June 24, 2015

Idaho’s Mental Health System and the ADA “Integration Mandate”

DRI was asked to provide testimony to the Idaho Advisory Committee of the U.S. Commission on Civil Rights concerning Idaho's mental health system and compliance with the U.S. Supreme Court Decision in Olmstead v. L.C. This is what I submitted.

Testimony of DisAbility Rights Idaho.


Idaho’s mental health services system is broken. Mental health crisis calls are stretching our law enforcement and emergency responders to the breaking point. Admissions to the state psychiatric hospitals are increasing and the prisons and jails have more inmates with serious mental illness than our hospitals do. Last but not least untreated or inadequately treated mental illness is causing enormous human suffering for people with mental illness and their families. Part of this crisis is the result of a lack of public funding for services, made worse by the significant cuts to state funded services and Medicaid since 2007. Part of the cause is a fragmented and disorganized collection of programs with conflicting priorities and inefficient parallel administrative structures. All of this was well documented in a 2008 study of Idaho’s mental health system commissioned by the legislature. The full text of that report is available on line, http://www.legislature.idaho.gov/sessioninfo/2008/interim/mentalhealth_WICHE.pdf (WICHE Report).


The WICHE report recommended that Idaho pool its resources for mental health and substance abuse treatment from all of its sources (Medicaid, Health and Welfare, Department of Corrections, federal block grants, counties, schools and private) and create  regional mental health authorities, with the power and authority to allocate the combined resources to meet local needs. The state mental health authority (Idaho Department of Health and Welfare, IDHW) would be the guarantor of services with the responsibility to insure that local agencies meet minimum standards and comply with state and federal requirements.


The report also condemned Idaho’s system for forcing people to reach some sort of crisis to get access to services. Access to mental health treatment for people who do not have Medicaid is available only to people who are involuntarily committed or who come into the system through the criminal courts, or who are at risk of harm to self or others. Since 2008, this situation has gotten much worse. A 40% cut to state funded services from 2007 to 2011 almost eliminated services for the 55% of Idahoans with serious and persistent mental illness who do not have Medicaid (unless their treatment is court ordered, or they pose a danger to themselves or others). Since 2008, some state level structural changes have been made. One Mental Health Crisis Center has been opened and one more approved. There has been a reduction in access to community services and Medicaid coverage of psychiatric rehabilitation services has been severely decreased.


Idaho’s History with Olmstead v. L.C. and Integrated Community Services


When the U.S. Supreme Court decided Olmstead v. L.C. 527 U.S. 581 (1999) (hereafter, Olmstead), it was concerned that, states with non-compliant systems would be swamped with individual suits and that litigious plaintiffs would move to the front of the waiting lists for services. The Court granted states protection from individual litigation if they developed a reasonable plan for compliance (Olmstead plan), and made consistent progress implementing it. Based on an Idaho Attorney General opinion, Idaho declared that the state was in full compliance with Olmstead, and that no plan was necessary. However, noting that there was widespread disagreement with this position, the Governor created a “Community Integration Committee” (CIC) to explore barriers to integrated services for people with disabilities, and to make non-binding recommendations to the state. The Committee consulted reports, evaluations, people with disabilities, and advocates.  The Committee’s last report was submitted in 2004 (attached). Idaho’s mental health system has deteriorated considerably since then.


Applying the ADA’s “Integration Mandate” to the State Mental Health System


Avoiding unnecessary institutional segregation requires a robust and flexible system of community services. The system must include access to mental health treatments like psychiatrists, medication management, psychotherapy, and counseling. For people at risk of institutionalization, it must also include rehabilitative services like psychoeducation, independent living skills, peer supports, and vocational services. Finally, the system must provide access to community supports such as affordable housing, medical care, case management and social services. Failure in any one of these areas can result in decompensation, relapse, re-hospitalization, arrest and incarceration, or suicide. The Olmstead decision, mandated the state system to be redesigned and even to include optional services like Home and Community Based Services (HCBS) waivers, in order to remove the institutional bias of the state’s Medicaid system. However, since the ADA applies to all state services, Idaho must remove institutional bias from the entire state operated mental health system. In other words, Idaho has an obligation to ensure that people with mental disabilities can get adequate mental health treatment and community supports without resorting to state hospitalization. Preventive treatment and supportive services are the key to avoiding unnecessary institutionalization, and segregation. While Olmstead addressed the needs of plaintiffs who were in the state hospital trying to get out, the principle also applies to people seeking mental health services to avoid institutional segregation. In this respect, Idaho’s mental health system falls short.


Idaho’s Department of Health and Welfare (IDHW) has two separate and very different systems which provide adult mental health services. Using national statistics, an estimated 75,000 Idahoans experience a serious mental illness each year.

41,000 of these have a serious and persistent serious mental illness (SPMI) that impairs their ability to function in society. About 19,000 of these Idahoans receive treatment through the Department of Health and Welfare for these illnesses each year. Only about 9,000 of them are covered by Medicaid; about 10,000 are not. Of the 21,000 people with SPMI who do not receive treatment from IDHW, some may be being treated privately, some are in jails or prisons, some get services from county indigent programs, some are receiving no treatment or services, some are homeless. We have no Idaho specific data on these subgroups.


The Division of Medicaid offers coverage for mental health services to people who qualify for Medicaid due to extremely low income combined with severe disability. Medicaid mental health services are covered under a managed care contract with Optum Health, Inc. People who have coverage from both Medicaid and Medicare also have the option of choosing a managed care plan offered by Blue Cross (True Blue).In the last three years, Optum has systematically reduced authorization for Community Based Rehabilitation Services (CBRS is the psychiatric rehabilitation service covered by the plan). They have increased authorization for clinical services like psychotherapy. However, community supports are often more important to preventing hospitalization than additional psychotherapy. For three years the amount of community based rehabilitation services authorized has declined significantly. Medicaid does not cover hospitalization for adults in psychiatric hospitals. So the financial burden of failed community supports is passed on to the Division of Behavioral health.

We do not have enough experience with the Blue Cross plan to know how they will deal with rehabilitation services


The Division of Behavioral Health (DBH) provides services to people with serious mental illness who do not qualify for Medicaid coverage or other insurance. Generally speaking, about 55% (about 9,000 per year) of the people receiving mental health services from IDHW receive only DBH services. DBH operates the two state psychiatric hospitals and provides some community services, such as therapy and Assertive Community Treatment (ACT) teams. Community services are mostly provided when ordered by a court for a criminal defendant, or when people are in crisis and pose a serious risk of harm to self or others.


Community Based Mental Health Services have declined and hospital admissions have increased since 2007.


In 2007, Idaho was spending just under $44 million on community Mental Health Services including ACT teams, and regional mental health centers. From SFY 2008 through SFY 2011 drastic cuts in state Community Mental Health (CMH) services were made. ACT teams were reduced and hundreds of people with severe and persistent mental illness lost ACT team support. IDHW closed many community mental health centers and cut services across the state. IDHW started this process before the recession and before the state legislature reduced budgets. The “budget cuts” (i.e. reduced appropriations) followed the service cuts and have never dropped as low as the state’s actual expenditures. Each year IDHW provided fewer services and requested less funding from the legislature. In 2011CMH expenditures had plummeted to just under $27 million, a 40% reduction from 2007. In 2014 it had rebounded slightly to about $30 million. During that time spending on state hospitals climbed from $27.8 million to $31.7 million.


Idaho Community Mental Health Funding 2007-2014

Source: Idaho Legislative Fiscal Reports



Source: Idaho Legislative Fiscal Reports

It is noteworthy that, starting in SFY2008, IDHW significantly cut services and expenditures well below the amounts appropriated by the legislature and continues to significantly underspend the appropriated amounts. During this time, many adults and children with mental illness have sought CMH services and been turned away by the Department. By 2010, the amount spent on community services was less than the amount spent on state hospitals and remains so to this day. However, the amount Idaho spends on services is not the ultimate issue in looking at Olmstead compliance. It is only relevant if the cuts in community services result in higher levels of institutional placements. Since 2007, state hospital admissions have steadily increased as the availability of community supports and services have declined.


Idaho State Hospital Admissions 2007-20014


Source: IDHW “Facts Figures and Trends” 2007-2014.  Note:  During 2008, SHS was required by the Joint Commission and the Centers for Medicaid and Medicare Services to reduce admissions due to a shortage of psychiatrists at the hospital.


CMH Expenditures vs.  State Hospital Admissions

Source: IDHW “Facts Figures and Trends” 2007-2014


When we map CMH expenditures over state hospital admission for the same time period we see a strong inverse correlation between CMH expenditures and state hospital admissions.

Another measure of the level of segregation of people with mental illness is the median length of stay (MLOS) at the state hospitals. Idaho’s MLOS statistics are not exceptional compared to other state hospitals and the yearly MLOS fluctuates without showing an overall trend since 2011.


These CMH figures apply only to the Division of Behavioral Health. We have no data which would tell us how many hospital admissions are DBH clients and how many are Medicaid patients. Although Optum has recently reduced access to Community Based Rehabilitation Services (CBRS), Medicaid patients in Idaho, generally have much better access to mental health treatment and community supports than DBH clients. People who have been diverted from the criminal justice system through a state mental health court, and receive services pursuant to the court’s order, may be exceptions to this rule.




Idaho is now dead last among all of the states in per capita expenditures on mental health services, http://kff.org/other/state-indicator/smha-expenditures-per-capita . Idaho is consistently in the top seven states for per capita suicide rates and the top five for juvenile suicide, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6345a10.htm . In 2007, Idaho was investing in preventive and supportive community services at a much higher rate. For some reason, in SFY 2008, the Idaho Department of Health and Welfare decided to drastically reduce its commitment to community based services and began to rely increasingly on hospitalization for delivery of mental health services. Although there are no statewide data, many local hospitals and law enforcement agencies report increased utilization of county programs, law enforcement, jails and hospital emergency departments in handling mental health crises. 2014 and 2015 appropriations show an incremental reversal of this trend, but there is ample evidence of a continuing institutional bias in Idaho’s Mental health system. This raises legitimate questions about Idaho’s compliance with Olmstead’s “integration mandate”.


Submitted by: James R. Baugh, Executive Director, DisAbility Rights, Idaho

February 12, 2015

Psychosocial Rehabilitation and the Idaho Medicaid Managed Care Contract

Implementation of Idaho’s Medicaid Managed Mental Health Contract with Optum Health, Inc. has had a rocky start and has resulted in some major changes in the delivery of Medicaid covered mental health services in Idaho. There have been problems encountered by mental health service providers in processing and obtaining authorizations for services, but this article will not address those issues. I intend to focus on the problems being experienced by Idahoans with serious mental illness (SMI) and children with serious emotional disturbance (SED), in obtaining community based mental health services and supports. Most of the controversy revolves around authorization of Community Based Rehabilitation Services (CBRS).

Confusing Terminology
For many years, Idaho Medicaid provided a service called Psychosocial Rehabilitation (PSR). This service consisted of a mental health worker meeting with a person with SPMI, or SED and teaching them skills related to surviving in the real world while coping with a serious mental illness. PSR workers helped their clients recognize recurring symptoms of their illness, stick to their treatment plans, evaluate the effectiveness of their medications and their side effects, cope with stressors in their lives (family crises, evictions, expulsions, deaths of loved ones, encounters with the police, etc.), and build independent living skills (budgeting, shopping, getting or keeping a job, dealing with chronic health conditions, etc.). The strict rule definition of PSR limits it to skill building activities, but when a PSR worker found a client without food, behind in their rent, out of medications, afraid to leave the house to go to the doctor appointment (or whatever), they often just helped the person deal with the crisis. They might take them to the grocery store to get some staples, coach them through a call to the landlord about the rent, drive them to the doctor appointment, or help them understand their diabetes diet restrictions. If they find them in a crisis, they might take them to the emergency department of the hospital. Bureaucrats may argue about whether all of these activities fall under the definition of PSR, but they are all needed if we hope for people with SPMI/SED to survive in the community and stay out of hospitals, jails, prison, juvenile justice system, or homeless shelters.

Optum doesn’t use the term Psychosocial Rehabilitation. They offer an identical service called Community Based Rehabilitation Services (CBRS). The Psychiatric Rehabilitation Association (PRA) uses the term Psychiatric Rehabilitation to cover this type of service. The American Psychiatric Association includes Psychosocial services in a larger category of "Psychotherapeutic Interventions" which include Psychosocial rehabilitation, and in-home and community based services such as "Psychoeducational services" and others not named in the treatment guidelines (see e.g., APA Treatment Guide –Bipolar Disorder p. 52).

Services for children are equally confusing. In addition to the terms used above, there are a host of packaged services and approaches which may include some or all of the services described as PSR, or CBRS. "Wrap Around Services" and "Intensive In-home services" are two phrases used by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U. S. Department of Health and Human Services, to describe evidence based approaches which include services that Optum calls CBRS, along with other services. In addition, there is great overlap between other services such as Assertive Community Treatment teams (ACT teams) and CBRS even though it also includes some things that a CBRS client would not receive. While these words and phrases do not always describe exactly the same things, they have many common features and they significantly overlap each other. A person receiving any one of these services might not be able to tell the difference between one and another. In this article, I will use Optum’s term, Community Based Rehabilitation Services (CBRS), unless the context requires something else.

What is Optum doing?

Since the implementation of Optum’s contract some patterns have emerged.

  1. CBRS services to children have been significantly reduced.

  2. CBRS Services to people with both a mental illness and an intellectual disability have been significantly reduced.

  3. CBRS services have been reduced for people with diagnoses other than Schizophrenia (although Dr. Berlant has acknowledged that there is evidence that CBRS is effective for a range of diagnoses).

  4. CBRS services have been reduced in frequency and duration for many recipients and authorizations for CBRS are very short term.

In general the reason for reducing or denying CBRS is that it is not "medically necessary" according to the Optum care levels which are said to be based on the treatment guidelines of the American Psychiatric Association (APA) or the practice parameters of the American Academy of Child and Adolescent Psychiatry(AACAP), or SAMHSA. You will not find "CBRS" in these guides because CBRS is a term invented by Optum to describe psychosocial rehabilitation services (PSR). Due to the confusion over terminology described above, it is more difficult to nail down the evidence for the service.

Children’s Services
Optum medical directors have declared publicly that CBRS is not an evidence based practice for children. The American Academy of Child and Adolescent Psychiatry would seem to disagree.

American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters – Schizophrenia:
Although further studies are needed, youth with EOS (Early Onset Schizophrenia) should benefit from adjunctive psychotherapies designed to remediate morbidity and promote treatment adherence. Strategies for the patient include psychoeducation regarding the illness and treatment options, social skills training, relapse prevention, basic life skills training, and problem solving skills or strategies. Psychoeducation for the family is also indicated to increase their understanding of the illness, treatment options, and prognosis and to develop strategies to cope with the patient’s symptoms.( Journal of the American Academy of Child & Adolescent Psychiatry, Volume 52, Number 9- September 2013. p. 986, note: this parameter is being revised)

AACAP – Treatment Guidelines – Bipolar

Bipolar disorder significantly affects social, family, academic, and developmental functioning. Therefore, in addition to efforts directed at reducing further episodes, psychosocial interventions are needed to address the myriad of disruptions that emerge in the wake of the disorder. Efforts to enhance family and social relationships, including therapies directed at communication and problem-solving skills, are likely to be helpful.(p.120)

Therefore, a comprehensive, multimodal treatment approach that combines psychopharmacology with adjunctive psychosocial therapies is almost always indicated for early onset bipolar disorder. Although medications help with the core symptoms of the illness, they do not necessarily address the associated functional and developmental impairments and the frequent need for support and skills building.(p.120)

The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for Medicaid Services (CMS) in the U.S. Department of Health and Human Services have issued a joint information bulletin with a list of evidence based psychosocial service models for children with SED. The bulletin concludes:
While the core benefit package for children and youth with significant mental health conditions offered by these two programs included traditional services, such as individual therapy, family therapy, and medication management, the experience of the CMHI and the PRTF demonstration showed that including a number of other home and community-based services significantly enhanced the positive outcomes for children and youth. These services include intensive care coordination (often called wraparound service planning/facilitation), family and youth peer support services, intensive in-home services, respite care, mobile crisis response and stabilization.

The only service in the Optum array which approaches or incorporates elements of these SAMHSA/CMS recommended services is CBRS.

The Psychiatric Rehabilitation Association (PRA) is the national group which Optum and Idaho Medicaid use to certify CBRS providers in Idaho. PRA offers a specialized certificate in Psychiatric Rehabilitation for Children (http://www.psychrehabassociation.org/practitioner-training-continuing-education/children%E2%80%99s-certificate-psychiatric-rehabilitation-courses ). It would seem clear that these recognized experts consider CBRS for children to be evidence based practice also. And if there is any lingering doubt that Children’s Psychosocial Rehabilitation as practiced under Idaho Medicaid is evidence based and provides an objective and measurable benefit, it has been dispelled by the research published in the peer reviewed journal article "Preliminary Evaluation of Children’s Psychosocial Rehabilitation for Youth With Serious Emotional Disturbance" Research on Social Work Practice, Vol. 19 No. 1, January 2009 p.5-18. A study conducted in Idaho by Nathaniel J. Williams. The study showed "Participants improved significantly in psychosocial functioning and psychological symptoms, with effect sizes ranging from large to small. Improvements were clinically significant for 78% of participants" (p.1) and "Of the participants, 78% exhibited clinically significant improvement in their overall functioning across an average treatment time of 13 months. Participants’ improvement on the CAFAS/PECFAS was statistically significant and reflected a large effect size. Reductions in the number of severe subscales were similarly robust. Finer grained analyses of the CAFAS/PECFAS subscales revealed that participants experienced statistically significant improvements in functioning and psychological symptoms."

Mental Illness and Intellectual Disability
Mental Health diagnoses are often ignored in people who have an intellectual disability (ID, formerly called mental retardation, MR) and as a result they do not receive appropriate mental health services. Nevertheless, studies show that mental illness is very common in people with ID. This applies to both children and adults. The AACAP practice parameters say:
Mental disorders occur more commonly in persons with MR than in the general population. However, the disorders themselves are essentially the same. Clinical presentations can be modified by poor language skills and by life circumstances, so a diagnosis might hinge more heavily on observable behavioral symptoms. (p.1)… The principles of psychiatric treatment are the same as for persons without MR, but modification of techniques may be necessary according to the individual patient's developmental level, especially communication skills. Medical, habilitative, and educational interventions should be coordinated within an overall treatment program.(p.8S)

Robert Lieberman in "Recovery from Disability: the Manual for Psychiatric Rehabilitation" explicitly includes Intellectual disabilities among those who will benefit from PSR/CBRS. (p.12). I have found nothing in the literature which says that CBRS is ineffective with people who have an intellectual disability. Many dually diagnosed Idahoans can attest to the benefits they received from PSR/CBRS and to the harm suffered when it was withdrawn too early. I have found many sources which say that PSR/CBRS providers need additional training and expertise to properly provide mental health services to people with ID, and sources which say that mental health systems improperly exclude people with ID from mental health services. However, such exclusion would be impermissible under the Americans with Disabilities Act and other anti-discrimination laws.

Diagnoses Other Than Schizophrenia
The APA guidelines for Bipolar Disorder say:
"When the functional impairments of bipolar disorder are severe and persistent, other services may be necessary, such as case management, assertive community treatment, psychosocial rehabilitation, and supported employment. These approaches, which have traditionally been studied in patients with schizophrenia, also show effectiveness for certain individuals with bipolar disorder…Nevertheless, the weight of the evidence suggests that patients with bipolar disorder are likely to gain some additional benefit during the maintenance phase from a concomitant psychosocial intervention",(APA Treatment Guidelines, p.52)"

It is important to note that the APA does not have guidelines for all major mental illness diagnoses. Therefore, it would be wrong to assume that the APA has any position on the appropriateness of CBRS for other diagnostic categories. Indeed, the guidelines themselves state:
These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate recommendation regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data, the psychiatric evaluation, and the diagnostic and treatment options available. (emphasis added, p.iv).

The Performance Standards for Psychiatric Rehabilitation of the Community Care Behavioral Health Organization , (2008 revision) use this standard:
General Description of Psychiatric Rehabilitation
Psychiatric Rehabilitation services are designed to address the needs of individuals with a history of severe mental illness as evidenced by a diagnosis of schizophrenia, major mood disorder, psychotic disorder not otherwise specified, schizoaffective disorder or borderline personality disorder of the DSM IV classification. The person receiving services must also have a moderate to severe functional impairment as a result of mental illness.(p.2)

Robert Paul Lieberman, M.D., Professor of Psychiatry UCLA Medical School (the founder of the field of evidence based psychiatric rehabilitation and the author of Recovery from Disability: the Manual for Psychiatric Rehabilitation) says:

The term "mental disability" is preferentially used to delineate the disorders afflicting patients who are appropriate recipients of rehabilitation… Psychiatric rehabilitation can benefit all those whose psychiatric disabilities endure beyond a relatively brief treatment of symptoms…Several terms have been used in the literature to delimit the population of the mentally disabled. The most frequent are terms such as "severely mentally ill", "chronic mental patients", and "seriously and persistently mentally ill"… A large number of individuals with disparate mental disorders listed here are often deemed disabled by the various criteria delineated above:
      • Schizophrenia

      • Bipolar disorder

      • Major Depression and disthymia

      • Obsessive-compulsive disorder

      • Social phobia

      • Panic and agoraphobia

      • Posttraumatic stress disorder

      • Some personality disorders such as borderline, schizotypal and schizoid

      • Developmental disorders such as pervasive developmental disorder or Down Syndrome (Recovery from Disability, p.9-11)

In my own search, I did not find any source which suggested that PSR/CBRS is only effective for people with schizophrenia. Dr. Berlant has acknowledged that CBRS may be appropriate for many people with Intellectual Disabilities depending on the nature and extent of the functional limitations involved. Optum spokespersons have publicly stated that there is no I.Q. cutoff for CBRS. In any case, the broad consensus is that psychiatric rehabilitation by whatever name, is generally indicated for anyone with a severe and persistent mental illness resulting in disability which persists beyond the period of acute treatment. CBRS is the only service in the Optum plan which can provide "psychosocial rehabilitation" or other ongoing psychosocial services. In fact, Optum does not offer any other psychosocial services which are evidence based such as, assertive community treatment, psycho-educational services, "wrap around" services or intensive in-home services. With the exception of case management, there is nothing to fill the gap between clinic services and hospitalization. For people who have severe and persistent mental illness, this is a serious shortcoming.


Proper use of Treatment Guides and Evidence Based practices
It is important to note that the APA practice guidelines do not cover all evidence based practices and are not properly used to refuse coverage for a treatment or service which is recommended by a treatment team for a particular person. The APA only has practice guidelines for 12 mental health diagnoses. They don’t include Shizoaffective, or Schizotypal disorders, for example. It would be wrong to assume that the lack of an APA guideline constitutes a basis for finding that CBRS is not evidence based for diagnoses which do not have guidelines. The APA says of the guidelines:
The guidelines linked on this page, excluding Major Depressive Disorder, are more than 5 years old and have not yet been updated to ensure that they reflect current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality's National Guideline Clearinghouse, these guidelines can no longer be assumed to be current.

Since only one guideline is current, the failure of the guidelines to take PSR/CBRS into account should not be determinative of whether it is medically necessary or evidence based. Perhaps more importantly the APA says of each guideline:
The American Psychiatric Association (APA) Practice Guidelines are not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and practice patterns evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available.

Similarly the AACAP declares:"These parameters are not intended to define the standard of care, nor should they be deemed inclusive of all proper methods of care or exclusive of other methods of care directed at obtaining the desired results."

It is simply improper to use the guidelines as a basis to deny a treatment when the treatment is benefitting a patient based on the assessment of the treating psychiatrist and other treating clinicians.

Idaho has a long history of providing psychiatric rehabilitation services to children, people with intellectual disabilities, and people with a variety of psychiatric diagnoses. Although these services have occasionally been of poor quality, overall Idahoans have benefitted greatly from them and many have suffered from their loss. Close individual review of the actual benefits of CBRS to any individual and professional scrutiny of the value of the service are desirable and responsible. Categorical denial of services to individuals who benefit from the service and who will be harmed by the loss of the service, serves no purpose and can cause great harm.

Jim Baugh

December 8, 2014

Idaho Medicaid Redesign and People with Disabilities: "Option 3.5"

The Governor’s Work Group on Medicaid Redesign made a new recommendation on November 14th, 2014 to support a “hybrid” version of Medicaid expansion. They called this recommendation “Option 3.5”. It provides Medicaid eligibility for qualifying families below the Federal Poverty Level (FPL), and uses Medicaid funding to purchase coverage on the state insurance exchange for qualifying families between 100% and 138% of the FPL. Implementing this recommendation, or any other option for Medicaid expansion, will be of significant benefit to many Idahoans with disabilities.

Contrary to popular opinion, not all Idahoans with disabilities, who are living in poverty, are eligible for Medicaid. Two large groups are currently excluded. Of the roughly 41,000 Idahoans who have a serious and persistent mental illness (SPMI), only about 9,000 adults are currently eligible for Medicaid. About 10,000 more get treatment each year from the Department of Health and Welfare, but only if their illness becomes so severe that that they pose a serious risk to themselves or others, or if services are ordered by a court. This group (SPMI) includes only those people whose mental illness is disabling and recurring. Providing access to health care coverage for families up to 138% of FPL would include almost all of these people. Medicaid redesign would provide federal funding for the care and treatment they need and relieve the burden on county indigent funds and state general funds for both the Catastrophic Health Care Fund, and the Division of Behavioral Health programs. Currently, most Idahoans with SPMI have no coverage for mental health treatment, or for the very expensive prescription drugs needed to control their symptoms.

People who acquire disabilities after a period of employment, and are unable to work can qualify for Social Security Disability benefits. However, federal law prevents these people from obtaining Medicare coverage for two years after the onset of their disability. If their Social Security benefits exceed $734/month, they are also excluded from Medicaid coverage. At any given time, there are tens of thousands of Idahoans with disabilities in this waiting period. A recent study of Idaho county indigent program claims conducted by Dr. Douglas Dammrose, revealed that 42% of the claimants fell into this category (http://www.healthandwelfare.idaho.gov/Portals/0/Medical/MoreInformation/08-14-2014%20Medicaid%20Redesign-Idaho%20Doug%20Dammrose.pdf ). 

There are other people with disabilities, including many veterans, who fall into this coverage gap due to individual circumstances. All of them would benefit from access to affordable health care coverage. Option 3.5” could have different effects depending on its implementation. Some plans on the exchange have very little coverage for mental health treatment. Some of the most effective treatments for many people with severe and persistent mental illness are not included in exchange based plans. People with SPMI need a robust benefits package to get adequate coverage and to maximize savings from state general fund programs. This can be provided through Medicaid or through “wrap around” coverage, but it is necessary to address the needs of people with SPMI. Many people in the Medicare waiting period may need long term in-home supports and services to keep them out of expensive nursing home placements. These services are typically covered under Medicaid but not under exchange policies. Idaho must insure that people with particular health care issues caused by disabilities, have access to regular Medicaid coverage or robust “wrap around” supplemental policies, to meet these needs and prevent higher cost services.


Any Medicaid redesign option, which provides access to affordable health care for people in the “coverage gap”, will benefit Idahoans with disabilities and state and county budgets. Option 3.5 will be most effective for people with serious and persistent mental illness and other disabilities if it includes regular Medicaid coverage for those who need services that are not covered by state insurance exchange policies.