Mental Health Services: Effectiveness of Insurance Coverage and Federal Programs for Children Who Have Experienced Trauma Largely Unknown
Published: 2002-08-22T00:00:00

Fast Facts:

Highlights:
section_title: What GAO Found
paragraphs: Eighty-eight percent of children nationwide have private or public health insurance that, to varying degrees, covers mental health services, including those that may be needed to help children recover from traumatic events, such as natural disasters, school shootings, or family violence. Despite the widespread prevalence of health insurance coverage for children, depending on their type of insurance coverage and where they live, children may face certain limitations in coverage or other barriers that could affect their access to needed services. The 16 percent of children who are enrolled in Medicaid and the State Children's Health Insurance Program public insurance programs generally have coverage for a wide range of mental health benefits, and those enrolled in Medicaid are not subject to day or visit restrictions. Beyond providing insurance that can give children access to mental health services, a range of federal programs can help children who have experienced trauma obtain needed services. GAO identified over 50 programs that can be used by grantees to provide mental health and other needed services to children who have never experienced trauma, although many of these programs have a broader focus and were not designed specifically for this purpose.

section_title: Letter
paragraphs: One-time traumatic events like natural disasters, terrorist incidents, and  school shootings as well as ongoing exposure to trauma such as family and  community violence can have serious psychological, emotional, and  developmental repercussions for children. In the short term, children’s  lives can be radically disrupted, and longer-term effects can include  difficulties in school, work, and personal relationships. If children who  have experienced trauma do not receive the care they need, these problems  can continue into adulthood.
Large numbers of children are at risk for trauma-related mental health  problems. The Department of Justice reported in 1997 that almost 9 million  children aged 12 to 17 had witnessed serious violence during their  lifetimes; Justice has also reported that during the period of 1993 through  1998, children under the age of 12 resided in 43 percent of households  where intimate partner violence was known to have occurred. Further, the  Department of Health and Human Services (HHS) reported that about  826,000 children and adolescents were found to be victims of abuse and  neglect in 1999.
In response to your request for information on the ability of children who  have experienced trauma to obtain mental health services, this report  addresses (1) the extent to which private health insurance and the primary  public programs that insure children–-Medicaid and the State Children’s  Health Insurance Program (SCHIP)–-cover mental health services needed  by children exposed to traumatic events and (2) other federal programs  that help children who have experienced trauma receive needed mental  health services. As requested, we are also providing national data that are  available through federal agency sources on the incidence of child abuse  and neglect, sexual assault, rape, intimate partner violence, and children’s  witnessing such violence. (See app. II.)
To determine the extent of private and public insurance coverage of mental  health services for children, we reviewed available employer survey data;  reviewed the benefit design of health plans provided by 13 insurers in the  individual market as well as state Medicaid programs and SCHIP programs;  and interviewed representatives of private insurers and public officials in  California, Georgia, Illinois, Massachusetts, Minnesota, and Utah. We  selected these states on the basis of variation in the number of  beneficiaries covered, in geographic location, in the extent to which the  insurance market is regulated, and in the design of the SCHIP program. To  describe other federal programs that can help pay for mental health  services for children who have experienced trauma or that try to ensure  that these children receive needed services, we reviewed grant program  documents obtained from officials of federal agencies, such as HHS,  Justice, the Department of Education, and the Federal Emergency  Management Agency (FEMA), and interviewed agency officials and  representatives of national health care and child advocacy organizations.  To gather information on services provided to children and on problems in  obtaining needed services, we reviewed the relevant literature and  contacted state and local mental health agencies, state crime victim  compensation and assistance agencies, child welfare and protective service  agencies, and other organizations receiving federal grants in California and  Massachusetts, as well as additional service providers with federal grants  in Colorado, Illinois, Minnesota, and Oregon. The programs and efforts we  discuss in this report do not represent an exhaustive list of all federally  funded programs that can address the mental health needs of children  exposed to traumatic events; they highlight a range of programs that target  varied populations, services, and systems that come into contact with this  population. In addition, we obtained data on child abuse and neglect,  intimate partner violence, and sexual assault that were collected and  analyzed by HHS’s Administration for Children and Families (ACF) and  Justice’s Bureau of Justice Statistics, National Institute of Justice, and  Federal Bureau of Investigation. We did not verify the accuracy of these  data. (For additional information on our methodology, see app. I.)
We conducted our work from September 2001 through August 2002 in  accordance with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: Many children across the country have been victims of, or witnesses to,  violence in their homes, schools, or communities. In 1999, according to the  most recent edition of a joint Justice and Education report, students aged  12 through 18 were victims of about 186,000 violent crimes at school and  about 476,000 violent crimes away from school. In addition, thousands of  children have been exposed to natural disasters or terrorist acts such as  those that occurred on September 11, 2001, placing them at risk for mental  health problems. While many children respond to these situations with  resilience, others suffer acute and chronic effects. Children’s reactions to  trauma may appear immediately after the traumatic event or may appear  days, weeks, months, or even years later. Researchers report that children  who experience traumatic events show a wide range of reactions, and their  nature and intensity vary on the basis of factors such as the type and  frequency of trauma, whether a child knew the offender or victim, the  strength of the family support system, and a child’s sex and age. For  example, children age 5 and younger typically react to traumatic events  with crying, screaming, and fear of being separated from a parent, while  adolescents tend to have reactions similar to adults, such as flashbacks,  nightmares, and suicidal thoughts. A child’s reactions to traumatic events,  including disasters, may also vary based on how well their parents cope  with the situation and on whether a child or parent has a preexisting mental  disorder. Some children have a special vulnerability to the impact of  traumatic events. Studies indicate that the impact is likely to be greatest for  a child who had previously been victimized or already had a mental health  problem.
Certain psychiatric diagnoses are associated with exposure to traumatic  events, including acute stress disorder, PTSD, depression, and conduct  disorder. Children with acute stress disorder can display multiple  symptoms, including reexperiencing of the event, avoidance of situations  that remind them of the traumatic event, sleep disturbances, poor  concentration, and regressive behavior. The disorder is of short duration,  with symptoms beginning within 4 weeks of a traumatic experience and  lasting from 2 days to 4 weeks. If symptoms continue, the diagnosis may be  reevaluated and changed to PTSD. PTSD is similar to acute stress disorder  and shares many of the same symptoms, but lasts longer. It is diagnosed  when symptoms persist more than a month, although the disorder may  develop either immediately after a traumatic event or several months later.  Exposure to traumatic events may also result in depression, which is  generally characterized by changes in appetite, sleep disturbances,  constant sadness, and irritability. Conduct disorder may also develop after  experiencing a traumatic event. The disorder is identified by a persistent  pattern of behavior that violates major age-appropriate societal norms,  such as aggression toward people and animals or destruction of property.
The prevalence of different diagnoses varies based on factors such as age  and sex. For example, a preliminary report on how the September 11, 2001,  attack affected New York City public school students found that children in  grades 4 and 5 were more likely than children in grades 6 to 12 to  experience PTSD and other disorders involving intense fear and avoidance  of usual activities, while the older children were more likely to have  conduct disorder or depression. Similarly, girls had higher rates of PTSD,  depression, and generalized anxiety than boys, who had higher rates of  conduct disorder.
Depending on the nature and severity of a traumatized child’s condition, a  variety of mental health treatment options and service settings may be  recommended. These include outpatient individual, family, or group  therapy; inpatient hospital care; and residential care. A range of service  providers, including psychiatrists, psychologists, psychiatric nurses,  counselors, and clinical social workers, may treat children who have  experienced trauma. Optimal care of these children often requires  participation by a variety of service systems, such as mental health and  social services.
The Surgeon General has reported that there are not enough mental health  professionals trained to work with children. Moreover, trauma experts  report that even professionals who are trained to work with children may  not have specialized training or experience in working with children who  have experienced trauma. Children whose families do not speak English  can have a particularly difficult time finding providers who can assist them.
Because the types of trauma that children experience vary considerably,  numerous pathways can lead to the identification, referral, assessment, and  treatment of traumatized children needing mental health services. These  pathways include families; schools; day care; primary health care; and the  law enforcement, juvenile justice, and child protective services systems.  However, the professionals working in these systems may not be trained to  identify children with trauma-related mental health problems. For example,  a recent report by the Surgeon General noted that primary care providers  often have little training on mental health services and vary in their  capacity to recognize and diagnose disorders and to coordinate with  mental health providers. In addition, the Institute of Medicine recently  concluded that health professionals are not sufficiently educated about  family violence. Further, not all teachers are aware of the connection  between academic or behavioral problems and the possibility that they are  related to a child’s exposure to violence. Justice has also reported that law  enforcement personnel are generally not sufficiently aware of the  psychological effects that witnessing violence can have on children.
At the national level, few data are available on the number of children who  need mental health services as a result of exposure to trauma and the  number who receive services. For example, there are no nationwide data  on the number of children in foster care and the juvenile justice system— populations likely to have been exposed to trauma—who need mental  health care, or on the number who have received treatment.
subsections: section_title: Private and Public Health Insurance Coverage for Children
paragraphs: Access to health care services, including mental health services, is highly  correlated to having health insurance coverage. According to March 2001  Current Population Survey data, over 67 million children nationwide have  health insurance coverage. More than two-thirds of children under age 19— almost 54 million—obtain health insurance privately, either as a dependent  under a parent’s or guardian’s employer-sponsored health plan or through  the individual insurance market. In addition, almost 14 million children are  enrolled in public programs such as Medicaid, SCHIP, or other federal  insurance programs. Although most children have insurance coverage, over  9 million remain uninsured. (See table 1.)
Despite widespread health insurance coverage of children, private health  insurance plans historically included greater restrictions on mental health  benefits than on benefits for other health services. Consequently, federal  and state laws have attempted to partially equalize benefit levels. The  federal Mental Health Parity Act of 1996 (MHPA) prohibits certain group  health plans sponsored by employers with more than 50 employees from  imposing annual or lifetime dollar limits on mental health benefits that are  more restrictive than those imposed on other benefits. As of March 2000,  more than half of the states had also passed laws that exceeded the federal  law by requiring that certain health insurers not only have parity in dollar  limits, but also in service limits and cost-sharing provisions. However,  these state mental health parity provisions do not affect employers who  pay their employees’ health expenses directly rather than by purchasing  insurance. Federal law permits states to regulate insurance, but employers’  self-funded health plans, which covered almost half of all employees  enrolled in employer-sponsored plans in 1999, are not affected by such  state insurance regulations.
Medicaid operates as a joint federal-state program to finance health care  coverage for certain categories of low-income individuals. Within  guidelines established by federal law, states have considerable flexibility in  how they structure their programs, including determining eligibility levels  and what benefits to cover. For example, federal law requires states to offer  Medicaid coverage to children age 5 and under if their family incomes are  at or below 133 percent of the federal poverty level and to children ages 6  to 18 if their family incomes are at or below the federal poverty level. To  offer coverage to additional children, many states have set family income  eligibility thresholds beyond these minimum federal levels.
Benefits covered by state Medicaid programs are either mandatory or  optional. For example, states are required to cover EPSDT services, which  include comprehensive, periodic health and developmental evaluations or  screenings. A state must cover any services necessary to treat physical and  mental conditions detected through these screenings, regardless of  whether the services are covered by the state’s Medicaid program. We  have previously reported that the extent to which children actually receive  EPSDT services is not fully known, largely because no reliable, national  utilization data exist for these services. States also have the option to  provide beneficiaries with a number of other services, such as inpatient  psychiatric and psychological services. HHS’s Centers for Medicare &  Medicaid Services (CMS), the federal agency that oversees Medicaid and  SCHIP programs, does not have current data that comprehensively  summarize the extent to which states cover mental health services;  however, other available sources suggest that the majority of states provide  some level of mental health coverage as an optional benefit.
In 1997, the Congress enacted SCHIP to provide health care coverage to  low-income children living in families whose incomes exceed the eligibility  limits for Medicaid. Although SCHIP is generally targeted to families with  incomes at or below 200 percent of the federal poverty level, each state  may set its own income eligibility limits within certain guidelines. As a  result, SCHIP maximum income eligibility levels vary considerably among  states, ranging from 100 to 350 percent of the federal poverty level. States  have three options in designing SCHIP: expand their Medicaid programs,  develop separate child health programs that function independently of the  Medicaid programs, or do a combination of both. States that implement  SCHIP by expanding Medicaid must use Medicaid’s enrollment structures  and benefit packages (including EPSDT services); in contrast, separate  SCHIP programs may depart from Medicaid requirements for benefits and  for the plans, providers, and delivery systems available. (See app. III for a  state summary of SCHIP programs.)
section_title: Federal Agencies with Responsibility for Assisting Children Who Have Experienced Trauma
paragraphs: Several federal departments and agencies have responsibility for  addressing the mental health needs of children who have experienced  trauma. For example, HHS agencies have responsibility for improving the  accessibility and delivery of mental health services, conducting research on  children’s mental health issues, disseminating information on promising  approaches for improving children’s mental health, and promoting the well- being of children. In addition to CMS, these agencies include ACF, the  Health Resources and Services Administration (HRSA), the Indian Health  Service, and SAMHSA. In addition, the National Institutes of Health, the  Centers for Disease Control and Prevention, and the Agency for Health  Care Research and Quality fund research on a range of topics related to  child victims and trauma, including the effects of trauma on children and  interventions to assist children who have experienced trauma. HHS’s Office  of Public Health and Sciences coordinates programs across agencies and  supports crosscutting initiatives involving children’s mental health.
FEMA is charged with providing financial and technical assistance to states  and federally recognized Indian tribes for crisis counseling and other  services to children and adults affected by presidentially declared  disasters, which can include earthquakes, fires, floods, hurricanes, and  terrorism. Justice seeks to mitigate the effects of violence on children,  including by paying for mental health services for children who are victims  of, or witnesses to, violent crimes. Offices within Justice that focus on this  population include the Office of Juvenile Justice and Delinquency  Prevention, the Violence Against Women Office, and the Office for Victims  of Crime (OVC), all within the Office of Justice Programs. In addition,  Education, through its Office of Elementary and Secondary Education,  oversees programs that can help students obtain services to ensure that  mental health problems do not interfere with their ability to learn.
section_title: Most Children Have Health Insurance Coverage, But Mental Health Coverage May Have Limits and Not Guarantee Access
paragraphs: Private health insurance plans, such as employer-sponsored or individually  purchased plans, and public programs, such as Medicaid or SCHIP, provide  health insurance coverage to 88 percent of children. Although most  children have health insurance, the level of mental health coverage  available to children varies and depends largely on the type of insurance  they have. While children enrolled in private insurance plans often face  limitations in their mental health coverage, such as the exclusion of certain  diagnoses from coverage or limits on the number of covered visits for  outpatient therapy, children in Medicaid and SCHIP programs generally  have coverage for a wide range of mental health services. The typically  broader coverage of Medicaid programs and SCHIP programs that are  Medicaid expansions is largely due to these programs being required to  cover all necessary health care for problems detected through an EPSDT  screening. Despite the availability of public insurance coverage, other  factors, such as low Medicaid reimbursement rates that discourage  provider participation or SCHIP cost-sharing requirements that may make  services unaffordable for some families, could affect children’s access to  services. Although little is known nationwide about the extent to which  children in public insurance programs receive mental health services,  available evidence suggests that children in some states may not be  receiving services they need.
subsections: section_title: Coverage Limitations in Private Health Insurance Plans Could Affect Children’s Ability to Obtain Mental Health Services
paragraphs: The extent to which private health insurance plans cover mental health  services varies. Most employer-sponsored health plans cover inpatient and  outpatient mental health services, as do individual insurers, although to a  lesser extent. However, private insurance plans often contain coverage or  other restrictions, which may limit the availability of mental health services  to enrollees, including children who have been exposed to trauma. For  example, private plans may impose day or visit limits on mental health  treatment, exclude certain diagnoses or benefits from coverage, or not  offer mental health coverage at all.
subsections: section_title: Employer-Sponsored Group Health Plans
paragraphs: Employer-sponsored group health plans, which cover over 50 million  children, or 66 percent, typically include mental health benefits that  children who have experienced trauma may need. However, many of these  plans impose more restrictive limits, such as day or visit limits, on mental  health benefits than on other benefits. For example, in a prior survey of  nearly 900 employers, we found that 87 percent of employer plans  complied with the dollar parity requirements of the MHPA but set other  limits that were not prohibited by MHPA, such as the number of allowable  outpatient visits or inpatient days for mental health treatment. In contrast,  few plans imposed limits on hospital days or office visits for health  conditions not related to mental health. In addition, a survey conducted by  Mercer/Foster Higgins of 2,813 employers that sponsor health plans found  that at least 73 percent of preferred provider organization (PPO), point of  service (POS), and health maintenance organization (HMO) health plans  offered by employers with more than 500 employees imposed annual limits  on mental health services. These plans most commonly imposed day and  visit limits on mental health services, with median limits of 30 inpatient  days and 30 outpatient visits per year. (See table 2.) Although for some  children these service levels are sufficient, these limits may not provide  adequate coverage for some traumatized children who require long-term  mental health treatment.
Limitations in mental health coverage are more pronounced for the over  3 million children covered by individual insurance plans. Unless precluded  by state law, mental health benefits in the individual market can be more  restrictive than other benefits in such areas as annual or lifetime dollar  limits on what the plan will pay and service limits, such as fewer covered  hospital days or outpatient office visits. The individual market may also  have higher cost-sharing, such as deductibles, copayments, or coinsurance.  We found such limitations among individual health plans we reviewed. For  example, one insurer imposed a lifetime limit of $10,000 on mental health  benefits, while another insurer that sells individual health plans in nearly 40  states includes mental health coverage only if required by state law.  Another insurer limited annual mental health coverage to $1,500 for each  member. (See app. IV for a summary of differences in individual market  health plan coverage for certain mental health treatments available to  children in six states.) In addition, few states require insurers in the  individual market to guarantee access to health insurance coverage for  people with mental disorders, leaving some children unable to obtain any  health insurance. We recently reported that in several states, applicants for  individual health insurance who had certain conditions, such as PTSD,  would likely be denied coverage by five of the seven insurers reviewed.
section_title: State Responses to Limitations in Private Health Insurance Plans
paragraphs: To address these and other limitations in mental health coverage, many  states have passed laws that exceed the requirements of MHPA. Among  the six states we reviewed, three—California, Massachusetts, and  Minnesota—mandated that health plans offer mental health benefits at the  same level as other benefits. The other three states—Georgia, Illinois, and  Utah—took varied approaches to requirements on mental health coverage.  Laws in these states apply only to certain types of health plans or do not  require health plans to include mental health coverage. However, self- funded employer group plans, which covered close to half of all private  sector employees in group health plans in 1999, are beyond the purview of  state regulation and thus exempt from these reforms. (See app. V for a  summary of selected laws related to mental health insurance coverage in  these states.)
section_title: State Medicaid and SCHIP Programs Typically Cover a Wide Array of Mental Health Benefits, but Children May Encounter Difficulties Obtaining Covered Services
paragraphs: The 16 percent of children enrolled in Medicaid and SCHIP typically have  coverage for a wide range of mental health benefits. However, coverage  limitations and other factors, such as Medicaid reimbursement rates to  providers and SCHIP cost-sharing requirements, could affect children’s  access to services and available data suggest that some enrolled children  are not receiving mental health services they need.
subsections: section_title: Medicaid Program
paragraphs: With few exceptions, the Medicaid programs in the six states we reviewed  provided children with coverage for a wide range of mental health services.  For example, all six states provided children with coverage for diagnostic  assessments, outpatient therapy, medication management, and mental  health treatment in residential care facilities, and did not impose day or  visit limits or cost-sharing requirements. In addition to specified mental  health services, Medicaid requires states to cover all necessary health  treatment services when a health problem that could affect a child’s  development is detected during an EPSDT screening, regardless of whether  the condition or treatment is explicitly covered by the state’s Medicaid  program.  A required element of an EPSDT screening is a comprehensive  history, which is supposed to include an assessment of a child’s mental  health needs. Although many states have developed recommended  screening protocols for health care providers to complete on specified  schedules, CMS defines screenings very broadly and considers any  encounter with a health care provider to be a screening sufficient to  identify and require the provision of needed services.
One mental health service that can be important to families of children who  have experienced trauma is respite care. Although respite care is not a  mandatory Medicaid service, states may use flexibility available under the  Medicaid statute to cover respite services, such as child care and weekend  group home services, in order to provide some relief for an eligible child’s  parent, guardian, or primary caregiver. By providing a temporary period  of time apart for parents and their children, respite care services can  decrease stress in the family and increase the likelihood that a child with a  mental illness can continue to live at home and avoid placement in an  institution. However, only one of the six state Medicaid programs we  reviewed—Minnesota—explicitly covered respite services for some  children with mental illness.
Despite having mental health coverage, children enrolled in Medicaid may  face constraints when they attempt to obtain covered services. For  example, children may have difficulty finding providers to treat their  mental health needs. Officials in the six states we reviewed said that their  states had shortages of mental health providers, especially child  psychiatrists, and that these shortages were particularly acute in rural  areas. In addition, some providers said that low Medicaid reimbursement  rates, coupled with delayed payments from states, discourage providers  from participating in Medicaid. Although not specifically focused on mental  health services, studies have compared Medicaid fee-for-service  reimbursement rates to Medicare and have shown that Medicaid rates are  significantly lower. For example, in the six states we reviewed, Medicaid  reimbursed physicians for a psychiatric diagnostic interview at rates that  ranged from 28 to 78 percent of the average national rate Medicare pays for  the same service.
The SCHIP programs in the six states we reviewed varied in their extent of  mental health service coverage and the extent to which they have instituted  cost-sharing requirements for covered beneficiaries. Four of the six SCHIP  programs we reviewed covered generally the same extensive mental health  benefits as Medicaid programs in their states. For example, SCHIP  beneficiaries in Minnesota have coverage for the same unlimited mental  health benefits as Medicaid beneficiaries and are not responsible for any  out-of-pocket costs. Similarly, the SCHIP benefits of Illinois, Georgia, and  Massachusetts generally mirror the benefits available under their state  Medicaid programs, albeit with limited cost-sharing that Medicaid does not  require. For example, Georgia families must pay a premium of $7.50 per  month for each child over age six, with a monthly limit of $15 per family.  Similarly, families in Illinois with incomes over 150 percent of the federal  poverty level must pay $5 for each outpatient or inpatient mental health  visit and a monthly premium of $15 for one child, $25 for two children, and  $30 for three children.
SCHIP children in California diagnosed with severe emotional disturbance are eligible for  these services through the county mental health departments.
Unlike California and Utah, whose SCHIP programs are largely modeled after private  insurance plans, states that elect to expand their Medicaid programs, such as Minnesota,  must offer the same comprehensive benefit package, including EPSDT services, to SCHIP  beneficiaries as they do to Medicaid beneficiaries. Officials in three other states we  reviewed—Georgia, Illinois, and Massachusetts—told us they also make EPSDT services  available to SCHIP enrollees, although these services are not required. may not provide sufficient coverage to some traumatized children who  require long-term mental health treatment.
In addition to inpatient day and outpatient visit limits, children in California  and Utah are also subject to cost-sharing requirements through SCHIP that  may make mental health services unaffordable for some families. For  example, depending upon the level of their income, families in California  must pay $5 for each outpatient visit and must also pay a monthly premium  of $4 to $9 for each child enrolled in the program, with a monthly limit of  $27 per family. Although Utah’s SCHIP program does not charge monthly  premiums, it requires families with incomes from 100 to 150 percent of the  federal poverty level to pay a $5 copayment for each outpatient visit, and  families with incomes from 151 to 200 percent of the federal poverty level  to pay for half of the total cost of the outpatient service.
section_title: Utilization of Mental Health Services
paragraphs: Little is known about the extent to which traumatized children with public  insurance utilize mental health services, largely because no reliable,  national utilization data exist for mental health services covered by  Medicaid or SCHIP. While states are required by law to submit annual  reports on the utilization of EPSDT services, CMS’s efforts to assemble  reliable information about EPSDT participation in each state have been  unsuccessful, despite 1999 revisions to the annual report that sought to  clarify and simplify reporting requirements. State-reported data are often  untimely or inaccurate, particularly in states where children receive  services through managed care plans that are prospectively paid on a  capitated basis, meaning the plans receive a flat payment per member,  regardless of the cost of treating the patient. Moreover, states are not  required to report mental health services provided under the EPSDT  program. Limitations in other CMS data reporting requirements also make  it difficult for the agency to determine the extent to which children are  receiving mental health services. For example, periodic reports on health  care utilization and expenditures that CMS requires states to submit do not  collect consistent data on mental health services covered by Medicaid and  SCHIP.
Although national data regarding publicly insured children’s use of mental  health services are not available, numerous lawsuits alleging shortcomings  in the provision of EPSDT services, coupled with individual state utilization  data that were available from most of the states we reviewed, indicate that  children enrolled in Medicaid or SCHIP may not be obtaining needed  services. According to the National Health Law Program, a national public  interest law firm, as of September 1, 2001, 49 court opinions had been  rendered on challenges alleging a state’s failure to properly implement  EPSDT or to provide access to necessary services. In several of these  cases, courts have found that a state violated EPSDT requirements by not  providing all necessary mental health services to children. For example,  in response to a class action lawsuit alleging that children were not being  provided with access to mental health services, the court approved a  consent decree by the parties under which West Virginia agreed to ensure  that all EPSDT screens and subsequent treatments include behavioral and  mental health services.
In addition, statewide utilization data collected by four of the six states we  reviewed—California, Illinois, Minnesota, and Utah—indicated that a small  percentage of children enrolled in the state’s Medicaid and SCHIP  programs, ranging from 0.7 percent of children in Illinois to 6 percent of  children in Minnesota, used mental health services. Utilization data  collected by Massachusetts, however, indicated that close to 16 percent of  the children enrolled in its Medicaid and SCHIP managed care program  were using available mental health services. Based on their experience  and their reviews of research, officials in California and Utah told us they  would expect the proportion of children needing mental health services to  be higher. State officials and providers told us that various factors, such as  the difficulty associated with identifying children with mental illness, lack  of parental awareness of mental illness, and the stigma associated with  mental illnesses, could contribute to lower than expected utilization of  services.
section_title: Type of Insurance Coverage and State of Residence Affect Mental Health Service Coverage and Costs
paragraphs: A child’s type of health insurance and state of residence generally  determine the extent of mental health coverage available. To demonstrate  the variation between public and private insurance programs in the  availability and cost of mental health services for children, as well as  variation among states, the following example outlines the covered  benefits and annual benefit limitations of various types of insurance  available to a hypothetical 5 year-old child who has experienced trauma  and resides in either California or Illinois. Depending on the recommended  treatment, which may include individual, group, or family therapy;  inpatient hospitalization; or care in a residential facility, the services  available and their cost to the child’s family could vary considerably. (See  fig. 2.)
For example, if enrolled in Medicaid, the child in California would have  coverage for all these services at no cost; if enrolled in SCHIP, the child  may not have coverage for residential care or transportation and could face  limits on the number of inpatient days and outpatient visits allowed. In  addition, the family of the SCHIP-enrolled child would be responsible for a  $5 copayment for each outpatient visit. This child would experience similar  differences among types of coverage in Illinois. Under Illinois’ Medicaid  and SCHIP programs, the child would have coverage for all these services  without limitations. However, the family of the child enrolled in SCHIP  would also have to pay a copayment for each outpatient visit, and  depending on the family’s income, could be responsible for a monthly  premium as well. In comparison, a child in Illinois who relied on coverage  from the individual insurer specified would not have coverage for  residential care and would be limited to 10 inpatient days and 20 outpatient  visits each year.
subsections: section_title: California
paragraphs: $15/visit and 20%  of charges premium)
section_title: Illinois
paragraphs: premium)
Maximum 20 visits with family therapy equal to 2 visits = service covered with limitations; = service not covered; and  N/A = information was not available.
The Medicaid programs in both states cover mental health services provided to enrollees in  residential care facilities but not the cost of room and board.
Some health plans in California do not choose to impose these limits on services. In addition, children  in California who are diagnosed with SED have coverage for all the services included in figure 2,  without limitations, through county mental health departments. Also, day and visit limits do not apply to  SCHIP children diagnosed with SMI.
Maximum of $27 premium per family per month.
Maximum family copayment of $250 per year.. However, copayments are not required for services  provided to SED children in county mental health centers.
These data represent conditions and in-network costs for a sample of PPO plans of employers with  500 or more employees; these plans had a median family deductible of $600. The data represent the  most common day and visit limitations and other costs, and the average employee premium portion for  family coverage.
Data are from a PPO that is one of the most popular health plans sold in the individual insurance  market in California and has a $1,000 deductible per person (maximum of $2,000 per family). Children  who are diagnosed with a SED or one of nine SMI are eligible for unlimited benefits and pay 25 percent  of service fees.
This applies only to a child in a family whose income exceeds 150 percent of the federal poverty level.  For two children, the premium is $25; for three, the premium is $30.
Maximum copayment per year per family is $100.
This example represents conditions for a sample of HMO plans of employers with 500 or more  employees. The data represent the most common day and visit limitations, and the average employee  premium portion for family coverage and outpatient copayment costs.
Data are from an HMO that is one of the most popular plans sold in the individual health insurance  market in Illinois.
A health plan official told us that this service is available to members who meet the plan’s medical  necessity criteria.
section_title: Federal Programs Can Help Children Who Have Experienced Trauma to Obtain Mental Health Services, But Extent of Assistance Is Largely Unknown and Little Evaluation Has Occurred
paragraphs: Beyond insurance, a range of federal programs–-including over 50 grant  programs we identified–-can help children who have experienced trauma  obtain needed mental health services. (See app. VI for descriptions of  selected federal grant programs.) Some federal programs pay for crisis  counseling, such as the crisis counseling program for victims of disasters,  which is administered by FEMA in collaboration with SAMHSA. Justice’s  VOCA Crime Victim Compensation grants and Crime Victim Assistance  grants to states help pay for mental health treatment needed by crime  victims. However, factors such as state eligibility requirements and mental  health service caps, as well as families’ lack of knowledge about the  programs, may limit some child victims’ ability to benefit from these  programs. Several federal grant programs encourage coordination among  mental health and other service systems—such as social services, health  care, and justice—so that children who have experienced trauma and their  families can more easily gain access to the full range of services they need.  One such program is SAMHSA’s National Child Traumatic Stress Initiative,  a recent effort specifically designed to take a coordinated approach to  improving mental health care for children who have experienced various  kinds of trauma. Some federal programs have a broader focus, such as  general mental health, or are targeted to specific populations, such as  children in foster care, but grantees can elect to use program funds to  provide mental health and other needed services to children who have  experienced trauma and their families. Little is known about the extent to  which these broader programs assist these children. Moreover, little is  known about the effectiveness of federal programs that help children who  have experienced trauma to obtain mental health services. For example,  FEMA and SAMHSA have not evaluated the effectiveness of the disaster  crisis counseling program.
subsections: section_title: Federal Disaster Grants Provide Some Mental Health Services to Children
paragraphs: Federal agencies provide financial and technical assistance to states and  localities to meet crisis-related mental health needs of children and adults  who are victims of natural disasters and mass violence. FEMA collaborates  with SAMHSA’s Center for Mental Health Services to provide financial and  technical assistance to states and federally recognized Indian tribes that  request aid for crisis counseling and other services for children and adults  affected by presidentially declared disasters. FEMA funds the program,  and SAMHSA, through an interagency agreement, provides technical  assistance, program guidance, and oversight. The Crisis Counseling  Assistance and Training grant funds are generally available for up to 12 months after a disaster declaration. FEMA reported that in fiscal year  2001, it had obligated about $16.2 million in crisis counseling funds.
In addition to crisis counseling, program funds are used for such activities  as training paraprofessionals to provide crisis counseling, distributing  information to increase public awareness about the effect disasters can  have on children, and helping identify and refer children who may need  longer term mental health treatment. For example, New York and Virginia  were declared disaster areas after the September 11, 2001, terrorist attacks  and, as of May 2002, FEMA had approved about $160.6 million in crisis  counseling grants. As of March 2002, New York had reported using the  FEMA funds to provide free crisis counseling to approximately 10,000  children under age 18 affected by the attacks. In addition, HHS has  allocated over $28 million for crisis counseling and other mental health and  substance abuse services to help areas affected by the terrorist attacks,  including $6.8 million that was awarded to eight states and the District of  Columbia to help support crisis mental health services and to assist mental  health and substance abuse systems in these locations. HHS also awarded  $10 million to 33 New York City and New Jersey community health centers  to support response-related services, including the provision of grief  counseling and other mental health services. The Congress also  appropriated $68.1 million to Justice to further meet the crisis counseling  needs of victims, their families, and crisis responders. According to Justice,  as of July 2002, the department had awarded more than $40 million of this  amount to California, New Jersey, New York, Massachusetts, Pennsylvania,  and Virginia.
According to federal officials, communities have generally found the  12-month time frame sufficient for responding to all but the most serious  types of disasters, and extensions of limited duration have occasionally  been approved. However, SAMHSA officials and trauma experts told us  that there are concerns about whether the crisis counseling grant’s time  frame is sufficient for identifying all children who may require trauma- related mental health assistance as a result of a large-scale natural disaster  or act of terrorism that results in mass casualties. These experts told us, for  example, that in the case of the 1995 bombing of the Alfred P. Murrah  Federal Building in Oklahoma City, the time frame was not sufficient to  find, assess the mental health needs of, and provide assistance to the large  number of children and adults who needed help. Although FEMA extended  total grant funding to about 33 months, crisis counseling services were still  needed after the funds had finally expired. As a result, Justice provided an  additional $264,000 to Oklahoma’s Project Heartland to fund crisis  counseling services needed by individuals with problems stemming from  the bombing. Because there was a resurgence of mental health problems  during the federal bombing trials, Justice also provided about $235,000 to  help provide victims and other family members with needed crisis  counseling services. According to a SAMHSA official, the September 11,  2001, attacks have led program officials to discuss whether changes are  needed in the nature and duration of federal assistance available to address  the special, longer-term mental health service needs that can arise from  mass casualty disasters, especially those caused by terrorism.
SAMHSA is collaborating with the National Association of State Mental  Health Program Directors on the association’s review of states’ emergency  response plans to identify ways that states can better plan for the mental  health care needs of disaster victims. According to trauma experts and  SAMHSA officials, most states have dedicated few resources to planning  for mental health needs that result from such events and most have  insufficient capacity to coordinate and mobilize the mental health services  needed for large-scale disasters. This could result in the loss of valuable  time, duplicative efforts, and missed opportunities to identify children who  could benefit from mental health assistance.
Another federal resource for crisis situations is Education’s School  Emergency Response to Violence program, commonly known as Project  SERV. Local school districts can apply for crisis response grants for  generally up to 18 months to help deal with the aftermath of violent or  traumatic events, such as school shootings and acts of terrorism.  Education officials said school districts have used grants for children’s  crisis counseling, school security, transportation to safe locations, and  translation services. In addition, under the program, Education can send  trauma and violence experts to a school district to help school personnel  handle disaster situations. In fiscal year 2001, Project SERV obligated  nearly $9.8 million to school districts responding to violence and disasters,  with nearly 90 percent of the funds awarded to schools in communities  affected by the September 11, 2001, terrorist attacks.
section_title: Federal Crime Victims Fund Pays for Some Children’s Mental Health Services
paragraphs: The federal Crime Victims Fund is an important federal funding source for  meeting the mental health needs of children who are victims of violent  crimes, including mass violence and terrorism. The fund is administered by  Justice’s OVC, and most of the funds available are used to support victim  compensation grants and victim assistance grants to all states, the District  of Columbia, Puerto Rico, and U.S. territories. Federal VOCA victim  compensation grants supplement state funds to provide direct financial  assistance and reimbursements to, or on behalf of, eligible crime victims or  their survivors for a wide range of crime-related expenses, including  those for mental health services. Federal victim assistance grants are  provided to the states, which in turn award these funds to eligible public  and private nonprofit organizations that work directly with crime victims to  determine their needs and provide them with a range of free services,  including mental health services. In fiscal year 2002, OVC allocated about  $477 million to these two grant programs.
subsections: section_title: Victim Compensation
paragraphs: States use federal victim compensation grants to supplement their efforts  to compensate eligible crime victims or their survivors who file claims with  state victim compensation programs for their crime-related expenses. In  some instances, children who witness crimes may be eligible for  compensation. State victim compensation programs provide financial  assistance and reimbursement to crime victims only to the extent that  other financial resources, such as health insurance, do not cover a victim’s  loss. Crisis counseling, individual and group therapy, psychiatric hospital  care, and prescription drugs are among the mental health services covered  by states. According to OVC, state victim compensation programs  reimbursed approximately $50 million in mental health expenditures to  children and adults in fiscal year 2000. The percentage of annual  compensation expenditures that provides reimbursement for mental health  services varies widely by state. For example, in fiscal year 2001, 91 percent  of California’s victim compensation funds that paid for services to children  were for mental health services, while 14 percent of Illinois’s compensation  funds that paid for children’s services were for mental health services.
State officials told us that the availability of victim compensation funds can  be particularly helpful for uninsured children or children whose insurance  does not cover all needed mental health services. For example, of the  claims for children’s services reimbursed by California’s compensation  program in fiscal year 2001, about 58 percent were for children who were  uninsured, 21 percent for children with private insurance, 10 percent for  children enrolled in Medicaid, and about 11 percent for children with other  financial resources. Similarly, Illinois officials told us that the state’s  compensation program serves many children who have no insurance.
Although crime victim compensation program guidelines require states to  reimburse victims for mental health expenses, states are given discretion in  setting program eligibility requirements and benefits. As a result, states  have different rules for who can qualify to receive compensation benefits.  In addition, states’ mental health benefits vary with respect to overall dollar  limits, whether there are caps on mental health coverage within those  limits and the amounts of those caps, the number of treatment sessions  allowed, and the length of time that crime victims can receive mental  health benefits through the victim compensation program. Furthermore, in  most states when there are multiple victims of a crime, they typically must  share the available overall maximum benefits. However, each family  member or secondary victim is typically eligible for mental health  counseling benefits up to specified caps, which generally apply to  individuals and do not have to be shared. For example, the total maximum  compensation in California for all victims of a crime is $70,000, with a  $10,000 cap on mental health services for all direct victims, and Minnesota’s  total maximum award limit is $50,000, with a $7,500 cap on mental health  services. In Massachusetts and Illinois, the overall compensation ceilings  are $25,000 and $27,000, respectively, with no mental health caps. New York  has the most generous compensation benefit, with no overall maximum  and no cap on reimbursement for victims’ mental health expenses. (See  app. VII for a summary of state benefit information.)
Whether state eligibility requirements and caps on mental health services  are preventing some children from obtaining needed services is largely  unknown. Federal and state victim compensation program officials told us  that most child claimants obtain reimbursement for needed mental health  services and that many do not reach their benefit limits. The state victim  compensation officials, however, also told us that eligibility requirements  and benefit limits may exclude some children who need assistance to pay  for mental health services. OVC has not undertaken a nationwide analysis  of the effect of state requirements and benefit limits on meeting the mental  health needs of child crime victims. Furthermore, OVC officials told us that  there are no detailed data at the national level on state compensation  programs’ payment for mental health services provided to children who  have experienced trauma. While OVC requires states to submit annual  reports on certain activities, including overall expenditures for mental  health services, it does not require information on expenditures for  children’s mental health services and the types of mental health services  provided to these children. Therefore, the number of children who have  benefited from the mental health coverage available through state victim  compensation programs is uncertain.
section_title: Victim Assistance
paragraphs: OVC’s victim assistance grants to the states are another vehicle that can  help children and their families obtain needed mental health services. In  fiscal year 2000, these grants were combined with state victim assistance  funds to award grants to about 4,300 public and private nonprofit  organizations that in turn provided crime victims with free medical, mental  health, social service, and criminal justice advocacy services. In contrast  to state victim compensation programs, which require crime victims to  submit detailed applications and supporting documentation, local  organizations that receive grants from state victim assistance programs  typically do not require as much documentation from crime victims before  providing them with needed assistance. State and local officials told us that  some crime victims many obtain faster help through victim assistance  programs than through filing compensation claims and waiting for  reimbursement for their crime-related expenses–-a process that took, on  average, about 23 weeks in fiscal year 2000.
State victim assistance agencies reported allocating about $542.6 million in  fiscal year 2000 to provide a range of services to about 3 million crime  victims. For example, nearly 1.5 million of these victims received crisis  counseling and about 230,000 received individual therapy. In the four  states we reviewed, children benefiting from these grants included those  who had been sexually or physically abused. (See table 3.)
State victim assistance programs have reported to OVC that their programs  helped children who have experienced trauma and their families in varied  ways. For example, California, Illinois, and Massachusetts officials  reported paying for individual and group therapy in cases where children  either did not have insurance or their insurance provided reimbursement  for fewer sessions than were needed. In addition, California and  Massachusetts officials reported that victim assistance funds had helped  provide comprehensive services to children and other family members,  including case management, counseling services in their native languages,  translation assistance, and help in filing claims for victim compensation.
section_title: Several Factors May Limit Some Children’s Use of Victim Compensation and Victim Assistance Benefits
paragraphs: Although many children who are crime victims obtain mental health and  other services through state victim compensation programs, federal, state,  and local officials told us that many victims do not file compensation  claims and that program limitations can constrain access to services. It is  difficult to determine the exact number of victimized children who need  trauma-related mental health services and who also need the financial  assistance available through state victim compensation programs to obtain  such services. Many crime victims may not need to file a claim for state  victim compensation because they have not incurred any crime-related  expenses or they have other resources, such as insurance, to help them pay  for needed services. Nonetheless, California and Illinois victim  compensation officials said that based on their analyses of claimant rolls  and crime victim statistics in their states, they believe that many potentially  eligible victims who could benefit from the assistance their programs offer  had not applied for compensation. For example, an Illinois Crime Victim  Compensation office analysis comparing 2000 county-level crime statistics  with compensation claims received in 2001 showed that while there were  30,630 violent crimes reported in Chicago, the state victim compensation  office received only 2,796 claims from victims in that city.
A 2001 Justice-funded report on state victim compensation and victim  assistance programs indicated that several program-related factors might  impede victims’ access to services supported by such programs. These  factors included (1) lack of knowledge about the programs’ existence, (2) lack of information on how to obtain available benefits, and (3) state  eligibility requirements that might make it difficult for some victims to  qualify for benefits. For example, most states stipulate that to qualify for  compensation, a victim must file a report with law enforcement authorities  shortly after a crime occurs, generally within 72 hours, and must cooperate  with these authorities. However, victims of some crimes, such as sexual  assault or domestic violence, may not report the crimes immediately and  may be apprehensive about cooperating with authorities due to fear of  retaliation by the offender. Other program barriers identified by state  program managers surveyed for the report included (1) limited outreach  and education, especially to racially and ethnically diverse populations and  to rural communities, (2) lengthy and complex compensation award  determination and payment processes, and (3) insufficient coordination  between state victim compensation and victim assistance programs and  with other agencies that work with these victims to eliminate gaps in  assistance or duplicative services.
Efforts to address some of these problems are under way in the states we  contacted. For example, the Los Angeles County District Attorney’s office  placed victim advocates in county courts to inform victims of their right to  benefit from the victim compensation and assistance programs and to help  children and their families obtain needed services, including mental health  care. In addition, California, Illinois, and Minnesota officials told us that  they are now more flexible with their time frames for filing crime reports  with police and will accept other official reports, such as those from child  protective agencies and forensic sexual assault examinations. OVC  published a report in 1998 that included a recommendation that state crime  victim compensation programs reexamine their mental health benefits to  ensure that they are adequate.
section_title: Federal Agencies Encourage Coordination to Meet the Needs of Children Who Experienced Trauma
paragraphs: Coordination among mental health, child welfare, education, law  enforcement, and juvenile justice systems can help ensure that children  who have experienced trauma and their families obtain comprehensive,  timely, and appropriate services. Several federal agencies have funded  grant programs to promote collaborations within and across these  systems—some of which have not traditionally worked together, such as  police and mental health professionals. For example, although research has  documented the frequent co-occurrence of domestic violence and child  abuse, government officials and family violence experts report that the  child welfare and domestic violence advocacy systems often fail to work  together to devise safe, coordinated, and effective responses to family  violence, due in part to differing missions, priorities, and perspectives. In  some instances, child welfare officials want to remove a child from a home  where domestic violence has allegedly occurred, while advocates for the  nonoffending parent argue that taking the child out of the home would  penalize that parent.
Justice awards grants to help support more than 350 Children’s Advocacy  Centers, which assist children who come into contact with the court  system as a result of being abused. The centers aim to bring together a  multidisciplinary team and promote coordination among various service  systems to ensure that a child’s multiple needs are met, including access to  mental health services for the child and other family members. Typically  consisting of law enforcement representatives, child protection workers,  prosecutors, victim advocates, and mental health professionals, the teams  work to ensure that the child does not have to recount the traumatizing  event in multiple interviews, which could result in additional trauma.
To help communities minimize the adverse impact of family and  community violence on young children, Justice initiated the Safe Start  Demonstration Project in 1999. The grant program, which will last about  5 years, is designed to improve access to, and the quality of, services for  young children who are at high risk of exposure to violence or who have  already been exposed to violence. The program’s goal is to help  communities strengthen partnerships among key service systems such as  Head Start, health care, mental health care, domestic violence shelters and  advocacy organizations, child welfare, and law enforcement. In fiscal year  2000, the agency awarded grants to nine communities, with each receiving  $250,000 for a first-year planning phase. In addition, grantees will receive  up to $670,000 annually for implementation activities.
Another way federal agencies are trying to encourage service systems to  work together is the Collaborations to Address Domestic Violence and  Child Maltreatment Project, which is jointly funded and administered by  eight agencies and offices within HHS and Justice. The one-time  demonstration grant, commonly called the Greenbook Project, funds  initiatives in six communities that are each receiving $350,000 annually for  3 years, starting in fiscal year 2000. The project’s goal is to help  communities develop partnerships among three key stakeholders—the  child welfare system, domestic violence groups, and juvenile and family  courts—to improve the delivery of services to victims of domestic violence  and their children. For example, a grantee in Colorado has used program  funds to hire a domestic violence advocate to work in the child welfare  system to improve screening for domestic violence and assess the risk to  children. The grantee has also used these funds to enhance an existing  program that houses police and child protective personnel at one location,  allowing them to jointly respond to domestic violence calls so they can deal  with the needs of all family members, including children who have  witnessed the violence.
Education, HHS, and Justice created the Safe Schools/Healthy Students  demonstration project in 1999 to help schools and communities draw on  three traditionally disparate service systems—education, mental health  care, and justice—to promote the healthy development of children and  address the consequences of school violence. The program, which through  fiscal year 2001 had made awards totaling about $439 million, requires local  education agencies to establish formal partnerships with mental health  providers and local law enforcement professionals. One of the project’s six  core elements is the enhancement of school- and community-based mental  health preventive and treatment services. In fiscal year 2001, the agencies  awarded about $177 million to 97 urban, suburban, rural, and tribal  community grantees.
SAMHSA’s National Child Traumatic Stress Initiative is a recent initiative  specifically designed to take a coordinated approach to improving mental  health care for children who have experienced various kinds of trauma.  Launched in October 2001, the 3-year effort is designed primarily to  (1) improve the quality, effectiveness, and availability of therapeutic  services for all children and adolescents who experience traumatic events,  (2) develop a national network of centers, programs, and stakeholders  dedicated to improving the identification, assessment, and treatment of  children, and (3) reduce the frequency and severity of negative  consequences of traumatic events through greater public and professional  understanding of childhood trauma and greater acceptance for child  trauma intervention services. SAMHSA has taken a tiered approach in  structuring the $30 million initiative by establishing three grantee  categories: a National Center for Child Traumatic Stress to coordinate the  overall initiative; 10 Intervention Development and Evaluation Centers,  which plan to develop scientifically-based improvements in treatment and  service delivery; and 25 Community Treatment and Services Centers, which  focus on treating victims of various types of trauma. The initiative  emphasizes partnerships and coordination among grantees at each level  and across levels. It also encourages grantees to collaborate with  professionals in various community service systems—including child  protection, justice, education, and health care—that interact with children  who have experienced trauma and their families. Because this initiative is  in its early stages, information on the effectiveness of its efforts is not  available.
section_title: Federal Programs with Broader Focus May Help Fund Services Needed by Children Who Experienced Trauma
paragraphs: Other federal grant programs not specifically targeted to assisting children  who have experienced trauma may also help fund mental health and other  services needed by these children and their families. These federal grants  focus on broader issues, such as general mental health or maternal and  child health services or services for specific populations, such as children  in foster care, homeless youth, or migrant farmworkers. (See app. VI for  descriptions of selected federal grant programs.) Grantees can, if they  choose, use these funds to provide a range of services beneficial to children  who have been traumatized. For example, funds from the Indian Health  Service’s Urban Indian Health Program, which provides health services to  child and adult American Indians living in urban areas, can be used to  screen, refer, and treat children who need mental health services due to  trauma. ACF’s Transitional Living for Homeless Youth program, which  operates transitional living projects and promotes self-sufficiency for  homeless youth, requires grantees to offer mental health services, either  directly or by referral. SAMHSA’s Comprehensive Community Health  Services for Children and Their Families program, commonly known as the  System-of-Care program, provides supportive services to children and  adolescents with SED and their families. Many of the children served  through this program have been exposed to violence in their homes and  many have been referred by social service and law enforcement agencies.  In fiscal year 2001, 45 communities received System-of-Care grants to fund  a range of services, including case management, intensive home-based  treatment services, family counseling, and respite care. State officials and  service providers told us that some of the broader federal grants improved  their ability to meet the needs of traumatized children and their families  because the grants can fund services that are not always eligible for  insurance reimbursement, such as case management and ancillary services  for parents, including child care and transportation.
Some of these broader federal grants also support screening and  identification of children with trauma-related mental health problems. For  example, ACF’s Head Start program, which promotes school readiness for  low-income children, requires grantees to ensure that each child receives  mental health screening within 45 days of entering the program. The  grantees are required to consult with mental health or child development  professionals, teachers, and family members in devising appropriate  responses to address identified problems. In 1990, HRSA and CMS  cosponsored the initiation of the Bright Futures project to help primary  care health professionals promote the physical and mental well-being of  children, recognize problems, and intervene early. Recently, HRSA funded  the development of mental health practice guidelines outlining risk factors  and potential interventions related to domestic and community violence.  In addition, HRSA and the National Highway Traffic Safety Administration  administer the Emergency Medical Services for Children program, which  provides funds to ensure that children’s services are well integrated into  the emergency medical system. Among its initiatives, the program provides  training grants to improve the ability of emergency medical services  workers and emergency department physicians and nurses to identify the  mental health needs of children in emergency situations.
Because they are not specifically designed to assist the mental health needs  of children who have experienced trauma, these grants’ data reporting  requirements often do not produce information on the extent to which  children have been screened for trauma-related problems and the number  of children who have obtained mental health services as a result of trauma.  In addition, program officials were generally unable to provide specific  information on the portion of program funds used to serve these children.
section_title: Few Federal Programs Have Evaluated Their Effectiveness in Assisting Children Who Experienced Trauma
paragraphs: Despite the many federal efforts that contribute to varying degrees to  helping children who have experienced trauma and their families obtain  mental health and other needed services, little is known about their  effectiveness. Few programs have undertaken formal evaluations to assess  program progress and results and to guide decisions to improve service to  targeted beneficiaries. For example, FEMA and SAMHSA have not  conducted an evaluation of the effectiveness of FEMA’s crisis counseling  program. SAMHSA officials told us that there were no immediate plans to  conduct such an evaluation. In 1995, FEMA’s Office of Inspector General  recommended that the agency, in consultation with experts in disaster  mental health and mental health outcomes research, evaluate the  effectiveness and efficiency of the crisis counseling program. In its  response to the recommendation, FEMA indicated that FEMA and  SAMHSA monitored grantee activities through grantee reports and joint  site visits. However, these activities do not constitute an evaluation of the  crisis counseling program. For example, the site visits generally involve  monitoring the grantee’s program to ensure that it is carrying out reported  activities and providing technical assistance. SAMHSA recently developed  guidance for grantees outlining recommended program evaluation  strategies. An agency official told us that grantees are encouraged to  conduct evaluations of their individual programs, but are not required to  adhere to the guidance in managing their programs. According to HHS, the  Department of Veterans Affairs’ National Center for Post-Traumatic Stress  Disorder will conduct case studies of past and current crisis counseling  program grantees’ programs and will make recommendations on  programwide evaluation activities. The scope and nature of these efforts  have not been fully determined. Education also has not evaluated Project  SERV, which provides crisis response grants to schools, and ACF has not  evaluated the Transitional Living for Homeless Youth program, which  requires grantees to offer mental health services to homeless youth.
Justice has funded a multiyear evaluation of the Crime Victim  Compensation and Victim Assistance programs. The study was designed to,  among other things, evaluate how the victim compensation and assistance  programs serve crime victims and how variations in program  administration and operations affect the effectiveness and efficiency of  services to victims. The initial report, issued in March 2001, primarily  consisted of a survey of state program managers’ views on program  operations and needed improvements. The final report, which is  scheduled for issuance in fall 2002, will be based on case studies of six  states’ compensation and assistance programs, including a survey of  compensation claimants and a survey of assistance clients in those states.  The results of the survey of compensation claimants will partly reflect the  experience of child victims and of victims who used mental health services.  Because the survey of assistance clients had less participation by adults  who could comment on a child’s experience, the study may provide less  information about child victims’ experience with the assistance program.  The case studies also involved discussions with state administrators and  service providers that received victim assistance funds on the programs’  ability to help child victims obtain mental health services.
Some federal grants include formal evaluation components, but have yet to  establish their evaluation framework, including detailed outcome  measures. For example, the Greenbook and Safe Start grants, which  support coordination efforts, included a year-long planning process to  develop their evaluation frameworks. However, as of May 2002, when these  grants had been under way for almost 2 years, neither had finalized its  evaluation process, including development of core performance measures.  SAMHSA’s National Child Traumatic Stress Initiative also plans to  undertake an evaluation of the overall initiative and individual grantee  projects. As of May 2002, SAMHSA and the grantees had begun to discuss  the evaluation framework but had not finalized it. In addition, other grants  have established their evaluation frameworks and performance measures,  but their evaluations have yet to yield results. For example, the Safe  Schools/Healthy Students program is collecting data, with an interim report  planned for fiscal year 2002 and a final report in fiscal year 2004.
section_title: Conclusions
paragraphs: Many children who have experienced trauma are resilient and may suffer  few ill effects. Others, however, require mental health services to help them  cope and minimize long-term psychological, emotional, or developmental  difficulties. While most children have health insurance that covers mental  health services to varying degrees, coverage limitations are common and  may constrain children’s ability to obtain care. Numerous federal grant  programs could expand the number of children whose mental health  services may be reimbursed or help increase the available services in a  community, but some children who need services may not benefit from  such programs. For example, some grants are awarded to a relatively small  number of communities and expire after a defined period, and evidence  suggests that families of some children who are eligible to benefit from  Justice’s victim compensation and assistance programs may not be aware  of the programs.
The effectiveness of federal programs that could help children who have  experienced trauma remains largely unknown. Some programs with  planned evaluations, such as the Greenbook Project, have lagged in  establishing their evaluation frameworks. SAMHSA’s recent National Child  Traumatic Stress Initiative, which focuses specifically on the mental health  needs of these children, intends to evaluate the results of grantee projects  and the overall program. This effort could develop information on ways to  effectively provide mental health services to traumatized children, but  because the initiative is new, it is too early to gauge its success. Justice’s  current evaluation of its Crime Victim Compensation and Crime Victim  Assistance programs should provide some information on the experience  of child victims in using the victim compensation program to obtain needed  mental health services, but may provide less information on children’s  ability to obtain mental health services through the victim assistance  program. FEMA and SAMHSA have not evaluated the effectiveness of the  long-standing disaster crisis counseling program and have no immediate  plans to conduct a programwide evaluation. Without evaluations of the  effectiveness of federal programs that have a clear goal of helping children  who experienced trauma to obtain mental health services, federal  managers and policymakers lack information that would help them assess  which federal efforts are successful; determine which programs could be  improved, expanded, or replicated; and effectively allocate resources to  identify and meet additional service needs.
section_title: Recommendation for Executive Action
paragraphs: We recommend that, to provide federal policymakers and program  managers with additional information on federal grant programs serving  children who have experienced disaster-related trauma, the Director of  FEMA work with the Administrator of SAMHSA to evaluate the  effectiveness of the Crisis Counseling Assistance and Training Program,  including its assistance to children who need mental health services as the  result of a disaster.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to four federal departments and agencies  for their review. FEMA, HHS, and Education submitted written comments  that are provided in appendixes VIII through X, respectively. HHS and  Education also provided technical comments, as did Justice. We have  modified the report, as appropriate, in response to written general and  technical comments.
In general, HHS stated that the report will be a useful tool for policymakers  and brings important attention to the needs of children exposed to  traumatic events. HHS and FEMA both agreed with our description of the  Crisis Counseling Assistance and Training Program and with our  conclusions on the importance of evaluating the program’s effectiveness.  HHS stated that it strongly agreed that evaluation activities are critical for  this program and other child trauma programs to ensure program  effectiveness and the appropriate use of resources. Both agencies said they  have begun, or plan to take steps, to engage in additional evaluation  activities, and HHS commented that it plans to continue ongoing evaluation  efforts to assure that services are appropriate, efficient, and responsive to  the needs of disaster victims. At their request, we modified the report to  reflect additional information the agencies provided on current evaluation  activities. However, neither the FEMA and HHS activities that we described  nor those that they cited in their comments constitute the programwide  evaluation of the program’s effectiveness that we are recommending.  Furthermore, FEMA did not indicate in its response whether it intends to  implement our recommendation to coordinate with SAMHSA to conduct  such an evaluation, which is needed to help federal policymakers and  program managers assess whether the Crisis Counseling Assistance and  Training Program is effectively assisting children who have experienced  disaster-related trauma.
HHS said that the draft report emphasized the lack of data on the  prevalence of children exposed to trauma and their mental health needs  but did not discuss National Institutes of Health and National Institute of  Mental Health research data, including data from nationally representative  surveys. The types of research studies HHS referred to in its comments  generally focus on specific communities or certain defined populations,  and existing nationwide surveys have limitations such as not covering  certain age ranges or addressing the full range of traumatic situations that  children may experience.  Appendix II of our draft report included ACF’s  nationwide data on children who have been abused and neglected and the  number of those who received mental health services. However, for other  kinds of trauma, there are few nationwide data estimating the number of  children who need mental health services due to these traumas and the  number who receive services.
HHS suggested that the report should more fully discuss the availability of  providers trained to help children who have experienced trauma. The  department said the country does not have a child mental health workforce  with the capacity to meet the needs of children and that responding to  PTSD in children requires even more specific training. The draft report did  refer to workforce issues that could affect children’s access to needed  mental health services, and we have included additional information in  response to HHS’s comments. A detailed discussion of workforce issues,  however, was not within the scope of this report. HHS also expressed  concern that the report did not discuss the need for more research on  specific mental disorders and effective treatments, the stigma often  associated with mental health problems and its effect on the delivery of  mental health services to children who have experienced trauma, or  problems in the public mental health system. We agree that these are  important issues and modified the report to acknowledge the potential role  of stigma. However, a detailed discussion of these issues was also outside  the scope of this report.
HHS further commented that the report should contain a more thorough  discussion of HRSA’s grants to help meet the mental health needs of  children. Appendix VI of the draft report described several HRSA grants,  including the Maternal and Child Health Block Grant. Based on the  department’s comments, we modified the appendix to describe additional  HRSA grants.
HHS acknowledged that the report provides information on the limits  insurance plans often place on mental health coverage, but said that the  draft report did not address the ramifications of mental health parity. We  added clarification that the federal mental health parity law does not  require group health plans to offer mental health benefits, but otherwise  believe the report provides ample information on the limits of federal and  state mental health parity laws.
Education concurred with the information discussed in the report. Like  HHS, the department raised concerns about the availability of mental  health providers to serve children who have experienced trauma.
As arranged with your offices, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days after its  issue date. We are sending copies of this report to the Secretary of Health  and Human Services, the Attorney General, the Secretary of Education, the  Director of the Federal Emergency Management Agency, appropriate  congressional committees, and others who are interested. We will also  make copies available to others who are interested upon request. In  addition, the report will be available at no charge on the GAO Web site at  http://www.gao.gov.
If you or your staffs have any questions, please contact me or Kathryn G.  Allen, Director, Health Care—Medicaid and Private Insurance Issues, at  (202) 512-7119. An additional contact and the names of other staff members  who made contributions to this report are listed in appendix XI.
section_title: Scope and Methodology
paragraphs: To do our work, we obtained program documents, pertinent studies, and  data from the Department of Health and Human Services’ (HHS)  Administration for Children and Families (ACF), Centers for Disease  Control and Prevention, Centers for Medicare & Medicaid Services (CMS),  Health Resources and Services Administration, Indian Health Service,  National Institutes of Health, Office of the Secretary, Office of the Assistant  Secretary for Planning and Evaluation, and Substance Abuse and Mental  Health Services Administration (SAMHSA); the Department of Justice’s  Bureau of Justice Statistics, National Institute of Justice, Office of Juvenile  Justice and Delinquency Prevention, Office for Victims of Crime, and  Violence Against Women Office; the Federal Emergency Management  Agency; the Department of Education; and the Department of Agriculture.  We also interviewed officials from these agencies. We also reviewed the  relevant literature and interviewed officials or obtained information from  national organizations including the American Academy of Child and  Adolescent Psychiatry, American Academy of Pediatrics, American  Psychiatric Association, American Psychological Association, American  Public Human Services Association, Child Welfare League of America,  Family Violence Prevention Fund, National Association of Crime Victim  Compensation Boards, National Association of Social Workers, National  Association of State Mental Health Program Directors, National Coalition  Against Domestic Violence, National Council of Juvenile and Family Court  Judges, and Prevent Child Abuse America.
To determine the extent to which private and public insurance programs  cover mental health services for children, we reviewed national employer  benefit surveys; reviewed the benefit design of health plans provided by 13  insurers in the individual market, state Medicaid programs, and State  Children’s Health Insurance Programs (SCHIP); and interviewed  representatives of private insurers and public officials in California,  Georgia, Illinois, Massachusetts, Minnesota, and Utah. These states were  selected on the basis of variation in the number of beneficiaries covered, in  geographic location, in the extent to which the insurance market is  regulated, and in the design of the SCHIP program. For information on the  extent to which employers offer mental health benefits to employees, as  well as the conditions under which coverage is made available, we relied  on private employer benefit surveys conducted in 2001, specifically those  of (1) William M. Mercer, Incorporated (formerly produced by Foster  Higgins) and (2) the Health Research and Educational Trust, sponsored by  the Kaiser Family Foundation. These surveys are distinguished from a  number of other private ones largely because of their random samples,  which allow their results to be generalized to a larger population of  employers.
For the mental health services covered by private individual market  insurers, we interviewed state insurance regulators in each of the six states  to learn about state laws related to the provision of mental health benefits  and to identify the insurers in the individual market in the state. We then  reviewed the benefit designs of popular health plans sold in the individual  market. To obtain information about the mental health coverage of the  public insurance programs in these states, we reviewed state Medicaid and  SCHIP plans, which specified program characteristics, including covered  benefits and limitations, and we interviewed program officials to obtain  information on income eligibility and service delivery models. In several of  the states, we also interviewed Mental Health Department officials,  providers, and consumer advocates.
To identify federal programs that help children who have experienced  trauma receive mental health services, we reviewed the Catalog of Federal  Domestic Assistance. After identifying programs, we interviewed and  collected information from federal program officials to confirm whether  these programs can support activities, such as mental health treatment,  screening and referral services, educational outreach, training for medical  and other professionals on the needs of children exposed to trauma, and  research and evaluation of mental health services. The federal program  officials also identified other programs and efforts that can address the  mental health needs of children exposed to trauma and provided  perspectives on barriers to these children receiving mental health services.  We obtained additional information on grants that appeared to be most  relevant to the population discussed in this report. The programs and  efforts we discuss in this report do not represent an exhaustive list of all  federally funded programs that can address the mental health needs of  children exposed to trauma; they highlight a range of programs that target  varied populations, services, and systems that come into contact with this  population. We report that these programs can provide mental health  services to this population because funds may be used for this purpose. We  were not generally able to obtain information on the nature of the services  provided or the level of service used by children exposed to trauma  because some programs we identified do not collect information  specifically on mental health services provided to children exposed to  trauma.
We obtained additional information on selected federally supported  programs and problems children face in obtaining needed mental health  services through site visits in California and Massachusetts. In these states,  we interviewed officials or obtained data from state and local mental health  agencies, state crime victim compensation and assistance programs, child  welfare and protective service agencies, and other organizations receiving  federal grants. We also contacted service providers with federal grants  located in Colorado, Illinois, Minnesota, and Oregon. We selected these  locations to visit or contact because they have organizations receiving  federal grants focused on children and trauma, such as SAMHSA’s Child  Traumatic Stress Initiative or HHS/Justice’s Greenbook Project, or  recognized experts in the field of child trauma.
We also obtained data on child abuse and neglect, domestic violence, and  sexual assault that were collected and analyzed by HHS’s ACF and Justice’s  Bureau of Justice Statistics, National Institute of Justice, and Federal  Bureau of Investigation. We did not verify the accuracy of these data.
We conducted our work from September 2001 through August 2002 in  accordance with generally accepted government auditing standards.
section_title: Victimization Data
paragraphs: This appendix presents information on child maltreatment, intimate  partner violence, and sexual assault. ACF data provide information on  children’s entry into the child protective service system and the services  that they and their families received (see tables 4 to 7); additional  information was provided by ACF on a program to increase contact  between children and their noncustodial parents. (See table 8.) Justice data  provide information on individuals who were victims of intimate partner  violence and sexual assault. (See tables 9 to 12 and fig. 3.) We did not  confirm the accuracy of these data.
subsections: section_title: Child Abuse and Neglect Data Collected by HHS’s Administration for Children and Families
paragraphs: In 1996, the Child Abuse Prevention and Treatment Act was amended to  require states receiving a Child Abuse and Neglect State Grant to report to  the National Child Abuse and Neglect Data System, to the extent  practicable, 12 specific data items on child maltreatment, such as the  number of victims of abuse and neglect and the number of children who  received services. States can voluntarily report data in other categories,  such as the number of children receiving mental health services. All states  submitted data for 1999, the most recent year for which data are available.  All states did not respond to all required items. For example, 10 states did  not report information on the number of victims who received services.  (See table 6.) ACF reported in Child Maltreatment 1999 that the required  child maltreatment data had been validated for consistency and clarity, but  ACF officials told us that state definitions vary, making comparisons  between states difficult.
section_title: Child Access and Visitation Data Collected by HHS’s Administration for Children and Families
paragraphs: The Personal Responsibility and Opportunity Act of 1996 authorized ACF  to provide $10 million to states to establish and operate access and  visitation programs. The overall goal of the program is to increase  children’s contact with their noncustodial parents. Individual grantees,  however, often have additional goals that relate to child well-being, such as  providing a safe, stress-free environment in which children and  noncustodial parents can interact, when a court has said that the child is at  risk for harm. Most families either self-refer to access and visitation  programs or are referred by courts, child support agencies, or child welfare  agencies. Eligible services include, but are not limited to, mediation,  counseling, education, development of parenting plans, visitation  enforcement, and development of guidelines for visitation and alternative  custody arrangements. These services are provided in urban, suburban,  and rural locations and are administered by state and county agencies,  courts, and nonprofit organizations. As a condition of receiving these  funds, states must report annually on program activities funded through  the grant and on funding priorities for the next fiscal year, one of which can  be counseling. (See table 8.)
section_title: Victimization Data Collected by the Department of Justice
paragraphs: Data that Justice has collected on victimization include information on  intimate partner violence and sexual assault. Justice’s Bureau of Justice  Statistics’ National Crime Victimization Survey provided estimates on  intimate partner violence over time (see figure 3), while the National  Violence Against Women Survey, jointly conducted by the National Institute  of Justice and HHS’s Centers for Disease Control and Prevention, provided  more detailed descriptions of intimate partner violence and victim  behavior. (See tables 9 and 10.) Justice’s Federal Bureau of Investigation  collects data on the forcible rape of women using the Uniform Crime  Reporting Program. (See table 11.) The program collects annual counts of  reported criminal activity from city, county, and state law enforcement  agencies; incidents not reported to law enforcement are not included in  counts. In addition, the Bureau of Justice Statistics collects information on  sexual assault convictions using the National Judicial Reporting Program.  (See table 12.)
section_title: Information on SCHIP Programs in the 50 States and the District of Columbia
paragraphs: States have flexibility in the way they design their SCHIP program. They  may expand their Medicaid programs, develop a separate child health  program that functions independently of the Medicaid program, or do a  combination of both. Although SCHIP is generally targeted to families with  incomes at or below 200 percent of the federal poverty level, each state  may set its own income eligibility limits within certain guidelines. (See  table 13.)
section_title: Selected Individual Insurers’ Coverage for Specified Mental Health Coverage in Six States as of 2002
paragraphs: The over 3 million children who are covered by an individual insurance  plan may face limitations in mental health coverage, largely because  federal and most state parity laws do not apply to health plans sold in this  market. Unless precluded by state law, restrictions on mental health  benefits in the individual market can include limitations on hospital days or  outpatient office visits or higher out-of-pocket expenses. Figure 4  summarizes differences in individual market preferred provider  organization (PPO) and health maintenance organization (HMO) health  plan coverage for certain mental health treatments available to children in  six states.
Plan C Plan D Plan E = service covered with limitations; and  = service not covered.
Under California’s parity law, limits do not apply to children with severe mental illnesses (SMI) or those  diagnosed with a serious emotional disturbance (SED).
Maximum of 20 total outpatient visits per year.
Patient is responsible for additional cost-sharing after the 48th individual or family therapy visit each  year. For group therapy, one visit is equal to half of an individual or family therapy visit, and enrollees  are responsible for the full treatment cost after the 96th group therapy visit each year.
Maximum of 30 outpatient visits per year with a maximum of 100 visits per lifetime.
Maximum of 15 outpatient visits per year.
All mental health services are limited to a total benefit of $1,500 per member per year.
One family therapy session is equal to two outpatient visits.
Maximum of 30 inpatient days per year.
Maximum of 45 inpatient days per year. One residential treatment day is counted as one inpatient day.
Patient is responsible for additional cost-sharing after the 30th inpatient day each year.
Maximum of 10 inpatient days per year.
Care received in a residential treatment center (a licensed 24-hour facility that offers mental health  treatment).
Room and board costs are not covered.
One day of residential care is equal to two inpatient days.
section_title: Summary of Selected Laws Regarding Mental Health Coverage in Six States
paragraphs: Many states have sought to equalize mental health and other benefits  beyond the requirements of the federal Mental Health Parity Act of 1996  (MHPA), which prohibited certain group health plans that are sponsored by  employers with more than 50 employees and include mental health benefits  from imposing annual or lifetime dollar limits on mental health benefits  that are more restrictive than those imposed on other benefits. Laws in the  six states we reviewed differed in the extent to which they addressed  mental health coverage and limitations.
Three states we reviewed—California, Massachusetts, and Minnesota— enacted laws that are more comprehensive than the federal parity law,  requiring certain health plans to offer mental health benefits to certain  populations with parity in service limits and cost-sharing. For example,  California law requires all health plans to provide mental health coverage  with the same restrictions and limits as other benefits to members with  severe mental illnesses (SMI) and children with serious emotional  disturbances (SED). (See table 14.) While states have primary  responsibility for regulating the business of insurance, they are preempted  by the Employee Retirement and Income Security Act of 1974 (ERISA)  from regulating employer-sponsored health plans. Therefore, state laws  that have sought to equalize mental and other benefits beyond MHPA do  not apply to self-funded employer-sponsored plans, through which close to  50 percent of employees with employer-sponsored coverage obtain health  insurance.
Illinois’s mental health coverage laws do not apply to all health plans;  further, Illinois’s laws allow health plans to limit the number of visits or  days of mental health treatment for children and require parity only for  serious mental illness. For example, Illinois law requires HMOs to offer  mental health coverage with annual minimums of 10 inpatient days and 20  individual outpatient visits for each member. Similar requirements,  however, do not exist for other types of health plans, such as PPOs. In  addition, Illinois requires group health plans with more than 50 employees  to provide coverage for serious mental illnesses under the same conditions  as coverage for other illnesses. (See table 15.)
The remaining two states—Georgia and Utah—address mental health  coverage similarly. State laws in Georgia and Utah do not require health  plans to include a minimum level of mental health coverage. Rather, both of  these states require health plans to offer an additional plan that exclusively  covers mental health services and can be purchased in addition to the  standard health plan. For example, Georgia’s mandated offer requirement  applies to individual, small group, and large group major medical health  plans, and requires coverage for annual and lifetime dollar mental health  benefits to be equal to or greater than coverage for physical illnesses.  Utah’s law requires only that group health plans offer mental health  coverage as an option.
section_title: Selected Federal Grant Programs That May Be Used to Help Children Exposed to Trauma Obtain Mental Health Services
paragraphs: Table 16 is a nonexhaustive list of federal grants that may be used to help  children who were exposed to trauma obtain mental health services. The  list includes 15 formula grants and 38 discretionary grants from seven  departments and agencies.
section_title: State Crime Victim Compensation Benefits, May 2002
paragraphs: The federal Crime Victims Fund, administered by Justice’s Office for  Victims of Crime, provides annual crime victim compensation grants to the  states’ crime victim compensation programs. Federal victim compensation  funds can help crime victims who file claims with state victim  compensation agencies obtain reimbursement for mental health expenses,  as well as lost wages, loss of support, and medical, dental, and funeral  expenses. Federal law requires that states provide certain benefits,  including mental health counseling benefits. However, states have  discretion in setting program eligibility requirements and benefit amounts.  According to the National Association of Crime Victim Compensation  Boards, most states’ overall maximum benefit is linked to the individual  crime rather than to individual primary victims, family members, or other  persons affected by the crime. When there are multiple secondary victims  of an individual crime, they typically must share the available maximum  benefits. However, maximum mental health counseling benefits are  typically linked to individual victims, with each family member or  secondary victim typically eligible for mental health counseling benefits up  to specified caps, unless otherwise stated. (See table 17.)
section_title: Comments from the Federal Emergency Management Agency
section_title: Comments from the Department of Health and Human Services
section_title: Comments from the Department of Education
section_title: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the person named above, key contributors to this report were  Susan Anthony, Alice L. London, Janina Austin, Sari Bloom, Emily Gamble  Gardiner, William D. Hadley, Christi Turner, and Behn Miller.
section_title: Related GAO Products
paragraphs: Private Health Insurance: Access to Individual Market Coverage May Be  Restricted for Applicants with Mental Disorders. GAO-02-339.  Washington, D.C.: February 28, 2002.
Bioterrorism: Public Health and Medical Preparedness. GAO-01-915.  Washington, D.C.: September 28, 2001.
Medicaid and SCHIP: States’ Enrollment and Payment Policies Can  Affect Children’s Access to Care. GAO-01-883. Washington, D.C.:  September 10, 2001.
Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health  Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001.
Health and Human Services: Status of Achieving Key Outcomes and  Addressing Major Management Challenges. GAO-01-748. Washington,  D.C.: June 15, 2001.
Major Management Challenges and Program Risks: Department of Health  and Human Services. GAO-01-247. Washington, D.C.: January 1, 2001.
Mental Health Parity Act: Despite New Federal Standards, Mental Health  Benefits Remain Limited. T-HEHS-00-113. Washington, D.C.: May 18, 2000.
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