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


  1. Maine Medical Assistance Manual, Chapter II, Section 17.01

  2. Koyanagi and Semansky (2001). Op. cit.

  3. Catalano, R., et al. Psychiatric Emergency Services and the System of Care. Psychiatric Services, 54(3): March 2003.

  4. As with all other references to the number of states offering a particular coverage, this figure is as of January 2004.

  5. Wisconsin Medicaid Provider Handbook -- Part H, Division VI: Mental Health Crisis Intervention Services.

  6. NAMI has been an influential force in advocating and maintaining standards for ACT programs. Additional materials regarding ACT can be found on its web site at

  7. West Virginia Medicaid State Plan (edited for clarity).

  8. For additional information concerning Minnesota's policies, please see: Department of Human Services Bulletin 03-53-01 -- "Medical Assistance Adult Mental Health Crisis Response Services" (March 2003), available at

  9. For rural ACT programs, ACT standards provide for slightly lower coverage.

  10. Koyanagi and Semansky (2001). Op. cit.

  11. Key Findings on States' Use of Medicaid to Finance ACT Services. (2003). The Lewin Group.

  12. According to the NAMI PACT standards, ACT teams shall average at least 3 contacts per consumer per week. However, "the ACT team shall have the capacity to provide multiple contacts a week with clients experiencing severe symptoms, trying a new medication, experiencing a health problem or serious life event, trying to go back to school or starting a new job, making changes in living situation or employment, or having significant ongoing problems in daily living. These multiple contacts may be as frequent as two to three times per day, seven days per week and depend on client need and a mutually agreed upon plan between clients and program staff."

  13. Online at

  14. Rehabilitation Services for the Mentally Ill. State Medicaid Directors Letter (1992).

  15. National Association of State Mental Health Program Directors Research Institute, Inc (2002). Implementation of Evidence-Based Services by State Mental Health Agencies: 2001. Alexandria VA. Available online at

  16. District of Columbia Medicaid State Plan

  17. Missouri Medicaid Provider Manual -- Community Psychiatric Rehabilitation Program, Section 13.15 (Intensive Community Psychiatric Rehabilitation Program). Available online at

  18. Liberman, R.P., Wallace, C.J., et al. (1998). Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia. American Journal of Psychiatry, 155, 1087-1091.

  19. Susan Langley, CMS Teleconference, October 2002.

  20. New Hampshire Department of Human Services, He-M 426.11 Mental Illness Management Services.

  21. Copeland, M. Evaluation of the Vermont Recovery Education Project Available online at

  22. PNFCMH (2003)

  23. DC, GA, FL, IA, KY, LA, MI, PA, SC, VT, WI

  24. In February, 2004, South Carolina was just beginning to implement its peer support specialist program, with the goal of having 34 peer specialists by the end of 2004. For more information, please see:

  25. Under its 1915(b) specialty mental health services waiver program, Iowa also requires its contractor to foster the development of peer support groups.

  26. Iowa Human Services Rules. 441-78.48(249a): Rehabilitation services for adults with chronic mental illness. Available online at

  27. Ibid.

  28. Ibid.

  29. Missouri Rules of Department of Mental Health: Chapter 4 -- Mental Health Programs. Available online at

  30. Burt, M. (2001). What will it take to end homelessness? Urban Institute Brief. Washington, DC: Urban Institute.

  31. PNFCM (2003)

  32. Iowa Department of Human Services Rules. 78.48(6)(a)(1). Available online at

  33. Minnesota Rehab Policy. Available online at

  34. "Homes Keep Mentally Ill Stable" Associated Press, January 30, 2004.

  35. Hannigan, T. & Wagner, S. (2003). Developing the "Support" in Supportive Housing: A Guide to Providing Services in Housing. Center for Urban Community Services . Available online at

  36. Ibid.

  37. Medicaid in Supportive Housing: Lessons for Policy-Makers. (2003). Corporation for Supportive Housing. Available online at

  38. Go to:

  39. President's New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003.

  40. New Freedom Commission Interim report. Available online at

  41. Nebraska Department of Social Services Manual: Rehabilitative Psychiatric Services. Available online at

  42. Georgia's Consumer-Driven Road to Recovery: A Mental Health Consumer's Guide for Participation in and Development of Medicaid Reimbursable Peer Support Services. Georgia Division of Mental Health, Developmental Disabilities, and Addictive Diseases. March 2003.

  43. In a home and community-based waiver program, states may cover supported employment services as an "extended habilitation service." A second exception is when a state furnishes mental health services under a "freedom of choice" waiver. Some states that operate such waiver programs cover vocational services by invoking the Section 1915(b)(3) "savings" provision (described in Chapter 6). Also states may furnish vocational services in a behavioral health carve-out in a comprehensive health care reform waiver program (also described in Chapter 6).

  44. Family Psychoeducation Implementation Resource Kit: Information for Public Mental Health Authorities. Available online at

  45. Koyanagi and Semansky (2001). Op. Cit.

  46. Texas Medicaid State Plan

  47. Kansas Medicaid State Plan

  48. Personal communication with Valley Mental Health Director, July 2003.

  49. Vermont Medicaid State Plan

  50. Maine Medical Assistance Manual, Chapter II, Section 17.04-3

  51. NASMHPD Research Institute (2001). Op. Cit.

  52. DC Medicaid State Plan

  53. Personal communication: Dr. Joseph Parks, Missouri Department of Mental Health Medical Director, January 2004.

  54. There are, of course, other co-occurring disorders beyond those discussed here. There also is a relatively high incidence of mental illness among individuals who have HIV/AIDS or have experienced a brain injury.

  55. SAMHSA (2002). Op. cit.

  56. Ibid.

  57. Ibid.

  58. PNFCMH (2003).

  59. National Association of State Mental Health Program Directors Research Institute (2002). Implementation of Evidence-Based Services by State Mental Health Agencies: 2001. Alexandria VA. NRI reported that four states were implementing evidence-based co-occurring disorder treatment practices statewide and another 26 in parts of their states. Another 11 were piloting or planning to implement these practices.

  60. National Association of State Mental Health Program Directors Research Institute (2002). State Mental Health Agency Organization and Structure: 2001. Alexandria, VA.

  61. New Mexico's efforts along these lines are profiled in: Christine A. Cline, MD, MBA and Kenneth Minkoff, MD (2002). A Strength-Based Systems Approach to Creating Integrated Services for Individuals with Co-occurring Psychiatric and Substance Abuse Disorders. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Administration. Available at

  62. Texas Administrative Code, Rules of the Texas Department of Mental Health and Mental Retardation, Title 25, Part II. Standards for Services to Persons with Co-Occurring Psychiatric and Substance Abuse Disorders, Chapter 411, Subchapter N. Available at

  63. Located at

  64. SAMHSA (2002), op. cit. Missouri's practice guidelines are located at

  65. See especially: National Association of State Mental Health Program Directors and National Association of State Alcohol and Drug Abuse Directors (2002). Exemplary Methods of Financing Integrated Service Programs for Persons with Co-Occurring Disorders. Final Report of the NASMHPD-NASADAD Task Force on Co-Occurring Disorders. Alexandria Virginia and Washington DC. See also SAMHSA (2002), op. cit.

  66. SAMHSA (2002), op. cit.

  67. Ibid. In 1997, state-federal Medicaid spending for substance abuse services was only about $1 billion compared to $20 billion for mental health services.

  68. Minnesota covers: (a) primary rehabilitation (intensive therapeutic services for individuals who do not require detoxification); (b) outpatient rehabilitation (services furnished in a supervised living facility, another community facility or the person's own home); (c) extended rehabilitation (individual and group counseling and education); (d) transitional rehabilitation (services in a transitional semi-independent living arrangement with an emphasis on after-care and securing employment); and, (e) collateral counseling.

  69. See:

  70. Koyanagi, C. and Semansky, R. (2001). Op. cit.

  71. Fletcher, R. Information on Dual Diagnosis. (2001). National Association of Dual Diagnosis. Available online at

  72. Teleconference -- Meeting the Needs of Individuals with Co-Occurring Developmental Disabilities and Mental Illness. November 20, 2003. Sponsored by: National Association of State Directors of Developmental Disabilities Services.

  73. However, the number of such individuals has declined considerably in the past decade, in part due to litigation concerning the adequacy and appropriateness of the services such individuals receive.

  74. Chas Moseley (2004). Survey on State Strategies for Supporting Individuals with Co-existing Conditions [NASDDDS Technical Report]. Available online at

  75. This agreement is located at

  76. Ohio Department of Mental Health -- Ohio Department of Mental Retardation and Developmental Disabilities Advisory Council. (2001). Clinical Best Practices for Serving People with Developmental Disabilities and Mental Illness. (2001). (Author) Available online at

  77. Pennsylvania Office of Mental Retardation Bulletin 00-02-16. December, 2002.

  78. Some states are permitted to provide habilitation services under the provisions of the Omnibus Budget Reconciliation Act of 1989. States that did not cover such services prior to the enactment of OBRA '89 are not permitted to add the coverage of habilitation services under the rehabilitation services option.

  79. Ohio Department of Mental Health et al. (2001). Op. cit.

  80. Georgia Department of Human Resources (2003). Community Mental Health Provider Manual. Available online at

  81. However, under an HCBS waiver program, a state can provide "extended state plan" services. This permits a state to cover additional services over and above any limits that may be in effect in the state plan.

  82. For a more detailed discussion see: Frawley, P. & Vecchione, E. (2001) Ten Years of Prevention: The Vermont Crisis Intervention Network. Impact 14:1 (University of Minnesota, Institute on Community Integration). Available at

View full report


"handbook.pdf" (pdf, 3.55Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®