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 individual’s 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 O’Brien 

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 Medicaid’s 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-strategysuicide-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 Alcoholism’s (NIAAA) empirically based “Alcohol 

Screening and Brief Intervention for Youth: A Practitioner’s 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/clinicalguides-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 TFOMH’s 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. MCPAP’s 

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 Children’s 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 Children’s 

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 Massachusetts’s mental health 

screening efforts can be found at: 

http://www.mass.gov/eohhs/gov/commissions-andinitiatives/cbhi/ http://www.teenscreen.org/images/stories/RosieDBriefProgramDirectors.pdf http

://www.teenscreen.org/images/stories/RosieDBriefPolicymakers.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 Carolina’s 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 state’s 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 physicianled 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 

and 

Adolescents

Recommended 

Screens

Purpose Links

Birth through 

60 months 

Ages and Stages 

Questionnaire: 

Social Emotional 

(ASQ:SE)

Any 

mental 

Health 

Condition 

http://eip.uoregon.edu/pdf/6month_asqse.pdf

http://eip.uoregon.edu/pdf/60month_asqse.pdf 

Birth through 

8 years

Pediatric 

Symptoms 

Checklist (PSC, 

PSC-Y)

Any 

Mental 

Health 

Condition

http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf

Ages 6 

through 18 

CRAFFT Alcohol 

Use

http://www.ceasar-boston.org/CRAFFT/pdf/CRAFFT_English.pdf

Ages 4-17 Pediatric 

Symptoms 

Checklist

Any 

Mental 

Health 

Condition

http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf
CMCS Informational Bulletin – Page 11 

Adolescents 

Only

Recommended Screens Purpose Links

Ages 12 through 

18 years

Patient Health Questionnaire9 Depression http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf

Center for Epidemiological 

Studies Depression Scale for 

Children (CES‐DC)

Depression http://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf

Ages 10-18 Global Assessment of 

Individual Needs—Short 

Screener (GAINS-SS)

Alcohol http://www.chestnutglobalpartners.org/Portals/7/CGP_PDF/GAIN/GSSWP.pdf
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.