Funding SBIRT for Young People in Medical Settings

Doctors, nurses and other medical providers play an important role in detecting and addressing drug and alcohol misuse among young people before a serious problem develops. Providers can implement SBIRT or screening questionnaires and early intervention initiatives during routine appointments, including well-child visits, school physicals or sports check-ups.

This section offers strategies for incentivizing and reimbursing providers for conducting SBIRT with young people in medical settings – including primary care, pediatrics and emergency medicine. The following payment sources are addressed:

MEDICAID PAYMENT MODELS

Medicaid and the Children’s Health Insurance Program (CHIP) pay for health care to low-income children across the United States through state and federal funding. Medicaid and CHIP programs are particularly important for young people of color, who are disproportionately represented in these programs.

One aim of the Medicaid program is to prevent serious health conditions, including substance use disorders. There are numerous delivery system and payment models currently available to states under the Medicaid program to prevent and address substance use disorders. A review of each of the models is beyond the scope of this resource. Instead, this tool covers the models best-suited to fund youth-focused substance use screening and brief intervention, including fee-for-service, managed care and health homes. This section also addresses how states can change Medicaid programs through state plans amendments (SPAs) and 1115 waivers.

FEE-FOR-SERVICE

In the fee-for-service model, providers are reimbursed by the state Medicaid program for each service (e.g., test, exam, procedure) they provide to Medicaid enrollees. States maintain a Medicaid plan with a list of these allowable services, reimbursement rates and other requirements for billing.

ADVOCACY STRATEGIES

Determine if your state has active SBIRT codes.

There are specific Medicaid billing codes available for screening and brief intervention services. However, states have to take action to activate (or “turn on”) these codes. To get the most up-to-date information on your states codes, reference your state’s Medicaid provider billing manual, which should be available online on your state’s Medicaid website.

If your state has active SBIRT codes: Collect information on any requirements or limitations to the codes.

Contact your state Medicaid office to gather the information below. These details should also be outlined in your state’s Medicaid Provider Manual or in a separate SBIRT manual that guides the delivery of SBIRT services and the process for reimbursement.

If your state does not have active SBIRT codes: Explore the pros and cons of activating the codes.

Advocates should consider the following before embarking on a campaign to activate SBIRT codes:

If your state does not have active SBIRT codes: Work with state Medicaid officials to activate codes.

If you decide to develop an advocacy campaign to activate the codes, see the Mobilizing Support for SBIRT section of the toolkit. Here are suggested steps to begin the process:

Example from Georgia: Advocates mounted a successful policy campaign to activate SBIRT codes. As of July 2017, health care providers can bill Medicaid for conducting SBIRT. This policy win was a result of building support through carefully crafted branded educational materials, a statewide coalition and participation in several study committees. Advocates also produced a policy brief and cost-benefit analysis for state officials.

RESOURCES

CAPITATED MEDICAID MANAGED CARE

Many states have established contracts with managed care organizations (MCOs) to coordinate and direct services for some or all of their Medicaid enrollees. Managed care arrangements vary by state and MCOs can offer services not provided in the state Medicaid plan. Under the capitated (also called risk-based) model, states hire MCOs, which may be for-profit or nonprofit. Some are safety-net plans designed to serve specialized populations.

The MCOs are responsible for arranging contracts with providers to deliver services and are paid a set amount per person per month, regardless of the services delivered to those consumers. The MCO then reimburses providers based on services provided (fee-for-service) and/or on quality of care or health outcomes (value-based payments).

The managed care model can create an incentive for MCOs and affiliated providers to prevent serious conditions and keep consumers healthy. It’s important to note that there are a wide variety of managed care arrangements and MCOs can take advantage of the model, for example, by cutting services to save money. However, well-designed MCOs with payment arrangements incentivizing better health outcomes can provide an opening for advocates to promote youth-focused prevention of substance use disorders to keep the population healthier.

ADVOCACY STRATEGIES

Learn if your state currently uses a managed care model.

This map is a good starting point in identifying if your state contracts with MCOs. Your state Medicaid officials can provide additional information on the use of MCOs in your state.

Work with state Medicaid officials to include substance use prevention in contracts with MCOs.

CMS requires all MCOs to offer an “appropriate range of preventive” services. You can work with your state officials to ensure drug and alcohol prevention is a covered service in all managed care plans in the state.

Example from Minnesota: The state withholds payments from MCOs that fail to conduct specified screenings during Child and Teen Checkups. One of the required screenings is a drug and alcohol assessment and follow-up with young people ages 12-20.

Encourage individual MCOs to incentivize prevention among their providers.

MCOs have the flexibility to create financial incentives for providers who offer certain services or meet certain benchmarks. Advocates can identify and develop relationships with the major MCOs in your state. Given their mission and/or financial interest in preventing serious or chronic conditions and the potential for cost savings, MCOs may be willing to incentivize SBIRT or other youth-prevention activities. For example, an MCO could require all primary care providers to conduct SBIRT for all patients. The plan could offer additional reimbursement for conducting SBIRT with patients or withhold payments from plans that do not comply.

Example from Oregon: The Oregon Health Authority established an incentive measure for Coordinated Care Organizations (CCOs) to increase the use of SBIRT services in primary care and mental health settings. To receive this incentive, CCOs must provide full screening and/or brief intervention services to 12% of patients 12 years of age and older.

Identify and work with safety net MCOs to incorporate prevention.

Safety-net health plans serve vulnerable populations and low-income communities, with a focus on integration, whole-person care and prevention. These plans can be an ideal setting for youth prevention efforts. You can reach out to the safety-net plans in your state and explore opportunities for new or enhanced prevention efforts.

Example from Kentucky: Passport Health Plan is a nonprofit community-based health plan that requires all primary care providers to conduct annual substance use screening with all patients using the SBIRT model. This universal screening requirement is written into provider contracts. Providers receiving capitated payments (set per person per month amount) receive an additional reimbursement payment for each screening conducted.

RESOURCES

MEDICAID HEALTH HOMES

The Medicaid Health Home is designed to serve consumers who have complex health conditions. The purpose of this model is to increase coordination of care across physical health, mental health, substance use disorders services and community supports. This can help states improve quality of care while reducing costs.

Under the health home model, states establish contracts with providers to serve as the central point of contact for consumers who have chronic health conditions. Health home providers are required to deliver or link enrollees to six specific care-coordination services. States receive additional funds from CMS for providing these services. 

While health homes are often designed for adults with long-term chronic conditions, the model is conducive to youth-focused drug and alcohol prevention. The model prioritizes coordination of care, significantly increasing the chances that any drug or alcohol misuse identified will be addressed promptly. Some states have developed child-centered health homes specifically for young people with chronic conditions, including California and Rhode Island.

ADVOCACY STRATEGIES

Encourage state officials to submit a state plan amendment to CMS to establish a child-centered health home.

Advocates can work with other key stakeholders and MCOs to recommend the creation of child-centered health homes that include substance use prevention. Pediatricians and children’s health advocates are likely allies and potential partners, as a child-centered health home would bring needed resources to children’s health services.

If there are child-centered health homes in your state, urge the providers to use SBIRT.

Advocates can make the case that child-centered health homes are well-suited for substance use prevention strategies like SBIRT. Youth with certain chronic conditions (e.g., mental health conditions, histories of trauma[i]) or in certain living arrangements (e.g., foster care) are more susceptible to early drug and alcohol use.

Example from Rhode Island: The Comprehensive Evaluation, Diagnosis, Assessment, Referral and Reevaluation (CEDARR) Family Centers in Rhode Island are child-centered health homes in which providers conduct depression screening for all enrollees 12 years and older, and connect patients to treatment or community resources when needed. These health homes were designed to bridge the gap between children’s physical and mental health care. Toward this aim, providers developed relationships and promoted collaboration between multiple systems across the state: behavioral health, child welfare, schools and health care providers.

RESOURCES

MEDICAID WAIVERS

The Centers for Medicare and Medicaid Services (CMS) offer states opportunities to develop innovative approaches to care through several waiver programsthat allow sidestepping of some Medicaid rules. One such program – the Section 1115 Demonstration Waiver Program – can be especially useful for promoting drug and alcohol prevention. CMS has previously requested 1115 waiver proposals that include substance use screening and cite SBIRT as a recommended practice for such waivers. While the current waiver guidelines do not specifically recommend SBIRT, CMS continues to encourage 1115 waivers to address substance use disorders and opioid misuse.

Many states are using this 1115 demonstration program to improve access to Medicaid and expand prevention, treatment and recovery services offered under the Medicaid program. Adding SBIRT to these types of waivers can boost the visibility of SBIRT and increase uptake by providers.

Examples from West Virginia and California: West Virginia’s 1115 waiver adds SBIRT to the state plan. In California, Medi-Cal (the state’s Medicaid program) requires SBIRT in primary care settings for all adult Medicaid enrollees.

ADVOCACY STRATEGIES

Learn if your state is planning a waiver or encourage your state to apply.

Advocates can engage with state officials in the development of 1115 waivers to ensure that prevention is a key factor. You can use the federally-required stakeholder engagement process to provide input on how prevention can help achieve waiver goals. You can also present the waiver as a way for the state to comprehensively address drug overdoses.

Identify allies to support your advocacy for a waiver.

State development of a waiver is a substantial undertaking and will require long-term planning. If you decide to press your state to file an 1115 waiver, work with other entities that have an interest in demonstration projects, such as hospitals, state officials and other consumer health advocates.

If your state decides to apply for an 1115 waiver, encourage state officials to seek support from the federal Medicaid Innovative Accelerator Program (IAP).

While the IAP program does not offer funding, it provides states with resources and technical assistance to support health reform efforts, with one program focusing explicitly onreducing substance use disorders. The first round of intensive TA and webinars has concluded, but the program now provides strategic guidance to states on the development 1115 waivers. The IAP program is supportive of SBIRT and encourages states to use the waiver process to establish Medicaid coverage of SBIRT or increase SBIRT reimbursement rates. 

RESOURCES

EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT)

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit mandates periodic health screenings for all young people under age 21 enrolled in Medicaid, and requires states to provide follow up intervention for issues detected. Mental health and substance use disorders screening is explicitly included in the EPSDT benefit.

Each state is required to establish a schedule for screening and assessments, which is typically based on the most current Bright Futures recommendations from the American Academy of Pediatrics. Outlined below are strategies for leveraging resources from the EPSDT benefit to support youth prevention, including SBIRT.

ADVOCACY STRATEGIES

Partner with children’s health advocates in your states.

The EPSDT benefit has long been the focus of children’s health advocacy. If you are interested in working to improve the EPSDT benefit to bolster drug and alcohol prevention, a good first step would be to locate statewide and local children’s health advocates and develop a partnership with those groups to learn what has been done to improve the benefit and to engage in any current initiatives related to EPSDT advocacy.

Advocate for substance use prevention to be included in the EPSDT benefit in your state.

Despite the intention of this program, many children are not receiving all of the required screenings[ii] and behavioral health screenings are often left out[iii]. First, find out if drug and alcohol screenings are listed in your state’s EPSDT schedule. If the benefit is already included, advocates can work with Medicaid officials to educate providers about the importance of behavioral health screenings. Arguments for including or promoting substance use screening may include:

Promote unbundling payments for developmental screens.

The way providers are paid for EPSDT screenings varies by state: some state Medicaid programs provide one bundled payment per visit to the provider for the well-child exam, which includes various screenings. Other states allow providers to bill for each screening separately. Advocates can work with the state Medicaid program to promote unbundled EPSDT billing codes. Key arguments for unbundling payments include:

Example from Georgia: The state Medicaid program adapted reimbursement policies to incentivize development screenings. The program raised the reimbursement rate for well-child visits required under the EPSDT benefit and unbundled developmental screening to offer additional payments for each screening.

RESOURCES

PRIVATE INSURANCE

Private insurance plans, whether offered through the workplace or purchased through state Marketplaces, can reimburse their providers for SBIRT and other preventive services using established private insurance billing codes. Several national companies already cover SBIRT, including Aetna[iv] and Cigna[v] and Anthem Blue Cross Blue Shield,[vi] but advocacy is needed to ensure that individual plans (e.g., the specific coverage offered by an employer) includes these services and that providers are delivering SBIRT to young people.

Advocacy is also needed to ensure more private insurers reimburse providers for SBIRT and encourage their providers to do so. Advocates, community members, plan enrollees and others can make the case to insurers that they should pay for and promote SBIRT use with young people.

ADVOCACY STRATEGIES

Identify plans in your state that reimburse providers for youth SBIRT.

There are a few avenues to access this information. One option is to survey the insurance companies in your state through an electronic survey. To increase participation, make phone calls before or immediately after sending the survey to provide context.

Advocates can ask their state department of insurance to survey or use other means to identify which private plans in the state do or do not include drug and alcohol screening. A good first step is to partner with consumer advocates who already have a relationship with the insurance director/commissioner. Your state association of insurers is another helpful resource and likely ally. The basis for your request could be:

While a statewide survey may not be feasible for your department of insurance, this request can bring attention to the need for prevention. If you are successful in gathering information on SBIRT coverage among plans in your state, you can hold up plans that provide SBIRT as models and pressure other plans to reimburse for the service. This information can also help you identify insurers for the targeted outreach outlined below.

Develop a plan for what you want from the private insurer(s) in your state.

Identify individuals or organizations in your state with influence or connections with the major insurers. This may include large businesses in key metropolitan areas, major hospitals or statewide provider organizations. Work with these organizations and other partners to develop an ask: Do you want the plans to cover SBIRT explicitly for youth? Are you asking the company to promote the use of SBIRT with youth among their providers?

Educate insurers about SBIRT as a best practice for prevention. Urge them to reimburse providers for this service and encourage plan administrators and providers in their plans to use SBIRT.

RESOURCES


[i] Dube S.R. et al. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: The adverse childhood experiences study. Pediatrics, 111(3), 564-72.

[ii] Center for Children and Families. (2014). OIG Report: States, Feds Must Do More to Ensure Kids on Medicaid Get Essential Screenings. Georgetown University Health Policy Institute. Retrieved from: http://ccf.georgetown.edu/2014/11/24/18967/

[iii] Children’s Defense Fund. (2006). The Barriers. What is it so difficult for children to get mental health screens and assessments? Retrieved from: http://www.childrensdefense.org/library/data/barriers-children-mental-health-screens-assesments.pdf

[iv] Supporting primary care physicians in helping patients with alcohol abuse issues. (2015). Aetna, Inc. Retrieved from: http://www.aetna.com/healthcare-professionals/documents-forms/alcohol-program.pdf

[v] Quanbeck et al. 2010.  A Cost-Benefit Analysis of Wisconsin’s Screening, Brief Intervention, and Referral to Treatment Program: Adding the Employer’s Perspective, Wisconsin Medical Journal, 109(1), 9–14.

[vi] Ibid