasamassed considerable knowledge and experienceabout how to develop capacity for the entirearray of community-based service and supportoptions. This experience can inform the craftingof essential benefits packages for Medicaid,Health Insurance Exchanges, and other insurancecompanies. If this array of services and supportsis not fully included in the essential benefitspackages, states should identify other fundingsources to ensure that missing services andsupports are available to supplement the benefits offered.

Key questions to consider include:

1. What is the definition of “essential benefits”for children’s behavioral health? How dothese compare with what is included intypical employer-based plans?

2. What array of services and supports,inclusive of culture-specific and culturallyadapted services and supports, should becovered under benchmark plans forMedicaid, Health Insurance Exchanges, andother insurance plans to meet the serviceneeds of children, particularly for those withserious and complex disorders?

3. What incentives can be incorporated to shiftcare from costly residential settings to homeand community-based services and supports?

4. Should states offer Health InsuranceExchange plans with varying levels ofcomprehensiveness for children’s behavioralhealth benefits?

5. What changes are needed in behavioralhealth coverage under CHIP, taking intoconsideration both parity legislation and the introduction of the new Health Insurance Exchanges?

6. What are the estimated costs associated withvarious benefit options for children’sbehavioral health benefits?

7. How should these services be managed?What cost control mechanisms can be put into place?

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8. How can information regarding the evidencebase for services and supports be factoredinto the decisions to be made by statesregarding benefits?

9. What types of culturally and linguisticallyappropriate services and supports should be offered?

10. What kinds of user-friendly materials shouldbe developed about children’s behavioralhealth benefits under the various types ofinsurance options to assist families to makeinformed choices among plans?

11. What other financing sources can be used toprovide any essential services and supportsthat are not included in the benefit packagesfor Medicaid, CHIP, Health InsuranceExchanges, and other insurance plans?

It is critical that state mental health, substanceabuse, and health policy makers understand andaddress these issues in crafting behavioral healthbenefit packages under the ACA, as well asregulations under parity legislation, so thatfamilies have access to the full array of home andcommunity-based services and supportsnecessary for effective treatment.

Eligibility and Enrollment Issues to Consider:A major issue for states to address is howMedicaid, CHIP, the plans offered in HealthInsurance Exchanges, and employer-basedinsurance policies will fit together, how benefitplans might differ among them, and how familieswill navigate these different plans based onchanges in their employment and income status.Individuals, especially those with disabilities(including behavioral health disorders), willrequire assistance in determining which optionsbest address their service needs. Further, manyindividuals eligible for Medicaid and CHIP arenot aware that they qualify for, or know how toenroll in, these public insurance programs, andmany will move from Medicaid and CHIP to theHealth Insurance Exchanges to employerinsurance policies as their incomes andemployment situations change.

States are required to develop “Express LaneEligibility” processes that allow individuals to apply for and enroll in Medicaid, CHIP, or Heath Insurance Exchange plans through websitesadministered by states using a simple two-pageform. States must also provide navigators toassist individuals, including members ofvulnerable and diverse populations, to completethis application and to counsel them in selectingthe correct insurance plan or public program.

The implementation of the system of careapproach in many states and communitiesalready includes some form of peer navigators,who frequently are parent support partners. TheNational Federation of Families for Children’sMental has developed materials and acertification process for parent support partners.This approach can provide effective models fordesigning “Express Lane” eligibility processesand navigator systems for Medicaid, CHIP, andHealth Insurance Exchange plans. In manystates, family organizations for children’s mentalhealth have expertise in providing peernavigators, and contracts with theseorganizations offer a viable approach fordelivering this service. Thus, system of caremodels currently operating in states offer guidance and resources to draw upon in providing peer navigation and family support, as well as inoutreach to diverse populations in need.


1. What culturally and linguisticallyappropriate, user-friendly materials aboutchildren’s behavioral health benefits areneeded assist individuals and families tochoose the correct plan?

2. What strategies can be implemented to assistindividuals and families to move amongMedicaid, CHIP, Health Insurance Exchangeplans, and employer-based policies as theirincome and employment situations change,so that they can retain needed behavioralhealth benefits and service continuity?



3. How can “peer navigators” be incorporatedinto the essential benefits packages to assistindividuals across all cultural groups,particularly those with disabilities, todetermine the insurance option that will bestmeet their own behavioral health serviceneeds and those of their children?

4. How can the experience of systems of care inutilizing peer navigators and peer supportproviders inform the development of peernavigator services under Medicaid, CHIP,and Health Insurance Exchanges?

5. What types of community outreach andmarketing strategies are needed to enrolleligible children in general and culturallydiverse children in particular in Medicaidand CHIP, and how will this be measured?

Medicaid andChildren’s HealthInsurance Program(CHIP) Expansion

Description: Medicaid and CHIP expansionsprovide a vehicle for delivering neededbehavioral health services to many morechildren. It is estimated that the expansions inMedicaid and CHIP programs will increase theirenrollment by 33% by 2019. Another benefit ofMedicaid expansion under the ACA is thatyoung adults exiting foster care will, starting in2014, be automatically enrolled in Medicaidthrough age 25. Those young adults will haveaccess to all necessary health and behavioralhealth services covered under the state plan.

Intersect with Systems of Care: The system ofcare approach can be used as the foundation and framework to ensure that the additionalchildren served by Medicaid and CHIP receivenecessary and appropriate behavioral health care. Many states and communities have already

implemented the system of care approach widely,or are in the process of doing so. As a result ofMedicaid and CHIP expansions, their systems ofcare will be able to expand access to services tomore children who are currently uninsured orunder-insured and will be able to receivereimbursement for these services. This additionalfederal funding through Medicaid and CHIP willlikely assist states to sustain and expand theservices currently offered in community systemsof care that are now supported with federalgrant dollars or scarce state resources.

Systems of care will also be impacted by theaddition of a new group of individuals that willnow be eligible for Medicaid, primarily adultswith incomes between 100% and 133% of thepoverty level. Many of these adults have not hadaccess to health and behavioral health servicesfor some period of time, and a significantnumber of them may be parents of children withbehavioral health needs. Existing systems of caremay already be serving some of these childrenunder Medicaid. The change in Medicaideligibility will allow their parents to receive theirown health and mental health coverage, enablingsystems of care to meet the behavioral healthneeds of the entire family with a comprehensiveand coordinated approach. In addition, based onthe ACA, system administrators will have theability to expand their system of care eligibilitycriteria to include young adults up to age 26 whoare exiting foster care and who still requirebehavioral health services.

Implementation Issues to Consider: Some statescurrently use only state general fund dollars topay for health care for adults between 100% and133% of poverty. These states can realizesignificant savings immediately when they beginto claim 100% federal revenue for theseindividuals under the ACA. In addition tosavings based on this change in Medicaideligibility, states will also receive a 23% savingsin their CHIP plans beginning in 2013, when

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federal financial participation (FFP) will beincreased. Savings that states realize could bereinvested to serve more children and familieswith behavioral health needs. Information anddata are needed for policy makers todemonstrate the need for redirecting savingsfrom Medicaid and CHIP to expand investmentsin systems of care.

States may also experience an increased demandfor primary health, mental health, and substanceabuse services as this new group of individualsbecomes insured. As a result, states will likelyneed to increase their provider networks to servethe expanded covered population. A model forstates is provided by systems of care that haveincorporated parents and paraprofessionals intheir provider networks to provide supports suchas mentoring, peer support, and respite care(Annapolis Coalition, 2007). Adopting thisapproach would assist states to meet theincreased demand for services.


1. How can savings in state funds from increased federal participation in Medicaid and CHIPbe reinvested in order to expand the array ofhome and community-based servicesprovided with the system of care approachand to serve more children and families?

2. What strategies are needed to meet theexpected increase in demand for behavioralhealth services among newly covered childrenand families?

3. What strategies can be implemented toensure that newly covered parents receive the behavioral health services they need inaddition to services related to their children’s needs?

4. How can provider networks be expanded tomeet the increased demand for behavioralhealth services? How should this workforcebe developed and trained in the system ofcare approach (that is, community-based,family-driven, youth-guided, individualized,

evidence-informed, culturally andlinguistically competent interventions and supports)?

5. How can parents and paraprofessionals beincorporated into provider networks toprovide services and supports to contributeto meeting increased demand?

Health Homes

Description: Health homes are a Medicaid option available for states to design programs to betterserve persons with chronic illnesses, seriousmental health conditions, and/or addictiondisorders. Health homes must provide for anindividual’s primary care and disability-specificservice needs in one location, and must providecare management and coordination for all of the services needed by each person. The major goal is to provide more comprehensive, coordinated, and cost-effective care for individuals with disabilitiesthan is generally provided when services arefragmented across multiple health providers andorganizations. A letter from the Centers for Medicare and Medicaid Services to state Medicaid Directors states that: “The health home provision authorized by the ACA provides an opportunityto build a person-centered system of care[emphasis added] that achieves improved outcomes for beneficiaries and better services and value for state Medicaid programs” (Centers forMedicare and Medicaid Services [CMS], 2010). The federal government will provide 90% Federal Medical Assistance Percentages (FMAP) for two years for certain services including comprehensive care management, care coordination, healthpromotion, comprehensive transitional care frominpatient to other settings including appropriatefollow-up care, individual and family support,referral to community and support services, andthe use of health information technology to linkservices, as feasible and appropriate. A secondgoal is for states to experiment with innovative



reimbursement methodologies for services,including case rates, inclusive salaries, and othermechanisms to save on the costs of care.

The ACA also delineates examples of providersthat may qualify as health homes, such asphysicians (including pediatricians, gynecologists,and obstetricians), clinical practices or clinicalgroup practices, rural health clinics, communityhealth centers, community mental health centers,home health agencies, or any other entity orprovider that is determined appropriate by thestate and approved by the Secretary of DHHS.Given the license to include other types ofentities, states may want to designate additionalproviders, subject to CMS approval, such asagencies that offer behavioral health services.Designated providers must have systems in placeto provide health home services and must satisfycertain qualification standards.

Health homes are designed to operate under a“whole-person approach” to care that addressesall of the health-related needs of the person anduses a “person-centered” planning process toidentify and provide needed services andsupports. Teams of health care professionals arealso expected to coordinate care. Teams can becomprised of medical professionals, socialworkers, and mental health and substance useprevention and treatment providers.

Intersect with Systems of Care: The healthhome concept is closely aligned with the systemof care approach, sharing many of the samevalues and operational principles. First, the ACAspecifies that health homes provide a broad arrayof services and supports which are all coreservices integral to the system of care approach.In the creation of health homes that servechildren with serious behavioral healthconditions, the coordination, individualization,and array of services and supports that comprisesystems of care provide an effective model tobuild into the health home approach. Existingsystem of care structures, such as care

management entities, may be uniquely qualifiedto be designated as health homes for childrenwith behavioral health disorders under the ACA.In addition, the creation of health homes forchildren and youth with serious behavioralhealth disorders provides a vehicle for expandingthe system of care approach across localitieswithin a state, the goal of SAMHSA’s currentsystem of care expansion initiative.

Additionally, health homes use an approach tocare that addresses all of the person’s needs anddoes not compartmentalize the person’s health orwell-being. A person-centered team approach isused to plan and deliver services that arecustomized to meet each person’s needs. Healthhomes then provide care and linkages to otherservices and supports that address both theclinical and nonclinical needs of an individual.Individualized service planning and delivery isalso a cornerstone of the system of careapproach and the primary way that it isimplemented at the service delivery level.Referred to as “wraparound,” a child and familyteam (including relevant service providers andprofessionals along with the family and youth) isconvened to identify needed services andsupports; create an individualized, culturally andlinguistically appropriate service plan; provideservices; and link the child and family to otherneeded services and supports. Considerable workby the National Wraparound Initiative hasresulted in the specification of principles andprocesses that characterize the wraparoundapproach, and numerous tools to support andassess implementation. Thus, the experience,expertise, and resources developed for servingchildren with mental health challenges with thesystem of care approach offers much to guide theimplementation of health homes.

Implementation Issues to Consider: Healthhomes offer a significant opportunity forchildren with serious behavioral health problemsand their families to receive care that is alignedwith the system of care concept and philosophy.

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In addition, the system of care approach itselfoffers exemplars, prototypes, and models thatcan serve as the basis for the implementation ofhealth homes—not only for children withbehavioral health disorders, but for other healthcare populations as well.


1. How can the system of care approach beused to inform the design, development, andoperation of health homes under the ACA?

2. How can care management entities thatspecialize in managing services for childrenwith serious behavioral health disorders serveas health homes under the ACA?

3. What new financing strategies are needed tosupport the initial start-up and developmentof health homes that have special expertise inchildren’s behavioral health?

4. What types of providers are qualified to bedesignated as health homes for children withbehavioral health disorders?

5. How can the broad array of services andsupports inherent in the system of careapproach be used as a model for the services and supports to be provided by health homes?

6. How can the individualized, culturally and linguistically competent wraparound approach to service planning and delivery be applied tothe service delivery approach used by healthhomes, particularly those serving childrenwith serious and complex behavioral healthchallenges and their families? What resourcesand tools might be valuable in this process?

7. What quality measures should be used forhealth homes in relation to children’sbehavioral health?

8. What innovative financial reimbursementmechanisms for health homes can offer thebest services most economically?

9. How can key child-serving systems be linkedto health homes?

1915(i) StateMedicaid PlanAmendments

Description: New 1915(i) State Medicaid PlanAmendments (SPAs) allow states a means tochange their Medicaid plans to offer Home andCommunity-Based Services (HCBS) as an optionfor serving more individuals. Individuals withincomes up to 150% of the federal poverty level,and individuals with disabilities receiving up to300% of the maximum Supplemental SecurityIncome (SSI) payment (for 2010, 300% of SSI isequal to $2,022 per month) will qualify forservices under this option. States may includeseveral different populations under a single1915(i) SPA. Examples of populations that can be served include: 1) adults with severemental illness, 2) seniors at risk of placement innursing homes, and 3) children with a seriousemotional disturbance.

States may not waive the requirement to provideservices statewide, nor can they limit the numberof participants in that state who may receive theservices if they meet the population definition. In order to limit costs, however, states may identify a very specific population in an SPA request. A state could, for example, focus an SPA only on children with serious emotional disorders who have hadtwo or more psychiatric hospitalizations, ratherthan include all children with serious emotionaldisorders, thereby limiting the number of eligibleindividuals and the associated cost impact on thestate. The SPA may also be phased in over a five-year period, allowing states time forproviders to develop new, flexible, home andcommunity-based services, and time to secure thefinancing necessary to implement the SPA. Onebenefit of 1915(i) SPAs is that children withincomes up to 150% of the poverty level nolonger must meet the criteria for institutionalcare to receive “waiver-type” services like respiteor wraparound facilitation (an intensive service



planning and case management process). Statesusing the 1915(i) SPA vehicle will neither bearthe burden of renewing a short-term waiverapplication and will not be required todemonstrate “cost neutrality.” 1915(i) SPAs willbe approved by CMS for a five-year period andmay be renewed.

Intersect with Systems of Care: Systems of carehave led the way in developing new intensive,home and community-based services for manychildren with serious mental health disorders inmost states. As noted, many states have alreadydeveloped and financed a broad array oftreatment services and supports includingintensive home-based services, respite care,family support, therapeutic behavioral aides,mentors, wraparound facilitation, intensive caremanagement, evidence-based practices, culture-specific interventions, and many others. Some ofthese services that comprise the system of careapproach have been financed through multipleMedicaid options and waivers. Other federal,state, and local funds have, however, been usedto cover these services when they are not coveredunder the Medicaid Clinic Services orRehabilitation Options or under waivers. The 1915(i) SPA now makes it possible to cover these services through a single mechanism,so long as they are offered statewide for thedefined population.

This option also offers an opportunity for statesto combine some or all of the services theycurrently offer using the system of care approachthat are covered under the Rehabilitation Optionand incorporate them under a 1915(i) SPA. Thiswould allow them to offer waiver-like serviceswithout the requirement of meeting the definitionof rehabilitation services (Public Health, 2010).For example, infant mental health services maybe provided without the need to demonstratethat the infant is being “rehabilitated,” whichcurrently is a requirement under theRehabilitation Option. Infants are not likely tohave a condition to rehabilitate, thus making

them ineligible for such services through theirMedicaid coverage. In addition, some servicessuch as respite care, parent support partners,intensive in-home services, and therapeuticbehavioral aides provide critical supports tomaintain children in their homes andcommunities, but may not meet the strictdefinition of rehabilitation. Moving these typesof services from the Rehabilitation Option to a1915(i) SPA allows these services and supports tobe provided without having to meet the criteriafor what constitutes rehabilitation.

The system of care approach offers a frameworkfor crafting 1915(i) SPAs, assisting states todetermine what services and supports should beprovided to qualifying children. States andcommunities using the system of care approachwill also benefit from this option, as it will allowthem to provide the more intensive, flexibleservices and supports that are both highly valuedby families, and essential for serving childrenwith complex needs in the community ratherthan in more costly residential settings. Statesshould be encouraged to submit applications for1915(i) SPAs for children with serious emotionaldisorders and their families in order to expandthe availability of the services typically offeredthrough systems of care that have demonstratedpositive outcomes.

Implementation Issues to Consider: 1915(i)SPAs offer states an incentive to maximizefederal Medicaid funds for services that are lesscostly than residential care. However, a concernfor states might be the potential costs associatedwith 1915(i) SPAs, primarily because the servicesmust be available statewide. Data are needed todetermine the estimated costs of making theseservices available statewide and to determinewhat resources are already being used to financethese services. This information can then be usedto determine whether or not it would be cost-efficient to make these services Medicaid billable.For example, a state may be spending $2 millionon respite care using 100% state dollars. If all

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children receiving respite care were included inthe SPA, by making this service Medicaidbillable, the state could expand availableresources to $4 million, provided that their statematch is 50% and that the population currentlyreceiving the service is Medicaid eligible. If thestate match is 25%, total available resourcescould potentially expand to $5.5 million, and thestate could then cover many more children whorequire this service, enabling the benefits toaccrue statewide with no additional costs to thestate. This same model could be used for otherservices such as family support or wraparoundfacilitation. It is critical for the children’sbehavioral health community to collectinformation assessing the advantages of pursuingthis option, and to inform high-level policymakers and decision makers.

In other instances, a state may move servicescurrently covered under the Clinic andRehabilitation Options into a 1915(i) SPA.Depending on the desired service array, a statecould make the case that it will be able to keepmore children out of psychiatric hospitals or residential treatment facilities by making intensive home and community-based services availableand by managing placements more effectively. States could also build a case for redirecting funds to intensive community-based services from morerestrictive and costly care such as residentialtreatment or psychiatric hospitalization. Forexample, if a state included wraparound facilitation, respite, therapeutic mentoring, parent support partners, intensive in-home services, andother intensive community-based services forchildren in addition to outpatient clinic services,then these services could be provided in lieu ofhigh-cost placements. In this example, a statecould build a business case for using the 1915(i)SPA, because the intensive community-based services could help reduce out-of-home placement costs. This is just one of many options that statescould consider regarding the use of 1915(i) SPAs.States and communities will need to work inpartnership to use this option effectively.


1. Should the state apply for a 1915(i) SPA for a defined population or sub-populationof children with serious behavioral health disorders?

2. Which of the expanded array of service andsupports that comprise the system of careapproach should be incorporated into a1915(i) SPA, including services that arecurrently funded under the other Medicaidoptions or waivers?

3. What data are needed to determine the cost-efficiency of including specific services andsupports under the SPA, and how will thatdata be collected?

4. Are the services and supports included in the 1915(i) SPA likely to result in reducedutilization of inpatient and residentialtreatment services and redirection ofresources to more effective home andcommunity-based approaches?

Money Follows the Person

Description: Enacted as part of the DeficitReduction Act (DRA) of 2005, the MoneyFollows the Person (MFP) Rebalancing Demonstration is part of a comprehensive strategy within Medicaid to assist states, in collaborationwith key stakeholders, to make widespreadchanges to their long-term care support systems.This initiative was included in the ACA andencourages states to reduce their reliance oninstitutional care while developing community-based, long-term care alternatives. The targetpopulation for this initiative includes childrenand youth with serious emotional disorders whohave been in psychiatric hospitals or PsychiatricResidential Treatment Facilities (PRTFs).

Congress initially authorized up to $1.75 billionin federal funds for the MFP Demonstrationprogram through 2011 to increase the use of



home and community-based services and reducethe use of institutionally-based services. Thefunds are also intended to strengthen the abilityof state Medicaid programs to ensure ongoing,high-quality home and community-based care toindividuals transitioning from institutions.

The ACA provides an opportunity for morestates to participate in MFP in addition to thosestates that are already participating in thedemonstration, and will help states continue tobuild and strengthen their demonstrationprograms. The ACA extended the MFPDemonstration Program through September 30,2016, with an additional $2.25 billionappropriated over four years. Any unusedportion of a state grant award made in 2016would be available to the state until 2020. TheACA also expanded the definition of the eligiblepopulation for the demonstration to includeindividuals who reside in an institution for morethan 90 consecutive days (down from 180 daysin the original MFP demonstration). This changemakes it possible for many children and youthwho receive treatment in PRTFs to transition tothe community with needed services andsupports that otherwise are typically coveredonly in a Medicaid waiver (such as wraparoundfacilitation, respite, therapeutic mentoring,intensive in-home services, parent supportpartners, and others), with the added benefit ofenhanced federal Medicaid match. A formula isused to determine the match that involvesdividing the current FMAP in half and thenadding that number to the current FMAP. A statecurrently at 50% would receive an enhancedmatch of 25%, which would take the entirematch to 75% FMAP, with an upper limit of90% FMAP. The enhanced federal match isavailable for 365 days after each individual’sdischarge from the institution.

Intersect with Systems of Care: The system ofcare approach provides a framework andphilosophy for serving children who qualify forMFP. Children and youth who qualify must meet

the requirement of having stayed in a PRTF,inpatient psychiatric unit, or state psychiatrichospital for at least 90 consecutive days. Thesechildren have the most serious functionalimpairments, and are typically served by multiplesystems, including mental health, education,child welfare, juvenile justice, developmentaldisabilities, and/or substance abuse. Such youthhave often experienced multiple episodes ofhospitalization and residential treatment andhave received many high-cost services frommultiple child-serving systems without adequatecoordination, individualization, family and youthinvolvement, or cultural competence.

Many states and communities have demonstratedhow the system of care approach can be usedeffectively to divert youth from inpatient andresidential treatment, as well as to successfullytransition youth in residential settings back to their homes, schools, and communities (Kamradt, Gilbertson, & Jefferson, 2008; Maryland Child & Adolescent Innovations Institute, 2008).Typically, a highly individualized approach isused to develop a service plan that includesintensive services and supports coordinated by askilled care manager. A care management entityis often the locus of accountability for thispopulation, managing both services and costs(Pires, 2010). States crafting their MFP programscan benefit from this experience by using thisapproach to create an effective “package” ofintensive, individualized services and supportsthat are managed as a cost-effective alternative toinstitutional treatment.

MFP can also assist states and communities buildthe capacity within their systems of care toimplement evidence-informed interventions,promising practices, and culture-specificinterventions. The additional funding fromenhanced federal match could help states andcommunities assess their readiness to implementthese practices (and potentially provide the fiscalsupport for start-up costs including training andcoaching for providers), to ensure that children

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and youth transitioning from residential settings will be served with the most effectivetreatment interventions.

Implementation Issues to Consider: Childrenand youth transitioning from restrictiveresidential settings often need an intensive,coordinated service delivery approach, withmultiple child-serving agencies partnering toprovide services and supports in the child’shome, school, and community. Experience hasshown that traditional outpatient clinic servicesare not sufficient to successfully serve childrenwith the most serious and complex disorders inthe community. Rather, a full array of intensivehome and community-based supports inaccordance with the system of care philosophyand approach is needed as alternatives totreatment in institutional settings—intensive,individualized, coordinated across systems,family driven and youth guided, and culturallyand linguistically competent, and with skilledcare management at the child and family level.


1. How will a partnership across child-servingsystems, providers, and family and youthorganizations be developed to plan andimplement an approach for transitioningyouth from residential to community-basedservices? What ongoing structures andprocesses are needed?

2. What intensive services and supports areneeded to successfully serve this populationin the community?

3. What is needed to implement anindividualized, wraparound approach toplanning and delivering services to this high-need population?

4. What evidence-informed, promising, andculture-specific interventions should beincorporated to ensure effective treatmentand support?

5. How will services and the system be managed?

Accountable CareOrganizations

Description: Accountable Care Organizations(ACOs) are structures created by the ACA thatare responsible for providing, managing, andcoordinating the total care of a definedpopulation of 5,000 or more individuals. ACOswill be created by linking a group of providerswithin a single entity with shared governance,and with clinical and financial incentives toprovide high-quality health services at a reducedcost. They may serve as a “neighborhood”medical and behavioral health care network thatconsists of multiple primary care practices,health homes, and specialty providers such asfamily-run organizations, residential treatmentservices, and hospitals.

The ACA calls for demonstration pilots of ACOsfor Medicare enrollees and at least one pilot of apediatric ACO, but does not specify howbehavioral health (or more specifically children’sbehavioral health) should be incorporated.Current planning for ACOs appears to beprimarily among large health care organizationsand hospital systems. Many of theseorganizations are attempting to acquire specialtypractices, such as nonprofit community mentalhealth centers, to bring behavioral healthexpertise into their medical-surgical networks.

Most states are in the early stages of definingACOs for their health systems and will havemajor decision-making authority about theirdesign, business models, operationalrequirements, quality standards, andperformance requirements. The NationalCommittee for Quality Assurance (NCQA) willissue draft standards for ACOs, and CMS willissue regulations for ACOs, in part based onongoing demonstrations.



Intersect with Systems of Care: ACOs will berequired to develop plans specifying the servicesthey will provide in their networks, how service delivery will be structured, how care management and other essential functions will be handled,and how services will be coordinated. Similar tothe applicability of the system of care frameworkto health homes, the system of care approach canprovide a value base, operational principles, adefined array of services and supports, and acollaborative cross-agency model for serviceplanning and delivery that can serve as a guidefor ACOs for the provision of behavioral healthservices to enrolled children and families.

Implementation Issues to Consider: Asignificant challenge in the creation of ACOs isto determine how behavioral health services willbe organized, licensed, regulated, financed, andmonitored within these structures. In addition,state leadership must determine if and how thesystem of care approach will be applied to thedesign and operation of these structures, and inparticular how this approach will be applied tochildren’s behavioral health services.

Although health reform is seen as an opportunityto better integrate physical health and behavioral health care, a concern is that research on managed care has found that when physical and behavioral health are integrated into one organization (perhaps like an ACO), behavioral health services lose focus, particularly when specific resources are not designated for those services. “Carving out”behavioral health has tended to result in greaterexpertise, resources, and better behavioral healthoutcomes, without necessarily sacrificingcoordination with physical health services (Pires,2002b). Care should be taken to consider lessonslearned from previous experience to inform thedevelopment of the new clinical and financialstructures called for under the ACA.

It is essential to consider mental health andsubstance use in planning ACOs and to carefullyconsider the types and the cultural diversity of

specialty providers that should be included in theACO structure to address children’s needs. Inaddition, consideration is needed to determinehow care management entities within systems ofcare may serve as health homes incorporatedwithin the ACOs.


1. Given the initial focus on Medicare, how willthe needs of children and families beconsidered in future ACO efforts?

2. What will be the relationship between ACOsand health homes? Will ACOs be globalstructures that incorporate health homes?

3. How can behavioral health organizationsbecome specialty health homes or specializedbehavioral health service providers within ACOs?

4. How can care management entities using thesystem of care approach be incorporated intoACOs as health homes or as some otherparticipating structure?

5. How will standards, licensing, and regulationof ACOs address behavioral health ingeneral, and children’s behavioral healthneeds in particular?

6. What quality measures should be assessed for ACOs in relation to children’s behavioral health?

7. Will small groups and individual providers beincluded within ACO structures and, if so, how?

8. How will care managers, nontraditionalproviders, peer to peer providers, culture-specific and other providers be included inACO networks?

9. What strategies can be used to ensure thatfamilies and consumers will have oversightand ombudsperson roles in ACOs?

10. Since multiple systems fund and providebehavioral health services for children, whatsystems should be included (health, mentalhealth, substance abuse, child welfare,juvenile justice, education), and how will thisnetwork be structured?

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ConclusionSystems of care and health reform intersect in anumber of important ways that haveimplications for the future implementation ofboth. The alignment of goals is clear in that bothsystems of care and health reform are designedto increase access to health care services, increasethe array of available services and supports,improve the coordination of care, improve thequality and outcomes of care, improve the cost-effectiveness of services, and better investresources. Systems of care have demonstratedthat the availability of a broad range oftreatment and support services for children’sbehavioral health is effective in preventing moreserious problems and in mitigating overall healthcare system costs. Further, an individualized,wraparound approach to service planning anddelivery has proven effective in many states andcommunities and has been the primary approachused to operationalize the system of carephilosophy at the service delivery level, ensuringthat children and their families receive optimal,appropriate, and cost-effective care. Carecoordination and management at the individualand system levels have reduced fragmentationand resulted in better use of resources. Systemsof care have demonstrated that there are, in fact,cost-reducing and cost-effective alternatives toserving children in hospitals, residentialtreatment centers, and other institutionalsettings, which is especially important during this time of fiscal challenges. These and otherelements of the system of care approach may be new for insurance companies, but have beenused effectively for many years by states and communities.

As planning and implementation activities forhealth reform gain momentum, it is essential toconsider the implications for children,adolescents, and young adults with behavioralhealth challenges and their families and todetermine how their needs will be addressed. Thesystem of care approach has been embraced asthe basis for a “paradigm shift” in the children’smental health field, as well as in other child-serving systems and even adult service systems.Given the close alignment of goals, the system ofcare approach provides a valuable frameworkand value base for health reform and definescritical elements of children’s behavioral healthservices that should be incorporated into theimplementation of the ACA. The ever-growingknowledge base and experience with systems ofcare can make a vital contribution to structuringACA implementation to effectively providechildren’s behavioral health services in order toachieve shared goals. In turn, the ACA andhealth reform provide a strategic and importantvehicle for sustaining and expanding systems ofcare and the gains made for children and youthwith behavioral health challenges and theirfamilies in states, communities, tribes, andterritories across the country.

As health reform continues to unfold, information will be needed to guide states and communitiesin addressing children’s behavioral healthservices. This Issue Brief is intended to fulfill thisfunction. Initial priorities for implementationinclude health homes, essential benefits packages,and Health Insurance Exchanges. SubsequentIssue Briefs in this series will provide timelyinformation on these aspects of the ACA andhow they intersect with systems of care.



ResourcesHealth ReformThe National Council of State LegislaturesState-by-state information about strategies,timelines and action plans for implementing the Affordable Care Act.www.ncsl.org/?tabid=20231

The Kaiser Family FoundationDescriptive information, timelines, and updateson implementation of the Affordable Care Act.www.kff.org

The Commonwealth FundInformation about health care reform, including state-specific information about ACA implementation.www.commonwealthfund.org/Innovations/View-All.aspx?topic=State+Health+Policy

The State ReformDiscussions and related documents about each state’s work on ACA.www.statereforum.org

Healthcare.govInformation on provisions of the ACA:www.healthcare.gov

Information specifically targeted at young adults:www.healthcare.gov/foryou/youngadults

Clickable map that shows the funding states have for implementing the ACA:www.healthcare.gov/center

Child Welfare Provisions in the ACAwww.napcwa.org/Legislative/admin_activities.asp

CLASS Act Provisions for Individuals with Developmental Disabilities and Co-occurring Disordershttp://healthreform.kff.org/~/media/Files/KHS/docfinder/crs_1511CLASSAct.pdf

www.advanceclass.org/background/fact-sheet

The California EndowmentStrategies for Successful State Implementation ofthe Affordable Care Act.www.communitycatalyst.org/doc_store/publications/Rubber_Meets_Road_Jan_2011.pdf

Grant Opportunities Under the ACAhttp://nashp.org/sites/default/files/PPACA_Demos_and_Grant_Programs_-final_July20_2010.pdf?q=files/PPACA_Demos_and_Grant_Programs_-final_July20_2010.pdf

Federal and State Cost Implications of ACAImplementation and Costs of ACA RepealStan Dorn, S., and Buettgens, M., December 2010. Net Effects of the Affordable Care Act on StateBudgets. Washington, DC: The Urban Institute. www.urban.org/UploadedPDF/1001480-Affordable-Care-Act.pdf

Buettgens, M., Dorn, S., and Carroll, C., July2011. Consider Savings as Well as Costs. StateGovernments Would Spend at Least $90 BillionLess With the ACA than Without It from 2014to 2019. Timely Analysis of Immediate HealthPolicy Issues. Princeton, NJ: Urban Institute andthe Robert Wood Johnson Foundation.www.rwjf.org/files/research/72582qsfull201107.pdf

www.rwjf.org/files/research/72582qsonepage201107.pdf—One-page report summary

Finkelstein, A., Taubman, S., Wright, B.,Bernstein, M. et al., July 2011. The OregonHealth Insurance Experiment: Evidence from the First Year. NBER Working Paper No. 17190.Cambridge, MA: National Bureau of Economic Research.www.nber.org/papers/w17190

Bazelon Center For Mental Health Law, 2011.Medicaid Lifeline for Children and Adults withSerious Mental Illnesses. Washington, DC: DavidS. Bazelon Center for Mental Health Law.www.bazelon.org/LinkClick.aspx?fileticket=ARq331Ujs3Q%3d&tabid=242

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System of Care ApproachStroul, B. & Blau, G. (2008). The system of carehandbook: Transforming Mental Health Servicesfor Children, Youth, and Families. Baltimore,MD: Paul H. Brookes Publishing Company

Health Insurance ExchangesDeborah Bachrach, D., Boozang, P., and Dutton,M., March 2011. Medicaid’s Role in the HealthBenefits Exchange: A Road Map for States. Princeton, NJ: Robert Wood Johnson Foundation.www.rwjf.org/files/research/72126medicaidhealthexchange201104.pdf

Urff, J. April, 2011. Building an Effective HealthInsurance Exchange. Boston, MA: Blue CrossBlue Shield of Massachusetts (BCBSMA)Foundation.http://bluecrossfoundation.org/Health-Reform/Lessons/~/media/Files/Health%20Reform/Lessons%20for%20National%20Reform%20from%20the%20Massachusetts%20Experience%20Toolkit%20Series%201.pdf

Corlette, S., Alker, J., Touschner, J., and Volk,JA, 2011. The Massachusetts and Utah HealthInsurance Exchanges: Lessons Learned. Princeton, NJ: Robert Wood Johnson Foundation www.rwjf.org/files/research/72105massutah201103.pdf

Raymond, A., March 2011. Lessons from theImplementation of Massachusetts HealthReform. Boston, MA: Blue Cross Blue Shield ofMassachusetts (BCBSMA) Foundation. http://bluecrossfoundation.org/~/media/Files/Health%20Reform/Lessons%20for%20National%20Reform%20from%20the%20Massachusetts%20Experience%20Lessons%20Learned.pdf

Pre-Existing Condition High Risk Insurance PoolsWebsite to access plans offered by DHHS orparticipating states:www.pcip.gov/stateplans.html

www.pcip.gov/LearnMore.html

Essential Benefits PackagesInstitute of MedicineWork on essential health benefitswww.iom.edu/Activities/HealthServices/EssentialHealthBenefits/2011-JAN-12.aspx

Kaiser Family FoundationDocument with strategies, state examples,requirements and funding for electronicenrollment systemswww.kff.org/healthreform/upload/8108.pdf

Centers for Medicare and Medicaid ServicesResources for providers such as Children’sCoverage Toolkitwww.insurekidsnow.gov

ACA and Co-Occurring Mental Health andSubstance Abuse Services OptionsGarfield, R., Lave, J., and Donohue, J.,November 2010. “Health reform and the scopeof benefits for mental health and substance usedisorder services.” Psychiatric Services. Vol. 61No. 11, pages 1081-1086.

National Federation of Families for Children’s Mental HealthInformation and certification for parent support partnershttp://ffcmh.org/national-initiative-for-parent-support-providers

Medicaid and CHIP ExpansionKaiser Family Foundation ResourcesKey Questions About Medicaid and its Role inState/Federal Budgets and Health Reformwww.kff.org/medicaid/upload/8139.pdf

Robert Wood Johnson Foundation ResourcesMedicaid, CHIP, and Health Insurance Exchangeswww.rwjf.org/files/research/72126medicaidhealthexchange201104.pdf

Report on Opportunities for Utilizing Medicaid and CHIP under Health CareReform—State of the Stateswww.rwjf.org/files/research/71835report.pdf



National Council of Community Behavioral HealthcareHealth Care Reform Implementation Timeline:Medicaid Provisionswww.thenationalcouncil.org/galleries/policy-file/Healthcare%20Implementation%20Timeline%20Medicaid%20Provisions.pdf

Centers for Medicare and Medicaid Services Guidance LettersState Option to Provide Health Homes forEnrollees with Chronic Conditionswww.cms.gov/smdl/downloads/SMD10024.pdf

Improving Access to Home and Community-Based Services—CMS 1915(i)www.cms.gov/smdl/downloads/SMD10015.pdf

Community First Choice OptionSummary of the provisions of the Medicaid CFC option, see Section 2401 of the Affordable Care Act (ACA) or go towww.thearc.org/document.doc?id=2605%20

Health HomesCMS Guidance Letter on Health Homeswww.cms.gov/smdl/downloads/SMD10024.pdf

American Academy of PediatricsDocument on Collaborative Projects onBehavioral Health Problemswww.aap.org/mentalhealth

Commonwealth Fund Resourceswww.commonwealthfund.org/Content/Newsletters/States-in-Action/2011/Jan/December-2010-January-2011/Feature/Feature.aspx

http://healthreformgps.org/wp-content/uploads/Abrams-Realizing-Health-Reforms-Potential.pdf

American Academy of Child and Adolescent PsychiatryPaper on children’s mental health and healthhomes and mental health toolkit for pediatricianswww.aacap.org

National Wraparound InitiativeTools for wraparound approachwww.nwi.pdx.edu

1915(i) State Plan AmendmentsCenters for Medicare and Medicaid ServicesCMS letter to State Medicaid Directors, datedAugust 6, 2020, outlines requirements for statesthat are submitting Medicaid Plan amendmentsfor 1915(i).www.healthreformgps.org/wp-content/uploads/he08092010_waiver.pdf

Money Follows the PersonCenters for Medicare and Medicaid ServicesCMS letter State Medicaid Directors, dated June 22, 2010, regarding extension of Money Follows the Person RebalancingDemonstration Program.www.cms.gov/smdl/downloads/SMD10012.pdf

Accountable Care OrganizationsNCQADraft standards for ACOswww.ncqa.org/portals/0/publiccomment/ACO/ACO%20Criteria_Public_Comment.pdf

National Council on Community BehavioralHealthCareDescriptive document on ACOs www.thenationalcouncil.org/galleries/default-file/Partnering%20With%20Health%20Homes%20and%20ACOs%20Full%20Paper.pdf

ACO Learning NetworkToolkits and other information on ACOswww.acolearningnetwork.org

Brookings Institution Resourceswww.brookings.edu/search.aspx?doQuery=1&q=Accountable%20Care

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ReferencesAnnapolis Coalition. (2007). Innovative practices in

behavioral health workforce development. Long Beach, CA: The Annapolis Coalition on the BehavioralHealth Workforce.

Centers for Medicare & Medicaid Services [CMS].(November, 2010). Health homes for enrollees withchronic conditions (SMDL # 10-024, ACA# 12).Baltimore, MD: Author.

Congressional Budget Office [CBO]. (2011). CBO’sanalysis of the major health care legislation enacted inMarch 2010. Retrieved June, 2011, fromhttp://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf

Federal Register. (2011). Federal Poverty Level. Vol. 76,No. 13, January 20, 2011, pp. 3637-3638.

Federation of Families for Children’s Mental Health.(2011). Parent Support Providers Certification. RetrievedJuly, 2001, from: http://ffcmh.org/national-initiative-for-parent-support-providers/certification-2/download-resources/

Friedman, R., Katz-Leavy, W., Manderscheid, R., &Sondheimer, D. (1998). Prevalence of serious emotionaldisturbance in children and adolescents. An update. In R.W. Manderscheid & M. A. Sonnenschein (Eds.), Mentalhealth, United States, 1998 (pp. 110-112). Washington,DC: U.S. Government Printing Office

Friedman, R., Kutash, K., & Duchnowski, A. (1996). Thepopulation of concern: defining the issues. In B. Stroul(Ed.) Children’s mental health creating systems of care ina changing society. Baltimore, MD: Paul H. BrookesPublishing Company.

Greenbaum, P., Dedrick, R., Friedman, R., Kutash, K.,Brown, E, Larideri, S., & Pugh, M. (1998). NationalAdolescent and Child Treatment Study (NACTS):Outcomes for children with serious emotional andbehavioral disturbance. In M. Epstein, K. Kutash, & A.Duchnowski (Eds.) Outcomes for children with seriousemotional and behavioral disorders and their families.Austin, TX: PRO-ED.

Gruttadaro, D., Markey, D., & Duckworth, K. (2009).Reinvesting in the community: A family guide toexpanding home and community-based services andsupports. Arlington, VA: National Alliance on Mental Illness.

Huang, L., Stroul, B., Friedman, R. M., Mrazek, P., Friesen,B., Pires, S., & Mayberg, S. (2005). Transforming mentalhealth care for children and their families. AmericanPsychologist, 60(6), 615.

Kamradt, B., Gilbertson, S., & Jefferson, M. (2008).Services for high-risk populations. In B. Stroul & G. Blau(Eds.), The system of care handbook: Transformingmental health services for children, youth and families(pp. 3-24). Baltimore: Paul H. Brookes Publishing Co.

Kessler, R. C., Chiu, W. T., Demier, O., & Walters, E. E.(2005). Prevalence, severity and comorbidity of twelve-month DSM-IV disorders in the National ComorbiditySurvey Replication (NCS-R). Archives of GeneralPsychiatry, 62, 6127-627.

Mental Health Parity and Addiction Equity Act of 2008,Pub. L. No. 110-343, § 122 Stat. 3765 (2008).

O’Brien, J. (2011). Draft description of a good and modern additions and mental health service system.Rockville, MD: Department of Health and HumanServices, Substance Abuse and Mental Health Services Administration.

O’Connell, M. E., Boat, T., & Warner, K. E. (Eds.) (2009).Preventing mental, emotional and behavioral disordersamong young people: Progress and possibilities.Washington, DC: The National Academies Press.

Maine Department of Health and Human Services. (July,2011). Wraparound Maine: A mental health service useand cost study. QI Data Snapshot, 3(3). Maine: Office ofContinuous Quality Improvement Services.

Manteuffel, B., Stephens, R., Brashears, R., Krikelyova, A.,& Fisher, S. (2008). Evaluation results and systems ofcare: A review. In B. Stroul & G. Blau (Eds.), The systemof care handbook: Transforming mental health servicesfor children, youth and families (pp. 3-24). Baltimore:Paul H. Brookes Publishing Co.

Maryland Child & Adolescent Innovations Institute.(2008). The Maryland care management model: Carecoordination using high-fidelity wraparound to supportthe strengths and needs of youth with complex problemsand their families. Baltimore, MD: University ofMaryland, School of Medicine.

Patient Protection and Affordable Care Act [ACA] of 2010,Public Law 111-148.

Pires, S. (2002a). Building systems of care: A primer.Washington, DC: National Technical Assistance Centerfor Children’s Mental Health, Georgetown UniversityCenter for Child and Human Development.



Pires, S. (2002b). Health care reform training project(HCRTP): Promising approaches for behavioral healthservices to children and adolescents and their families inmanaged care systems—1: Managed care design andfinancing. (FMHI Publication #211-1) Tampa FL:University of South Florida, Louis de la Parte FloridaMental Health Institute, Research and Training Centerfor Children’s Mental Health.

Pires, S. (2008). Building systems of care: A primer forchild welfare. Washington, DC: National TechnicalAssistance Center for Children’s Mental Health,Georgetown University Center for Child and Human Development.

Pires, S. (2010). Building systems of care: A primer (SecondEdition). Washington, DC: National Technical AssistanceCenter for Children’s Mental Health, GeorgetownUniversity Center for Child and Human Development.

President’s New Freedom Commission on Mental Health.(2003). Subcommittee on Children and FamiliesSummary Report. Retrieved March 2005 fromhttp:///www.mentalhealthcommission.gov/subcommittee/children_family020703.doc

Public Health, 42 C.F.R. pt. 440.130 (2010).

Stroul, B. (2002). Issue Brief. Systems of care: A frameworkfor system reform in children’s mental health.Washington, DC: National Technical Assistance Centerfor Children’s Mental Health, Georgetown UniversityCenter for Child and Human Development.

Stroul, B., & Blau, G. (Eds.). (2008). The system of carehandbook: Transforming mental health services forchildren, youth, and families. Baltimore, MD: Paul H.Brookes Publishing Co.

Stroul, B., Blau, G., & Friedman, R. (2010). Updating thesystem of care concept and philosophy. Washington, DC:Georgetown University Center for Child and HumanDevelopment National Technical Assistance Center forChildren’s Mental Health.

Stroul, B., Blau, G., & Sondheimer, D. (2008). Systems ofcare: A strategy to transform children’s mental healthcare. In B. Stroul & Blau G. (Eds.). (2008). The system ofcare handbook: Transforming mental health services forchildren, youth, and families (pp. 3-24). Baltimore, MD:Paul H. Brookes Publishing Co.

Stroul, B., & Friedman, R. M. (1986 rev ed). A system ofcare for children and adolescents with severe emotionaldisturbances. Washington DC: Georgetown UniversityCenter for Child Development, National TechnicalAssistance Center for Children’s Mental Health.

Stroul, B., & Friedman, R. M. (1996). The system of careconcept and philosophy. In B. Stroul (Ed.), Children’smental health. Creating systems of care in a changingsociety. (pp. 1-22). Baltimore, MD: Paul H. BrookesPublishing Co., Inc.

Stroul, B., Pires, S., Armstrong, M., McCarthy, J., Pizzigati,K., Wood, G. McNeish, R., & Echo-Hawk, H. (2009).Effective financing strategies for systems of care:Examples from the field—A resource compendium forfinancing systems of care: Second edition. (FMHIPublication #235-03). Tampa FL: University of SouthFlorida, Louis de la Parte Florida Mental HealthInstitute, Research and Training Center for Children’sMental Health.

Substance Abuse and Mental Health ServicesAdministration [SAMHSA]. (2011a). Leading change: A plan for SAMHSA’s roles and actions 2011-2014. HHS Publication No: (SMA) 11-4629). Rockville, MD:Author.

Substance Abuse and Mental Health ServicesAdministration [SAMHSA]. (2011b). FY 2001 GrantRequest for Applications (RFA): Planning Grants forExpansion of the Comprehensive Community MentalHealth Services for Children and their Families Program(Short Title: System of Care Expansion Planning Grants.Rockville, MD: Author.

U.S. Department of Health and Human Services [DHHS].(1999). Report of the Surgeon General. Rockville MD:U.S. Department of Health and Human Services,National Institutes of Health, National Institute of Medicine.

U.S. Department of Health and Human Services, Health Resources and Services Administration [DDHS].(2010). Affordable Care Act (ACA) Maternal, Infant, and Early Childhood Home Visiting Program. Retrieved in July, 2011 at https://www.cfda.gov/?s=program&mode=form&tab=step1&id=2c3045007119a2ee42fae72fb74498f6

U.S. Department of Health & Human Services [DHHS].(2010). Health homes for enrollees with chronicconditions SMDL# 10-024 ACA #12. Washington, DC:Centers for Medicare and Medicaid Services [CMS].Retrieved from https://www.cms.gov/smdl/downloads/SMD10024.pdf

U.S. Public Health Service. (2000). Report of the SurgeonGeneral conference on children’s mental health: Anational action agenda. Washington DC: Author.

Washington Post. (2010). Landmark: The inside story ofAmerica’s new health-care law and what it means for usall (Public Affairs Report). The Washington Post: Author.

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