Mental Health Services: Effectiveness of Insurance Coverage and  
Federal Programs for Children Who Have Experienced Trauma Largely
Unknown (22-AUG-02, GAO-02-813).				 
                                                                 
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.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-813 					        
    ACCNO:   A04665						        
  TITLE:     Mental Health Services: Effectiveness of Insurance       
Coverage and Federal Programs for Children Who Have Experienced  
Trauma Largely Unknown						 
     DATE:   08/22/2002 
  SUBJECT:   Children						 
	     Health insurance					 
	     Mental health care services			 
	     California 					 
	     Crisis Counseling Assistance and			 
	     Training Program					 
                                                                 
	     Georgia						 
	     Illinois						 
	     Indian Health Service's Urban Indian		 
	     Health Program					 
                                                                 
	     Medicaid Program					 
	     Minnesota						 
	     SAMHSA National Child Traumatic Stress		 
	     Initiative 					 
                                                                 
	     State Children's Health Insurance			 
	     Program						 
                                                                 
	     Utah						 
	     Massachusetts					 

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GAO-02-813

                                       A

Report to Congressional Requesters

August 2002 MENTAL HEALTH SERVICES Effectiveness of Insurance Coverage and
Federal Programs for Children Who Have Experienced Trauma Largely Unknown

GAO- 02- 813

Letter 1 Results in Brief 2 Background 6 Most Children Have Health
Insurance Coverage, But Mental Health Coverage May Have Limits and Not
Guarantee Access 13

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 28 Conclusions 47 Recommendation for
Executive Action 48 Agency Comments and Our Evaluation 48

Appendixes

Appendix I: Scope and Methodology 51

Appendix II: Victimization Data 54 Child Abuse and Neglect Data Collected
by HHS*s Administration for

Children and Families 54 Child Access and Visitation Data Collected by
HHS*s Administration

for Children and Families 63 Victimization Data Collected by the
Department of Justice 65

Appendix III: Information on SCHIP Programs in the 50 States and the
District of Columbia 70

Appendix IV: Selected Individual Insurers* Coverage for Specified Mental
Health Coverage in Six States as of 2002 73

Appendix V: Summary of Selected Laws Regarding Mental Health Coverage in
Six States 75

Appendix VI: Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services 79

Appendix VII: State Crime Victim Compensation Benefits, May 2002 94

Appendix VIII: Comments from the Federal Emergency Management Agency 98

Appendix IX: Comments from the Department of Health and Human Services 100

Appendix X: Comments from the Department of Education 106

Appendix XI: GAO Contact and Staff Acknowledgments 107 Related GAO
Products 108 Tables Table 1: Type of Insurance Coverage for Children under
Age 19 in

2000 9 Table 2: Percentage of Health Plans Offered by Employers with

More Than 500 Employees That Limited Inpatient and Outpatient Mental
Health Services in 2001 15 Table 3: Number of Victims in Selected
Categories Served by State Victim Assistance Programs in Four States,
Fiscal Year

2001 37 Table 4: Number of Referrals to Child Protective Services and

Substantiated Cases of Child Maltreatment, by State, 1999 55 Table 5:
Information on Child Victims of Maltreatment, by State, 1999 57

Table 6: Services Provided to Child Victims of Maltreatment, by State,
1999 59 Table 7: Number of Reports of Child Maltreatment, by Source of

Report and State, 1999 61 Table 8: Child Access and Visitation Grant Data,
by State 63 Table 9: Estimated Number of Persons Raped or Physically
Assaulted by an Intimate Partner during Lifetime and

Previous 12 Months, by Sex of Victim 66 Table 10: Estimated Rates of Law
Enforcement Actions, as Reported by Victims of Selected Intimate Partner
Crimes 67

Table 11: Instances of Forcible Rape of Women Reported to Police, All
Ages, 2000 68 Table 12: Sexual Assault Convictions in State Courts, 1998
69 Table 13: Program Type, Maximum Income Eligibility Levels, and

Fiscal Year 2001 Enrollment for SCHIP Programs in the 50 States and the
District of Columbia 70 Table 14: Summary of Parity Laws That Exceed
Federal Standards in Three States 76 Table 15: Summary of Selected Laws
Related to Mental Health

Coverage in Illinois 77 Table 16: Selected Federal Grant Programs That May
Be Used to Help Children Exposed to Trauma Obtain Mental Health

Services 79

Table 17: Crime Victim Compensation Maximum Overall Benefits and Maximum
Mental Health Benefits 94

Figures Figure 1: Comparison of State Medicaid and SCHIP Coverage for
Selected Mental Health Treatments in California and

Utah 22 Figure 2: Public and Private Insurance Coverage Options in
California and Illinois for a Hypothetical 5- Year Old Child

Who Has Experienced Trauma 27 Figure 3: Estimated Number of Victims of
Intimate Partner

Violence, by Sex, 1993 to 1998 66 Figure 4: Selected Individual Insurers*
Coverage for Specified Mental Health Services Available to Children in Six

States 73

Abbreviations

ACF Administration for Children and Families CMS Centers for Medicare &
Medicaid Services DSM Diagnostic and Statistical Manual of Mental
Disorders EPSDT Early and Periodic Screening, Diagnostic, and Treatment
ERISA Employee Retirement Income Security Act of 1974 FEMA Federal
Emergency Management Agency HHS Department of Health and Human Services
HMO health maintenance organization HRSA Health Resources and Services
Administration MHPA Mental Health Parity Act of 1996 OVC Office for
Victims of Crime POS point of service PPO preferred provider organization
PTSD posttraumatic stress disorder SAMHSA Substance Abuse and Mental
Health Services Administration SCHIP State Children*s Health Insurance
Program SED serious emotional disturbance SMI severe mental illness VOCA
Victims of Crime Act

Letter

August 22, 2002 The Honorable Richard J. Durbin The Honorable Edward M.
Kennedy The Honorable Paul Wellstone United States Senate

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. 1 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.)

1 In this report the term children encompasses both younger children and
adolescents.

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.

Results in Brief Eighty- eight percent of children nationwide, or over 67
million, 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. 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. Employer- sponsored health plans cover nearly two-
thirds

of children nationwide, or over 50 million, and federal law requires plans
that cover more than 50 employees and include mental health benefits to
cover mental health services to the same extent as other services in terms
of annual or lifetime dollar limits. However, the federal law does not
preclude these employer- sponsored plans from including other features,
such as day or visit limits, that are more restrictive for mental health
services. In addition, the 4 percent of children, or over 3 million,
covered by private- sector individual health insurance may face even
greater coverage restrictions. For example, insurers in the individual
market may offer only

limited mental health coverage, such as a lifetime limit of $10, 000 on
mental health benefits; exclude specific disorders from coverage, such as
posttraumatic stress disorder (PTSD); or offer no mental health coverage
at all.

The 16 percent of children, or over 12 million, who are enrolled in
Medicaid and SCHIP 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. In addition to any mental health
services that states explicitly cover in their Medicaid programs, federal
law requires states to provide all children enrolled in Medicaid with any
service necessary to treat physical and mental conditions detected through
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
screenings. Because EPSDT is not a mandatory component of SCHIP, however,
states have more discretion in how they design their SCHIP programs,
including the extent to which they cover mental health services. In states
that model

their SCHIP programs on private insurance plans rather than Medicaid,
children may face day or visit limits, as in California and Utah. In
addition, certain other factors, such as the availability of providers
willing to participate in the Medicaid program or cost- sharing
requirements of SCHIP, could also constrain the ability of some children
to obtain needed services.

The extent to which children enrolled in Medicaid and SCHIP receive
covered mental health services is not fully known, but available evidence
suggests that enrolled children in some states may not be obtaining
services they need.

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. We identified over 50

programs* primarily in HHS, Justice, FEMA, and Education* that can be used
by grantees to provide mental health and other needed services to children
who have experienced trauma, although many of these programs have a
broader focus and were not designed specifically for this purpose. Some
federal programs pay for crisis counseling, such as the Crisis

Counseling Assistance and Training Program to assist victims of disasters,
which is administered by FEMA in collaboration with HHS*s Substance Abuse
and Mental Health Services Administration (SAMHSA). Justice*s Victims of
Crime Act (VOCA) Crime Victim Compensation grants to states are an
important federal source of funding for mental health services for victims
of crimes. However, children*s access to benefits may be constrained by
states* eligibility requirements or program limitations, such as caps on
mental health services. In addition, other factors may also hamper some
child victims* ability to obtain financial assistance for needed mental
health services. These include families* lack of knowledge about state
victim compensation programs and state program requirements such as filing
a police report within 72 hours of a crime. Several federal grant

programs encourage coordination among mental health and other service
systems* such as child welfare, 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. Furthermore, some federal grants,
such as Justice*s VOCA Crime Victim Assistance grants to states, can
improve service providers* ability to meet the needs of children who have
experienced trauma by providing access to services, such as case
management, that may not be covered by insurance.

While federal grant programs expand the number of children whose mental
health services may be reimbursed or help increase the available services
in a community, 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. Moreover, little
is known about the effectiveness of federal programs that can help
children who have experienced trauma to obtain mental health services or
about

gaps in access to needed services. SAMHSA*s National Child Traumatic
Stress Initiative, which is specifically designed to take a coordinated
approach to improving mental health care for children who have experienced
various kinds of trauma, plans to evaluate both its overall program and
individual components. If carefully implemented, the SAMHSA evaluations
have the potential to provide information on ways to effectively provide
mental health services to children who have experienced trauma. Some key
programs have not conducted evaluations to assess their effectiveness in
helping traumatized children obtain needed

mental health services, and others have lagged in establishing their
evaluation frameworks. For example, FEMA and SAMHSA have not evaluated the
effectiveness of the disaster crisis counseling program. Without
evaluations of the effectiveness of federal programs that have a clear
goal of helping children who experienced trauma 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. We are
recommending that the Director of FEMA work with the Administrator of
SAMHSA to evaluate the effectiveness of the disaster crisis counseling
program. We provided a draft of this report to four departments and
agencies for their review. FEMA and HHS concurred with our discussion of
the Crisis Counseling Assistance and Training Program, agreed that
evaluation of this program is needed to ensure program effectiveness, and
stated that they have initiated additional evaluation activities. However,
the activities they described do not constitute the

programwide effectiveness evaluation we are recommending and FEMA did not
indicate whether it intends to implement our recommendation to coordinate
with SAMHSA to conduct such an evaluation. Both HHS and Education
suggested that the report more fully address their concerns that the
mental health workforce does not include enough appropriately trained

providers to meet the service needs of children who have experienced
trauma. We included additional information on this subject, but a detailed
discussion of this issue is outside the scope of this report. HHS also
suggested that the report treat in greater depth several other topics,
including the role of stigma associated with mental health problems. We
modified the report to acknowledge the role of stigma, but although we

agree that this and other subjects are important, detailed discussion of
them is outside the scope of this report. Justice provided technical
comments.

Background 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. 2 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. 3 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. 4

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 2
Phillip Kaufman et al., Indicators of School Crime and Safety: 2001
(Washington, D. C.: U. S. Departments of Education and Justice, 2001).

3 See, for example, Joy Osofsky, The Impact of Violence on Children (Los
Altos, Calif.: The David and Lucile Packard Foundation, Winter 1999). 4
See, for example, Betty Pfefferbaum, *Posttraumatic Stress Disorder,*
Child and Adolescent Psychiatry, 3 rd ed. (forthcoming).

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. 5

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.

5 Applied Research and Consulting, Columbia University Mailman School of
Public Health, and the New York State Psychiatric Institute, Effects of
the World Trade Center Attack on NYC Public School Students: Initial
Report to the New York City Board of Education, for the New York City
Board of Education (New York, N. Y.: May 2002).

The Surgeon General has reported that there are not enough mental health
professionals trained to work with children. 6 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. 7 In addition, the Institute of Medicine recently
concluded that health professionals are not sufficiently educated about
family violence. 8 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. 9

6 HHS, SAMHSA, Center for Mental Health Services, Mental Health: A Report
of the Surgeon General (Rockville, Md.: 1999); HHS, Report of the Surgeon
General*s Conference on Children*s Mental Health: A National Action Agenda
(Washington, D. C.: 2000); HHS,

SAMHSA, Center for Mental Health Services, Mental Health: Culture, Race,
and Ethnicity* A Supplement to Mental Health: A Report of the Surgeon
General (Rockville, Md.: 2001).

7 HHS, Public Health Service, Office of the Surgeon General, The
Integration of Mental Health Services and Primary Health Care: Report of a
Surgeon General*s working meeting on the integration of mental health
services and primary health care, November 30- December 1, 2000, Atlanta,
Georgia (Rockville, Md.: 2001).

8 Institute of Medicine, Confronting Chronic Neglect: The Education and
Training of Health Professionals on Family Violence (Washington, D. C.:
2001). 9 See, for example, Steve Marans and Miriam Berkman, Community
Development* Community Policing: Partnership in a Climate of Violence
(Washington, D. C.: Department of Justice, Mar. 1997).

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. 10 Private and Public
Health

Access to health care services, including mental health services, is
highly Insurance Coverage for

correlated to having health insurance coverage. According to March 2001
Children 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.)

Table 1: Type of Insurance Coverage for Children under Age 19 in 2000
Percentage of Type of insurance children under 19 a

Private Employer- sponsored 65.9 Private/ Individual 4. 1 Public Medicaid
(including SCHIP) 16.3

Medicare b 0.5 TRICARE c 1.2 Uninsured 12.0 a Some people may receive
coverage from several sources. To avoid double counting, we assigned an
individual reporting coverage from two or more sources to one source,
based on a hierarchy in the following order: employer- sponsored,
Medicare, Medicaid, TRICARE, private/ individual, and uninsured.
Therefore, percentages for specific sources of coverage, such as Medicaid,
may be underestimated. b Children with a disability or End- Stage Renal
Disease may be eligible for Medicare.

10 See, for example, Bradley Stein et al., *Violence Exposure Among
School- Age Children in Foster Care: Relationship to Distress Symptoms,*
Journal of the American Academy of Child and Adolescent Psychiatry, vol.
40, no. 5 (2001).

c TRICARE is a program administered by the Department of Defense for
families of active duty, retired, and deceased service members. Source:
GAO analyses of March 2001 Current Population Survey.

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.
11 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. 12

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. 13 To 11 29 U. S. C. S: 1185a (2000). However,
MHPA does not require these group health plans to

offer mental health benefits. 12 The Employee Retirement Income Security
Act of 1974 (ERISA) generally preempts states from regulating employee
health plans, although state governments maintain the ability to regulate
health insurance sold in their states. 29 U. S. C. S: 1144 (2000).

13 In 2002, the federal poverty level was $18,100 for a family of four.
Medicaid eligibility is mandatory for all children born after September
30, 1983 whose family incomes are less than or equal to the federal
poverty level. By September 2002, mandatory Medicaid eligibility will
apply to all children (under age 19) who meet the income requirements. See
42 U. S. C. S: 1396a( a)( 10)( A)( i)( VII), (l)( 1)( D) and (l)( 2)( C).

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. 14 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. 15 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. 16

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. 17 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

14 42 U. S. C S: 1396( r)( 5). 15 See U. S. General Accounting Office,
Medicaid: Stronger Efforts Needed to Ensure Children*s Access to Health
Screening Services, GAO- 01- 749 (Washington, D. C.: July 13, 2001). 16
For example, see Bazelon Center for Mental Health Law, Recovery in the
Community: Funding Mental Health Approaches for Rehabilitative Approaches
Under Medicaid (Washington, D. C.: Nov. 2001) and Commerce Clearing House
Incorporated, Medicaid and

Medicare Guide Volume 4, Medicaid State Plans, Medicare and Medicaid Laws
(Chicago, Ill.: Nov. 1996). However, these sources do not fully capture
the extent to which states cover mental health services for children.
Since states report their provision of mental health services to CMS
differently, summary information of state coverage of these services is
difficult to compile. For example, a state may report these services as
psychological services, rehabilitation services, clinical services, or as
part of its managed care program.

17 The Balanced Budget Act of 1997 (Pub. L. No. 105- 33) established SCHIP
as Title XXI of the Social Security Act. SCHIP is set out at 42 U. S. C.
S: 1397aa et seq.

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.)

Federal Agencies with Several federal departments and agencies have
responsibility for

Responsibility for Assisting addressing the mental health needs of
children who have experienced

Children Who Have trauma. For example, HHS agencies have responsibility
for improving the

Experienced Trauma 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
wellbeing 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.

Most Children Have Private health insurance plans, such as employer-
sponsored or individually

Health Insurance purchased plans, and public programs, such as Medicaid or
SCHIP, provide

health insurance coverage to 88 percent of children. Although most
Coverage, But Mental

children have health insurance, the level of mental health coverage Health
Coverage May

available to children varies and depends largely on the type of insurance
Have Limits and Not

they have. While children enrolled in private insurance plans often face
limitations in their mental health coverage, such as the exclusion of
certain Guarantee Access 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. Coverage Limitations in The extent to which
private health insurance plans cover mental health Private Health
Insurance

services varies. Most employer- sponsored health plans cover inpatient and
Plans Could Affect

outpatient mental health services, as do individual insurers, although to
a Children*s Ability to Obtain

lesser extent. However, private insurance plans often contain coverage or
other restrictions, which may limit the availability of mental health
services 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.

Employer- Sponsored Group Employer- sponsored group health plans, which
cover over 50 million

Health Plans 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. 18 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. 19 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. 20 (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.

18 U. S. General Accounting Office, Mental Health Parity Act: Despite New
Federal Standards, Mental Health Benefits Remain Limited, GAO/ HEHS- 00-
95 (Washington, D. C.: May 10, 2000).

19 Mercer/ Foster Higgins, National Survey of Employer- Sponsored Health
Plans 2001: Report on Survey Findings (New York, N. Y.: 2002). The Mercer/
Foster Higgins survey is representative of all employers in the United
States with at least 10 employees, and results are often reported
separately for employers with 500 or more employees. 20 Another employer
benefit survey by the Kaiser Family Foundation and Health Research and
Educational Trust, Employer Health Benefits 2001 Annual Survey, (Menlo
Park, Calif.

and Chicago, Ill.: 2001), found similar benefit limits among workers
enrolled in employersponsored health plans it surveyed. Nearly half of
employees enrolled in surveyed health plans were limited to mental health
services of 30 or fewer inpatient days or outpatient visits. Eighty- seven
percent lacked coverage for unlimited, annual outpatient mental health
visits, while 84 percent lacked coverage for unlimited inpatient days for
mental health treatment.

Table 2: Percentage of Health Plans Offered by Employers with More Than
500 Employees That Limited Inpatient and Outpatient Mental Health Services
in 2001

Percentage of health plans PPO HMO POS

Plans with annual inpatient day limits 78 77 78 Plans with annual
outpatient visit limits 78 77 73 Note: Data for indemnity (fee- for-
service) health plans were not reported in 2001 because sufficient data
for these plans were not available. According to Mercer/ Foster Higgins,
only 6 percent of employees of large employers were enrolled in indemnity
plans in 2001.

Source: Mercer/ Foster Higgins National Survey of Employer- Sponsored
Health Plans, 2001.

Individual Health Insurance Limitations in mental health coverage are more
pronounced for the over

Market 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. 21

State Responses to Limitations in To address these and other limitations
in mental health coverage, many Private Health Insurance Plans

states have passed laws that exceed the requirements of MHPA. 22 Among the
six states we reviewed, three* California, Massachusetts, and Minnesota*
mandated that health plans offer mental health benefits at the

21 See, U. S. General Accounting Office, Private Health Insurance: Access
to Individual Market Coverage May Be Restricted for Applicants with Mental
Disorders, GAO- 02- 339 (Washington, D. C.: Feb. 28, 2002). Some states do
not allow insurers in the individual market to deny coverage to
applicants. We reported that 11 states required individual market carriers
to guarantee applicants access to health insurance coverage, and certain
carriers guaranteed access voluntarily in an additional 5 states and the
District of Columbia. In the remaining 34 states, carriers may deny
coverage to high- risk individuals. However, 27 of these 34 states have
high- risk pools, which are typically state- created, not- for- profit
associations that offer comprehensive health insurance benefits to high-
risk individuals and families who have been or would likely be denied
coverage. High- risk pool coverage typically costs 125 to 200 percent of
standard rates for healthy individuals.

22 In May 2000, we reported that 43 states and the District of Columbia
had laws that addressed mental health coverage in employer- sponsored
group plans; 29 were more comprehensive than the federal law, requiring
parity not only in dollar limits but also in service limits or cost-
sharing provisions. Ten states required that mental health benefits be on
par with other benefits for all coverage sold in the individual market.
See U. S. General

Accounting Office, Mental Health Parity Act: Despite New Federal
Standards, Mental Health Benefits Remain Limited, GAO/ HEHS- 00- 95
(Washington, D. C.: May 10, 2000).

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,
selffunded 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.)

State Medicaid and SCHIP The 16 percent of children enrolled in Medicaid
and SCHIP typically have

Programs Typically Cover a coverage for a wide range of mental health
benefits. However, coverage

Wide Array of Mental Health limitations and other factors, such as
Medicaid reimbursement rates to Benefits, but Children May

providers and SCHIP cost- sharing requirements, could affect children*s
access to services and available data suggest that some enrolled children
Encounter Difficulties

are not receiving mental health services they need. Obtaining Covered
Services

Medicaid Program 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. 23
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.

23 A residential treatment center is a licensed 24- hour facility that
offers mental health treatment.

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. 24 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. 25

24 Under section 1915 (c) of the Social Security Act, 42 U. S. C. S:1396n(
1) (2000), states may request waivers of certain federal requirements in
order to develop Medicaid- financed, community- based services, including
respite care.

25 Minnesota has a waiver that provides coverage for home and community-
based services, including respite care for some persons with disabilities.
However, according to a CMS official, only a small group of children*
those with mental illness who are at risk of being placed in a nursing
facility* are eligible for these waiver services. Although the Medicaid
programs in the remaining five states we reviewed do not explicitly cover
respite care, providers in these states may rely on other sources of
funding to provide these services to Medicaid enrollees. For example,
according to a Utah official, the state provides community

mental health centers with funds specifically earmarked for respite
services.

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. 26 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. 27

26 See, American Academy of Pediatrics, Division of Health Policy
Research, Department of Practice and Research, Medicaid Reimbursement
Survey, 2001- 50 States and the District of Columbia (Elk Grove Village,
Ill.: 2001), and the Lewin Group, Comparing Physician and Dentist Fees
Among Medicaid Programs, June 2001, a special report prepared at the

request of the Medi- Cal Policy Institute (Oakland, Calif.: 2001). 27
These rates do not apply to mental health services provided through
capitated, managed care plans. To varying degrees, four of the six states
we reviewed*- California, Massachusetts, Minnesota, and Utah*- provide
mental health services to Medicaid or SCHIP children through a managed
care plan that is prospectively paid a capitated per- member permonth rate
or through other risk arrangements.

SCHIP 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. 28

28 The maximum annual copayment for outpatient or inpatient mental health
visits in Illinois is $100 per family.

In contrast to these four states, SCHIP beneficiaries in California and
Utah generally have coverage for fewer benefits than Medicaid
beneficiaries and may face limits on treatment days and visits. Unlike
their state Medicaid programs, the SCHIP programs in each of these states
are modeled after the private insurance plan available to public employees
in the state. 29 These SCHIP plans are not required to cover residential
care or targeted

case management services and are not required to provide all enrolled
children with EPSDT screenings or coverage for services these screenings
identify as necessary. 30, 31 (See fig. 1.) Also, children in Utah*s SCHIP
program are allotted a maximum of 30 outpatient visits and 30 days of
inpatient care per year and are not covered for family therapy visits. 32
Similarly, California SCHIP allows participating health plans to limit

children to 20 outpatient visits and 30 days of inpatient care per year.
Some health plans have chosen not to impose these limits; health plans
that do impose limits told us that children rarely reach them. In
addition, these

limits do not apply to children in California who are diagnosed with a
serious emotional disturbance (SED) or one of nine severe mental illnesses
(SMI). 33 These children are eligible to receive unlimited mental health
services. Whether limits in California and Utah SCHIP plans prevent

children from obtaining needed services is unknown; however, these limits
29 California*s SCHIP program has two components: a separate, stand- alone
child health program that functions independently of the state Medicaid
program and an expansion of the state Medicaid program. According to data
provided by the state, most California SCHIP children* over 506, 000 in
January 2002--- were enrolled in the separate, stand- alone component of
the program, while about 33, 000 children were enrolled in the Medicaid
expansion component in June 2001.

30 SCHIP children in California diagnosed with severe emotional
disturbance are eligible for these services through the county mental
health departments. 31 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. 32
A Utah state official said that by creating a separate SCHIP plan with
certain benefit limitations (rather than expanding the state Medicaid
program), the state was able to offer SCHIP coverage to significantly more
children.

33 California law defines severe mental illness as (1) schizophrenia, (2)
schizoaffective disorder, (3) bipolar disorder (manic- depressive
illness), (4) major depressive disorders, (5) panic disorder, (6)
obsessive- compulsive disorder, (7) pervasive developmental disorder or
autism, (8) anorexia nervosa, or (9) bulimia nervosa.

may not provide sufficient coverage to some traumatized children who
require long- term mental health treatment.

Figure 1: Comparison of State Medicaid and SCHIP Coverage for Selected
Mental Health Treatments in California and Utah California Utah Medicaid
SCHIP a Medicaid SCHIP

Diagnostic assessment b c

Individual therapy Group therapy Family therapy Medication management
Inpatient care

d e Residential care

f Targeted case management Nonemergency transportation Key: = service
covered; = service covered with limitations; and = service not covered.

a SCHIP children in California who are diagnosed with SED have coverage
for all of these services without limitations through the county mental
health departments. In addition, day and visit limits do not apply to
SCHIP children diagnosed with SMI. b Health plans may limit outpatient
care for non- SED/ non- SMI children to 20 visits per year.

c Health plans limit enrollees to a maximum of 30 visits per year. d
Health plans may limit inpatient care for non- SED/ non- SMI children to
30 days per year. e Health plans limit enrollees to a maximum of 30 days
per year and 60 days in a 3- year period. f 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. Source: State Medicaid
and SCHIP health plans.

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. 34 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. 35

Utilization of Mental Health Little is known about the extent to which
traumatized children with public

Services 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. 36 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.

34 The annual copayment amount in California is limited to a maximum of
$250 per family for each benefit year. Copayments are not required for
services provided to SED children at county mental health centers.

35 Annual copayment amounts in Utah are limited to a maximum of $500 for
families with incomes from 100 to 150 percent of the federal poverty level
and $800 for families with incomes from 151 to 200 percent of the federal
poverty level.

36 For additional information, see U. S. General Accounting Office,
Medicaid: Stronger Efforts Needed to Ensure Children*s Access to Health
Screening Services, GAO- 01- 749 (Washington, D. C.: July 13, 2001).

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. 37 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. 38 37 See Emily Q. v. Belshe, No. CV- 98- 4181-
WDK, C. D., Cal., May 5, 1999 (court held that therapeutic behavioral
services were required to be provided under EPSDT); French v. Concannon,
No. 97- CV- 24- B- C, D. Me., July 16, 1998 (in response to lawsuit
challenging state*s failure to provide notice of mental health services
availability, state agreed to modify its EPSDT materials to include
specific information about mental health screening and treatment). 38 See
Sanders v. Lewis, No. 2: 92- 0353, S. D. W. Va., March 1, 1995.

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. 39
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. 40 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.

Type of Insurance Coverage A child*s type of health insurance and state of
residence generally

and State of Residence determine the extent of mental health coverage
available. To demonstrate Affect Mental Health

the variation between public and private insurance programs in the Service
Coverage and Costs

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.)

39 In states that provided mental health services to Medicaid or SCHIP
children through both prepaid managed care plans and traditional fee- for-
service arrangements, utilization data provided were the most recent
available (all were from state fiscal years 2000 or 2001) and were for the
delivery system that covered the majority of children. For Illinois and
Minnesota, the data included children in both Medicaid and SCHIP. Medicaid
utilization rates in California and Utah were approximately 5 percent.
Utilization data were not available from Georgia.

40 In Massachusetts, at least 85 percent of children in the Medicaid and
SCHIP programs are covered through a managed care program. Utilization
data provided were from fiscal year 2001.

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. 41 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.

41 The California Medicaid program covers mental health services provided
to enrollees in residential care facilities but not the cost of room and
board.

Figure 2: Public and Private Insurance Coverage Options in California and
Illinois for a Hypothetical 5- Year Old Child Who Has Experienced Trauma

Extent of coverage Other costs to the Monthly

child's family Individual,

Number of Inpatient

Number of Residential

Transportation premium

Inpatient Outpatient group,

visits per hospitalization inpatient

treatment a

in dollars and family year

days per therapy

year California

Medicaid Unlimited Unlimited $0

$0 $0 SCHIP b

Maximum Maximum

$4- 9 c $0

$5/ visit d

20 visits 30 days

Employer Maximum

Maximum N/ A N/ A

$191 10% of

$15/ visit sponsored

30 visits 30 days

(employee charges

and 20% group

share of of charges

insurance e

family premium)

Individual Maximum

Maximum $79

-Physician Physician

insurance f

20 visits 30 days

all but $25/ all but $25/

visit visit

-Hospital all but $175/ day

Illinois

Medicaid Unlimited Unlimited $0

$0 $0 SCHIP Unlimited Unlimited $15

g $0 $2- 5/ visit

h Employer

Maximum Maximum

N/ A N/ A $172

$0 $11/ visit

sponsored 30 visits

30 days (employee

group share of

insurance i

family premium)

Individual Maximum

Maximum k

$113 20% of

20% of insurance

j 20 visits

10 days costs costs

with family therapy equal to 2 visits

Key: = service covered; = service covered with limitations; = service not
covered; and N/ A = information was not available. a 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.

b 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. c Maximum of $27
premium per family per month.

d Maximum family copayment of $250 per year . . However, copayments are
not required for services provided to SED children in county mental health
centers. e 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. f
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. g 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. h
Maximum copayment per year per family is $100.

i 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. j Data are from an HMO
that is one of the most popular plans sold in the individual health
insurance

market in Illinois. k A health plan official told us that this service is
available to members who meet the plan*s medical

necessity criteria. Sources: State Medicaid and SCHIP health plans,
Mercer/ Foster Higgins National Survey of EmployerSponsored Health Plans
2001, and individual insurers in California and Illinois.

Federal Programs Can Beyond insurance, a range of federal programs*-
including over 50 grant

Help Children Who programs we identified*- can help children who have
experienced trauma obtain needed mental health services. (See app. VI for
descriptions of

Have Experienced selected federal grant programs.) Some federal programs
pay for crisis

Trauma to Obtain counseling, such as the crisis counseling program for
victims of disasters, Mental Health

which is administered by FEMA in collaboration with SAMHSA. Justice*s VOCA
Crime Victim Compensation grants and Crime Victim Assistance Services, But
Extent of grants to states help pay for mental health treatment needed by
crime

Assistance Is Largely victims. However, factors such as state eligibility
requirements and mental

health service caps, as well as families* lack of knowledge about the
Unknown and Little

programs, may limit some child victims* ability to benefit from these
Evaluation Has

programs. Several federal grant programs encourage coordination among
Occurred

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.

Federal Disaster Grants Federal agencies provide financial and technical
assistance to states and

Provide Some Mental Health localities to meet crisis- related mental
health needs of children and adults

Services to Children 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 42 and other services for children and
adults

affected by presidentially declared disasters. 43 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.

42 The goals of crisis counseling include helping disaster survivors
understand their current situation and reactions, mitigating additional
stress, developing coping strategies, providing emotional support, and
encouraging links with other individuals and agencies who can help
survivors return to their predisaster level of functioning. Services may
be provided by mental health professionals and trained paraprofessionals.

43 States and tribes must demonstrate that existing state and local
resources are inadequate to provide for these services. Individuals are
eligible to obtain crisis counseling services if they were residents of
the designated disaster area or were located in the area at the time of
the disaster and are experiencing mental health problems caused or
aggravated by the

disaster.

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. 44 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. 45 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. 46

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. 47 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 trauma44

FEMA crisis counseling grant funds cannot be used to provide treatment for
substance abuse, mental illnesses, developmental disabilities, or any
preexisting mental health conditions.

45 In addition, at the request of New York and Virginia, a portion of
their crisis counseling grant funds was provided by FEMA directly to
Connecticut, the District of Columbia, Massachusetts, New Jersey, and
Pennsylvania.

46 The fiscal year 2002 Defense Emergency Supplemental Appropriations Act
provided funds to Justice for these additional crisis counseling grants.
47 Most extensions have been primarily for administrative purposes and
have generally been for periods of 3 months or less.

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. 48 Education
officials said school districts have used grants for children*s crisis
counseling, school security, transportation to safe locations, and

translation services. 49 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.

48 Project SERV awards in fiscal year 2001 ranged from $50,000 to $4, 225,
000. 49 By statute, Project SERV funds may not be used for medical
services or drug treatment or rehabilitation, except for pupil services or
referral to treatment for students who are victims of, or witnesses to,
crime. 20 U. S. C. S: 7164( 2). Pupil services are provided by school
counselors, school social workers, school psychologists, and other
qualified professional personnel involved in providing assessment,
diagnosis, counseling, educational, therapeutic, and other necessary
services (including certain services defined in section 602 of the
Individuals with Disabilities Education Act). 20 U. S. C. S: 7801( 36)(
B). Education officials report that services have included individual,
group, and family counseling.

Federal Crime Victims Fund The federal Crime Victims Fund is an important
federal funding source for

Pays for Some Children*s meeting the mental health needs of children who
are victims of violent

Mental Health Services crimes, including mass violence and terrorism. The
fund is administered by Justice*s OVC, and most of the funds available 50
are used to support victim

compensation grants and victim assistance grants to all states, the
District of Columbia, Puerto Rico, and U. S. territories. 51 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 52 for a wide range of crime- related
expenses, including those for mental health services. 53 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. 54

50 The Congress has placed a cap on the amount of money in the Crime
Victims Fund available to OVC for funding crime victim- related programs
and activities. In fiscal year 2001, $537.5 million of the approximately
$776.5 million in the Crime Victims Fund was made available to OVC for
allocation. In addition to funding its two formula grant programs, OVC is
authorized to use the Crime Victims Fund allocation to fund other victim-
related activities, such as providing grants to help Indian tribes improve
the handling of child abuse cases, funding projects to identify ways for
improving the delivery of victim services, and supporting a special
compensation program for child and adult victims of international
terrorism, as required by the Victims of Trafficking and Violence
Prevention Act of 2000. OVC is authorized to set aside up to $50 million
from Crime Victims Fund allocations for an emergency reserve fund to
assist victims of terrorism or mass violence and fund the International
Terrorism Victim Compensation Program.

51 OVC provides federal Victim Compensation grants and Victim Assistance
grants to all 50 states, the District of Columbia, Puerto Rico, the U. S.
Virgin Islands, and Guam. OVC also provides Victim Assistance grants to
American Samoa and the Northern Mariana Islands. 52 Survivors of homicide
victims are also eligible for state victim compensation.

53 VOCA requires states, at a minimum, to award compensation for victims*
medical and dental costs, mental health counseling and care, lost wages,
and funeral expenses. VOCA compensation program guidelines give states
flexibility to offer compensation for other crime- related expenses, such
as for crime scene cleanup, forensic sexual assault examinations, and loss
of support, to the extent authorized by state statute or policy.

54 In addition, in fiscal year 2001, OVC used its emergency reserve fund
to allocate $16.6 million in supplemental victim compensation grants and
victim assistance grants to New York, Pennsylvania, and Virginia to assist
children and adults affected by the September 11, 2001, terrorist attacks.

Victim Compensation 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. 55 In some instances, children who witness
crimes may be eligible for compensation. 56 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. 57 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.

55 Claims for child victims can be filed on their behalf by their parents
or other guardians; children can also file on their own behalf when they
reach the age of 18. 56 Although providing victim compensation to children
who witness violence is not specifically required by VOCA, the National
Association of Crime Victim Compensation Boards told us that most states
consider children who have witnessed violence to be victims of a crime and
thus potentially eligible for victim compensation.

57 OVC could not provide separate reimbursement data for children and
adults. We were able to obtain selected data on some children*s services
in some states.

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. 58 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

58 In California, family members of homicide victims and custodial parents
or primary caretakers of child victims are also subject to the $10,000
cap. However, other victims have a $3,000 cap for mental health benefits.
In Minnesota, each secondary victim can obtain reimbursement for up to 20
counseling sessions.

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.

Victim Assistance 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. 59
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. 60 In the
four states we reviewed, children benefiting from these grants included
those who had been sexually or physically abused. (See table 3.)

59 State victim assistance agencies provide grants to such entities as
mental health agencies; domestic violence shelters; rape crisis centers;
child abuse programs; and victim service units in law enforcement
agencies, prosecutors* offices, hospitals, and social service agencies.

60 Data were not available on the number of children who received mental
health services.

Table 3: Number of Victims in Selected Categories Served by State Victim
Assistance Programs in Four States, Fiscal Year 2001

Type of victimization California Illinois Massachusetts Minnesota

Child physical abuse 4, 758 646 1, 291 4, 769 Child sexual abuse 21,817 5,
742 3, 380 7, 569 Adults molested as children 5,327 945 1, 351 1, 324
Source: Statewide Victim Assistance Performance reports.

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.

Several Factors May Limit Although many children who are crime victims
obtain mental health and Some Children*s Use of

other services through state victim compensation programs, federal, state,
Victim Compensation and

and local officials told us that many victims do not file compensation
Victim Assistance Benefits 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. 61

61 Separate analyses were not done on children and adult crime victims.

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. 62

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. 63

62 Urban Institute, The National Evaluation of State Victims of Crime Act
Compensation and Assistance Programs: Findings and Recommendations from a
National Survey of State Administrators, for the Department of Justice,
National Institute of Justice (Washington, D. C.: Mar. 2001).

63 Department of Justice, OVC, New Directions from the Field: Victims*
Rights and Services for the 21st Century (Washington, D. C.: May 1998).

Federal Agencies Coordination among mental health, child welfare,
education, law

Encourage Coordination to enforcement, and juvenile justice systems can
help ensure that children

Meet the Needs of Children who have experienced trauma and their families
obtain comprehensive, Who Experienced Trauma

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, 64
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. 65 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 64 See, for
example, Jeffrey L. Edelson, The Overlap Between Child Maltreatment and
Woman Abuse (St. Paul, Minn.: Minnesota Center Against Violence and Abuse,
Apr. 1999).

65 Through a cooperative agreement, Justice provides funds to the National
Children*s Alliance, a not- for- profit organization that assists
communities seeking to plan, establish, and improve Children*s Advocacy
Centers, which in turn administers grants that fund the establishment and
expansion of Children*s Advocacy Centers.

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. 66 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. 67 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. 68 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 66
HHS participants are the Office of the Secretary (Office of the Assistant
Secretary for

Planning and Evaluation); ACF (Children*s Bureau and the Family Violence
Program); and Centers for Disease Control and Prevention (National Center
for Injury Prevention and Control). Justice participants are all in the
Office of Justice Programs*- Violence Against Women Office, OVC, Office of
Juvenile Justice and Delinquency Prevention, and National Institute of
Justice.

67 The sites are located in El Paso County, Colorado; Grafton County, New
Hampshire; Santa Clara County, California; Lane County, Oregon; St. Louis
County, Missouri; and San Francisco County, California. 68 The project was
developed in response to recommendations presented in a report

published in 1999 by the National Council of Juvenile and Family Court
Judges, entitled

Effective Intervention In Domestic Violence & Child Maltreatment Cases:
Guidelines for Policy and Practice (Reno, Nev.: 1999).

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. 69 The initiative emphasizes
partnerships and coordination among grantees at each level and across
levels. It also encourages grantees to collaborate with

69 The program was initially funded at $10 million and those funds were
awarded to 18 grantees. The National Center for Child Traumatic Stress,
which is a partnership between the University of California, Los Angeles,
and Duke University, received about $3.1 million. Five Intervention
Development and Evaluation Centers received grants ranging from about
$568, 000 to $600,000, and 12 Community Treatment and Services Centers
received grants ranging from about $285,000 to about $348,000. In fiscal
year 2002, the Congress

appropriated an additional $20 million. In June 2002, SAMHSA awarded 5
additional Intervention Development and Evaluation Center grants, ranging
from about $600,000 to about $1.8 million, and 13 additional Community
Treatment and Services Center grants, ranging from about $117,000 to about
$1 million. These additional grants totaled about $11.4 million.

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.

Federal Programs with Other federal grant programs not specifically
targeted to assisting children

Broader Focus May Help who have experienced trauma may also help fund
mental health and other

Fund Services Needed by services needed by these children and their
families. These federal grants

Children Who Experienced focus on broader issues, such as general mental
health or maternal and child health services or services for specific
populations, such as children

Trauma 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. 70 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.

70 Michael Jellinek, Bina P. Patel, and Mary C. Froehle (eds.), Bright
Futures in Practice: Mental Health Practice Guide, Volume 1 (Arlington,
Va.: National Center for Education in Maternal and Child Health, 2002).

Few Federal Programs Have Despite the many federal efforts that contribute
to varying degrees to Evaluated Their

helping children who have experienced trauma and their families obtain
Effectiveness in Assisting

mental health and other needed services, little is known about their
Children Who Experienced

effectiveness. Few programs have undertaken formal evaluations to assess
program progress and results and to guide decisions to improve service to
Trauma 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. 71 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.

71 FEMA, Office of Inspector General, Inspection of FEMA*s Crisis
Counseling Assistance and Training Program, Inspection Report I- 01- 95
(Washington, D. C.: June 1995).

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. 72 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. 73 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.

72 Findings of that survey were discussed earlier in this report. 73
Minors could not participate in either survey. Participants in the
compensation survey included adults who filed claims on behalf of
children.

Conclusions 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.

Recommendation for We recommend that, to provide federal policymakers and
program

Executive Action 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. Agency Comments and

We provided a draft of this report to four federal departments and
agencies Our Evaluation

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.

Janet Heinrich Director, Health Care* Public Health Issues

Appendi Appendi xes x I

Scope and Methodology 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.

Appendi x II

Victimization Data This appendix presents information on child
maltreatment, 74 intimate partner violence, 75 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.

Child Abuse and In 1996, the Child Abuse Prevention and Treatment Act was
amended to Neglect Data Collected

require states receiving a Child Abuse and Neglect State Grant to report
to the National Child Abuse and Neglect Data System, to the extent by
HHS*s

practicable, 12 specific data items on child maltreatment, such as the
Administration for

number of victims of abuse and neglect and the number of children who
Children and Families

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.

74 ACF defines child maltreatment as including physical abuse, neglect,
medical neglect, sexual abuse, and psychological maltreatment. 75 CDC
defines intimate partner violence as actual or threatened physical or
sexual violence, or psychological or emotional abuse by a spouse, ex-
spouse, boyfriend, girlfriend, exboyfriend, ex- girlfriend, or date.

Table 4: Number of Referrals to Child Protective Services and
Substantiated Cases of Child Maltreatment, by State, 1999 Number of

Percentage of Child

investigations investigations population

Referrals Referrals

Number of substantiating

substantiating State

(under 18) a screened out b screened in b investigations c maltreatment d

maltreatment d

Alabama 1, 066, 177 e 24,586 24,586 8,610 35.0 Alaska 196,825 1,767 7, 806
13,270 3,766 28.4 Arizona 1,334,564 e 32,635 32,635 5,650 17.3 Arkansas
660,224 11, 883 17,036 17,036 5,482 32.2 California 8,923,423 e 227,561
227,561 73,188 32.2 Colorado 1,065,510 17, 325 28,774 e ee Connecticut
828, 260 12, 701 30,452 30,452 11,281 37.1 Delaware 182,450 2,049 6, 316
5,965 1,346 22.6 District of Columbia 95, 290 340 4, 048 e ee Florida 3,
569, 878 e 152,989 95,790 13,338 13.9 Georgia 2, 056, 885 22, 917 47,032
47,032 16,024 34.1 Hawaii 289,340 4,861 2, 733 4,646 2,669 57.5 Idaho
350,464 7,672 9, 363 9,363 835 8. 9 Illinois 3, 181, 338 e 61,773 61,773
18,779 30.4 Indiana 1, 528, 991 6,548 53,897 91,625 21,608 23.6 Iowa
719,685 11, 464 18,666 18,666 6,716 36.0 Kansas 698,637 12, 072 18,897
18,974 5,894 31.1 Kentucky 965,528 e 37,285 63,384 18,585 29.3 Louisiana
1,190,001 e 28,123 26,868 7,244 27.0 Maine 290, 439 11, 058 4,450 4, 450
2,349 52.8 Maryland 1,309,432 e 31,220 31,220 8,103 26.0 Massachusetts
1,468,554 22, 654 38,715 34,108 17,851 52.3 Michigan 2,561,139 58, 596
69,133 65,591 13,721 20.9 Minnesota 1,271,850 e 16,466 16,466 7,228 43.9
Mississippi 752,866 e 18,389 18,389 4,077 22.2 Missouri 1, 399, 492 51,
362 46,269 46,259 6,117 13.2 Montana 223,819 e 10,043 10,043 1,262 12.6
Nebraska 443,800 2,964 8, 456 8,456 2,183 25.8 Nevada 491,476 e 13,384
13,384 3,983 29.8 New Hampshire 304, 436 6,150 6, 107 6,107 580 9. 5 New
Jersey 2,003,204 e 43,874 74,585 9,222 12.4 New Mexico 495,612 6,802 6,
846 11,638 3,586 30.8 New York 4,440,924 179,879 139,564 136,489 46,980
34.4

(Continued From Previous Page)

Number of Percentage of Child

investigations investigations population

Referrals Referrals

Number of substantiating

substantiating State

(under 18) a screened out b screened in b investigations c maltreatment d

maltreatment d

North Carolina 1,940,947 e 75,013 127,522 36,976 29.0 North Dakota 160,092
e 4,109 4, 109 e e Ohio 2,844,071 e 79,400 79,400 8,749 11.0 Oklahoma 882,
062 18, 180 35,141 35,141 9,864 28.1 Oregon 827,501 16, 989 17,686 17,686
8,073 45.7 Pennsylvania 2, 852, 520 6,135 13,175 22,437 5,076 22.6 Rhode
Island 241,180 4,342 7, 882 7,882 2,501 31.7 South Carolina 955,930 5,663
18,209 18,209 5,518 30.3 South Dakota 198,037 e 2,770 6, 316 1,163 18.4
Tennessee 1, 340, 930 e 19,782 e ee Texas 5, 719, 234 29, 379 131,920
110,837 26,978 24.3 Utah 707,366 7,792 17,514 17,514 5,991 34.2 Vermont
139, 346 e 2,263 2, 263 923 40.8 Virginia 1,664,810 15, 538 32,270 32,270
4,767 14.8 Washington 1,486,340 39, 207 35,940 35,940 5,128 14.3 West
Virginia 403,481 5,791 17,274 17,274 5,587 32.3 Wisconsin 1,348,268 e
20,183 34,311 9,791 28.5 Wyoming 126, 807 2,305 2, 505 2,505 855 34.1

Total for states 70,199,435 1,177,874 1, 795,924 1, 838,427 486,197 26.5 f
reporting data a Child population data are from the U. S. Bureau of the
Census 1999 population estimates, as reported

by ACF. b Referrals are screened out if the allegation does not warrant
investigation. For example, the allegation

may not meet the statutory definition of child maltreatment, may not
contain sufficient information upon which to proceed, and/ or may not
pertain to the population served by the agency. Referrals alleging
maltreatment are screened in if the child protective services agency
decides that they are appropriate for investigation or assessment. c ACF
reports that the number of investigations may differ from the number of
referrals screened in

because referrals and investigations might not occur in the same year and
there are variations in the way that states compile data. In most states,
investigations may cover more than one child. d An allegation is
substantiated if the agency*s investigation concludes that the allegation
of

maltreatment or risk of maltreatment is supported, according to law or
policy set by the state. e State did not report data.

f Average for all reporting states. Source: HHS, ACF, Child Maltreatment
1999: Reports from the States to the National Child Abuse and Neglect Data
System (Washington, D. C.: 2001).

Table 5: Information on Child Victims of Maltreatment, by State, 1999
Percentage of victims by category of maltreatment a Number of victims of
State maltreatment Physically abused Neglected Sexually abused

Alabama 13,773 40.9 46. 0 23.1 Alaska 5,976 29.6 60. 5 15.2 Arizona 9,205
24.8 58. 4 5. 6 Arkansas 7,564 27.2 68. 9 37.0 California 130,510 17.5 56.
3 9. 1 Colorado 6,989 27.6 70. 7 15.1 Connecticut 14,514 16.2 90. 2 4. 1
Delaware 2,111 25.3 37. 5 11.1 District of Columbia 2,308 14.4 71. 8 1. 7
Florida 67,530 17.8 39. 8 6. 5 Georgia 26,888 13.4 63. 1 8. 4 Hawaii 2,
669 6. 5 8.1 5. 3 Idaho 2,928 29.0 49. 5 13.1 Illinois 33,125 11.2 40. 6
10.2 Indiana 21,608 31.1 124. 9 25.6 Iowa 9,763 25.2 63. 1 11.1 Kansas
8,452 30.8 49. 5 15.7 Kentucky 18, 650 27. 6 63. 7 7.7 Louisiana 12, 614
20. 9 68. 1 6.5 Maine 4, 154 34. 4 59. 2 21.5 Maryland 15, 451 b bb
Massachusetts 29, 633 b bb Michigan 24, 505 20. 9 70. 8 6.5 Minnesota 11,
113 24. 8 77. 4 7.3 Mississippi 6,523 26.6 47. 0 21.1 Missouri 9, 079 24.
1 49. 6 26.0 Montana 3,414 9. 2 62. 0 9.2 Nebraska 3,474 21.6 64. 5 9. 8
Nevada 8,238 14.6 22. 1 2. 8 New Hampshire 926 27. 5 65. 2 25.7 New Jersey
9,222 23.3 62. 7 8. 0 New Mexico 3,730 22.3 52. 4 6. 0 New York 64, 045
24. 8 23. 3 5.6

(Continued From Previous Page)

Percentage of victims by category of maltreatment a Number of victims of
State maltreatment Physically abused Neglected Sexually abused

North Carolina 36, 976 3.6 87. 8 3. 7 North Dakota 1,284 12.5 64. 0 7. 2
Ohio 55, 921 28. 0 53. 3 14.1 Oklahoma 16,210 24.9 98. 0 8. 0 Oregon 11,
241 13. 2 21. 1 11.8 Pennsylvania 5, 076 62. 1 3. 8 80.4 Rhode Island
3,485 26.6 84. 6 8. 9 South Carolina 9,580 13.7 54. 8 6. 3 South Dakota
2,561 25.1 70. 9 10.0 Tennessee 10,611 20.0 43. 5 21.0 Texas 39,488 29.3
59. 6 14.9 Utah 8,660 16.6 28. 8 21.8 Vermont 1, 080 22. 0 43. 7 40.4
Virginia 8,199 31.1 64. 7 14.4 Washington 8,039 27.1 70. 8 9. 0 West
Virginia 8,609 25.1 43. 8 8. 6 Wisconsin 9,791 21.9 42. 2 37.9 Wyoming 1,
221 29. 4 63. 9 9.0

Total for states 828,716 21.4 c 56. 0 c 11.3 c reporting data a
Percentages do not add up to 100 because some states reported additional
types of maltreatment

that are not included here. b State did not report data.

c Average for all reporting states. Source: HHS, ACF.

Table 6: Services Provided to Child Victims of Maltreatment, by State,
1999 Percentage of victims who received services, by type of service
Family preservation Number of victims

services in the Mental health

Counseling State of maltreatment Any services

past 5 years a services b services c

Alabama 13, 773 15.6 d dd Alaska 5,976 30. 7 d dd Arizona 9,205 d d 27. 3
27.8 Arkansas 7,564 100. 0 d 1.9 12.9 California 130, 510 53. 3 d dd
Colorado 6,989 34. 4 24. 0 d d Connecticut 14, 514 53.6 d dd Delaware 2,
111 62.9 d 1.2 1. 7 District of Columbia 2, 308 71.4 d dd Florida 67, 530
64.5 25.3 d d Georgia 26, 888 52.7 d dd Hawaii 2,669 d dd 9.0 Idaho 2, 928
30.6 13.8 d d Illinois 33,125 15. 1 d dd Indiana 21,608 51. 8 d 0.1 <0.1
Iowa 9,763 65. 2 4. 1 d d Kansas 8, 452 28.8 34.7 d d Kentucky 18, 650 53.
5 d 8.1 8. 8 Louisiana 12, 614 68. 0 13. 6 1.6 1. 5 Maine 4, 154 25.1 d dd
Maryland 15, 451 d ddd Massachusetts 29, 633 d ddd Michigan 24, 505 81. 0
d dd Minnesota 11, 113 84. 2 d dd Mississippi 6,523 100.0 d dd Missouri 9,
079 69. 4 11. 3 d 3.0 Montana 3, 414 41.3 d dd Nebraska 3, 474 d d 0.3 d
New Hampshire 926 65. 7 d dd New Jersey 9, 222 69.0 d 0.1 <0.1 New Mexico
3, 730 60.8 d 54. 2 d New York 64, 045 d d <0. 1 d Nevada 8,238 d ddd

(Continued From Previous Page)

Percentage of victims who received services, by type of service Family
preservation Number of victims

services in the Mental health

Counseling State of maltreatment Any services

past 5 years a services b services c

North Carolina 36, 976 52. 1 0.3 d 20.0 North Dakota 1, 284 d ddd Ohio 55,
921 50. 5 50. 0 d d Oklahoma 16, 210 56.2 18.0 d 3.0 Oregon 11, 241 32. 6
16. 9 d d Pennsylvania 5, 076 63. 2 d 1.2 78.4 Rhode Island 3, 485 100. 0
d 34. 5 d South Carolina 9, 580 99.9 d dd South Dakota 2, 561 60.3 d dd
Tennessee 10,611 d ddd Texas 39,488 d 11. 1 21. 4 29. 9 Utah 8,660 54. 3
5. 2 20. 6 9. 4 Vermont 1, 080 35. 8 12. 4 d d Virginia 8, 199 74.8 d dd
Washington 8, 039 84.5 d d 4.5 West Virginia 8,609 48. 7 7. 6 0. 1 d
Wisconsin 9,791 94. 5 d dd Wyoming 1, 221 37. 3 22. 0 0.7 8. 1

Total for states reporting data 828, 716 55.8 e 21. 6 e 8.3 e 14.8 e

a Family preservation services include services to prevent out- of- home
placement, support reunification of children with their families, support
the continued placement of children in adoptive homes, or support other
permanent living arrangements. b Mental health services are provided by
clinicians, physicians, and social workers in mental health

agencies to address clinically diagnosed problems. Services are often
time- limited and may include residential and/ or outpatient treatment. c
Counseling refers to family and individual counseling services provided by
case workers and clinicians

in social services agency settings. d State did not report data.

e Average for all reporting states. Source: HHS, ACF.

Table 7: Number of Reports of Child Maltreatment, by Source of Report and
State, 1999 Other Social

Mental Legal/ law

relatives Tot al State services Medical health enforcement Education
Parents

and friends reports a

Alabama 1, 922 2,283 930 4, 149 4, 017 2,721 3, 703 24, 586 Alaska 2, 136
1, 112 b 1, 962 2, 471 832 1, 925 13, 270 Arizona 1,418 3, 294 1,307 5,
717 5, 405 2,586 5, 284 32, 635 Arkansas 1,898 1, 294 1,041 1, 662 2, 061
676 3, 125 17, 036 California 38, 341 19,118 b 33, 333 39,386 3 26,129
227, 561 Colorado b bb bbbbb Connecticut 2, 561 3,140 2, 408 5, 545 6, 489
2,043 1, 831 30, 452 Delaware 280 515 260 1,628 955 581 828 6,316 District
of Columbia 672 192 156 768 320 96 788 4, 048 Florida 21,591 12,142 6, 037
26, 590 19,200 14,375 24,609 152, 989 Georgia 3, 979 3,660 2, 784 7, 445
8, 677 3,885 9, 552 47, 032 Hawaii 630 564 b 688 674 193 510 5, 063 Idaho
500 618 100 1, 425 1, 726 1,050 1, 651 9, 363 Illinois 9, 451 8,695 b 9,
989 10,265 4,551 7, 780 61, 773 Indiana b bb bbbbb Iowa 3,010 1, 386 525
2, 237 2, 804 152 b 18, 666 Kansas 3,279 1, 501 181 1, 741 3, 694 1,957 2,
344 18, 834 Kentucky 1,139 683 b 2,164 2, 355 6, 075 14, 387 63,384
Louisiana 3, 631 2, 900 b 3, 771 4, 896 1,802 4, 364 28, 123 Maine 503 317
426 503 765 253 785 4, 450 Maryland b bb bbbbb Massachusetts b bb bbbbb
Michigan 12, 237 3,353 6, 136 8, 902 5, 000 6,022 11,721 69, 133 Minnesota
1,456 1, 559 631 3, 685 3, 716 1,458 1, 993 17, 098 Mississippi 1,158 2,
106 b 2, 517 3, 187 809 5, 162 18, 389 Missouri 5, 136 3,058 2, 364 5, 544
5, 243 1,738 13,813 46, 269 Montana 1,182 548 219 1, 504 1, 687 808 2, 144
10, 043 Nebraska 464 555 280 1, 737 987 593 1, 245 8, 456 Nevada 937 1,
086 438 1, 913 2, 643 1,111 2, 707 13, 384 New Hampshire 749 510 560 799
1, 217 172 1, 157 6, 107 New Jersey 8,138 9, 358 b 11, 874 14,564 6,617
10,903 74, 585 New Mexico 807 893 610 3, 957 2, 616 627 1, 900 11, 638 New
York 36, 639 13,025 b 7, 797 13,128 9,520 14,784 139, 564 North Carolina
20, 778 10,056 b 12, 623 22,727 9,855 32,262 127, 522

(Continued From Previous Page)

Other Social

Mental Legal/ law

relatives Tot al State services Medical health enforcement Education
Parents

and friends reports a

North Dakota 533 217 288 817 780 361 552 4, 109 Ohio 12, 198 4,990 2, 737
12, 260 8,974 b 20, 124 79, 400 Oklahoma 4, 191 2,283 2, 223 3, 755 3, 939
2, 021 7956 35,141 Oregon 1,824 1, 721 145 5, 043 2, 650 567 1, 995 17,
686 Pennsylvania 3, 011 3,431 1, 290 1, 725 5, 067 2,210 1, 940 22, 397
Rhode Island 1,020 1, 223 b 962 1, 431 527 825 9, 168 South Carolina 1,724
2, 198 502 2, 763 3, 558 1,433 2, 785 18, 209 South Dakota b 259 172 1,
175 899 284 903 4, 709 Tennessee 2, 419 2,906 b 6, 352 4, 187 1,454 9, 251
33, 682 Texas 6, 992 14,637 4, 183 15, 944 24,322 13,450 27,380 131, 920
Utah 2,034 937 454 3, 642 1, 361 755 2, 981 17, 514 Vermont 160 165 191
393 502 221 242 2, 273 Virginia 1,948 2, 626 1,364 4, 951 6, 430 3,114 5,
355 32, 270 Washington 6,822 2, 929 1,452 3, 844 5, 908 2,804 6, 656 35,
940 West Virginia 2,025 913 699 1, 221 2, 166 1,774 3, 243 17, 274
Wisconsin 5,354 1, 868 1,628 6, 849 6, 114 3,169 5, 062 36, 295 Wyoming b
bb bbbbb

Total for states 238,877 152,824 44,721 245, 865 271,163 117,305 306, 636
1,805, 756 reporting data Percentage of total

13.2 8. 5 2.5 13.6 15. 0 6. 5 17.0 100.0 reports Note: According to ACF
officials, the number of reports is based on those reports of child
maltreatment that resulted in an investigation, but there are variations
in the way that states compile their data.

Social services personnel, medical personnel, mental health personnel,
legal and law enforcement personnel, educators, child day care providers,
and foster care and adoption providers may, depending on state law, be
legally required to report suspected maltreatment as part of their job. a
Total for each state also includes reports from other sources not listed
in the table. Of the

approximately 1.8 million reports nationwide, 3 percent of the reports
came from child day care providers, foster care and adoption providers,
alleged victims, or alleged perpetrators, and 20.7 percent of the reports
came from another or unknown source. b State did not report data.

Source: HHS, ACF, Child Maltreatment 1999: Reports from the States to the
National Child Abuse and Neglect Data System (Washington, D. C.: 2001).

Child Access and The Personal Responsibility and Opportunity Act of 1996
authorized ACF

Visitation Data to provide $10 million to states to establish and operate
access and

visitation programs. The overall goal of the program is to increase
Collected by HHS*s children*s contact with their noncustodial parents.
Individual grantees, Administration for

however, often have additional goals that relate to child well- being,
such as Children and Families

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.)

Table 8: Child Access and Visitation Grant Data, by State Parents served
in

Counseling targeted as a State fiscal year 1998 priority area in fiscal
year 2000

Alabama 276 Yes Alaska 8 No Arizona a Ye s Arkansas 222 Yes California 5,
812 Yes Colorado 588 Yes Connecticut a Ye s Delaware 18 No District of
Columbia 158 No Florida 6, 668 No Georgia 213 Yes Hawaii 200 Yes Idaho 230
Yes Illinois 359 Yes Indiana 1, 166 Yes Iowa 189 Yes

(Continued From Previous Page)

Parents served in Counseling targeted as a State fiscal year 1998 priority
area in fiscal year 2000

Kansas 329 a Kentucky 1, 630 Yes Louisiana 290 No Maine 774 Yes Maryland
156 Yes Massachusetts 265 Yes Michigan 456 a Minnesota 314 a Mississippi
305 Yes Missouri 1, 051 Yes Montana 389 Yes Nebraska 211 Yes Nevada 248
Yes New Hampshire 112 Yes New Jersey 6, 363 Yes New Mexico 539 Yes New
York 1, 021 Yes North Carolina b Ye s North Dakota a a Ohio 1,045 a
Oklahoma 56 Yes Oregon 464 Yes Pennsylvania 878 Yes Rhode Island 71 a
South Carolina 166 Yes South Dakota 264 a Tennessee 3,622 a Texas 3, 649
Yes Utah 392 a Vermont 1, 079 Yes Virginia 1, 108 Yes Washington 1,061 a
West Virginia a Ye s Wisconsin 276 Yes Wyoming a Ye s

Total for states 44, 691 reporting data

Note: The most recent year for which states reported data on parents
served is fiscal year 1998. Information on the provision of counseling
services comes from state descriptions of their proposed activities and
funding priorities for fiscal year 2000, not the services they actually
provided. This table includes only those programs that reported serving
parents. States may not have reported these data for some service programs
or may have funded additional programs for purposes other than serving
parents, such as general training. a State did not report data.

b North Carolina reported that the fiscal year 1998 money was returned to
ACF, so there are no data to report. Source: HHS, ACF, Child Access and
Visitation Grants: State Profiles (Washington, D. C.: Oct. 2001) http://
www. acf. dhhs. gov/ programs// cse/ pol/ im- 01- 03a/ index. html
(downloaded March 4, 2002).

Victimization Data Data that Justice has collected on victimization
include information on

Collected by the intimate partner violence and sexual assault. Justice*s
Bureau of Justice

Statistics* National Crime Victimization Survey provided estimates on
Department of Justice 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 76 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.)

76 Forcible rape includes assaults or attempts to commit rape by force or
threat of force, but does not include statutory rape or other sex
offenses.

Figure 3: Estimated Number of Victims of Intimate Partner Violence, by
Sex, 1993 to 1998 1,200,000

1,000,000 800,000 600,000 400,000 200,000

0 1993 1994 1995 1996 1997 1998

Female Male

Source: Department of Justice, Bureau of Justice Statistics, Bureau of
Justice Statistics Special Report: Intimate Partner Violence (Washington,
D. C.: 2000).

Table 9: Estimated Number of Persons Raped or Physically Assaulted by an
Intimate Partner during Lifetime and Previous 12 Months, by Sex of Victim

Lifetime Previous 12 months Type of violence Women Men Women Men

Rape 7,754, 000 278,000 201,000 a Physical assault 22,254, 000 6, 863,000
1,309,000 835, 000 Note: Based on estimates of men and women in the United
States aged 18 years and older, U. S. Bureau of Census, Current Population
Survey, 1995.

a The number of male rape victims was insufficient to calculate a reliable
estimate. Source: Department of Justice, National Institute of Justice and
HHS, Centers for Disease Control and Prevention, Prevalence, Incidence,
and Consequences of Violence Against Women: Findings from the National
Violence Against Women Survey (Washington, D. C.: 1998). The federal
National Violence Against Women Survey consisted of a nationally
representative sample of 8, 000 U. S. women and 8,000 U. S. men. The
survey was conducted from November 1995 to May 1996.

Table 10: Estimated Rates of Law Enforcement Actions, as Reported by
Victims of Selected Intimate Partner Crimes Rape victims a Physical
assault victims Stalking victims Women Women Men Women Men Total crime
victims (n) 441 1,149 541 343 47

Reported to police (%) 17.2 26. 7 13.5 51.9 36.2 Did not report to police
(%) 82.8 73. 3 86.5 48.1 63.8

Crime victims reporting to police (n) b 75 370 73 178 17

Police took report (%) 77.6 76. 2 64.4 67.4 64.7 Police arrested or
detained attacker (%) 47.4 36. 4 12.3 28.7 c Police referred victim to
prosecutor or court (%) 10.5 33. 9 23.3 28.1 c Police referred victim to
services (%) c 25. 1 17.8 21.3 c Police gave victim advice on self-
protective c 26. 1 17.8 23.1 35.3 measures (%)

Police did nothing (%) c 11. 1 19.2 18.5 c Note: Estimates are based on
the most recent intimate partner victimization since age 18. a Estimates
not calculated for male rape victims due to the small sample size.

b Estimates are based on responses from victims whose victimization was
reported to police and exceed 100 percent because some victims reported
multiple police responses. c Estimates not calculated because fewer than
five in sample cell.

Source: Department of Justice, National Institute of Justice and HHS,
Centers for Disease Control and Prevention, Extent, Nature, and
Consequences of Intimate Partner Violence: Findings from the National
Violence Against Women Survey (Washington, D. C.: 2000). The federal
National Violence Against Women Survey consisted of a nationally
representative sample of 8, 000 U. S. women and 8,000 U. S. men. The
survey was conducted from November 1995 to May 1996.

Table 11: Instances of Forcible Rape of Women Reported to Police, All
Ages, 2000 State Forcible rape

Alabama 1,482 Alaska 497 Arizona 1,577 Arkansas 848 California 9,785
Colorado 1,774 Connecticut 678 Delaware 424 District of Columbia 251
Florida 7,057 Georgia 1,968 Hawaii 346 Idaho 384 Illinois 4,090 Indiana
1,759 Iowa 676 Kansas 1,022 Kentucky 1,091 Louisiana 1,497 Maine 320
Maryland 1,543 Massachusetts 1,696 Michigan 5,025 Minnesota 2,240
Mississippi 1,019 Missouri 1,351 Montana 301 Nebraska 436 Nevada 860 New
Hampshire 522 New Jersey 1,357 New Mexico 922 New York 3,530 North
Carolina 2, 181 North Dakota 169

(Continued From Previous Page)

State Forcible rape

Ohio 4,271 Oklahoma 1,422 Oregon 1,286 Pennsylvania 3, 247 Rhode Island
412 South Carolina 1, 511 South Dakota 305 Tennessee 2,186 Texas 7,856
Utah 863 Vermont 140 Virginia 1,616 Washington 2,737 West Virginia 331
Wisconsin 1,165 Wyoming 160

Tot al 90, 186

Source: Department of Justice, Federal Bureau of Investigation, Crime in
the United States 2000 (Washington, D. C.: 2001).

Table 12: Sexual Assault Convictions in State Courts, 1998 Percentage

Mean maximum Estimated

of felons sentence for felons number of

sentenced to sentenced to convictions

incarceration incarceration

Sexual assault 29,693 82 94 months Rape 11,622 84 125 months Other assault
18,071 80 74 months All felony offenses 927,717 68 39 months Source:
Department of Justice, Bureau of Justice Statistics, Felony Sentences in
State Courts, 1998 (Washington, D. C.: 2001).

Information on SCHIP Programs in the 50

Appendi x III

States and the District of Columbia 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.)

Table 13: Program Type, Maximum Income Eligibility Levels, and Fiscal Year
2001 Enrollment for SCHIP Programs in the 50 States and the District of
Columbia

SCHIP program type Maximum income

eligibility by Medicaid

percent federal Enrollment - fiscal State expansion Separate SCHIP
Combination

poverty level year 2001

Alabama X 200 68, 179 Alaska X 200 21, 831 Arizona X 200 86, 863 Arkansas
X 100 2, 884 California X 250 693, 048 Colorado X 185 45, 773 Connecticut
X 300 18, 720 District of Columbia X 200 2, 807 Delaware X 200 5, 567
Florida X 200 298, 705 Georgia X 235 182, 762 Hawaii X 200 7,137 Idaho X
150 16, 896 Illinois X 185 83, 510 Indiana X 200 56, 986 Iowa X 200 23,
270 Kansas X 200 34, 241 Kentucky X 200 66, 796 Louisiana X 150 69, 579
Maine X 200 27, 003 Maryland X 300 109, 983 Massachusetts X 200 105, 072
Michigan X 200 76, 181

(Continued From Previous Page)

SCHIP program type Maximum income

eligibility by Medicaid

percent federal Enrollment - fiscal State expansion Separate SCHIP
Combination

poverty level year 2001

Minnesota X 280 49 a Mississippi X 200 52, 436 Missouri X 300 106, 594
Montana X 150 13, 518 Nebraska X 185 13, 933 Nevada X 200 28, 026 New
Hampshire X 300 5,982 New Jersey X 350 99, 847 New Mexico X 235 10, 347
New York X 250 872, 949 North Carolina X 200 98, 650 North Dakota X 140
3,404 Ohio X 200 158, 265 Oklahoma X 185 38,858 Oregon X 170 41, 468
Pennsylvania X 200 141, 163 Rhode Island X 250 17, 398 South Carolina X
150 66, 183 South Dakota X 200 8,937 Tennessee X 100 8, 615 Texas X 200
500, 950 Utah X 200 34, 655 Vermont X 300 2, 996 Virginia X 200 73, 102
Washington X 250 7, 621 West Virginia X 200 33, 144 Wisconsin X 185 57,
183 Wyoming X 133 4, 652

Total 16 16 19 4, 601, 098

a Minnesota*s SCHIP program covers children under age 2 who are in
families with incomes that are from 275 to 280 percent of the federal
poverty level. Minnesota has a state- funded insurance program that covers
most non- Medicaid children in families with incomes up to 275 percent of
the federal poverty level.

Source: Centers for Medicare & Medicaid Services, The State Children*s
Health Insurance Program Annual Enrollment Report: Federal Fiscal Year
2001 (Baltimore, Md.: Feb. 6, 2002), p. 10,

Selected Individual Insurers* Coverage for Specified Mental Health
Coverage in Six

Appendi x IV

States as of 2002 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.

Figure 4: Selected Individual Insurers* Coverage for Specified Mental
Health Services Available to Children in Six States California a

Georgia Illinois Massachusetts Minnesota Utah Plan A Plan B Plan C Plan D
Plan E Plan F Plan G Plan H Plan I Plan J Plan K Plan L

Plan type PPO HMO

PPO HMO PPO HMO PPO HMO PPO HMO PPO PPO Deductible

$1,000 $0 $500 $0 $1,000 $0 $250 $0 $500 $500 $500 $500 amount

Individual therapy b

b c

d b

e f Group therapy b

b c

d b

f Family therapy

b b

c d

b, g f

Inpatient care h

i h j

h k

k f Residential care

l i

m n Key: = service covered; = service covered with limitations; and =
service not covered.

a 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). b Maximum of 20 total outpatient visits per year.

c 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. d Maximum of 30 outpatient visits per year with a maximum
of 100 visits per lifetime.

e Maximum of 15 outpatient visits per year. f All mental health services
are limited to a total benefit of $1,500 per member per year. g One family
therapy session is equal to two outpatient visits. h Maximum of 30
inpatient days per year.

i Maximum of 45 inpatient days per year. One residential treatment day is
counted as one inpatient day. j Patient is responsible for additional
cost- sharing after the 30th inpatient day each year. k Maximum of 10
inpatient days per year. l Care received in a residential treatment center
(a licensed 24- hour facility that offers mental health treatment). m Room
and board costs are not covered.

n One day of residential care is equal to two inpatient days. Source:
Individual insurers in each of the six states. We obtained this
information from insurers from February through April 2002.

Summary of Selected Laws Regarding Mental

Appendi x V

Health Coverage in Six States 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.

Table 14: Summary of Parity Laws That Exceed Federal Standards in Three
States California a Massachusetts b Minnesota c

Health plan Every health care Any individual, group, All HMOs; all
applicability d service plan that

and HMO plan individual and group provides hospital,

plans that provide medical, or surgical

mental health or coverage

chemical benefits Population

All plan members with Plan members (1)

All enrolled covered SMI and children with with biologically

individuals SED e

based mental illness, (2) in need of raperelated services, and (3) who are
children under 19 with certain non- biologically based mental illnesses f

State law requires Mental health benefits No mental health

Mental health benefits must be provided and

service limitation can must be provided and have the same limits be less
than those have the same limits and restrictions as

imposed for physical as medical condition physical benefits

conditions g benefits a See California Health & Safety Code S: 1374.72
(2002). b See General Laws of Massachusetts, Chapter 175, Section 47B
(2002). c See Minnesota Statutes S:S: 62Q. 47( a); 62A. 152; 62E. 06
(2001). d These state laws generally apply to group health plans that
employers purchase for their employees but not to employers who self- fund
their plans, meaning they pay their employees* health expenses directly. e
SMI is defined as (1) schizophrenia, (2) schizoaffective disorder, (3)
bipolar disorder (manicdepressive

illness), (4) major depressive disorders, (5) panic disorder, (6)
obsessive- compulsive disorder, (7) pervasive developmental disorder or
autism, (8) anorexia nervosa, and (9) bulimia nervosa. SED children are
generally defined as having mental disorders identified in the most recent
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)
that result in behavior inappropriate to their age. As a result of their
mental disorders, SED children will also (1) have substantial impairment
in at least two specified areas, such as self- care or family
relationships, and

one of the following must occur* child must be at risk of removal from the
home or have already been removed or the child must have mental disorders
and impairments present for more than 6 months; (2) display psychotic
features or have risk of suicide or violence; or (3) meet special
education eligibility requirements. f Biologically based mental illnesses
are defined as (1) schizophrenia, (2) schizoaffective disorder,

(3) major depressive disorder, (4) bipolar disorder, (5) paranoia and
other psychotic disorders, (6) obsessive- compulsive disorder, (7) panic
disorder, (8) delirium and dementia, (9) affective disorders, and (10) any
biologically based mental disorders appearing in the DSM that are
scientifically recognized and approved by certain state officials. Rape-
related services include the diagnosis and treatment of rape- related
mental or emotional disorders for victims of a rape or an assault with
intent to commit rape. Covered services for children under 19 include the
diagnosis and treatment of nonbiologically based mental, behavioral, or
emotional disorders that substantially interfere with or substantially
limit the functioning and social interactions of such child or adolescent,
evidenced by (1) inability to attend school as a result of the disorder;
(2) need to hospitalize as a result of the

disorder; or (3) a pattern of conduct or behavior caused by the disorder
that poses a serious danger to self or others. g State law also mandates
medically necessary minimum benefits of 60 inpatient days and 24
outpatient visits for members over 19 with non- biologically based mental
disorders. Source: Individual state laws.

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. 77 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.)

Table 15: Summary of Selected Laws Related to Mental Health Coverage in
Illinois All HMOs a Group health plans b

Population All enrolled individuals Members with serious mental covered
illnesses c State law Plans must offer an annual

Mental health benefits must be requires minimum of 10 inpatient days and

under the same conditions as 20 individual outpatient visits of coverage
for other illnesses with a mental health coverage

minimum of 45 inpatient days and 35 outpatient visits annually Note: These
state laws generally apply to group health plans that employers purchase
for their employees but not to employers who self- fund their plans,
meaning they pay their employees* health expenses directly. a See 50
Illinois Administrative Code S: 5421.130 (2002).

b See 215 Illinois Compiled Statutes Annotated S: 5/ 370c (2001). c
Serious mental illness means the following psychiatric illnesses as
defined in the most current edition of the DSM published by the American
Psychiatric Association: (1) schizophrenia; (2) paranoid and

other psychotic disorders; (3) bipolar disorders (hypomanic, manic,
depressive, and mixed); (4) major depressive disorders (single episode or
recurrent); (5) schizoaffective disorders (bipolar or depressive); (6)
pervasive developmental disorders; (7) obsessive- compulsive disorders;
(8) depression in childhood and adolescence; and (9) panic disorder. See
215 Illinois Compiled Statutes Annotated S: 5/ 370c (2001).

Source: Illinois state law.

77 For individuals who do not suffer serious mental illness, Illinois law
requires group plans to offer coverage for reasonable and necessary
treatment and services, but permits the plan to require the insured to pay
up to 50 percent of treatment expenses.

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.
78 Utah*s law requires only that group health plans offer mental health
coverage as an option.

78 However, Georgia law permits individual and small group major medical
health plans to impose annual limits on the number of inpatient treatment
days and outpatient treatment visits for mental health benefits that
differ from those imposed for physical illnesses.

Selected Federal Grant Programs That May Be Used to Help Children Exposed
to Trauma

Appendi x VI

Obtain Mental Health Services 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.

Table 16: Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Department of Agriculture Cooperative State Research, Education, and
Extension Service

Discretionary grants

Children, Youth and $8, 481,000 Land grant Children and youth at risk

To support educational programs that Families at Risk universities* of not
having their

target high- risk youth. Programs may extension fundamental needs for

include mental health education and services safety, shelter, food, and
referrals. Activities allowed under this care met

grant include parental education, public awareness programs, and technical
assistance and training to providers who interact with children and their
families.

Department of Education

Office of Elementary and Secondary Education

Formula grants

Safe and Drug- Free $472,017,000 State Children and youth who To support
programs that prevent violence

Schools and departments of

are enrolled in and in and around schools, prevent illegal use

Communities: State education

attending school of alcohol, tobacco, and drugs, and

Grants (primarily kindergarten coordinate with federal, state, school, and
through grade 12)

community efforts to foster a safe and drug- free learning environment.
Governors

Children and youth not The Governor*s Program supports

normally served by state programs of drug and violence prevention or local
educational

and early intervention by communitybased agencies, or populations

organizations and other public and that need special

private entities. services or additional resources (for example, For both
these program components, youth in detention

medical treatment is prohibited but facilities, runaway and

counseling and therapeutic services homeless youth)

provided by mental or behavioral health professionals are allowed.

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Discretionary grants

School Emergency $10,000,000 Localeducational

School- aged children and To help schools respond to immediate and
Response to agencies others affected by school

long- term needs resulting from a violent or Violence violence
(kindergarten

traumatic crisis and to provide increased (Project SERV) through grade 12)

security and ongoing counseling. The program can support screening,
assessment, counseling, and referrals to mental health professionals.

Elementary School $32,500,000 Localeducational

Children, families, To support the establishment or Counseling

agencies schools, and counseling expansion of elementary school
Demonstration

staff counseling programs, including hiring and Program

training of school counselors, school psychologists, and school social
workers. School counseling programs are

encouraged to provide in- service training on counseling issues to school
personnel.

Department of Health and Human Services (HHS)

Administration for Children and Families

Formula grants

Child Abuse and $22,013,000 States Abused and neglected

To support and improve state child Neglect State

children and their families protective service systems. Funds can be
Grants

used to develop structural elements that could help with mental health
service delivery to children in the child protection

system. Child Welfare $291,986,000 States, Indian Families and children in

To establish, extend, and strengthen child Services: State tribes need of
child welfare

welfare services provided by public Grants services

welfare agencies to enable children to remain in their own homes, or,
where that is impossible, to provide alternate

permanent homes for them. Allowable services include mental health
screening, assessment, treatment, and referral.

Promoting Safe and $375,000,000 States, certain

Families and children in To assist families and children to stabilize

Stable Families Indian tribes that need of services to

their lives, prevent out- of- home placement are determined

stabilize their lives, of children, enhance child development, to be
eligible enhance child

and increase competence in parenting based on grant development, and

abilities. Mental health service may be formula promote adoption

provided if it promotes adoption or family preservation needs.

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Children*s Justice $17,000, 000 c States Victims of child abuse

To improve the handling and prosecution Act Formula Grant and neglect,
child sexual

of child abuse cases and reduce trauma abuse and exploitation

for children. The grant does not fund direct service provision, but could
support child State governments

advocacy centers and mental health referrals and assessments. Family
Violence

$116,918, 000 c States, Indian Victims of family violence To assist in
establishing, maintaining, and

Prevention and tribes,

and their dependents expanding programs and projects to Services/ Grants
for tribal

prevent family violence and to provide Battered Women*s

organizations immediate shelter and related assistance Shelters: Grants to

for victims of family violence and their States and Indian dependents.
Children*s mental health Tribes

services are not a focus of this program, but may be supported by grant
recipients.

Family Violence $11,937, 300 c State domestic Victims of domestic

To support planning and coordination Prevention and violence

violence, their efforts, intervention and prevention Services/ Grants for
coalitions

dependents, families, activities, and efforts to increase the Battered
Women*s

other interested persons, public awareness of domestic violence Shelters:
Grants to

and the general public issues and services for battered women State
Domestic and their children. Children*s mental Violence Coalitions

health services are not a focus of this program, but may be supported by
grant recipients.

Social Services $1,700,000,000 States Individuals and families in To
assist states in delivering a wide range Block Grant need of social
services of social services to needy children and

adults. States may address the prevention of neglect, abuse, or
exploitation of children and adults. Service categories include counseling
services and information and referral services.

Temp or a r y $16, 488, 667, 000 c States, federally Needy families with

To provide assistance so that children can Assistance

recognized children be cared for in their own homes, including for Needy
Families tribes, specified collaboration with child welfare services to
Alaskan

identify and provide counseling services Native entities

to children in needy families who are at risk of abuse or neglect; to
reduce dependency by promoting job preparation, work, and marriage; to
reduce and prevent out- of- wedlock pregnancies; and to encourage the
formation and

maintenance of two- parent families.

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Discretionary grants

Child Abuse and $26,150,000 Grants:

Abused and neglected To improve activities to prevent, assess, Neglect
Depending on children and their families identify, and treat child abuse
and neglect Discretionary grant priorities,

through research, information Activities

may include state dissemination, and technical assistance.

and local public agencies, nonprofit

organizations, universities Contracts: Forprofit companies, small
businesses, and other organizations meeting qualifications of the request
for

proposals Family Violence

$11,937, 300 c Public and Victims of family violence,

To establish, maintain, and expand Prevention and

private agencies, their dependents, programs to prevent family violence
and Services/ Grants for

federally families, other interested provide immediate shelter and
assistance

Battered Women*s recognized

persons, and the general to victims and their dependents through Shelters:

Indian tribes, public

the funding of federally selected subject Discretionary Grants

Alaska Native areas, such as family violence community villages,

awareness campaigns. Children*s mental or Alaska Native

health services are not a focus of this Regional

program, but may be supported by grant Corporations

recipients. Grants to States for

$10,000, 000 c States Custodial and To support and facilitate access and
Access and

noncustodial parents and visitation by noncustodial parents with
Visitation Programs

children their children. Activities may include mediation, counseling,
development of parenting plans, visitation enforcement, and development of
guidelines for visitation.

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Head Start d $6,535,000,000 Localities, Low income children, To ensure
school readiness and parental

federally birth to approximately age

involvement and to promote recognized

5 comprehensive health, educational, Indian tribes,

nutritional, social, and other services for public or private

low- income children. Grantees are nonprofit or forprofit encouraged to
build collaborative agencies relationships with mental health providers
and promote access to mental health services, including screening,
assessments, and referrals.

Runaway and $41,963,780 States, localities,

Runaway and homeless To assist community programs that

Homeless Youth federally

youth under the age of 21 address the immediate needs of runaway

(Basic Center recognized

and their families youth and their families. Services are

Program) Indian tribes,

delivered outside of law enforcement, private entities, child welfare,
mental health, and juvenile and coordinated

justice systems, and may include mental networks of

health screening, treatment, referral, and these

public awareness programs. entities. None of these entities may be part of

the law enforcement or juvenile justice system.

Education and $14,999,000 Private nonprofit

Runaway and homeless To provide street- based services to youth Prevention
to

agencies, street youth under the living on the street who are at risk of,
or

Reduce Sexual including age of 21

being subjected to, sexual abuse, Abuse of Runaway, nonfederally
prostitution, or sexual exploitation. Homeless

recognized Allowable activities include mental health

and Street Youth Indian tribes and screening, treatment, referral, and
public urban Indian awareness programs. organizations

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Transitional Living $39,201,020 States, localities,

Homeless youth, ages 16 To establish and operate transitional living for
Homeless Youth federally

to 21 projects, promote self- sufficiency, and recognized avoid long- term
dependency for homeless Indian youth. Services may include counseling or
organizations, mental health referrals.

private entities, and coordinated networks of these entities. None of
these entities may be part of the law

enforcement or juvenile justice system.

Centers for Medicare & Medicaid Services

Formula grants

Medical Assistance $143, 029, 433, 000 c States Low- income persons who To
assist states in the provision of

Program (Medicaid) are over age 65, blind or adequate medical care to
eligible needy

disabled, members of persons.

families with dependent children, low- income children and pregnant

women, certain Medicare beneficiaries, and others as determined by the
state within federal guidelines

State Children*s $3, 115, 200, 000 c States Targeted low- income

To initiate and expand health assistance Health Insurance

children to uninsured, low- income children. Program

Health Resources and Services Administration

Formula grants

Maternal and Child $595,727, 279 c States Pregnant women, To maintain and
strengthen state

Health Services mothers, infants and

leadership in planning, promoting, Block Grant to

children, and children coordinating, and evaluating health care States
with special health care services. Allowable services can include needs,
particularly those

mental health screening, diagnosis, of low- income families referral,
parent and public education, and training of professionals.

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Discretionary grants

Community Health $1,077,578,000 Public and

People in medically To develop and operate community health Centers e
nonprofit

underserved areas centers that provide preventive and private entities,
primary health care services, and link including faithbased clients with
Medicaid and mental health

and and substance abuse treatment. communitybased Allowable services
include mental health screening, diagnosis, treatment, referral,

organizations and public awareness programs.

Health Center $109,790,000 Public and

Homeless individuals, To deliver primary health services and Grants
nonprofit

including children substance abuse services. Allowable for Homeless

private entities, services include mental health screening, Populations e

including faithbased diagnosis, treatment, referral, and public

and awareness programs. communitybased

organizations Health Centers

$113,617,000 Public and Migrant agricultural

To develop and operate health centers Grants

nonprofit workers, seasonal

and migrant health programs that provide for Migrant and

private entities, agricultural workers, and primary health care services,

Seasonal including faithbased members of their families

supplemental health services, technical Farmworkers e and assistance, and
environmental health communitybased services. Allowable services include
mental health screening, diagnosis, organizations

treatment, referral, and public awareness programs.

Health Centers $16,237,000 Public and

Residents of public To improve access to primary care Grants nonprofit

housing services and to reduce infant mortality by for Residents of
private entities, providing public housing residents health Public Housing
e

including faith services. Allowable services include based and mental
health screening, diagnosis, community

treatment, referral, and public awareness based

programs. organizations

Healthy Schools, $19,500,000 Public and

Students attending To increase access to comprehensive

Healthy nonprofit

schools (kindergarten primary and preventive health care for Communities e

private entities, through grade 12) that underserved children,
adolescents, and

including faith serve low income or high

their families. Allowable services include based and risk children

mental health screening, diagnosis, community treatment, referral, and
public awareness based

programs. organizations

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Emergency Medical $18,986, 000 c States, schools

Children who come in To improve existing emergency medical Services for

of medicine contact with emergency services systems and develop and
Children f

medical services systems evaluate improved procedures and protocols for
treating children. Allowable activities include development of mental
health practice guidelines, prevention activities, and training of
professionals. Indian Health Services

Discretionary grants

Urban Indian Health $1, 352,654 Urban Indian Indians residing in urban To
provide health- related services, Program organizations

centers including mental health services, alcohol with which the and
substance abuse services, Secretary of

immunization services, and child abuse Health and

prevention and treatment. Allowable Human Services

activities include mental health screening, has entered into

treatment, referral, and public awareness a contract or

programs. grant under Title V of the Indian Health Care

Improvement Act Office of the Secretary

Discretionary grants

Public Health and $265,000, 000 g Federal Individuals and families in To
provide supplemental funding for public Social Services agencies,

areas affected by public health and social service emergencies. Emergency
Fund

states, localities, health and social services

and other service emergencies

providers in affected areas

Substance Abuse and Mental Health Services Administration Formula grants

Community Mental $398,999, 999 c States Children with serious

To enable states to implement a Health Services

emotional disturbance comprehensive community- based system Block Grant

and adults with serious of care for children with serious emotional mental
illness disturbance and adults with serious mental illness. Allowable
services are defined by the state*s mental health plan, and can include
outreach, mental and other health care services, individualized supports,
rehabilitation, housing, and

education.

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Discretionary grants

National Child $30,000,000 States, localities,

Children and adolescents To identify or develop effective treatments
Traumatic Stress

Indian tribes, exposed to trauma,

and services; collect clinical data on child Initiative h nonprofit

service providers, and trauma cases and services; develop organizations
researchers

resources on trauma for professionals, consumers, and the public; develop
trauma- focused public education initiatives and professional training
programs.

Circles of Care $2, 400,000 Tribal American Indian/ Alaskan To provide
American Indian/ Alaska Native governments, Native children and their
communities with tools and resources to urban Indian families who are

design systems of care for people with organizations

experiencing or at risk for mental health service needs. Allowable serious
emotional activities include public awareness

disturbance programs and professional training.

Community $7, 800, 000 c Local

Youth, community To promote mental health and prevent Prevention
governments, providers, and localities youth violence and substance abuse
Coalitions

local private through the development of self (Partnership)

nonprofit sustaining coalitions between government Demonstration

organizations and community service delivery systems. Grant and agencies i

Allowable activities include mental health screening, treatment, referral,
and public awareness programs.

Community Action $5, 500,000 States, localities,

Children with serious To adopt and implement exemplary Grants for Service

nonprofit emotional disturbance

practices related to the delivery and System Change

organizations, and adults with serious

organization of mental health services for tribal

emotional illness children with serious emotional governments disturbance,
adults with serious mental illness, and those with co- occurring
disorders.

Comprehensive $96,000,000 States, localities,

Children under age 22 To develop collaborative community Community Mental
federally

with a diagnosed serious based systems of care. Grantees will

Health Services for recognized tribal emotional disturbance, ensure that
children receive an Children and Their

governments serious behavioral individualized service plan; each plan
Families

disorder, or serious designates a case manager; and funding

mental disorder is provided for the mental health services

required to meet the child*s needs.

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Targeted Capacity $14,500,000 Localities, Indian

Children (pre- natal to 18), To increase the capacity of cities,

Expansion tribes youth in the juvenile counties, and tribal governments to
Cooperative

justice system, homeless provide prevention and treatment services

Agreements to Meet persons, persons with cooccurring

to meet emerging and urgent mental Emerging and

mental illness health needs in their communities by Urgent Mental and
substance abuse, building service system infrastructure.

Health Services and adults in the criminal Allowable activities include
mental health

Needs of justice system. Five and screening, assessment, treatment,

Communities: one- half million of the

referral, and parent education. Building Mentally

total $14.5 million was Healthy

targeted for children, Communities

prenatal to 18. Youth Violence

$9, 100,000 States, localities, Children and families To support
collaborations of community

Prevention private organizations to promote the prevention of

Cooperative organizations, youth violence, substance abuse, and

Agreements Indian tribes,

other mental health and behavior Cooperative schools and

problems, and to implement interventions Agreements for

school systems, and treatment services to enhance Collaborative community

positive mental health in youth. Allowable Community Actions

coalitions. Only activities include youth violence

To Prevent Youth education,

prevention and mental health promotion Violence and mental health,
activities and programs. Promote Youth

and substance Development

abuse agencies of state and local governments may apply.

Department of Justice

Office of Justice Programs

Formula grants

Crime Victim $93,957, 000 j States Victims of crime that To compensate
crime victims for Compensation results in physical or

expenses resulting from the crime, personal injury k including mental
health counseling and care, loss of wages, and funeral

expenses. Crime Victim

$383,027, 323 j States Victims of crime and To support state victim
assistance Assistance those who are survivors

programs. These programs provide funds of victims of crime

to community agencies that assist crime victims through crisis
intervention, counseling, emergency shelter, and criminal justice
advocacy.

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Discretionary grants

Child Development: $514, 000 l University m Children and youth

To develop a model program to help police Community Policing exposed to
family, school,

officers and mental health professionals and community violence,

provide each other with training, and professionals who

consultation, and support and provide respond to community

direct intervention to children who are violence victims, witnesses, or
perpetrators of violent crime.

Safe Havens: $15,000,000 States, local Children and parents in

To support safe places for supervised Supervised governments, abusive
situations visitation and safe exchange of children by Visitation and
Indian tribal

and between parents through and Safe Exchange governments in
implementation, planning, and Grant Program

cooperation with demonstration grants. Implementation

public or private funds may be used to expand the services

entities offered by supervised visitation centers, including mental health
services.

Safe Kids/ Safe $3, 000, 000 n Local

Children and adolescents To break the cycle of early childhood Streets
Initiative communities,

who have been, or are at victimization and later juvenile Indian tribal
risk of being, abused or

delinquency by strengthening community Governments o

neglected, and their approaches, including system reform, families

provision of services, prevention education, and data collection and
evaluation. Allowable services include mental health screening, referral,

counseling, and public awareness. Safe Start Initiative $10,000,000
States, localities,

Children between birth To create comprehensive community and tribal

and age 6 at high risk of service delivery systems by expanding
governments

exposure to violence or partnerships and improving access to

applying on who have been exposed services for young children at high risk
of

behalf of a to violence exposure to violence, or who have been

collaborative exposed to violence, and their families. group of public or
Grantees may provide mental health private agencies screening, treatment
services, referrals, and and public awareness as part of their
organizations

program. Tribal Youth

$1, 000,000 Federally American Indian and To improve mental health and
substance Program, Mental

recognized Alaskan Native Youth abuse services for American

Health Project American Indian

Indian/ Alaskan Native youth and to and Alaskan support juvenile
delinquency prevention Native tribes and intervention efforts by
developing culturally sensitive services for youth involved in or at risk
of needing tribal or state juvenile mental health programs.

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Victims of Child $23,085, 926 c National

Children, families, and To promote training of judicial personnel Abuse
organizations

agencies who provide regarding child abuse, investigation and designated
in the services to child abuse

prosecution of child abuse through the congressional victims

criminal justice system, court- appointed appropriations special
advocates, and children*s process. Funds

advocacy centers. are provided to the National Children*s Alliance to

support Children*s Advocacy

Centers. Funds also support National Court Appointed Special Advocates.

Children*s Justice $3, 000, 000 c Federally

Native American youth To improve how child sexual abuse cases

Act Partnerships for recognized

who are victims of child are handled by American Indian tribes

Indian Communities Indian tribes,

abuse with emphasis placed on reducing nonprofit Indian additional trauma
to the child victim.

organizations Allowable services include mental health treatment and
support services, referral to

mental health providers, and public awareness programs.

Crime Victim $17,817, 630 c American Indian

Victims of federal crimes, To support training and technical

Assistance/ and Alaska

victim assistance assistance to crime victim assistance

Discretionary Grants Native tribes and

agencies programs, fund demonstration projects

tribal conducted by assistance programs, and

organizations, support services provided to victims of states, eligible
federal crimes assistance programs. This victim service

grant supports the Crime Victim agencies, private

Assistance in Indian Country program. nonprofit agencies, and others.
Eligible applicants vary based on the

grant program.

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Rural Domestic $39,945,000 Rural states:

Rural women and To support projects that provide treatment,

Violence and Child states, localities, children who are the

counseling, and assistance to victims of Victimization

nongovernmental victims of domestic

child abuse, dating violence, and domestic Enforcement Grant agencies, and

violence, dating violence, abuse; to address cooperative efforts Program

federally and child abuse

between systems to investigate and recognized

prosecute cases; and to develop Indian tribes p

prevention and education strategies. Nonrural states: states on behalf of
rural

communities in the state

Multiagency

Discretionary grants

Collaborations To $3, 750, 000 r Nonprofit Maltreated children and

To promote collaborations between child Address Domestic organizations

parents who have protective services, domestic violence Violence and Child
and government

experienced domestic service providers, courts, and community Maltreatment

agencies violence

groups and to plan and implement policies (HHS/ Justice) q

and procedures that promote the safety and well- being of battered parents
and their maltreated children.

Crisis Counseling $16,240, 509 s States Disaster victims in

To provide immediate, short- term crisis Assistance and

federally designated counseling services to address mental

Training Program major disaster areas

health problems caused or aggravated by (Federal Emergency a major
disaster or its aftermath. Management Agency/ HHS)

Safe $171,588,449 t Local education Preschool and school age

To assist school districts in developing Schools/ Healthy agencies in
children, adolescents, comprehensive services to promote Students
partnership with

and healthy childhood development and

(Education/ local public

their families who are at prevent violence and alcohol and other

HHS/ Justice) mental health

risk of being involved in drug abuse. Grantees must enter into a
authorities, law

violence formal agreement with mental health

enforcement as perpetrators, victims, service providers that describes
referrals

agencies or witnesses

and other procedures for providing mental health services to students.

(Continued From Previous Page)

Funding for fiscal year 2002

(unless otherwise

Eligible Grant/ agency noted) a applicants b Targeted beneficiaries Grant
program description

Mental Health and $6, 072,466 Federally

Tribal Indian communities To establish demonstration programs that
Community Safety

recognized with youth mental health

promote Indian youth mental health, Initiative for

Indian tribes, and community safety

education, and substance abuse- related American

tribal problems (for example, services, and support juvenile

Indian/ Alaska Native organizations child abuse and youth

delinquency prevention and intervention Children, Youth and violence)

through the development of culturally Families Grants

sensitive programs. Allowable services (Justice/ HHS/ include mental
health screening, Education/

treatment, referral, and public awareness Department of the

programs. Interior) u

a All funding is amount appropriated unless otherwise noted. b In this
column, the term "state" includes the District of Columbia, the
Commonwealth of Puerto Rico, the United States Virgin Islands, and
generally any other territory or possession of the United States unless
otherwise noted. c Estimated fiscal year 2002 obligations.

d This program description includes Head Start and Early Head Start. Head
Start and Early Head Start programs are for children from birth to the age
when the child enters the school system, which will vary by child. Head
Start and Early Head Start must serve children until kindergarten or first
grade if

kindergarten is not available in the child*s community. e Community Health
Centers, Health Center Grants for Homeless Populations, Health Centers
Grants

for Migrant and Seasonal Farmworkers, Health Centers Grants for Residents
of Public Housing, and Healthy Schools, Healthy Communities are all part
of HRSA*s Consolidated Health Centers Program. Under this program there
have been periodic opportunities for existing grantees to compete for
additional program funds to help them expand and enhance specific
services, such as mental health/ substance abuse services. f This program
is jointly administered with the Department of Transportation*s National
Highway Traffic

Safety Administration. g Estimated fiscal year 2001 obligations.

h This program is not currently accepting new applications. i The
localities and nonprofit organizations/ agencies that are designated to
act on behalf of a larger coalition may apply. The coalition must consist
of at least seven organizations or agencies. j Fiscal year 2002
allocation.

k Victims must be determined to be eligible under the state victim
compensation statute, which may declare that coverage extends generally to
any crime resulting in injury, or may list all specific crimes that can be
covered. l Fiscal year 2000 obligation.

m This grant was awarded to the Child Development- Community Policing
Program at the Yale Child Study Center at the Yale University School of
Medicine, in collaboration with the New Haven Department of Police
Service, New Haven, Connecticut. n Fiscal year 2002 obligation.

o Units of local or state governments and nonprofit agencies may apply for
the grant on behalf of a collaboration of community groups.

p States designated as rural are Alaska, Arizona, Arkansas, Colorado,
Idaho, Iowa, Kansas, Maine, Montana, Nebraska, Nevada, New Mexico, North
Dakota, Oklahoma, Oregon, South Dakota, Utah, Vermont, and Wyoming. q This
program is more commonly referred to as the *Greenbook Project,* and is a
one- time

demonstration initiative. r Funds are not separately appropriated for this
program, rather, they are allocated by the participating

agencies from discretionary accounts. s Fiscal year 2001 obligation.

t Estimated fiscal year 2002 obligation as of July 22, 2002. u The
departments participating in this initiative, which is administered by
HHS*s Indian Health Service, have identified several grant programs that
will be coordinating in this effort, including Justice*s

Community- Oriented Policing Services Public Safety Partnership and
Community Policing Grants, funded in cooperation with Education, and HHS*s
American Indian and Alaskan Native Community Planning program. The
initiative also involves Justice*s Tribal Youth Program, Mental Health
Project and HHS*s Circles of Care Program, which are described in this
table, respectively, under Justice*s Office of Justice Programs
discretionary grants and HHS*s SAMHSA discretionary grants. Sources:
Agency program officials, GAO analysis of agency grant documents, and the
Catalog of

Federal Domestic Assistance (Washington, D. C.: General Services
Administration, 2002), http:// www. cfda. gov, (downloaded at various
times between September 2001 and August 2002).

State Crime Victim Compensation Benefits,

Appendi x VII

May 2002 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.)

Table 17: Crime Victim Compensation Maximum Overall Benefits and Maximum
Mental Health Benefits State Maximum overall per crime Maximum mental
health counseling benefits per crime

Alabama $15, 000 Up to 50 outpatient treatment sessions in 2 years ($ 6,
250 cap); $15,000 cap for inpatient treatment.

Alaska $40, 000; $80,000 in death cases with $2, 600 cap for primary
victims; $600 cap for secondary victims; multiple victims $1, 200 cap for
custodial parents of sexually abused victims

Arizona $20, 000 Up to 36 months Arkansas $10, 000; $25,000 for
catastrophic

$3, 500 cap outpatient; $3, 500 cap inpatient injuries a California $70,
000 $10,000 cap for direct victims, family of homicide victims, custodial

parents or primary caretakers of minor victims, and per relative in
homicides; $3,000 cap for other secondary victims Colorado $20, 000 (each
judicial district in the state

Determined by district compensation programs (each district can may set
lower maximum) b specify limits)

Connecticut $15, 000; $25,000 in homicides $15,000 cap; $25, 000 cap in
homicides (up to six sessions for family of homicide victims without
submitting application for compensation)

Delaware $25, 000; $50,000 for catastrophic $25,000 cap; $50, 000 cap in
catastrophic cases

injuries a District of Columbia $25, 000 $25,000 cap Florida $25, 000;
$50,000 in catastrophic cases a $2, 500 cap or up to 3 years for adults;
$10,000 cap for minor

victims; $2, 500 cap for child witnesses

(Continued From Previous Page)

State Maximum overall per crime Maximum mental health counseling benefits
per crime

Georgia $25, 000 $3, 000 cap Hawaii $20, 000 $5, 000 cap Idaho $25, 000
$2, 500 cap for direct victims; $500 cap per family member in homicide and
sexual assault victims (maximum of $1,500 per

family) Illinois $27, 000 $27,000 cap Indiana $15, 000 $1, 500 cap for
direct victims if therapist charges sliding scale fees

based on victims* income and $1,000 cap if no sliding scale used; $1, 000
cap per family member in homicide, sexual assault, and domestic violence
cases

Iowa No overall limit; maximums for each $3, 000 cap for nonmedical
therapy; therapy under psychiatrist*s expense category, e. g., $15,000
medical supervision is considered under medical benefits category with

$15,000 cap for primary victims and $3,000 limit for survivors of homicide
victims; $1, 000 cap per family member of non- homicide victims

Kansas $25, 000 $3, 500 cap; $1,000 cap per family member in homicides
Kentucky $25, 000 $25,000 cap Louisiana $10, 000; $25,000 when injuries
result in Up to 26 sessions or 6 months, whichever comes first, with $5,
000

total and permanent disability cap for direct victims, $2,000 cap for
indirect victims Maine $15, 000 $15,000 cap Maryland $45, 000 $5, 000 cap;
$1,000 cap for each family member up to $5,000 Massachusetts $25, 000
$25,000 cap Michigan $15, 000 Up to 26 sessions Minnesota $50, 000 $7, 500
cap for direct victims; up to 20 sessions for each secondary

victim Mississippi $15, 000 $3, 000 cap Missouri $25, 000 $2, 500 cap
Montana $25, 000 $2, 000 cap or 12 months with possibility of extension
(based on review by a mental health professional working with the Crime

Victims Unit Board of Control) for primary victims; for secondary victims,
$2,000 cap or 12 months per person for spouse, parent, child, or sibling
of a homicide victims and for the parent or sibling of a minor who is the
victim of a sex crime

Nebraska $10, 000 $2, 000 cap Nevada $50, 000 $3, 500 cap; additional $5,
000 in extreme cases New Hampshire $10, 000 per primary victim and $2, 000
cap

secondary victim for each victimization occurring on or after July 1,
1997; $5, 000 otherwise

New Jersey $25, 000; $50,000 for catastrophic Up to 100 sessions or
$10,000 cap, whichever is greater

injuries a New Mexico $20, 000; $50,000 for catastrophic Up to 30
sessions; preauthorization required for additional sessions injuries a

(Continued From Previous Page)

State Maximum overall per crime Maximum mental health counseling benefits
per crime

New York No medical maximum; $30,000 lost No categorical limit wages/
support North Carolina $30, 000; $33,500 in homicides Up to 1 year for
adults; 2 years for children age 10 and under

North Dakota $25, 000 80% of charges Ohio $50, 000 per victim per incident
$50,000 cap; $2,500 cap per immediate family member Oklahoma $20, 000 $3,
000 cap for primary victims may be waived in extreme cases. For families
of homicide victims, $500 cap per person and $3, 000

cap per family. Complex or lengthy therapy is reviewed by panel composed
of mental health professionals working with the Crime Victims Compensation
Board. Oregon $44, 000 $20,000 cap for direct victims and family in
homicides; $10,000 cap

for children who witness domestic violence; limited family therapy in
child sexual abuse cases Pennsylvania $35, 000 $35,000 cap Puerto Rico
$3,000 per person; $5,000 per family $3, 000 cap per person; $5, 000 per
family Rhode Island $25, 000 $25,000 cap South Carolina $15, 000; $25,000
for catastrophic injuries

Up to 180 days of treatment or 20 sessions, whichever is greater per Crime
Victims* Advisory Board approval a

South Dakota $15, 000 Up to 24 sessions for primary victims; 18 sessions
for family members in homicides; 6 sessions for parents of juvenile
victims and spouses of rape victims

Tennessee $30, 000 $30,000 cap Texas $50, 000; with additional $75,000 for

$3, 000 cap; $400 per day, 30- day limit on inpatient psychiatric care
catastrophic injuries a Utah $25, 000; $50,000 medical in homicide,

$2, 500 cap for primary victims; $1,000 cap for secondary victims
attempted homicide, aggravated assault,

(immediate family members, individuals residing in the household drunk
driving

at the time of the crime, and other individuals essential to wellbeing and
treatment of primary victims); may be extended after review by mental
health professionals working with the Office of Crime Victim Reparations

Vermont $10, 000 Up to 20 sessions with treatment plan, may request
extensions at 20- session increments for crime- related symptoms still
needing treatment

Virginia $15, 000 $15,000 cap for direct victims; $2, 500 cap for
survivors of homicide victims

Virgin Islands $25, 000 Up to 10 sessions Washington $150,000 for medical
and mental health

Up to 40 sessions for children; reports are required after 6 sessions
costs, which may be waived in special

and after 15 sessions; report to the state Crime Victim circumstances;
$30,000 for nonmedical

Compensation Program and preauthorization required for more expenses;
$40,000 for pension and death

sessions. benefits, less other nonmedical expenses paid

West Virginia $25, 000 in personal injury cases; $25,000 cap for direct
victims; $1, 000 cap for secondary victims $35, 000 in homicides

(Continued From Previous Page)

State Maximum overall per crime Maximum mental health counseling benefits
per crime

Wisconsin $40, 000; plus additional $2,000 for $40,000 cap funeral
expenses Wyoming $15, 000; $25,000 for catastrophic $15,000 cap direct
victims; $1, 500 cap for associated victims injuries a a Each state uses
its own definition of catastrophic injuries.

b In Colorado, each of the 22 judicial districts has a victim compensation
program. Source: National Association of Crime Victim Compensation Boards,
2002.

Comments from the Federal Emergency

Appendi x VIII Management Agency

Comments from the Department of Health and

Appendi x IX Human Services

Appendi x X Comments from the Department of Education

Appendi x XI

GAO Contact and Staff Acknowledgments GAO Contact Helene F. Toiv, (202)
512- 7162 Staff

In addition to the person named above, key contributors to this report
were Acknowledgments

Susan Anthony, Alice L. London, Janina Austin, Sari Bloom, Emily Gamble
Gardiner, William D. Hadley, Christi Turner, and Behn Miller.

Related GAO Products

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.

(290097)

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a

GAO United States General Accounting Office

Page i GAO- 02- 813 Child Trauma and Mental Health Services

Contents

Contents

Page ii GAO- 02- 813 Child Trauma and Mental Health Services

Contents

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Page 1 GAO- 02- 813 Child Trauma and Mental Health Services United States
General Accounting Office

Washington, D. C. 20548 Page 1 GAO- 02- 813 Child Trauma and Mental Health
Services

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Appendix I

Appendix I Scope and Methodology

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Appendix I Scope and Methodology

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Appendix II

Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix II Victimization Data

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Appendix III

Appendix III Information on SCHIP Programs in the 50 States and the
District of Columbia

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Appendix III Information on SCHIP Programs in the 50 States and the
District of Columbia

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Appendix IV

Appendix IV Selected Individual Insurers* Coverage for Specified Mental
Health Coverage in Six States as of 2002

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Appendix V

Appendix V Summary of Selected Laws Regarding Mental Health Coverage in
Six States

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Appendix V Summary of Selected Laws Regarding Mental Health Coverage in
Six States

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Appendix V Summary of Selected Laws Regarding Mental Health Coverage in
Six States

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Appendix VI

Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VI Selected Federal Grant Programs That May Be Used to Help
Children Exposed to Trauma Obtain Mental Health Services

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Appendix VII

Appendix VII State Crime Victim Compensation Benefits, May 2002

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Appendix VII State Crime Victim Compensation Benefits, May 2002

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Appendix VII State Crime Victim Compensation Benefits, May 2002

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Appendix VIII

Appendix VIII Comments from the Federal Emergency Management Agency

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Appendix IX

Appendix IX Comments from the Department of Health and Human Services

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Appendix IX Comments from the Department of Health and Human Services

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Appendix IX Comments from the Department of Health and Human Services

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Appendix IX Comments from the Department of Health and Human Services

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Appendix IX Comments from the Department of Health and Human Services

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Appendix X

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Appendix XI

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