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News

Jan 9, 2024

by

As a CCLP policy fellow, Milena helps organize and coordinate public policy development, assisting in coalition-building, community outreach, legislation, litigation, and administrative advocacy.

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Barriers to behavioral health care: survey responses

by | Jan 9, 2024

Community Insight, Equity work, Health, Lived Experience

A therapist with a clipboard sits across from a patient. The two are engaged in conversation.

In March through May of 2023, CCLP released a mental health survey to Colorado residents. While the survey wasn’t a validated instrument, the answers are anecdotal submissions that provide a window into people’s experience. This article will be reviewing those answers submitted, while keeping the individuals who responded anonymous.

 

Intake appointments

All outpatient behavioral health care starts with an intake appointment, whether it be with a therapist, psychologist, or a behavioral health specialist.  Unfortunately, scheduling this first appointment is often a difficult task for many. In our survey we asked individuals, “How long has it/does it take for you to obtain an intake appointment?” The average response indicated six weeks, but we regularly heard wait times as long as two to three months and in some cases even greater than six months.

In one instance a respondent reported that they were able to get an intake appointment for their child that same month they called — however, two days before the scheduled appointment it was cancelled unexpectedly. This family was told there were no providers available, so a new intake appointment was scheduled for three months later.

In Colorado, each Regional Accountable Entity (RAE), is responsible for contracting and supporting a network of care providers in a managed care plan. Their contracts with the state provide timeliness standards that apply to behavioral health services. Non-urgent intake appointments are to be received by the Medicaid member within seven (7) days according to these contracts.[1] Despite this, based on the feedback CCLP received in the survey, individuals and families are not receiving timely access to care. Without regular oversight and enforcement to ensure these timelines are being met, there will continue to be inequities and barriers in accessing mental and behavioral health care.

Waiting for outpatient care

When forced to wait for outpatient care, individuals and families often go to their local emergency department if they are in crisis. While this may be a necessary move for treatment, emergency departments are often only able to provide medication management for two to three days at most, with no ongoing therapy or counseling services while the individual is being treated. And those on Medicaid sometimes face additional hurdles in the hospital, particularly in proving treatment is medically necessary. One respondent in the survey reported that while in the emergency room seeking a higher level of care, Medicaid denied payment for treatment — even though the person had an official behavioral health diagnosis. The definition of what is medically necessary,[2] which guides what care the Medicaid program will ultimately reimburse, is often open to interpretation, putting the Medicaid member at risk of not getting treatment they need.

One family reported that they were denied by Medicaid for residential treatment even after their child had multiple inpatient hospitalizations and several mental health holds. The doctor who had evaluated the child told the parents it was urgent for the child’s safety that she receive a higher level of care. Despite this, she was denied residential treatment services for two months. After waiting for three months in appealing the denial, she was finally approved for residential services, but now they had to wait for a spot to open up. The family reports that they have been, “on a residential waitlist since January 2023.” And that their “daughter almost died in February.” They were still waiting at the time of the survey. As of this publication date, it is unknown whether their child has started residential treatment.

I wish I could say this is the only family who has had this happen, but in my experience, those who do not meet the strict standards for a mental health hold[3] at the time of assessment in the emergency department often get discharged from the hospital without follow-up care in place. Indeed, others reported in the survey that individuals who are not deemed “sick enough” to quality for inpatient services are the ones who do not receive treatment. A behavioral health provider responded in the survey and said that their patients, “get denied a lot even when [they] are justified for receiving the services.” This is true even for children under 21, who would benefit from an expanded definition of medical necessity.[4]

Care Coordination

Care coordination, as shown, has been severely lacking within our behavioral health system, causing harm and creating gaps for individuals and families in receiving appropriate treatment.[5] CCLP is hopeful that these issues will be better addressed as new statutory provisions begin to go into effect next year with the new Behavioral Health Administration (BHA).[6] For example, the new law will provide a requirement that once a Medicaid patient is put on a mental health hold, the hospital has a responsibility to notify the managed care entity (RAE) of the discharge and need for follow-up care.[7] Additionally, the BHA is required to be notified of the mental health hold if the facility cannot locate an appropriate placement for the patient.[8] Once notified, the BHA will be tasked with supporting the facility in locating an appropriate placement option.

 

It is too soon to tell if these changes will have significant impacts for families like the ones who responded to our survey, but CCLP remains committed to improving access to behavioral health care for individuals and families in Colorado.

 

******

[1] Colorado Department of Health Care Policy & Financing, Health First Colorado Managed Care Contracts, Dec 2023. https://hcpf.colorado.gov/health-first-colorado-managed-care-contracts. See Section 9, Network Development and Access Standards, at 9.4.13.5.2. in the contracts.

[2] 10 CCR 2505-10 § 8.076.1.8.  Medical necessity is defined as a “program good or service . . . that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or development effects of an illness, condition, injury or disability.

[3] CRS §27-65-105. A mental health hold is generally involved only when a person “appears to be an imminent danger to others or to himself or herself or appears to be gravely disabled.”

[4] 10 CCR §2505-10, 8.280.1. Early and Periodic, Screening, Diagnosis and Treatment.

[5] See HEDIS [Healthcare Effectiveness Data and Information Set] Measurement Year 2021 Aggregate Report for Health First Colorado (Colorado’s Medicaid Program), produced by Health Services Advisory Group, Inc., available at  https://hcpf.colorado.gov/sites/hcpf/files/Aggregate%20Report%20for%20Health%20First%20Colorado%202022.pdf.

[6]Kim, Boram, Colorado to Make Numerous Reforms to its Behavioral Health Administration to Address Operational Delays, State of Reform, June 2023. https://stateofreform.com/featured/2023/06/colorado-to-make-numerous-reforms-to-its-behavioral-health-administration-to-address-operational-delays/

[7] CRS §27-65-106.8.d.II. [effective January 1, 2024]

[8] CRS §27-65-106.7.a. [effective January 1, 2024]

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HEALTH:
HEALTH FIRST COLORADO (MEDICAID)

Health First Colorado is the name given to Colorado’s Medicaid program. Medicaid provides public, low-cost health insurance to qualifying adults and children. It is an entitlement program funded by the federal, state, and county governments and is administered by counties in Colorado. Those who are required to pay must pay a small co-pay when receiving certain health care services.

State Department: Department of Health Care Policy and Financing

Eligibility: Most adults 18 to 64 are eligible for Medicaid in Colorado if their household income is at or below 133% of the federal poverty limit (FPL). Pregnant women are eligible with incomes of up to 195% FPL, while children under 18 may be eligible if the live in a household with income at or below 142% FPL. Some adults over 65 may also be eligible for Medicaid.

Program Benefits: Through Medicaid, low-income Coloradans are eligible for a range of health care services at little to not cost. Services provided include doctors visits, prescription drugs, mental health services, and dental care. Co-pays for certain individuals may be needed for certain services.

Program Funding and Access: Colorado funds our Medicaid program through state and federal dollars. Medicaid is an entitlement program, which means that all who are eligible for Medicaid can access the program, regardless of the funding level in a given year. This does not mean that it is always easy to access Medicaid, even when eligible. And since the program is administered by counties, funding levels for county staff and other administrative roles can make it easier or harder for Coloradans to access the program. On top of this, not all medical providers accept Medicaid which limits the ability of Coloradans to seek health services even if enrolled, such as if the nearest provider is a 2+ hour drive away.

Note: This data is from before the pandemic and does not reflect changes in enrollment rules during the COVID-19 pandemic and public health emergency.

Statewide Program Access 2015-19: Over the study period of this report, an average of 89.0% of the population at or below 133% of FPL (i.e., the population who is likely to be eligible for Medicaid) were enrolled in Medicaid in Colorado.

FOOD SECURITY:
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

The Supplemental Nutrition Assistance Program or SNAP helps low-income Coloradans purchase food by providing individuals and families with a monthly cash benefit that can be used to buy certain foods. SNAP is an entitlement program that is funded by the federal and state governments and administered by counties in Colorado.

State Department: Department of Human Services

Eligibility: Currently, Coloradans qualify for SNAP if they have incomes below 200% FPL, are unemployed or work part-time or receive other forms of assistance such as TANF, among other eligibility criteria. Income eligibility for SNAP was different during the study period of this report than today—it was 130% FPL back in 2019 for example. The US Department of Agriculture uses the population at or below 125% FPL when calculating the Program Access Index (or PAI) for SNAP. We follow this practice in our analysis despite Colorado currently having a higher income eligibility threshold.

Program Benefits: SNAP participants receive a monthly SNAP benefit that is determined by the number of people in their household and their income. Benefit amounts decrease as income increases, helping households avoid a sudden loss of SNAP when their incomes increase, even by a minor amount. Benefits are provided to an Electronic Benefit Transfer (EBT) card that can be used to purchase eligible food items, such as fruits and vegetables; meat, poultry, and fish; dairy products; and breads and cereals. Other items, such as foods that are hot at their point of sale, are not allowable purchases under current SNAP rules.

Program Funding and Access: SNAP, like Medicaid, is a federal entitlement program. This means that Colorado must serve any Coloradan who is eligible for the program. As such, funding should not be a limit to how many Coloradans can be served by the program. However, funding for administration of SNAP at the state and county level can limit the ability of county human service departments to enroll those who are eligible. Other program rules and administrative barriers can make it difficult for Coloradans to receive the benefits they are legally entitled to receive.

Statewide Program Access 2015-19: Over the study period of this report, an average of 61.1% of the population at or below 125% of FPL (i.e., the population who is likely to be eligible for SNAP) were enrolled.

FOOD SECURITY:
SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

The Special Supplemental Nutrition Program for Women, Infants, and Children, also know as WIC, provides healthcare and nutritional support to low-income Coloradans who are pregnant, recently pregnant, breastfeeding, and to children under 5 who are nutritionally at risk based on a nutrition assessment.

State Department: Department of Public Health and Environment

Eligibility: To participate in WIC you must be pregnant, pregnant in the last six months, breastfeeding a baby under 1 year of age, or a child under the age of 5. Coloradans do not need to be U.S. citizens to be eligible for WIC. In terms of income, households cannot have incomes that exceed 185% FPL. Families who are enrolled in SNAP, TANF, Food Distribution Program on Indian Reservations (FDPIR), or Medicaid are automatically eligible for WIC. Regardless of gender, any parents, foster parents, or caregivers are able to apply for and use WIC services for eligible children.

Program Benefits: WIC provides a range of services to young children and their parents. These include funds to purchase healthy, fresh foods; breastfeeding support; personalized nutrition education and shopping tips; and referrals to health care and other services participants may be eligible for.

Program Funding and Access: WIC is funded by the US Department of Agriculture. The state uses these federal funds to contract with local providers, known as WIC Clinics. In most cases, these are county public health agencies, but that is not the case in all Colorado counties. Some WIC Clinics cover multiple counties, while others are served by multiple clinics. Private non-profit providers are also eligible to be selected as a WIC Clinic.

Statewide Program Access 2015-17: Between 2015 and 2017, an average of 52.2% of the population eligible for WIC were enrolled in the program in Colorado.

Financial Security:
Colorado Works

Colorado Works is the name given to Colorado’s program for Temporary Assistance to Needy Families or TANF. It is an employment program that supports families with dependent children on their path to self-sufficiency. Participants can receive cash assistance, schooling, workforce development and skills training depending on the services available in their county.

State Department: Department of Human Services

Eligibility: In general, Coloradans are eligible to enroll in TANF if they are a resident of Colorado, have one or more children under the age of 18 or pregnant, and have very low or no income. For example, to be eligible to receive a basic cash assistance grant through TANF, a single-parent of one child could not earn more than $331 per month, with some exclusions—and would only receive $440 per month (as of 2022). That said, there are other services provided by counties through TANF that those with incomes as high as $75,000 may be eligible for. In addition to these, participants in TANF are required to work or be pursuing an eligible “work activity” or work-related activity. Any eligible individual can only receive assistance if they have not previously been enrolled in TANF for a cumulative amount of time of more than 60 months—this is a lifetime limit that does not reset. Counties may have additional requirements and offer benefits that are not available in other counties in Colorado.

Program Benefits:  While the exact benefits that one is eligible for under TANF can vary, all qualified participants are eligible to receive a monthly cash payment, call basic cash assistance. Other than cash assistance, counties are have a lot of choice in how to use their TANF funding; generally a use of TANF funds is appropriate so long as it advances one or more of the four purposes of the program: (1) provide assistance to needy families so that children can be cared for in their own homes or in the homes of their relatives; (2) end the dependence of needy families on government benefits by promoting job preparation, work, and marriage; (3) prevent and reduce the incidence of out-of-wedlock pregnancies; and (4) encourage the formation and maintenance of two-parent families.

It is important to note that those eligible for TANF are also eligible for many of the other programs we’ve included in this report, such as SNAP, Medicaid, and CCCAP.

Program Funding and Access: Colorado funds its TANF program through funds received from the federal government through the Temporary Assistance for Needy Families block grant. Most of the federal funds are allocated by the state to counties, which are required to provide a 20% match of state funding. Federal and state rules allow the state and counties to retain a portion of unspent funds in a TANF reserve.

Statewide Program Access 2015-19: Over the study period of this report, an average of 50.7% of the population at or below 100% of FPL (i.e., the population who is likely to be eligible for TANF) were enrolled in TANF in Colorado.

EARLY LEARNING:
COLORADO CHILD CARE ASSISTANCE PROGRAM (CCCAP)

The Colorado Child Care Assistance Program provides child care assistance to low-income families and caregivers living in Colorado in the form of reduced payments for child care. It is a program funded by the federal, state, and county governments and is administered by counties in Colorado. The share owed by parents/caregivers is determined on a sliding scale based on the family’s income.

State Department: Department of Early Childhood Education

Eligibility: Counties set eligibility for families separately, but must serve families with incomes at or below 185% of the Federal Poverty Limit. Families accepted to the program are no longer eligible once their income exceeds 85% of the state median income. Parents or caregivers must be employed, searching for work, or engaged in another approved activity to be eligible for CCCAP. Parents and caregivers enrolled in Colorado Works (Temporary Assistance to Needy Families or TANF) or in the child welfare system are also eligible to participate in CCCAP. Generally, CCCAP serves families with children under 13, although children as old as 19 may be eligible under certain circumstances.

Program Benefits: If a family is eligible for CCCAP and has income, they may likely have to pay a portion of their child’s or children’s child care costs each month. The amount that families owe is based on their gross income, number of household members, and the number of children in child care in the household. As such, households tend not to experience a benefit cliff with CCCAP when they see their incomes increase

Program Funding and Access: Colorado funds the CCCAP program using federal dollars it receives from the Child Care and Development Block Grant program. The state allocates federal and state funds to counties using a formula that takes into account factors like current caseloads and the number of eligible residents. Assistance is available until the county’s funds are spent, so the number of families that can be served is often a function of how much funding is available and the income and composition of the household that applies. It is not uncommon for counties to overspend or underspend their allocations of funds. The state reallocates unspent funds from counties who underspent to those who overspent. While underspending could indicate a problem with the way a county administers its CCCAP program, it could just as likely be a sign that there are few providers in the county who participate in CCCAP—or a lack of providers generally.

Statewide Program Access 2015-19: Over the study period of this report, an average of 10.8% of the population at or below 165% of FPL and younger than age 13 (i.e., the population who is likely to be eligible for CCCAP) were enrolled in CCCAP.

Housing:
HUD rental assistance programs

The US Department of Housing and Urban Development (HUD) has three housing assistance programs that we look at together: Housing Choice Vouchers (Section 8), Project-based Section 8, and Public Housing. In Colorado, these programs provided assistance to over 90% of the households who received federal housing assistance from all HUD programs. Through federally funded, local or regional public housing agencies (PHAs) are the agencies that administer these programs, through not all are available in all counties. These are not the only programs available in Colorado that assist households afford the cost of housing, such as units funded through federal and state tax credit programs.

State Department: Department of Local Affairs

Eligibility: Generally, households with incomes under 50% of the area median income (AMI) of the county they live in are eligible for these rental assistance programs, although PHAs have discretion to select households with incomes at higher percentages of AMI. That said, HUD requires that 75% of new vouchers issued through the Housing Choice Voucher/Section 8 program in a given year are targeted to households with incomes at or below 30% of AMI. PHAs are also able to create criteria that give priority to certain types of households who are on waiting lists for these programs.

Program Benefits: These rental assistance programs help households afford the cost of housing by reducing their housing costs to around 30% of their household income. In the case of the Housing Choice Voucher program, the PHA pays the voucher holder’s landlord the remaining portion of the rent.

Program Funding and Access: Funding and access are both challenges for these rental assistance programs. In addition to limitations on the number of public housing units or housing vouchers a PHA can manage or issue, lack of funding compared to the need constrains the ability of PHAs to assist low-income households. In 2020, Coloradans were on waitlists for Housing Choice Vouchers for an average of 17 months. Waitlists also exist for the other rental assistance programs.

Statewide Program Access 2015-19: Over the study period of this report, an average of 21.1% of renter households with incomes at or below 50% AMI (i.e., the population who is likely to be eligible for HUD rental assistance programs) were living in subsidized housing.