National Alliance on Mental Illness
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NAMI Submits Comments on State
Children's Health Insurance Program

For Immediate Release, 4 Jan 00
Contact: Chris Marshall

January 4, 2000
Health Care Financing Administration
Department of Health and Human Services
Attention: HCFA-2006-P
P.O. Box 8018
Baltimore, MD 21244-8010



NAMI - the National Alliance for the Mentally Ill - is pleased to offer these comments on the November 8, 1999 proposed rule for the SCHIP program. NAMI is a nationwide grassroots organization with 210,000 members - consumers and families directly impacted by severe mental illness.

The recent White House Conference on Mental Illness and the Surgeon General's report both pointed to the prevalence of treatable disorders among children and adolescents, and at the same time noted the low percentage of those in need who actually access services at all. Tragic events in the national news over the past year have focused public attention on the issue of mental illnesses in adolescents. The popular press has taken up the challenge to research the questions and to inform the public.

As the Nation's Voice on Mental Illness, NAMI is centrally concerned about these issues. The enactment of SCHIP offered opportunity for expanded teatment resources for these children and adolescents. For this opportunity to be realized several decision points must be addressed. We point these out in this commentary.

Children with serious or severe mental illnesses, which NAMI affirms as brain disorders , are reasonably covered for treatment and services when Medicaid eligible, because of Medicaid's EPSDT provisions. NAMI urges that in those states which opt to develop their SCHIP programs outside of Medicaid, the additional children brought into health coverage have the same level of treatment and service as Medicaid provides for serious or severe mental illness.

Unfortunately, the new Title XXI of the Social Security Act as promulgated in Public Law 105-33 was not enacted in a way that requires this kind of parity. NAMI recognizes that HCFA, in writing a proposed regulation implementing the legislation, can not go beyond the clear limits of the statutory text.

The law mentions mental health services to such children only three times.

1) In Subpart D, sec. 457-402 "Child health assistance and other definitions," the text states that for the purposes of this subpart, "child health assistance" means "payment for part or all of the cost of health benefits coverage provided to targeted low-income children, for:"

inpatient mental health services defined at (a)(9) as "including services furnished in a State-operated mental hospital and including residential or other 24-hour therapeutically planned structured services."

outpatient mental health services defined at (a)(10) as "including services furnished in a State-operated mental hospital and including community-based services."

Both (a)(9) and (10) specifically exclude substance abuse treatment services, but these are separately listed at (a)(17) and (18). The construction in a definitions section means only that payment may be made for these services. It does not mean payment shall be made for these services.

2) Section 457-430, "Benchmark-equivalent health benefits coverage" divides services into (b) required and (c) additional. Coverage "must" be included for required services which are limited to: hospital, physicians', lab, well-child including immunizations, and emergency services [from 457.410 (b)(3)] Coverage "may" be included for additional services specified in sec. 457-402. The only adumbration of a requirement for coverage of mental health services is found at (c)(2):

"If (emphasis added) the benchmark coverage package used by the State for purposes of comparison in establishing the aggreagate actuarial value of the benchmark-equivalent coverage package includes coverage for … mental health …the actuarial value of the coverage must be at least 75 percent of the value of the coverage for such a category or service in the benchmark plan used for comparison by the State."

3) But this requirement is substantially qualified at (c)(3):

"If (emphasis added) the benchmark coverage package does not cover one of the … services in paragraph (c)(2) of this section, then the benchmark-equivalent coverage package may, but is not required to (emphasis added), include coverage for that category of service.)

Congressional intent appears to have been that coverage for targeted low-income children in the SCHIP program should not be more generous than the specified benchmark plans, unless a State opts to have it so. This stance is usual in legislation authorizing programs of federal assistance.

NAMI hopes that in those twenty-eight states that have enacted mental illness parity statutes, State decision-makers will conform their SCHIP program to the intent of their state's parity legislation--rather than to the minimum requirement of the 75 percent actuarial equivalence to the benchmark average. The needs of so many children, eligible for SCHIP as part of the targeted population, will be far better served. State and local resources will certainly be conserved over the long run as well, across several public sector areas besides just health: education, public safety, corrections.

NAMI urges that states which have not yet enacted parity statutes also include a full range of mental illness services in their SCHIP plans when they opt to develop these outside of Medicaid. The resource conservation point applies equally to these states.

NAMI is particularly concerned about states that began their SCHIP programs as the Medicaid-extension option but, upon renewal, are reported to be switching to designs outside of Medicaid-thus losing for children with serious or severe mental illness the EPSTD safety net which so far exceeds the 75 percent actuarial equivalent test.

Plan Amendment
In the Overview section, relating to Subpart D, it is noted that states using the benchmark benefit package option need not submit an amendment when the benchmark package changes. Granted, the benchmark plan does not have to include mental health services. But when it does initially, and subsequently drops them, there is no requirement to call this to HCFA's attention-at least not by filing a plan amendment. NAMI believes this is unacceptable.

Protection from Disenrollment
In Subpart E of the Overview section, it is noted that failure to pay cost-sharing cannot by itself be cause for disenrollment. Due process must be ensured. States are given suggestions as to what further to ascertain before taking disenrollment action against a child. NAMI supports this.

Adding "Families"
NAMI applauds the beneficiary protections consistent with the President's directive regarding the Consumer Bill of Rights and Responsibilities (Overview, Subpart I), which "ensure that beneficiaries are given the opportunity to participate in and make informed medical decisions, to have access to needed services, and to be treated with dignity and respect." These are the very things that have been often denied to persons with a severe and persistent mental illness--a brain disorder-because of stigma and discrimination. This statement could be improved by adding "families." It is particularly appropriate since parental consent would be a requisite for almost any treatment furnished under the SCHIP program.

Preexisting Conditions
While we understand it is in the law, we believe the HIPAA-allowable conditions for permitting a waiting period for services for a preexisting condition are inimical to the purposes of initiating coverage for children cut off from access to services precisely because they lack coverage. Most if not all such children should be assessed, diagnosed, and treated immediately in response to their health deficiencies. This is a matter for the Congress to re-consider.

Automatic Disqualification For Inpatient Status
At 457.310(c)(2) children who are residents in a public institution or patients in an IMD (Institute for Mental Disease) are excluded from eligibility at the time of initial determination or at redetermination of eligibility. Yet once eligible, their care in either setting may be supported by SCHIP funds. Cannot safeguards other than exclusion from eligibility be implemented to prevent substitution of SCHIP funds for existing federal, state, or private sector funding? The program allows for spend-down as a state option. The interaction of these provisions creates an apparent contradiction. If a family has to place their child in (psych specialty) residential treatment in any of the 48 states which exercise the option to cover such care through Medicaid for children under the age of 22, and has supported such care with their own family funds until they have "spent down" below the 200% of poverty threshold for SCHIP-why should their child not be eligible in simple equity? When a family whose child cannot qualify for Medicaid becomes financially eligible for SCHIP coverage, isn't it discriminatory to exclude their child because of the child's in-patient psychiatric status?.

The SCHIP law and proposed regulation permit an eligible child to be treated in a state psychiatric facility or a private one following eligibility determination. What happens during a course of medically necessary inpatient services when redetermination occurs? Automatic disqualification, and its dire consequences for the child under treatment and its family, are wholly unacceptable..

Home and Community-based Services, Nursing Care Services
The health care services and related supportive services enumerated at 457.410, particularly: "respite care services, training for family members" are especially relevant to families which have children with severe and persistent mental illness-brain disorder. NAMI would appreciate attention being called to their eligibility and relevance in plans that offer supplemental mental health services. The same comment applies to: "advanced practice nurse services, and pediatric nurse services….in a home, school, or other setting."

Substance Abuse Treatment Services
While the listings for mental health services, inpatient and outpatient, in 457.410 specifically exclude substance abuse services, we note the inclusion of these as separate listings. We call attention to these because of the high incidence of co-occuring disorders among adolescents with presenting symptoms of one or the other. Even though these services lack the 75% actuarial measure required when mental health services (and/or prescription drug, vision, and hearing services) are included, states should consider their inclusion for comprehensive treatment of adolescents with co-occuring mental and substance abuse disorders.

Emergency and Post-stabilization Services
NAMI applauds the proposal at 457.410 to require guaranteed access without prior authorization to emergency services, and the expectation that post-stabilization would be treated as in Medicaid and Medicare. In a suicide attempt or a situation of strong suicide ideation-where a prudent layperson would judge the involved child or adolescent in need of emergency medical treatment-what happens in a state that has no mental health coverage in its SCHIP plan?

Children With Special Needs
NAMI appreciates HCFA's calling attention in commenting on 457.410(b) to a state's option to offer different health benefit coverage to children with special needs. "The state can define the health benefit coverage to include supplemental services for children with special needs or physical disabilities." Why doesn't the text name mental disabilities as well? Such children may be encompassed within "special needs" but the additional listing of physical disabilities appears to belie that disability can be mental as well.

Cost-sharing for Children with Chronic Conditions
NAMI commends HCFA for stating at 457.510 its belief that a "statutory change will be needed to prevent the additional burden of cost sharing on children with chronic conditions." The statute does not require states to count the beneficiary's cost of paying for services not covered under the plan toward the cumulative cost sharing cap. This condition is so often experienced in families with a child with a severe and persistent mental illness or other similarly disabling condition, and official disregard for the burden of uncovered costs incurred which often destroy the family is reprehensible.

NAMI thanks the Health Care Financing Administration for the opportunity to comment on the proposed regulations. Should there be any occasion to discuss them, please contact Robert Bohlman at NAMI at (703) 516-7997. E-mail:

i designated "serious emotional disturbance" in the authorizing legislation for HHS' Substance Abuse and Mental Health Services Administration, P.L. 102-321.