PolicyLab

Youth in Pennsylvania—and across the country—are experiencing an unprecedented behavioral health crisis and facing substantial challenges accessing necessary supports. Nearly a quarter of Pennsylvania children have at least one diagnosed emotional, behavioral or developmental condition. Yet, three out of five youth who die by suicide do not have a documented mental health diagnosis. Most children who need mental health care have difficulty obtaining it or are unable to obtain it. The last decade has seen a 200% climb in emergency department visits for youth mental health emergencies. 

Early identification and intervention are key to providing youth and their caregivers with needed supports to preserve and promote well-being. Preventive behavioral health care, offered when a child has some concerning behavioral health symptoms—and before crises emerge—can be delivered in primary care, meeting families where they are.  

The diagnosis requirement for behavioral health services hinders prevention 

But covering the costs for preventive services is a challenge. Most behavioral health services are only reimbursable for children diagnosed with behavioral health disorders. This is particularly problematic for young children, whose presenting concerns often do not match the type, intensity, or frequency of symptoms to warrant a behavioral health diagnosis. One goal of preventive behavioral health care is to help prevent children from developing behavioral health disorders in the first place.  

Drawing on our experiences with integrated behavioral health care through Children’s Hospital of Philadelphia programs like Healthy Minds, Healthy Kids and HealthySteps, we’ll review how some states deliver and pay for these services and how this could inform efforts in Pennsylvania. 

Learning from other states   

Improving child behavioral health outcomes requires rethinking payment for behavioral health care services, particularly in public programs like Medicaid and the Children's Health Insurance Program (CHIP). Medicaid and CHIP are themselves impactful and they influence commercial health plans’ reimbursement policies. 

Federal guidance from the Centers for Medicare & Medicaid Services (CMS) recommends not requiring a behavioral health diagnosis for service provision, and at least nine states have established policies that take this approach.  

Each of these state examples gives providers and payors guidance on how to deliver and pay for these services. In our review, we found the following to be important elements of the policies: 

1. How a child becomes eligible for preventive care 

In multiple states, children are eligible for preventive behavioral health services based on clinicians’ judgment. For example, in New York, Medicaid-enrolled providers can designate services as medically necessary; in Arizona, behaviors and/or symptoms need to be documented. Colorado provides a broad definition for medical necessity in the absence of a diagnosis. 

Other states have imposed more specific guidance. California covers services if the recipient has persistent mental health symptoms, at least one of a set of risk factors, or a parent or guardian who has one of a set of risk factors. In Massachusetts, children are eligible for services if they have a positive behavioral health screen. 

2. How providers code and bill for the services 

Most states use ICD-10 Z-codes, which represent social, economic, and environmental factors that influence health, and R-codes, which represent symptoms or indicators of health difficulties that are not part of a particular disorder, to code and bill for preventive behavioral health services. For instance: 

• New York permits use of one code to bill for preventive services (Z65.9 - Problem related to unspecified psychosocial circumstances)
• Arizona, California, Massachusetts and Oregon allow use of multiple Z-codes
• Colorado permits Z-codes and R-codes
• Minnesota guides providers to use R-codes or unspecified diagnosis codes 

3. Covered services and provider types 

Other variations in policy include the breadth and duration of services and provider types who may deliver them. For most of these states, preventive behavioral health services include family, group and individual psychotherapy. Maine, Massachusetts and Minnesota limit the number of sessions per year. Most allow licensed psychologists, licensed clinical social workers (LCSWs), licensed professional counselors, and licensed marriage and family therapists (LMFTs) to utilize these preventive billing codes to be reimbursed for services. Some states also allow others such as physicians and nurse practitioners to use them. 

Our key takeaways  

Although these approaches are moving towards meeting children’s needs, the following strategies may have the best chance of successful implementation and impact:  

• Clinician judgment, in collaboration with the patient and caregiver/s, is an effective way to identify when a child needs support and quickly begin providing care. Requiring a screening tool may be limiting, given that available validated screening tools do not capture the full range of potential presenting social/emotional concerns and given the need for providers to incorporate a new tool into their practice.
• A simple and straightforward billing mechanism can promote uptake. One code, or fewer codes, may be preferable to a large set.
• States can support broad reach by covering the same set of services that are available to children with a formal behavioral health diagnosis, and by allowing a broad range of providers to deliver them, including licensed psychologists, LCSWs, licensed professional counselors and LMFTs.
• Ensuring that the experience is not stigmatizing for patients can support their engagement. PolicyLab research on caregivers’ perspectives on social needs screening highlights the complexity of screening and documentation of needs.
• All children and youth under age 21 can benefit from access to preventive services. 

An opportunity for Pennsylvania 

In Philadelphia, Community Behavioral Health (CBH)—which provides behavioral health coverage for Philadelphians with Medicaid—allows behavioral health professionals at Federally Qualified Health Centers (FQHCs) to be reimbursed for preventive behavioral health care using Z-codes. And this is a game-changer. We’ve heard from colleagues that having the option to bill Z-codes allows clinicians to effectively and quickly respond to families’ needs—often in one session. 

The Strong Minds, Bright Futures partnership names preventive services before crisis as one of five priorities to transform youth behavioral health in Pennsylvania. Across the Commonwealth, health care organizations are integrating behavioral health providers into pediatric primary care, creating an opportunity to increase availability of these services. 

In line with pioneering states and Philadelphia CBH, Pennsylvania could facilitate the delivery of preventive behavioral health care through Medicaid coverage of behavioral health services for children under age 21 who do not (yet) have behavioral health diagnoses. Medicaid reimbursement of one or more codes that indicate medical necessity such as Z codes would extend maximum benefits to children in Pennsylvania.