Using Medicaid to Support Working Age Adults with Serious Mental Illnesses in the Community: A Handbook. Endnotes


  1. See O’Brien, J., Lanahan, P., and Jackson, E. (2003). Recovery in the Community: Volume II: Program and Reimbursement Strategies for Mental Health Rehabilitative Approaches Under Medicaid. Washington, DC: Bazelon Center for Mental Health Law. Available for purchase from the Bazelon Center:

  2. Partial hospitalization is a structured program of active treatment. The program may be furnished in hospital out-patient settings or by community mental health centers. A physician or therapist must certify that partial hospitalization is necessary in order to avoid more costly inpatient hospitalization.

  3. Federal policies and guidance concerning the IMD exclusion is contained in the State Medicaid Manual, Part 4 (Services), Sections 4390-4390.1.

  4. The exclusion is located ni §1905(a) (paragraph B) of the Social Security Act. The authority for a state to furnish services to residents age 65 and older in an IMD is in §1905(a)(14) of the Act.

  5. §1905(i) of the Act; 42 CFR 435.1009

  6. Prior to the enactment of Medicaid, the Social Security Act had excluded payments for services furnished to state mental health facility residents.

  7. At the time Medicaid was enacted, state mental health facility outlays exceeded the estimated initial costs of the Medicaid program.

  8. P.L. 92-603; §1905(a)(16) of the Social Security Act.

  9. P.L. 100-360, §1905(i) of the Social Security Act.

  10. State Medicaid Manual, op. cit.

  11. Burwell, B., Sredl, K., & Eikan, J. (2003). Medicaid long-term care expenditures in FY 2002. Cambridge, MA: The MEDSTAT Group, Inc.

  12. Five states now operate HCBS waiver programs for children with serious emotional disturbances.

  13. This table was developed by Steve Day at the Technical Assistance Collaborative.

  14. CFR Outpatient services: 42 CFR 440.20(a). Clinic services : 42 CFR 440.130(d).

  15. §1905(a)(2)(A) of the Social Security Act.

  16. §1905(a)(9) of the Social Security Act.

  17. Virginia Department of Medical Assistance Services (June 2000). Mental Health Clinic Manual.

  18. Ibid. Beneficiary must meet all of the following criteria: “(1) Requires treatment in order to sustain behavioral or emotional gains or to restore cognitive functional levels which have been impaired; (2) Exhibits deficits in peer relations, deficits in dealing with authority, hyperactivity, poor impulse control, clinical depression, or demonstrates other dysfunctional symptoms having an adverse impact on attention and concentration, the ability to learn, or the ability to participate in employment, educational, or social activities; (3) Is at risk for developing or requires treatment for maladaptive coping strategies; and (4) Presents a reduction in individual adaptive and coping mechanism or demonstrates extreme increase in personal distress.”

  19. Peer support is a component rehabilitative service that is just beginning to be included in state plans. While it is a recommended part of comprehensive coverage, states must be sure they work closely with CMS in obtaining coverage approval. See the description of Georgia’s approved coverage of peer support in Chapter 5.

  20. O’Brien et al. (2003), op. cit.

  21. Several of these services are also available to children with SED (severe emotional disturbance).

  22. Available at

  23. Based in part on personal communication from Sharon Autio, Minnesota Department of Human Services. Information about mental health services in Minnesota is at Information concerning the rehab option is at

  24. Minnesota does not have a close-ended list of areas, but provides examples such as "interpersonal communication skills, community resource utilization and integration skills, crisis assistance, relapse prevention skills, health care directives, budgeting and shopping skills, healthy lifestyle skills and practices, cooking and nutrition skills, transportation skills, medication education and monitoring, mental illness symptom management skills, household management skills, employment-related skills, and transition to community living services."

  25. P.L. 99-272

  26. CMS Letter to State Medicaid Directors: July 25, 2000. Olmstead Update #3. Available at

  27. 42 CFR 440.120(a).

  28. For a discussion of the potential implications of this change, Please see: Jeffrey S. Crowley (2004). The New Medicare Prescription Drug Law: Issues for Dual Eligibles with Disabilities and Serious Conditions. Washington DC: Kaiser Commission on Medicaid and the Uninsured. Available at

  29. Fail-first policies require that certain medications only be available if alternative, lower cost medications are found ineffective.

  30. For information on the measures that states have taken to slow down prescribed drug spending, see: Crowley, J, Ashner, D., and Elam, L. (2003) Medicaid Outpatient Prescription Drug Benefits: Findings from a National Survey, 2003. Kaiser Commission on Medicaid and the Uninsured: Washington DC.

  31. Bazelon Center for Mental Health Law (October 2003). Medicaid Policies on Outpatient Prescription Psychiatric Drugs: A Survey.

  32. 42 CFR 440.10.

  33. 42 CFR 440.167.

  34. The description of West Virginia’s plan amendment is based on the National Association of State Medicaid Directors’ Center for Workers with Disabilities Project Directors’ Alert (April 2002). “WV Wins PAS State Plan Approval.”

  35. A state may not cover personal assistance in its Medicaid program for the sole purpose of supporting the employment of individuals. Hence, this type of change is limited to states that already offer personal assistance.

  36. In particular, California provides that “Services in support of work are only available to the extent that service hours used at work are included in the total personal care service hours authorized for the recipient based on the recipient’s need for services in the home. Authorized personal care services utilized by a recipient for work shall be services that are relevant and necessary in supporting and maintaining employment and shall not supplant any reasonable accommodations required under the Americans with Disabilities Act or other legal entitlements or third-party obligations.”

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