In Plain English–EPSDT

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In Plain English–EPSDT

What is an “Entitlement”?

Some of the most important rights to mental health care for children and youth come from federal “entitlement” programs. In order to benefit from and protect these rights, it is critical to understand them.

What does it mean to have an entitlement to mental health care?

Generally, an entitlement is a guarantee of access to a benefit that is established by law.  In other words, the prescribed benefit is a legal right that must be provided to anyone who meets the criteria for receiving it. In the context of mental health, eligible children have a right to receive particular mental health care services if they meet the statutory qualifications for those benefits.

Many children have an entitlement to mental health care under Medicaid’s Early Periodic Screening, Diagnosis and Treatment (EPSDT) provisions. Medicaid is a public health insurance program covering over 20 million low-income children nationwide.  States that choose to participate in the Medicaid program (all 50 states do) are required under federal law to provide specific physical and mental health services to all Medicaid eligible youth under age 18.  Many states cover young people up to age 22.  Under the EPSDT provisions, states must screen youth for health needs, including mental health disorders and also provide necessary diagnosis and treatment services to help improve conditions that are discovered.

A young person may have a right to receive EPSDT mental health services if they meet three general eligibility criteria:

  1. The child must be eligible for Medicaid. Most children qualify for Medicaid because their family income is very low or because they are disabled or in foster care. For more information on Medicaid Eligibility see the NHELP website. 
  2.  A qualified health professional or clinician determines that a particular service is medically necessary to correct or ameliorate a child’s mental health condition.
  3. The medically necessary mental health service is a covered service under federal Medicaid law.  EPSDT covered services include a comprehensive array of benefits, including individual counseling, case management, medication and monitoring, intensive home and community-based services, in-patient hospitalization, among others.

EPSDT-Vector

Every young person who meets these three eligibility criteria has a legal right to receive the prescribed mental health service.  Under Medicaid’s state and federal partnership approach, it is the states that have a legal obligation to provide mandatory mental health care.

Unfortunately, states often fail to meet the EPSDT legal obligation to individuals and groups of children in violation of the law.  As a result, advocates across the country must work hard to protect young people’s entitlement to mental health care under the EPSDT program.  Young Minds Advocacy Project is involved in two cases seeking to enforce children’s right to intensive care coordination and home and community-based services and supports in California  

[See Katie A] and Washington [See T.R.].  You can help defend young people’s rights by educating yourself about EPSDT’s guaranteed benefits and getting involved in ongoing efforts to hold states accountable for providing all necessary mental health services under Medicaid.

For more information, check out these websites:

  • National Health Law Project’s Factsheet on Recent Medicaid EPSDT Litigation

 

This post is the first in our In Plain English series, which breaks down some of the key issues and concepts of children’s mental health advocacy.  Do you have some jargon that you want translated? Let us know by posting a comment or sending an email to info@youngmindsadvocacy.org

By |2016-11-17T17:26:31+00:00February 5th, 2013|EPSDT, Featured Posts, In Plain English|0 Comments

About the Author:

Wesley Sheffield
Wesley Sheffield is an Associate Attorney at Young Minds.