Determining Medical Necessity using EPSDT Guidelines: Los Angeles DMC-ODS Case Application of Screening & Assessment
Erik Sherman, MSW
The teenage years typically mark the first exposure to substances, and thus the first risks of developing a substance use disorder (SUD). Interventions designed to reduce the risk of developing a SUD later in life or to treat an active SUD can change the course of a young person’s life. Providers have struggled for years to provide adequate prevention and treatment services under previous Drug Medi-Cal constraints. In May 2018, the California Institute of Behavioral Health Solutions invited Dr. Rachel Gonzales-Castaneda, PhD, MPH to present the treatment modalities available for reimbursement under the Drug Medi-Cal-Organized Delivery System 1115 Waiver (DMC-ODS); discuss the intersection of DMC-ODS Waiver with the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits; and illustrate a model for the use of these benefits as implemented in the Los Angeles County Organized Delivery System. This webinar was presented as a component of the DMC-ODS Waiver Forum, funded by the Blue Shield of California Foundation. Dr. Gonzales-Castaneda is an Associate Professor at the Department of Psychology, Azusa Pacific University, and an Associate Research Psychologist, at the UCLA Integrated Substance Abuse Programs.
Until the ODS waiver rules were implemented, youth at risk of developing a substance use disorder had a limited set of options to address SUDs; there were no routine screening practices, no standardized assessments, and limited coverages for treatment interventions. Interventions were primarily group-based, with individual sessions reserved for crises and special cases. Under the ODS waiver, there is greater coverage for individual modalities, and case management, family therapy, and recovery support are also covered. While this expansion in services is important, it is only a part of the benefits available under EPSDT. Dr. Gonzales-Castaneda discusses both the importance of and opportunities to provide organized screenings and diagnostic assessments to the youth population.
Screening is discussed as a top priority. As it’s estimated that only 5% of the youth population will use substances in a problematic way, an additional 70% of the youth population reports past year use of substances. By implementing frequent screenings, and conducting those screenings at appropriate intervals, health professionals and treatment providers will be able to intervene with youth at high risk of developing a SUD before those symptoms either develop or worsen. Good screening protocols will deploy prevention and education efforts towards low or mild risk youth substance users while referring those with more significant risk to treatment providers for further assessment. In this way, SUD treatment systems can most efficiently use the often-limited treatment resources to assess the highest risk cases.
Dr. Gonzales-Castaneda discusses two validated screening tools for youth: the CRAFFT (Car, Relax, Alone, Forget, Friends/Family, Trouble) and S2BI (Screening to Brief Intervention). She discusses the differences between the two, and their relative strengths and limitations, and provides an example of how LA County has integrated the two tools in a way that both offsets weaknesses of each tool and leads into a more thorough assessment of SUD risk. These risk questions are integrated into both screening and diagnostic instruments, allowing for placement in the correct service type when a youth presents for assessment to a service provider. The assessment tool also incorporates DSM 5 language, creating a bridge between screening, assessment, and diagnosis.
Dr. Gonzales-Castaneda concludes by discussing the “at risk” component of LA County’s treatment service design. This “outpatient” level of service—designated ASAM 1.0-AR, is provided using youth EPSDT benefits and is limited to a total of 4 hours of service. This brief intervention is provided to youth that present with SUD risk, but fall short of the criteria required to formally diagnose a SUD. The first two hours of this benefit are devoted to completing the risk screener, full ASAM assessment, completing intake, and creating an abbreviated treatment plan. The remaining 2 service hours are distributed over four 30-minute sessions, of which two focus on counseling and psychoeducation, and two focus on case management.
Click here to listen to the webinar and view the Powerpoint to learn more about the use of the EPSDT benefit to provide comprehensive screening, diagnostic, treatment, and preventive health care services for individuals under the age of 21 who are enrolled in full scope Medicaid (Medi-Cal). The Adolescent ASAM assessment developed for Los Angeles County which integrates an at-risk assessment is included.