Background: The Department of Social and Health Services (DSHS) contracts with regional support networks (RSN) to provide mental health services for adults and children who suffer from serious mental illness or severe emotional disturbance and meet access-to-care standards. An RSN may be a county, group of counties, or a nonprofit or for-profit entity. RSNs are required to provide:

crisis and involuntary treatment services for all residents in the region;
medically necessary community based mental health treatment services covered under the state Medicaid plan; and
limited other services for individuals not covered under the Medicaid program.

During the 2015 fiscal year, the Department provided mental health services to approximately 48,000 children through contracts with 11 RSNs.

The Health Care Authority (HCA) administers the Medicaid program, which is a state-federal program that provides health care for low-income state residents who meet certain eligibility criteria. In Washington state, Medicaid is called Apple Health. Apple Health for Kids is free for all children in families below 210 percent of the federal poverty level. Families above that level may be eligible for the same coverage at a low cost. HCA is responsible for providing medically necessary community-based mental health treatment services covered under the state Medicaid plan for Medicaid clients who do not meet access-to-care standards.

Federal law requires group and individual health plans to provide coverage for several types of preventive health services. For infants, children, and adolescents, these services include evidence-informed preventive care and screenings provided for in the Health Resources Services Administration (HRSA) comprehensive guidelines. The HRSA's comprehensive guidelines have adopted the American Academy of Pediatric's "Periodicity Schedule of the Bright Futures Recommendations for Preventive Health Care" (Periodicity Schedule). The Periodicity Schedule establishes a recommended timetable for patients to receive preventive services from birth through 21 years of age. In 2015, the American Academy of Pediatrics updated the Periodicity Schedule, recommending annual depression screenings for children ages 11 through 21 years of age.

Medicaid programs are not required to follow the Bright Futures guidelines. However, Medicaid includes benefits under the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) for enrollees under 21 years of age. EPSDT covers health screening visits, which are regularly scheduled examinations and evaluations of the general physical and mental health, growth, development, and nutritional status of infants, children, and youth.

Summary of Bill: The Children's Mental Health Work Group (Work Group) is established, consisting of four legislators, one from each caucus of the Senate and House of Representatives; four alternate legislators; five executive members; a representative of tribal governments; and a representative of each of the following: behavioral health organizations, community mental health agencies, Medicaid-managed care organizations, pediatricians or primary care providers, providers that specialize in early childhood mental health, the evidence-based practice institute, parents or caregivers who have been a recipient of early childhood mental health services, foster parents, child health advocacy groups, child care providers, and the managed health care plan serving foster children. The Work Group must review barriers that exist to identifying and treating mental health issues in children with a particular focus on birth to five, including at a minimum:

appropriate assessment tools to establish eligibility for services;
billing issues related to serving the parent or caregiver;
workforce issues;
barriers to billing and payment for behavioral health services provided within primary care settings;
the adoption of standards for training and endorsement of professionals;
supports for child care providers to reduce expulsions of children from child care and preschool; and
outreach strategies to effectively disseminate information about available mental health services.

The Work Group must report its findings by December 1, 2016.

HCA and DSHS must report annually to the Legislature, staring December 1, 2017, on the status of access to behavioral health services for children from birth through age 17. The reports must include measures including the rate of access of mental health or substance use treatment by children aged 6-17 within 30 days of an emergency room visit related to mental health or substance use, the percentage of health plan members with an identified mental health need who received mental health services during the reporting period, and the percentage of children served by behavioral health organizations, including the type of services provided.

Effective January 1, 2017, subject to the availability of funding, HCA must require universal annual screening and provider payment for depression for children aged 13-21, as recommended by the Bright Futures Guidelines of the American Academy of Pediatrics.

HCA must collaborate with the University of Washington to establish a pilot program, referred to as the PAL Plus pilot program, in a rural area of the state to expand the partnership access line program and offer additional mental health support services to children in primary care settings. A preliminary evaluation is due December 31, 2017, and a final evaluation on December 31, 2018.

The Joint Legislative Audit and Review Committee (JLARC) must conduct an inventory of mental health service models available to students in schools, school districts, and educational service districts and report its finding by October 31, 2016.

An intent section states that the Legislature intends to encourage the use of behavioral health therapies that are empirically supported and only prescribe medications for children and youth as a last resort.

The bill is subject to a null and void clause.

Staff Summary of Public Testimony: PRO: This is an important step forward to strengthen mental health. Half of adults with mental health issues have those issues appear before the age of 14. A work group considered these issues over the last interim. We can teach coping skills to children before they reach K-12. We need to study billing problems and workforce problems. The PALS access line pilot program would provide critical access to psychiatric consultation with primary care doctors in rural areas. Otherwise, the only alternative is to pull out the prescription pad. The depression screening is two questions unless there is an indication of a problem, in which case there are nine questions. A teen will sometimes tell a doctor things they won't tell their parent. If you provide mental health consultation to a provider and parent, you can teach parenting skills to the parent that can help. In pediatrics, earlier is better, and prevention is cost effective. Mental health issues need to be identified early and addressed before they become devastating. Early identification gives us tools we can use to prevent real psychoses. The coverage for depression screenings will bring Medicaid up to the nationally recognized standard of care that private carriers already cover. Just as we screen all children for poor vision, we should screen them for mental health. The PALS line has been so important to our practice in Seattle. We have heard for years about challenges that families have accessing mental health services for their children. The focus is on access, network adequacy, and holding folks accountable. Do we have the right kind of providers? Effective programs and practices exist, but access is limited statewide. Our goal is to avoid long-term suffering and the negative impacts that can occur without early intervention for children. Focusing attention on children through the work group will go a long way towards reducing barriers to access. Suicide is a leading cause of death among youth. Screening provides an opportunity to identify youth who are at risk and not connected to care.