DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
 
CMCS Informational Bulletin 
 
 
DATE:   March 27, 2013 
 
FROM:   Cindy Mann, Director  
Center for Medicaid and CHIP Services  
 
SUBJECT:   Prevention and Early Identification of Mental Health and Substance Use 
Conditions 
 
 
The Medicaid program provides coverage to 27 million children under age 18 in the United 
States.  A core component of this coverage is the Early and Periodic Screening, Diagnostic and 
Treatment (EPSDT) benefit, which ensures that the health care needs of children and youth are 
addressed to maximize their growth and development.  Prevention and early identification of 
health conditions, which is a key component of EPSDT, promotes positive health outcomes and 
can reduce health care costs across an individuals lifespan.  The Center for Medicaid and CHIP 
Services (CMCS) is issuing this Informational Bulletin to help inform states about resources 
available to help them meet the needs of children under EPSDT, specifically with respect to 
mental health and substance use disorder services.  
   
Many of these resources are from states themselves, and we look forward to continuing to work 
with states and stakeholders to add to this resource list and to provide further assistance in 
ensuring that children receive the care they need.  Please contact John OBrien 
at john.obrien3@cms.hhs.gov for questions about this Bulletin or to suggest additional resources. 
 
Background 
 
According to the U.S. Surgeon General, while 11 percent of youth have been diagnosed with a 
mental illness, two-thirds of youth who have a condition are not identified and do not receive 
mental health servicesi.  Research by the National Institute on Mental Health found that half of 
all lifetime cases of mental illness or substance use begin by age 14ii.  Recent information 
regarding mental health and substance use disorder conditions among children indicates:    
 
  The rate of current illicit drug use among all youth (Medicaid and non-Medicaid) aged 12 
to 17 is 10.1 percent, 25% higher than individuals age 18 or older.iii    
 
  Suicide was one of the top 10 causes of death of students in the United States in 2009iv.    
Almost 14 percent of these students have seriously considered suicidev.  Six percent 
report having attempted suicide one or more times in the past 12 months.  The presence  CMCS Informational Bulletin  Page 2 
of major depression, bipolar disorder and alcohol and drug abuse are frequent risk factors 
for suicidal behaviors. 
   
  Children exposed to trauma, including maltreatment, family violence, and neglect, exhibit 
symptoms consistent with individuals diagnosed with post-traumatic stress disorder, 
attention deficit/hyper-activity disorder, depression, and conduct disorder/oppositional 
defiant disordervi. 
 
Mental Health and Substance Use Disorder Screening in EPSDT  
  
The EPSDT benefit is Medicaids comprehensive preventive child health service designed to 
assure the availability and accessibility of health care services and to assist eligible individuals 
and their families to effectively use their health care resources.  (See, 42 U.S.C.  1396(r)(1)(B); 
and 42 CFR 441, Subpart B.)  The EPSDT program assures that health problems, including 
mental health and substance use issues, are diagnosed and treated early before they become more 
complex and their treatment more costly.  Under the EPSDT benefit, eligible individuals must be 
provided periodic screening (well child exams) as defined by statute.  One required element of 
this screening is a comprehensive health and developmental history including assessment of 
physical and mental health development.  Part of this assessment is an age appropriate mental 
health and substance use health screening.  As noted in the section above, early detection of 
mental health and substance use issues is important in the overall health of a child and may 
reduce or eliminate the effects of a condition if diagnosed and treated early.  If, during a routine 
periodic screening, a provider determines that there may be a need for further assessment, an 
individual should be furnished additional diagnostic and/or treatment service.   
 
In addition to the required periodic screens, EPSDT provisions ensure that children receive 
medically necessary physician screenings in order to detect a suspected illness or condition not 
present or discovered during the periodic exam.  The screening may also trigger the need for a 
further assessment to diagnose or treat a mental health or substance use condition.    
 
Clinical Guidelines and Screening  
 
Significant advancements in early detection of mental health and substance use conditions have 
taken place over the past decade.  Numerous validated screens are available for use by medical 
professionals, and extensive research has proven them effective.  Further, professional resources 
are growing to assist primary care providers in the identification and treatment of conditions, and 
when necessary, linkages to specialists are improving.  This includes tools that can assess the 
social and emotional development for infants and young children.   
 
Numerous organizations in the medical community have issued clinical guidelines calling for 
early identification and screening for mental illness and substance use disorders.  For instance: 
 
  The American Academy of Pediatrics (AAP), through its publication Bright Futures, 
recommends an assessment of psychosocial and mental health and substance use at all 
well-child visits, newborn to age 21.  In 2009 the AAP released an extensive toolkit for 
its members to assist them in the identification and treatment of these conditions among  CMCS Informational Bulletin  Page 3 
their patients. http://brightfutures.aap.org.  In addition, AAP has released guidance 
regarding Screening, Brief Intervention and Referral to Treatment ( SBIRT), improving 
mental health services in primary care settings and recognizing and managing perinatal 
and postpartum depression.  These briefs can be found 
at: http://pediatrics.aappublications.org/content/128/5/e1330.full.html   http://pediatrics.a
appublications.org/content/123/4/1248.full 
http://pediatrics.aappublications.org/content/126/5/1032.full.html 
 
  The Society for Adolescent Medicine released a position paper Meeting the Health Care 
Needs of Adolescents in Managed Care, which focused on mental health and substance 
use 
conditions.  http://www.adolescenthealth.org/AM/Template.cfm?Section=Position_Paper
s&Template=/CM/ContentDisplay.cfm&ContentID=1481  
 
  The American Medical Association (AMA) released its Guidelines for Adolescent 
Preventive Services (GAPS), which includes recommendations for mental health and 
substance use screening. http://www.ama-assn.org/resources/doc/ad-hlth/suicidealgor.pdf 
 
  The Surgeon General released the 2012 National Strategy for Suicide Prevention that 
provided specific recommendations for developing and implementing protocols and 
programs for clinicians and clinical supervisors, first responders, crisis staff, and others 
on how to implement effective strategies for communicating and collaboratively 
managing suicide risk. http://www.surgeongeneral.gov/library/reports/national-strategy-
suicide-prevention/full_report-rev.pdf  
 
  The American Society of Addiction Medicine (ASAM) developed training for healthcare 
professionals to appropriately screen for and identify substance abuse, plan and 
implement a tailored brief intervention, improve care management and referral skills for 
brief treatment or severe problem/addiction treatment. http://www.sbirttraining.com     
 
  National Institute Alcohol Abuse and Alcoholisms (NIAAA) empirically based Alcohol 
Screening and Brief Intervention for Youth: A Practitioners Guide was designed to 
allow practitioners who manage the health and well-being of children and adolescents to 
conduct fast, effective alcohol screens and brief interventions. The guide was released in 
October 2011.  The American Academy of Pediatrics (AAP) endorsed the guide. The 
guide was also focus tested with pediatricians as well as family practice physicians, nurse 
practitioners and physician assistants. http://www.niaaa.nih.gov/publications/clinical-
guides-and-manuals/alcohol-screening-and-brief-intervention-youth  
 
  The United States Preventive Services Task Force (USPSTF) has also developed 
recommendations for primary care clinicians and health systems.  In March 2009, the 
USPSTF reviewed and issued recommendations regarding screening for various mental 
health and substance use among people age 12 years and older.  The USPSTF preventive 
services recommendations for these screenings can be found 
at http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm . 
  CMCS Informational Bulletin  Page 4 
 
There are a number of screening tools that are recommended by these various medical 
associations for use to identify children and adolescents with a mental health and/or substance 
use condition.  Several tools also assess the social and emotional development of infants and 
young children.  These screening tools, organized by age are listed in Table One with related 
links to the tools and instructions.   
 
Professional Development and Training 
 
Several national and state professional organizations or associations efforts have developed 
approaches to assist providers to locate important treatment and support resources for individuals 
who have been identified as having, or are at risk of having, a mental health or substance use 
condition. 
 
National Network of Child Psychiatry Access Programs (NNCPAP) 
 
The National Network of Child Psychiatry Access Programs (NNCPAP) brings together 
collaborative programs, through which child psychiatrists support pediatricians and other 
primary care providers via phone consultations or other types of curbside consultations.  These 
collaborative programs are a promising approach to leverage the existing supply of child 
psychiatrists to assist primary care providers in meeting the mental health service needs of 
children and youth.  The mission of the NNCPAP is to promote the development, sustainability, 
and quality of child mental health and psychiatry access programs designed to address the mental 
health needs of children and adolescents within the primary care setting.  For more information 
and a list of programs by state, visit: http://nncpap.org/members/current-programs/  
 
American Academy of Pediatrics (AAP) 
 
In 2004, the AAP Board of Directors formed the American Academy of Pediatrics Task Force on 
Mental Health (TFOMH).  The Task Force (TFOMH) articulated (with the AAP Committee on 
Psychosocial Aspects of Child and Family Health) mental health competencies for primary care; 
developed guidance for addressing systemic and financial barriers to providing mental health 
care in primary care settings; and provided tools and strategies to assist pediatricians in applying 
chronic care principles to children with mental health problems.  In 2009, AAP released a toolkit 
for use by its providers to improve identification of mental illness and enhance treatment in 
primary care.  After the task force sunset, the Mental Health Leadership Work Group (MHLWG) 
was formed to facilitate integration of the TFOMHs work into the fabric of the AAP and 
pediatric practice.  Its activities focus on transforming systems, transforming practice, building 
clinician skills, disseminating clinical tools, enhancing community resources for MH/SUD care, 
and partnering with families and organizations. 
http://www2.aap.org/commpeds/dochs/mentalhealth/ 
 
American Academy of Family Physicians 
 
The American Academy of Family Physicians (AAFP) has recognized the important role its 
members play in the unification of the psychiatric and physical models of health care.  AAFP has  CMCS Informational Bulletin  Page 5 
a strong platform to enhance the role its members play in the mental health care of individuals 
they treat.  The Academy believes that mental health services are an essential element of the 
health care services continuum, and that promotion of mental health and the diagnosis and 
treatment of mental illness in the individual and family context are integral components of family 
medicine.  Through residency training and continuing medical education, family physicians are 
prepared to manage mental health problems in children, adolescents, and adults. 
http://www.aafp.org/online/en/home/policy/policies/m/mentalhealthcareservices.html 
 
Emergency Nurses Association  
 
The Emergency Nurses Association has established a regional mentorship network to facilitate 
implementation of nurse-delivered alcohol SBIRT in emergency departments and to increase the 
number of emergency departments that implement alcohol 
SBIRT.  https://www.ena.org/IQSIP/Safety/Injury%20Prevention/SBIRT/Grants/Pages/Default.a
spx   
 
American Academy of Child and Adolescent Psychiatry (AACAP) 
 
Improved access to mental health services for children, adolescents and their families is a 
priority for the American Academy of Child and Adolescent Psychiatry (AACAP).  Recognizing 
that the lack of child and adolescent psychiatrists (CAPs) is a prominent problem throughout the 
country and that many primary care clinicians (PCCs) are struggling with children entering their 
practices with various mental health problems, AACAP is promoting collaborative mental health 
partnerships between child and adolescent psychiatrists and PCCs.  A critical component of this 
effort is early identification of mental health or substance use condition by primary care 
providers.  AACAP has developed resources to assist primary care providers in the 
identification, treatment and referral to specialty care for persons with mental 
illness. http://www.aacap.org/cs/systems_of_care_and_collaborative_models/collaboration_with
_primary_care 
 
The Massachusetts Child Psychiatry Access Project (MCPAP)  
 
MCPAP is a system of regional children's mental health consultation teams designed to help 
primary care providers (PCPs) meet the needs of children with psychiatric problems.  MCPAPs 
goals include: 
  Improve access to treatment for children with psychiatric illness; 
  Promote the inclusion of child psychiatry within the scope of practice of primary care;  
  Restore a functional primary care/specialist relationship between PCPs and child 
psychiatrists; and 
  Promote the rational utilization of scarce specialty resources for the most complex and 
high-risk children. 
Additional information regarding the MCPAP can be found at http://mcpap.com/ 
 
Clinical Quality Reporting  Screening and Early Intervention 
  CMCS Informational Bulletin  Page 6 
The Childrens Health Insurance Program Reauthorization Act (CHIPRA) of 2009, the Health 
Information Technology for Economic and Clinical Health (HITECH) Act of 2009, and the 
Patient Protection and Affordable Care Act all introduced new clinical quality reporting 
programs that apply to Medicaid and CHIP providers.  These clinical quality reporting programs 
add to existing Medicare quality reporting programs, as well as measure sets that may be used by 
state Medicaid programs and private plans, such as HEDIS measures.  Several core measure sets 
have now been identified, which include a number of measures related to screening and early 
intervention for children and youth with potential mental health and substance use conditions.  
Collecting and reporting on the services below can help providers to meet quality measurement 
goals and assist states in their efforts to track whether screening and follow up care occurs.   
 
These clinical quality reporting programs add to existing Medicare quality reporting programs, 
as well as measure sets that may be used by state Medicaid programs and private plans, such as 
HEDIS measures.  These clinical quality reporting programs have resulted in the identification of 
several core measure sets, which include a number of measures related to screening and early 
intervention for children and youth with potential mental health and substance use conditions.  
Collecting and reporting on the services below can help providers to meet quality measurement 
goals and assist states in their efforts to track whether screening and follow up care occurs  
 
Some specific reporting measures that states may consider in their approach to their tracking 
efforts are listed below, with separate headings for those applicable to patients under 18 years of 
age and those for adults patients, which may be relevant to patient 18 -21 years of age and 
eligible for the Medicaid EPSDT benefit.  Please note that the quality measures and measure sets 
noted below are not exhaustive and will continue to evolve.    
    
Measures applicable to pediatric patients (may also apply to adults): 
 
  Screening for clinical depression and follow-up plan among individuals 12 years of age 
and older (NQF #418/PQRS #134).  Applicable measure sets include:  
  HITECH Act: Stage 2 Meaningful Use Recommended Core Sets (pediatric 
and adult) 
  Initial Core set of Health Care Quality Measures for Medicaid- Eligible 
Adults 
  Medicare Physician Quality Reporting System  
  Group Practice Reporting Option (GPRO) Accountable Care Organizations 
(ACO) 
   
  Use of standardized screening tools for potential delays in social and emotional 
development during the first three years of life. (Child and Adolescent Health 
Measurement Initiative).  Applicable measure sets include:  
  CHIPRA Core Set of Pediatric Quality Measures  
 
  Follow-up after hospitalization for mental illness among patient six years and older (NQF 
#576).  Applicable measure sets include:  
  CHIPRA Core Set of Pediatric Quality Measures  CMCS Informational Bulletin  Page 7 
  Initial Core set of Health Care Quality Measures for Medicaid- Eligible 
Adults 
  Health Home Core Set 
 
  Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment (NQF 
#1365).  Applicable measure sets include: 
  HITECH Act: Meaningful Use of Electronic Health Records 
 
  Maternal depression screening - applies to children with a visit who turned 6 months of 
age in the measurement period (NQF #1401).  Applicable measure sets include: 
   HITECH Act: Meaningful Use of Electronic Health Records 
 
  Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder 
(ADHD) Medication (continuation and maintenance phase).  Applicable measure sets 
include:  
  CHIPRA Core Set of Pediatric Quality Measures 
  HITECH Act: Stage 2 Meaningful Use Recommended Core Set (pediatric) 
 
State Initiatives 
 
Screening can be a first step to identify a possible mental health or substance use condition.  
There is a renewed interest in tracking whether screening occurs and if follow up care is 
provided.  For instance, various CMS care coordination initiatives (e.g. Accountable Care 
Organizations, Health Homes) seek to track measures related to depression screening and follow 
up to care.  In addition, a number of state Medicaid programs have taken unique and interesting 
approaches to screening, follow up treatment and quality improvement.  Several state examples 
are discussed below. 
 
Massachusetts 
 
Since 2008, The Massachusetts Medicaid program (MassHealth) implemented the Childrens 
Behavioral Health Initiative (CBHI).  The CBHI program was developed as part of a legal 
judgment (Rosie D. vs. Patrick).  The Rosie D. judgment required Massachusetts to implement 
universal behavioral health screening of MassHealth (Massachusetts Medicaid program) 
members under the age of 21 during well-child visits.  Since December 31, 2007, MassHealth 
has directed all primary care clinicians seeing youth under 21 to use one of several approved 
screening tools during well-child visits.  Screening rates have risen from 15% for the first quarter 
since implementation (Jan-Mar 2008) to 65% in the most recent quarter for which we have data 
(Jan-Mar 2012).  (Rates for children 6 months  17 are higher: from 69% to 74% in the most 
recent quarter.)  The percentage of youth identified with a potential behavioral health needs 
averages 7.5 to 9 % each quarter.  More information regarding Massachusettss mental health 
screening efforts can be found at:  
http://www.mass.gov/eohhs/gov/commissions-and-
initiatives/cbhi/ http://www.teenscreen.org/images/stories/RosieDBriefProgramDirectors.pdf http
://www.teenscreen.org/images/stories/RosieDBrief-
Policymakers.pdf http://mcpap.typepad.com/files/pccscreening-toolkit.pdf   CMCS Informational Bulletin  Page 8 
 
North Carolina  
 
The State of North Carolina has made significant strides in its effort to improve the delivery of 
Childhood Developmental Screening (including screening for mental health conditions) and 
Referral to Services.  The North Carolina Assuring Better Child Health and Developmental 
Program (ABCD) exponentially increased the number of screening tests administered during 
Medicaid well child visits to identify children and youth that were at risk of mental health 
disorders and developmental disabilities.  North Carolinas ABCD program relied on their 14 
local community care networks (known as Community Care of North Carolina (CCNC)) to 
improve their EPSDT screening efforts.  Improved communication between medical offices, 
mental health agencies and families were critical to their strategy for accomplishing their goal.  
The ABCD program identified standardized screening tools and trained physicians on their use 
without disrupting workflow.  The ABCD program also facilitated better relationships between 
primary care practices and community agencies to coordinate care for children whose screens 
indicated the need for mental health services.  More information regarding the North Carolina 
ABCD program, can be found 
at:  http://www.communitycarenc.com/search/?search_text=ABCD 
 
The Division of Medical Assistance administers the EPSDT services program under the name 
Health Check.  The complete billing guide (including developmental and behavioral health 
policy located on pages 21 -25) can be found 
at http://www.ncdhhs.gov/dma/healthcheck/FINAL_Health_Check_Billing_Guide.pdf 
 
 
Colorado 
 
In 2011, the Colorado Department of Health Care Policy and Financing (HCPF), which 
administers the State Medicaid and Child Health Plan Plus programs, began promoting its 
Healthy Living initiatives.  These initiatives are intended to improve the health of Medicaid and 
CHP+ recipients, staff and the community and focus on oral health, mental health, nutrition and 
fitness and tobacco free living. The HCPF web site contains information for clients on how to 
access these health care services from their provider.  As a resource to primary care providers, 
HCPF developed toolkits for each of the Healthy Living areas to provide guidance on how to 
document and address these issues of health promotion in Medicaid/ CHP+ clients.  The 
Behavioral Health: Focus on Depression toolkit includes the following:  
 
  Information on depression screening resources and tools for providers 
  Specific CPT code (99420) for depression screening in adolescents 11-20 years old 
  Information of diagnosis (ICD-9) and treatment (E&M) codes 
  Recommendations and phone numbers for making referrals to the states Behavioral 
Health Organizations (BHOs) and other community resources 
  Additional information about performance measures and tracking screening results 
 
Information regarding the Colorado program can be found 
at: http://www.colorado.gov/cs/Satellite?c=Document_C&childpagename=HCPF%2FDocument CMCS Informational Bulletin  Page 9 
_C%2FHCPFAddLink&cid=1251608852128&pagename=HCPFWrapper 
and http://www.colorado.gov/cs/Satellite/HCPF/HCPF/1251590394753 
 
South Carolina:  
 
South Carolina has a CMS CHIPRA quality demonstration grant that supports quality 
improvement work at 18 pediatric practices across the state, ranging from a small practice to a 
large Federally Qualified Health Center.  The grant program is called Quality through 
Technology and Innovation in Pediatrics or Q-TIP.  The goals of the grant are to improve 
pediatric care through the use of quality measures; health information technology; a physician-
led quality improvement network; and the integration of mental health into the pediatric medical 
home model.  To assist pediatric practices in addressing mental health, grantee practices are 
provided with supports, including standardized mental health screening tools, academic detailing 
and coordination with mental health providers.  Learning collaboratives for primary care 
pediatric practices focused on mental health screening and the integration of mental health into 
the pediatric patient centered medical home are planned for 2013. 
 
 
 
 
    CMCS Informational Bulletin  Page 10 
 
TABLE ONE 
Children  Recommended  Purpose  Links 
and  Screens 
Adolescents 
Birth through  Ages and Stages  Any  http://eip.uoregon.edu/pdf/6month_asqse.pdf 
60 months  Questionnaire:  mental 
Social Emotional  Health    
(ASQ:SE)  Condition 
http://eip.uoregon.edu/pdf/60month_asqse.pdf   
Birth through  Pediatric  Any  http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf  
8 years  Symptoms  Mental 
Checklist (PSC,  Health   
  PSC-Y)  Condition 
 
Ages 6  CRAFFT  Alcohol  http://www.ceasar-boston.org/CRAFFT/pdf/CRAFFT_English.pdf  
through 18  Use 
Ages 4-17  Pediatric  Any  http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf  
Symptoms  Mental 
Checklist  Health 
Condition 
 
    CMCS Informational Bulletin  Page 11 
 
Adolescents  Recommended Screens  Purpose  Links 
Only 
Ages 12 through  Patient Health Questionnaire- Depression  http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf  
18 years  9 
  Center for Epidemiological  Depression  http://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf  
Studies Depression Scale for 
Children (CES DC) 
Ages 10-18  Global Assessment of  Alcohol  http://www.chestnutglobalpartners.org/Portals/7/CGP_PDF/GAIN/GSS-
Individual NeedsShort  WP.pdf  
Screener (GAINS-SS)  CMCS Informational Bulletin  Page 12 
 
                                                           
i i Bright Futures guidelines recommend an assessment of psychosocial and behavioral health at all well-child visits, newborn to 
age 21. 
ii Lifetime Prevalence and Age-of-Onset Distributions of DSM IV Disorders in the National Comorbity Survey 
Replication, Kessler, R., Berglund, P., Demler, O., Jin, R., Merikangas, K., Walters, E, Archive of General Psychiatry, 
Volume 62, June 2005 pages 593-602.  
iii Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey of Drug Use 
and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Page 80. 
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.   
iv Center for Disease Control, Injury, Prevention and Control:  Data and Statistics (WISQARSTM - 
http://www.cdc.gov/Injury/wisqars/pdf/10LCD-Age-Grp-US-2009-a.pdf  
v Center for Disease Control, Youth Risk Behavior Surveillance(YRBS) Data, 2009 
vi A subsequent tri-agency Information Bulletin will be released to address the identification and treatment of 
trauma in children and adolescents.