DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
 
 
              SHO# 20-002 
   
RE:  Access to Mental Health and 
Substance Use Disorder Services for 
Children and Pregnant Women in the 
Childrens Health Insurance Program 
 
March 2, 2020 
 
Dear State Health Official: 
 
The passage of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and 
Treatment for Patients and Communities Act (P. L. 115-271), referred to as the SUPPORT Act, 
on October 24, 2018, among other things, strengthens behavioral health coverage for children 
and pregnant women eligible through the Childrens Health Insurance Program (CHIP).  Section 
5022 of the SUPPORT Act amends section 2103(c)(5) of the Social Security Act (the Act) to 
make behavioral health coverage a required benefit for CHIP effective October 24, 2019.      
 
Section 5022 of the SUPPORT Act specifically requires that child health and pregnancy related 
assistance include coverage of mental health services (including behavioral health) necessary to 
prevent, diagnose, and treat a broad range of mental health symptoms and disorders, including 
substance use disorders.  The statute also stipulates that these services must be delivered in a 
culturally and linguistically appropriate manner.  It applies to all CHIP eligible populations 
regardless of the type of coverage (e.g., benchmark coverage) elected by the state under a 
separate CHIP under section 2103 of the Act.  We also note that the requirements in the 
SUPPORT Act are distinct from those in the Mental Health Parity and Addiction Equity Act 
(P.L. 110-343)(MHPAEA).  Additional information is provided in the section below entitled,  
Behavioral Health Related Regulations in CHIP. 
 
The purpose of this State Health Official (SHO) letter is to describe this new provision, and 
provide guidance to states with separate CHIPs on the actions necessary to implement the 
requirements of section 5022 of the SUPPORT Act.  In general, states with a separate CHIP will 
need to submit a CHIP (Title XXI) state plan amendment (SPA) to demonstrate compliance with 
section 5022 of the SUPPORT Act in areas related to coverage of behavioral health screening, 
prevention and treatment services, strategies to facilitate use of appropriate screening and 
assessment tools and the requirement that these services be provided in a culturally and 
linguistically appropriate manner.  This letter also provides states with the attached SPA template 
created for use during the SPA submission process.   
 
 
 
 
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Background  
 
a.  Importance of Behavioral Health Services for Children and Pregnant Women 
 
Mental health is key to overall health and plays a critical role in the well-being of children and 
pregnant women.  There are unique vulnerabilities and developmental implications when it 
comes to mental health and substance use disorder conditions in children and pregnant women.  
Mental health disorders usually first arise in childhood, adolescence or early adulthood.  As 
many as one in six U.S. children between the ages of 6 and 17 has a treatable mental health 
disorder.1  In 2018, an estimated 21.2 million people aged 12 or older needed substance use 
treatment.  About 1 in 26 adolescents aged 12 to 17 (3.8 percent), and about 1 in 7 young adults 
aged 18 to 25 (15.3 percent) needed treatment.2  Several common mental health conditions 
impact Medicaid and CHIP children at higher rates than the general child population including 
conduct disorder, anxiety disorder, depression, autism spectrum disorder, and attention deficit 
disorder.3   
 
With respect to pregnant women, approximately 40 percent experience psychological difficulties 
during or after pregnancy with 10 to 15 percent being diagnosed with a mental illness.4  Low 
income women are more likely to develop some form of depression compared to other mothers, 
ranging from 40 to 60 percent suffering depressive symptoms.5  Pregnant women also face 
challenges with substance use.  A history of trauma has been associated with risk of substance 
use in women.  During 1999 through 2014, the national prevalence of opioid use disorders 
increased 333 percent from 1.5 cases per 1,000 delivery hospitalizations to 6.5, an average 
annual increase of 0.4 per delivery hospitalizations per year6.  In 2018, 9.9 percent of pregnant 
women drank alcohol, 11.6 used tobacco, and 5.4 percent used an illicit substance.7    
 
SUPPORT Act Requirements 
 
As noted above, section 5022 of the SUPPORT Act requires that child health and pregnancy 
related assistance include coverage of mental health services (including behavioral health) 
necessary to prevent, diagnose, and treat a broad range of mental health symptoms and disorders, 
including substance use disorders.  This section describes the requirements for all states with 
separate CHIPs to cover specific behavioral health related screening and preventive services, 
                                                 
1 Whitney, D.G., Peterson, M.D., JAMA Pediatrics.  (2019). US National and State-Level Prevalence of Mental Health Disorders 
and Disparities of Mental Health Care Use in Children. 
2    Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the 
United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH 
Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services 
Administration. Retrieved from https://www.samhsa.gov/data/.   
3 MACPAC.  (2016)  Medicaid Access in Brief:  Childrens Use of Behavioral Health Services.  Accessed at 
https://www.macpac.gov/wp-content/uploads/2016/06/Childrens-access-to-behavioral-health-services.pdf. 
4 Gilbert, H., Gurvich, C. and Kulkarni. (2015). Journal of Nursing Care. Special Issues for Pregnant Women with Mental Illness.  
5 Centers for Medicare and Medicaid Services. (2016). Maternal Depression Screening and Treatment: A Critical Role for 
Medicaid in the Care of Mothers and Children. Accessed at https://www.medicaid.gov/federal-policy-
guidance/downloads/cib051116.pdf. 
6 Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM. Opioid Use Disorder Documented at Delivery Hospitalization  
United States, 19992014. MMWR Morb Mortal Wkly Rep 2018;67:845849. 
7 Substance Abuse and Mental Health Services Administration. (2018). The National Survey on Drug Use and Health: 2018. 
Accessed at https://www.samhsa.gov/data/report/2018-nsduh-detailed-tables. This may be an underrepresentation of the actual 
prevalence of substance use during pregnancy because it is often under-diagnosed. 
 
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adhere to a periodicity schedule, and identify a strategy for facilitating the use of age-
appropriate, validated screening tools.   
 
Screening and Preventive Services 
 
a.  Coverage of Behavioral Health Related Screenings and Preventive Services  
Screening8 and preventive services improve overall health by identifying illnesses earlier, 
managing them more effectively, and treating them before they develop into more complicated, 
debilitating conditions.  This makes routine screening, early identification, and treatment of 
behavioral health conditions particularly important for children and pregnant women.  Several 
organizations make evidence-based recommendations for screening and preventive services for 
populations in a primary care setting.  The American Academy of Pediatrics (AAP) publishes the 
Bright Futures periodicity schedule, referred to as Recommendation for Preventive Pediatric 
Health Care. 9 AAP/Bright Futures provides a schedule of screenings recommended at each 
well-child visit from infancy through adolescence.  The majority of states have already adopted 
the current version (fourth edition published in March 2019) of the AAP/Bright Futures 
periodicity schedule for both CHIP and Medicaid children.  Some states have maintained a 
previous version of this schedule, or made modifications to it.  The U.S. Preventive Services 
Task Force (USPSTF)10 also recommends clinical preventive services for children and adults, 
including pregnant women.    
 
All states will be required to provide coverage of all of the developmental and behavioral health 
related screenings, and preventive services recommended by AAP/Bright Futures, as well as 
those with a grade of an A or B by USPSTF.  This new requirement is consistent with the 
prevent and diagnose provisions specified in section 5022 of the SUPPORT Act.  The 
required screenings and services are specified in Table 1 below, and the detailed AAP/Bright 
Futures periodicity schedule can be viewed at the organizations website. 
 
In addition, states will be required to specify the periodicity schedule they have adopted for 
children.  If a state elects a periodicity schedule other than the current version of the AAP/Bright 
Futures periodicity schedule, it will have to ensure that the types of screening and preventive 
services, and the recommended schedule for delivering these services at well-child visits, are at 
least comparable to the most up-to-date AAP/Bright Futures standards.  In the future, states will 
need to ensure that they are covering screens and preventive services consistent with the most 
recently published AAP schedule.  These requirements are consistent with industry standards in 
the private and public sector, and currently in practice in the majority of states.  We recognize 
that periodicity schedules serve as a guideline for recommendations in this area, but clinical 
judgement will continue to be an important element in the provision of these services.  
 
                                                 
8 Screening is a formal process that employs a standardized tool to detect a particular concern or condition.  Universal screening 
is performed on all individuals at certain ages to identify those at risk of a particular condition.  Selective screening is performed 
for individuals who have already been identified as at risk of having a behavioral health condition.   
9 The Health Resource and Services Administration (HRSA) launched the Bright Futures program in 1990 to address a need for 
unified guidance on how to design the most modern, efficient, and comprehensive pediatric checkup.  The Bright Future/AAP 
periodicity schedule is available at:  https://www.aap.org/en-us/Documents/periodicity_schedule.pdf.  
10 The Agency for Healthcare Research and Quality supports the USPSTF, an independent panel of experts on prevention and 
evidence-based medicine, to provide rigorous recommendations on prevention to the federal government and the public.  
The USPSTF recommendations are available at:  https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-
recommendations/#more. 
 
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Section 6.2.1-BH of the attached CHIP state plan template allows states to specify the periodicity 
it has selected, and Section 6.3.1.1-BH asks states to provide an assurance that they provide the 
relevant AAP and USPSTF screens and preventive services below.   
 
 Table 1:  Required Types of Behavioral Health Screens and Preventive Services  
Type of Preventive Service  Applicable Population   Source of 
Recommendation  
Developmental Screening   Children  AAP 
Autism Spectrum Disorder Screening   Children  AAP 
Developmental Surveillance11  Children  AAP  
Psychosocial/Behavioral Assessment12   Children  AAP 
Tobacco, Alcohol, or Drug Use Assessment13  Children  AAP 
Depression Screening  Children and adolescents   AAP and USPSTF 
Maternal Depression Screening14  Pregnant women  AAP  
Tobacco use interventions   Children and adolescents   USPSTF 
Perinatal depression: counseling and intervention   Pregnant women  USPSTF 
Tobacco use counseling  Pregnant women   USPSTF 
Unhealthy alcohol use screening, counseling and  Pregnant women  USPSTF 
interventions  
 
In addition to the required behavioral health screening and preventive services described in Table 
1, we expect that most, if not all, states may provide other types of behavioral health screenings 
and preventive services for a range of behavioral health conditions.  The attached template at 
6.3.1-BH includes a section for states to describe these services. 
 
b.  Age-Appropriate, Validated Screening Tools 
Incorporation of age appropriate, validated screening tools15 in the screening process is another 
important component to successfully addressing behavioral health conditions early on.  Studies 
have shown that broad use of validated screening tools are more effective in detecting behavioral 
health problems in primary care settings, compared to less rigorous approaches to identifying 
behavioral health conditions.16  Many organizations support the use of validated screening tools.  
AAP has compiled a list of these tools for children, which can be found at 
https://screeningtime.org/star-center/#/screening-tools#top.  USPSTF also includes links to 
validated screening tools in its published recommendations by each type of screening, which can 
                                                 
11Developmental surveillance is a flexible, continuous process whereby knowledgeable professionals perform skilled 
observations of children during the provision of health care. The components of surveillance include eliciting and attending to 
parental concerns, obtaining a relevant developmental history, making accurate and informative observations of children, and 
sharing opinions and concerns with other relevant professionals.  Bright Futures Health Supervision Visits. 
12 AAP considers Psychosocial/Behavioral Assessment to be performed in the same manner as a screening, however, the existing 
tools in this area are assessment tools.  For this reason, the term assessment has been retained in the periodicity schedule.      
13 A Tobacco, Alcohol, or Drug Use risk assessment should be performed with appropriate action to follow if the assessment 
proves positive, according to the AAP periodicity schedule.   
14 The American College of Obstetricians and Gynecologists (ACOG) also recommends depression screening for pregnant 
women.  https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-
Practice/Screening-for-Perinatal-Depression.   
15 A validated instrument is one that has been psychometrically tested for reliability (the ability of the instrument to produce 
consistent results), validity (the ability of the instrument to produce true results), and sensitivity (the probability of correctly 
identifying a patient with the condition).  This definition is provided by The Joint Commission at 
https://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx. 
16 Simonian S, Tarnowski K. Utility of the Pediatric Symptom Checklist for behavioral screening of disadvantaged children. 
Child Psychiatry Hum Dev. 2001;31(4):269278. 
 
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be found at https://www.uspreventiveservicestaskforce.org/BrowseRec/Index.  Below is a list of 
examples of validated screening tools. 
 
 Table 2:  Examples of Validated Behavioral Health Screening Tools17 
Name of Screen  Type of Screen and Applicable Population(s)  
Ages and Stages Questionnaire: Social- Social-emotional Development for Children  
Emotional (ASQ-SE-2)  
Edinburgh Postnatal Depression Scale (EPDS)  Maternal Depression  
Modified Checklist for Autism in Toddlers (M- Autism in Toddlers 
CHAT-R/F) 
Brief Screener for Alcohol, Tobacco and other  Substance Use Disorder Risk Among Adolescents  
Drugs (BSTAD) 
CRAFFT18   Alcohol and drugs for Adolescents and Adults, 
including Pregnant Women   
 
All states will be required to identify a strategy for facilitating the use of age-appropriate, 
validated screening tools for children and pregnant women in primary care settings.  Examples of 
facilitation efforts in this area include covering the costs of administering the tools, and/or the 
costs associated with purchasing these tools, requiring managed care organizations and their 
networks to use such tools in primary care practice, providing education, training, and technical 
resources in this area (such as a list of validated screening tools established by the state and/or 
national organizations with expertise in this area).  Some states may already be facilitating the 
use of such screening tools and may provide a description of an existing strategy. Section 
6.3.1.2-BH of the attached template provides a place for states to provide a description of this 
strategy.   
 
Behavioral Health Treatment Services and Validated Clinical Assessment Tools 
 
Research emphasizes the importance of offering a variety of evidence-based services across 
different types of settings and levels of intensity given the nature of the individualized and 
changing needs of children with complex behavioral health conditions.  While coverage of 
traditional services (i.e., case management and family therapy) are important, coverage of other 
types of community-based support services (i.e., intensive case management and wraparound), 
are also considered essential for children and pregnant women with more complex needs. 
Treatment of pregnant women should include a focus on the mother as well as the child.  This 
section describes the requirements for all states with separate CHIPs to: 
 
  Demonstrate that its benefit array is sufficient to treat a broad range of behavioral health 
symptoms and disorders;   
  Cover Medication-Assisted Treatment (MAT) and  tobacco cessation benefits; and  
  Identify a strategy to facilitate the use of validated clinical assessment tools for 
determining the most appropriate services for children and pregnant women experiencing 
behavioral health issues. 
                                                 
17 Other organizations, such as ACOG and SAMHSA, make recommendations for screening tools for pregnant women.  ACOG: 
https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co711.pdf?dmc=1.  SAMHSA. 
https://store.samhsa.gov/system/files/sma18-5054.pdf  Prenatal and postpartum care.  As noted in the table heading above, this 
table is designed to provide examples of tools.  CMS is not endorsing any specific tool.    
18 CRAFFT stands for the key words of six of the items in the tool, car, relax, alone, forget, friends, trouble. 
 
  Page 6  State Health Official 
 
 
a.  Behavioral Health Benefit Package 
We recognize that there are state specific factors to consider in developing and maintaining a 
behavioral health benefit package, and that there is variation across states in terms of the services 
offered.  Given these considerations, and the evolving evidence-base in this area, CMS is not 
specifying an exhaustive list of services to be covered under the CHIP state plan in order to meet 
the new statutory requirement to treat a broad range of behavioral health symptoms and 
disorders.  States will have to describe their behavioral health services in the state plan in order 
for CMS to determine whether their overall benefit array and levels of care within the benefit 
array are sufficient to treat a broad range of behavioral health conditions consistent with section 
2103(c)(5) of the Act. 
All states that provide coverage to separate CHIP populations will have to describe the amount, 
duration and scope of each benefit at Section 6.3-BH of the attached state plan template.  There 
is an exception for states that have already demonstrated that they provide the Early and Periodic 
Screening, Diagnostic, and Treatment (EPSDT) benefit that is identical to Medicaid.19  These 
states will only need to provide an assurance at Section 6.2.22.1 of the attached state plan 
template that any type of amount, duration, and/or scope limitation associated with its benefits 
can be exceeded if medically necessary.    
In addition to the required screenings described in Table 1 above, we are requiring Medication-
Assisted Treatment (MAT) for opioid use disorders (OUDs) and tobacco cessation benefits 
because these treatments are considered to be the most clinically appropriate services available 
for the applicable conditions, and therefore, a critical part of any states behavioral health benefit 
array.  Tobacco cessation programs have a proven track record of reducing smoking rates and 
health care costs, and improving health outcomes.  Studies have repeatedly demonstrated the 
efficacy of MAT, a combination of behavioral interventions and medications to treat opioid use 
disorders, in reducing illicit drug use and overdose deaths,20 and improving retention in 
treatment.21  We note that MAT is only required as clinically appropriate for children.  MAT will 
also be a required Medicaid service for opioid use disorders.  Additional guidance in this area 
will be forthcoming.    
We encourage states to review previous guidance we have released, on treatment services that 
are supported by scientific evidence, when considering whether an existing benefit array meets 
this new CHIP requirement.   
  Guidance to States and School Systems on Addressing Mental Health and Substance Use 
Issues, Joint CMCS and SAMHSA Informational Bulletin, released on July 1, 2019.  
https://www.medicaid.gov/sites/default/files/Federal-Policy-
Guidance/Downloads/cib20190701.pdf. 
                                                 
19 States have demonstrated this through the mental health parity review process. 
20 Schwartz, R. P., Gryczynski, J., OGrady, K. E., Sharfstein, J. M., Warren, G., Olsen, Y. Jaffe, J. H. (2013). Opioid agonist 
treatments and heroin overdose deaths in Baltimore, Maryland, 1995- 2009. American Journal of Public Health, 103(5), 917-922.  
21 Kresina, T. F., Melinda, C., Lee, J., Ahadpour, M., & Robert, L. (2015). Reducing mortality of people who use opioids through 
medication-assisted treatment for opioid dependence. Journal of HIV & Retro Virus, 1(1).  
 
  Page 7  State Health Official 
 
  Opportunities to Design Innovative Service Delivery Systems for Adults with Serious 
Mental Illness or Children with a Serious Emotional Disturbance, SMD#18-011, released 
on November 13, 2018.  https://www.medicaid.gov/federal-policy-
guidance/downloads/smd18011.pdf.   
  Strategies to Address the Opioid Crisis, SMD#17-003, released on November 1, 2017.   
https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf. 
  Coverage of Behavioral Health Services for Youth with Substance Use Disorders, Joint 
CMCS and SAMHSA Informational Bulletin, released on January 26, 2015.  
https://www.medicaid.gov/federal-policy-guidance/downloads/cib-01-26-2015.pdf. 
  Coverage of Behavioral Health Services for Children, Youth, and Young Adults with 
Significant Mental Health Conditions, Joint CMCS and SAMHSA Informational 
Bulletin, released on May 7, 2013.   https://www.medicaid.gov/federal-policy-
guidance/downloads/cib-05-07-2013.pdf.  
 
b.  Validated Clinical Assessment Tools 
A proper clinical assessment is a key element in connecting individuals to the appropriate type 
and intensity of behavioral health treatment when they need it.  An assessment is a 
comprehensive and formal process of defining the nature of a particular concern, determining a 
diagnosis, evaluating current level of functioning, and developing specific treatment 
recommendations to improve health and functioning.  Some validated tools also include 
mechanisms for tracking the outcomes of treatment plans, to help ensure that services are 
delivered appropriately and effectively.22  Many states use validated assessment tools, such as 
those listed below:  
 
Table 3:  Examples of Validated Clinical Assessment Tools 
Child and Adolescent Service Intensity Instrument (CASII)23 
Child and Adolescent Strength and Needs (CANS)24 
American Society of Addiction Medicine (ASAM) Level of Care Tool 
 
Similar to the requirement for all states to identify a strategy for facilitating the use of age-
appropriate, validated screening tools for children and pregnant women with behavioral health 
conditions in primary care settings, states will also be required to identify a strategy for 
facilitating the use of validated assessment tools at Section 6.4.2-BH of the attached state plan 
template or provide a description of an existing strategy in this area.  The facilitation examples 
provided above for screening tools are the same for assessment tools, such as covering the costs 
of administering the tools, and/or the costs associated with purchasing these tools, providing 
education, training, and technical resources to clinicians in this area.  All states will also be 
required to specify the assessment tools they are currently using at Section 6.4.1-BH of the 
attached template.     
                                                 
22 A validated instrument is one that has been psychometrically tested for reliability (the ability of the instrument to produce 
consistent results), validity (the ability of the instrument to produce true results), and sensitivity (the probability of correctly 
identifying a patient with the condition).  This definition is provided by The Joint Commission at 
https://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx.  
23 The CASII tool was developed by the American Academy of Child and Adolescent Psychiatry (AACAP) and applies to 
children ages 6 through 18.  AACAP also has a screening tool for children under 6, which is the Early Childhood Service 
Intensity Instrument.   
24 The CANS tool was developed by the Praed Foundation.   
 
  Page 8  State Health Official 
 
 
 
Delivery of Culturally and Linguistically Appropriate Services  
 
It is essential that all aspects of the delivery of behavioral health coverage be reflective of the 
diversity of the communities that they serve and strive to become and remain culturally and 
linguistically competent. Culturally and Linguistically Appropriate Services (CLAS) are defined 
as services that are respectful of, and responsive to, individual cultural health beliefs and 
practices, preferred languages, health literacy levels, and communication needs and employed by 
all members of an organization at every point of contact, according to the Health and Human 
Services Office of Minority Health National Standards for Culturally and Linguistically 
Appropriate Services in Health Care.25 
 
Section 5022(b)(2) of the SUPPORT Act explicitly requires behavioral health coverage be 
delivered in a culturally and linguistically appropriate manner regardless of delivery system.  
States will need to provide an assurance consistent with this provision in 6.5-BH of the attached 
state plan template.   
 
There are existing CHIP regulations at 42 CFR 457.110, 457.340(e), 457.1207, and 457.1230(a), 
and related to the provision of linguistically appropriate services, such as establishing a 
methodology for identifying the prevalent non-English languages spoken by enrollees and 
potential enrollees, and making oral and written interpretation available in each prevalent non-
English language.  For guidance on developing a language access plan, please go to 
https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Language-Access-
Plan.pdf. 
 
In addition, regulations at 457.1230(a) require that managed care organizations participate in the 
States efforts to promote the delivery of services in a culturally competent manner to all 
enrollees, including those with limited English proficiency and diverse cultural and ethnic 
backgrounds, disabilities, and regardless of gender, sexual orientation or gender identity.   
 
Additional guidance on the broader topic of cultural competency has also been published by the 
U. S. Department of Health and Human Services.26   
 
Access to Care   
 
Ensuring and continually improving access to high-quality, evidence-based treatment, is as 
critical as designing and maintaining an array of behavioral health benefits.  States must adhere 
to existing CHIP rules at 42 CFR 457.495 and 457.1230 in this area.  These rules require that 
states assure access to covered services, monitor and treat enrollees with chronic, complex, or 
serious medical conditions, and process in a timely manner decisions related to prior 
authorization of services.  Benefits provided through a managed care delivery system must also 
include contract provisions to assure adequate capacity to serve the expected enrollment, and 
                                                 
25 https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/CLAS-Toolkit-12-7-16.pdf 
26 https://www.thinkculturalhealth.hhs.gov/clas/standards,https://www.thinkculturalhealth.hhs.gov/clas/blueprint 
 
 
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meet other standards associated with coverage, coordination, continuity of care, and 
authorization of services.   
 
SPA Submission Process 
 
States should follow the regular process for submitting a CHIP SPA as specified at 2106(b) of 
the Act and 42 CFR 457.60, and 457.65.  A CHIP amendment may be retroactive, but in order to 
obtain an effective date of October 24, 2019 as required under the SUPPORT Act, states must 
submit the SPA no later than the end of the state fiscal year that includes that date.  We 
encourage states to submit a SPA that solely focuses on addressing section 5022 of the 
SUPPORT Act rather than including additional amendments.  
 
As a reminder, submissions will need to follow the applicable public notice, tribal consultation, 
and effective date regulations. For CHIP SPAs, the submission must comply with tribal 
consultation requirements at section 2107(e)(1)(C) of the Act and public notice requirements in 
42 CFR 457.65, as well as any state-specific policies in these areas. 
 
Behavioral Health Related Regulations in CHIP  
 
The requirements in section 5022(d) of the SUPPORT Act are distinct from existing CHIP 
regulations at 457.402 and 457.410(b).  Regulations at 457.402 specify services that can be 
considered child health assistance, including behavioral health services.  Regulations at 
457.410(b) list benefits that are mandatory in CHIP, which do not include behavioral health 
services.  Coverage of behavioral health services has been optional to states prior to the 
SUPPORT Act.   
 
The SUPPORT Act requirements are also distinct from those in the Mental Health Parity and 
Addiction Equity Act.  Division C, section 512 of the MHPAEA (P.L. 110-343) amended section 
2705(a)27 of the Public Health Service Act to require mental health and substance abuse parity in 
group health plans.  Section 2103(c)(7) of the Act, as amended by the SUPPORT Act, requires 
that states with separate CHIPs providing mental health or substance use disorder benefits ensure 
that the financial requirements and treatment limitations applied to these benefits are applied in 
the same manner as required under 2705(a) of the Public Health Service Act for such group 
health plans. 28   MHPAEA also provides that if a states CHIP coverage includes the EPSDT 
benefit, it will be deemed to satisfy parity requirements.29  MHPAEA does not mandate 
behavioral health coverage, although the majority of states have elected to provide some 
behavioral health coverage to their separate CHIP populations.   
 
While the SUPPORT Act builds on MHPAEA, it is different in two important ways.  Unlike 
MHPAEA, the SUPPORT Act explicitly requires coverage of behavioral health services.  In 
addition, EPSDT deeming is not an included provision in the SUPPORT Act.  Recent state 
efforts to come into compliance with MHPAEA will serve as a helpful point of reference in 
determining whether a states existing behavioral health coverage will meet the new criteria at 
section 2103(c)(5) of the  Act.  However, all states with a separate CHIP, including those that 
                                                 
27 Renumbered as section 2726(a) of the PHS Act by section 1001(2) of PPACA (P.L. 111-148). 
28 Section 2103(c)(7) of the Social Security Act describes mental health parity requirements in CHIP.   
29 Section 2103(c)(7)(B) of the Social Security Act describes the mental health parity EPSDT deeming option in CHIP.   
 
  Page 10  State Health Official 
 
have already demonstrated compliance with MHPAEA, are required to submit a SPA to 
demonstrate compliance with section 5022 of the SUPPORT Act.30     
 
Closing 
 
CMS looks forward to its continued work with states on the implementation of this legislation, 
and ensuring that all CHIP-eligible children and pregnant women have access to the behavioral 
health coverage they need.  States should consult with CMS if they have questions related to the 
guidance in this letter.  We also encourage you to reach out to your CHIP project officer with 
any specific questions or concerns, or you may contact Meg Barry, Acting Director of the 
Division of State Coverage Programs at 410-786-1536 or meg.barry@cms.hhs.gov. 
    
 
 
Sincerely,  
 
 
 
              Calder Lynch 
Deputy Administrator and Director 
Center for Medicaid & CHIP Services 
                                                 
30 The requirement to submit this SPA is approved under OMB control number 0938-1148.