Maryland state government recently announced significant changes to the delivery of Wraparound in the state. Funding for the largest program is being terminated, after newer programs with some similar components have been introduced. There is confusion among both families who have been receiving Wraparound and those families who were on the Wraparound waiting list. Providers, stakeholders and advocates also have questions about the changes. The below discusses the announced changes and their consequences.
Wraparound is an intensive treatment process for youth with severe mental health or behavioral needs and their families.
The Wraparound process aims to achieve positive outcomes by providing a structured, creative and individualized team planning process that, compared to traditional treatment planning, results in plans that are more effective and more relevant to the child and family. Additionally, Wraparound plans are more holistic than traditional care plans in that they are designed to meet the identified needs of care-givers and siblings to address a range of life areas.” (National Wraparound Initiative).
Numerous studies have shown that Wraparound produces outcomes that are superior to treatment-as-usual or to residential treatment, at a much lower cost than residential treatment. Wraparound has been implemented in Maryland for more than a decade through different funding sources. Maryland received several federal systems of care grants and a federal Psychiatric Residential Treatment Facility (PRTF) demonstration grant that supported the implementation of Wraparound, and then expanded Wraparound through the “Stability” and “Safety” initiatives, which have been overseen by the Governor’s Office for Children. Since the implementation and growth of Wraparound, Maryland has seen a significant reduction in the use of residential treatment for youth: from 993 youth served in Residential Treatment Centers (RTCs) in 2004 to just 679 youth in 2014.
Wraparound in Maryland has contained several key components:
- Care Coordination
- Child and Family Team meetings
- Plans of Care (POC), which are individualized to each family. POCs frequently contain traditional services such as individual and family therapy, but also may have less traditional home- and community-based services, including:
- Intensive in-home services
- Respite care
- Mobile crisis response and stabilization
- Family peer support
- Experiential therapies (such as art or equine therapy)
- Flexible funds for various goods or services that were identified in the Plan of Care
As the PRTF demonstration and federal systems of care grants have ended over the last few years, the Stability and Safety initiatives offered through the Governor’s Office for Children, with the capacity to serve 350 families at a time, are the principal ways for families to access Wraparound.
As part of its commitment to continue making Wraparound available to youth who would benefit and their families, the Behavioral Health Administration (BHA) took steps to obtain federal approval to use Medicaid dollars to fund Wraparound. BHA sought and obtained approval to do so through a 1915(i) State Plan Amendment, which allows Maryland to bill Medicaid for Wraparound services. The 1915(i) specifies that the above-mentioned components of Wraparound in Maryland (intensive in-home services, respite care, mobile crisis response and stabilization, family peer support, experiential therapies and flexible funds) be available to all youth and families that qualify.
Unfortunately, only a very limited number of youth will be able to receive Wraparound through the 1915(i) due to restrictive eligibility criteria. A youth must have a very acute psychiatric history, which typically must include three in-patient psychiatric hospitalizations in the last year and their family’s income must be at or below 150% of the federal poverty level. Moreover, Maryland has until 9/30/19 to fully implement the 1915(i). So initially Wraparound through the 1915(i) will not be available in all jurisdictions.
In addition to the 1915(i), the state has implemented another Medicaid-funded program to provide care coordination called Mental Health Case Management (MHCM) or Targeted Case Management (TCM). TCM, while a beneficial service, is much less comprehensive than Wraparound. TCM delivers services such as care coordination and family-driven plans of care to children and youth with intensive mental health or behavioral needs and their families, but it does not include many of the above-mentioned service components that are available in Wraparound. And a child must be Medicaid-eligible in order to receive TCM.
Given the success of Wraparound in Maryland, and the significant limitations of the 1915(i) and TCM programs, families, providers and advocates were surprised when the state announced the end of the Stability and Safety initiatives. The announcement specified that the contract with Maryland Choices, Maryland’s Care Management Entity (which has been administering Wraparound in Maryland), will end as of June 30, 2016, and the door has been closed on new enrollments as of October 1, 2015. The recent announcement has raised many concerns:
- Families on Medicaid who would have been eligible for Wraparound through the CME are now eligible for Wraparound only if their income is at or below 150% of the federal poverty level - if not, they are eligible for Targeted Case Management only.
- Families with private insurance that might have been eligible for Wraparound through the CME are no longer eligible for any services.
In summary, there is concern that Maryland might experience a reversal of the progress that has been made over the last 10 years in reducing out-of-home placements, including residential treatment placements and voluntary placement agreements. There is also a concern that Maryland families with youth with severe mental health or behavioral needs will once again be unable to access intensive, community-based services for their child.
If your family is impacted by these announced changes and needs assistance, please contact MCF’s Director of Public Policy Ann Geddes at firstname.lastname@example.org.