• Tue. Mar 28th, 2023

Medicaid Protection of Behavioral Well being Providers in 2022: Findings from a Survey of State Medicaid Packages


Mar 17, 2023

Medicaid performs a key position in protecting and financing take care of individuals with behavioral well being circumstances. Practically 40% of the nonelderly grownup Medicaid inhabitants (13.9 million enrollees) had a psychological well being or substance use dysfunction (SUD) in 2020. Most enrollees with behavioral well being circumstances qualify for Medicaid due to their low incomes. Behavioral well being providers will not be a particularly outlined class of Medicaid advantages: some might fall underneath obligatory Medicaid profit classes (e.g., psychiatrist providers could also be coated underneath the “doctor providers” class), and states may additionally cowl behavioral well being advantages by elective profit classes (e.g., case administration providers, prescribed drugs, and rehabilitative providers). Behavioral well being providers for youngsters are significantly complete as a consequence of Medicaid’s EPSDT profit for youngsters: kids identified with behavioral well being circumstances obtain any service obtainable underneath federal Medicaid regulation essential to appropriate or ameliorate the situation. Nonetheless, the identical just isn’t required for adults.

To higher perceive the variation in entry to behavioral well being providers for adults in Medicaid, KFF surveyed state Medicaid officers about behavioral well being advantages coated for grownup enrollees of their fee-for-service (FFS) packages. These questions have been a part of KFF’s Behavioral Well being Survey of state Medicaid packages, fielded as a complement to the twenty second annual finances survey of Medicaid officers performed by KFF and Well being Administration Associates (HMA). A complete of 45 states (together with the District of Columbia) responded to the behavioral well being advantages survey. This problem transient makes use of the survey information to explain the panorama of behavioral well being service protection throughout states, together with themes throughout and inside service classes. Further state-by-state element is accessible in KFF’s Medicaid Behavioral Well being Providers information assortment. Additional coverage context is accessible in a collection of behavioral well being briefs that may be accessed within the “Behavioral Well being Supplemental Survey” part on this web page.

Medicaid protection of behavioral well being providers assorted reasonably throughout states, with the median variety of coated providers at 44 of the 55 providers queried (Determine 1). We supplied state Medicaid officers with an inventory of 55 behavioral well being advantages and requested them to point which have been coated underneath their FFS Medicaid packages for adults, as of July 1, 2022 (for extra data on survey strategies, see Appendix A). We grouped the advantages queried by service class: institutional care/intensive, outpatient, SUD, naloxone (with out prior authorization), disaster, built-in care, and different providers. Notably, all however one state (SC) reported protection of at the least half of all providers queried, with a median protection fee of four-fifths of all providers (44 of 55). These excessive charges of protection mirror state developments in recent times to increase Medicaid providers throughout the behavioral well being care continuum—nonetheless, protection of providers might not translate into entry to care, significantly given workforce shortages that make accessibility a problem for Medicaid enrollees (in addition to individuals with non-public insurance coverage). We additionally requested states that reported protection of every service to point any copay necessities in addition to notable limits on the providers (akin to day limits or different utilization controls, together with prior authorization necessities). Throughout providers, most states reported no copay necessities, however limits have been extra widespread.

These findings are restricted to FFS Medicaid and don’t comprehensively seize variation in protection for managed care organizations (MCOs) or Part 1115 waivers. Inside every service class, we requested states to notice variations in protection for populations receiving providers from MCOs or by Part 1115 waivers. Most states proceed to depend on MCOs to ship inpatient and outpatient behavioral well being providers, and these MCOs might supply providers to their grownup enrollees that differ from these obtainable on a FFS foundation. States additionally might use Part 1115 waivers to function their Medicaid packages in ways in which differ from what’s required by federal statute; these can embody “complete” waivers that make broad modifications in Medicaid advantages and different program guidelines or extra focused demonstrations. For state-specific data on behavioral well being profit protection variation in MCOs or Part 1115 waivers as reported by states, see footnotes on indicators within the information assortment. See additionally Appendix A for a abstract of survey strategies.

Throughout responding states, protection charges have been highest for SUD and outpatient providers and lowest for disaster providers (Determine 2). As indicated in Determine 2, for every service class, nearly all of responding states coated greater than 50% of the providers queried, with at the least a couple of states reporting protection of 100% of providers queried. Some states reported excessive protection charges throughout service classes, together with six states that cowl greater than 90% of all providers queried: NY, AZ, OR, MI, NJ, and WV. Every of those states cowl all providers in a number of of the classes: for instance, MI and OR every cowl 100% of the providers queried within the institutional, outpatient, SUD, and built-in care classes.

Further element on definitions of and developments inside every service class, together with copays and limits, is included within the bullets under. For an in depth desk exhibiting the variety of states with protection of every particular person profit, see Appendix B.

  • Institutional care and intensive providers are sometimes reserved for conditions that require the next stage of care and monitoring, akin to behavioral well being emergencies or long-term remedy for these with ongoing wants. Though a big majority of responding states report protection of inpatient psychiatric hospital providers and 23-hour statement, fewer than half of states report protection of psychiatric residential remedy and grownup group houses. Inside this class, limits and copays are commonest for psychiatric inpatient care, with greater than one-third of protecting states reporting limits and almost one-fifth reporting copays. In states with out Part 1115 waivers of the IMD fee exclusion, the variety of psychiatric or residential care services that settle for Medicaid could also be restricted.
  • Outpatient providers embody a variety of psychiatric providers supplied in outpatient settings. Providers on this class vary from psychiatric testing—which can be used to tell analysis of psychological well being circumstances—to extra intensive providers, like partial hospitalization providers—a extra intensive remedy that happens a number of instances per week on an outpatient foundation. Whereas all or almost all states cowl analysis and testing providers in addition to particular person, household, and group remedy, there may be extra variation in protection of ADL/Expertise coaching, case administration, and day remedy providers. Inside this class, states have been most certainly to report limits for case administration and copays for remedy (particular person, household, or group).
  • Providers to deal with SUD have been queried in classes that observe the extent of care standards from the American Society of Dependancy Drugs (ASAM), starting from early intervention to extra intensive providers, akin to medically monitored intensive inpatient providers (which can be topic to the IMD exclusion). Most states reported the very best protection charges for SUD providers in comparison with the opposite classes, probably bolstered by provisions within the SUPPORT Act. Inside this class, almost all states cowl outpatient SUD remedy, whereas states have been least more likely to cowl clinically managed excessive depth residential providers. As providers develop in depth, the variety of states putting limits on the service additionally will increase. Additionally inside this service class, all or almost all states reported protection of medicines for SUD remedy, together with buprenorphine, naltrexone, and methadone. About one-third of states report limits for buprenorphine, however fewer limits are reported for naltrexone, which isn’t a managed substance. For many SUD medicines, about one-quarter of states report copay necessities (whereas fewer states report copays for providers throughout the ASAM ranges).
    • We additionally requested states to report protection of naloxone (with out prior authorization necessities), which is used to reverse an opioid overdose and is prescribed to individuals with opioid use dysfunction, however could also be obtainable over-the-counter sooner or later. Practically all states cowl at the least one formulation of naloxone with no prior authorization. A handful of states place different limits on these prescriptions and fewer than one-third of states require copays. (Information for this service class just isn’t proven in Determine 2, however might be present in Appendix B.)
  • Disaster providers present specialised responses to enrollees experiencing behavioral well being emergencies. These providers intention to cut back the reliance on regulation enforcement professionals, emergency departments, and different organizations staffed by people who find themselves not behavioral well being professionals. States have been much less more likely to cowl disaster providers in comparison with different classes: for many states, disaster providers was the class for which the state reported the bottom protection fee, together with a number of states that reported protecting none of the disaster providers queried. In distinction, 4 states (AZ, NM, NY, and TN) reported protecting each disaster service queried. The wide selection of protection throughout states might mirror the rising nature of disaster administration in behavioral well being. Inside this class, states most steadily coated cellular disaster providers (about three-quarters of responding states). This comparatively increased protection fee might be partly linked to the American Rescue Plan Act’sprovision of a brand new possibility and enhanced funding for states to supply community-based cellular disaster intervention providers.
  • Built-in care providers present behavioral well being care along with bodily well being care. Examples embody psychological well being screening in major care settings and psychiatric analysis with medical providers. Historically, bodily and behavioral well being providers have been delivered individually, however a rising physique of proof helps their integration. Protection of providers on this class varies; collaborative care mannequin providers are coated least steadily and psychiatric evaluations with medical providers, in addition to Medicaid particular person/household counseling, are coated most frequently. For many built-in care providers, few states reported copays, and limits have been considerably extra widespread (fewer than one-fifth of states).

We additionally requested states to report protection of some further behavioral well being advantages in an “different” class. For instance, greater than four-fifths of responding states cowl peer help providers, that are supplied by people who’ve personally skilled behavioral well being challenges. These professionals might assist enrollees with emotional help or navigation of well being care or different social providers. Peer helps has been recognized as one methodology that states are utilizing to increase the Medicaid behavioral well being workforce.

Wanting forward, states might proceed the pattern of increasing Medicaid behavioral well being advantages and may additionally improve entry to behavioral well being care by different packages or insurance policies. Since FY 2016, behavioral well being advantages have been essentially the most frequent class of service expansions reported on KFF’s annual Medicaid finances survey. For instance, in FY 2022 and/or FY 2023, a lot of states reported increasing protection of disaster providers and/or of providers aimed to enhance the combination of bodily and behavioral well being care. As entry to behavioral well being care is a key Medicaid precedence at each the state and federal ranges, these developments are more likely to proceed into the long run. Notably, complete protection of behavioral well being providers has been linked to increased Medicaid acceptance charges by suppliers. Along with additional increasing protection of behavioral well being providers, states might take further coverage actions to extend entry and enhance outcomes for enrollees with behavioral well being circumstances. For instance, states might pursue initiatives to deal with behavioral well being workforce shortages, akin to by adopting everlasting expansions of behavioral well being telehealth coverage to facilitate entry to care. State Medicaid businesses may additionally play a task in growing, implementing, and serving to to fund a statewide disaster system, together with 988 disaster hotline providers. KFF surveyed states on these and different behavioral well being insurance policies, with the outcomes to be revealed in a collection of briefs that may be accessed within the “Behavioral Well being Supplemental Survey” part on this web page. Lastly, along with state Medicaid coverage, federal laws might proceed to form the behavioral well being panorama for Medicaid enrollees.

This work was supported partly by Properly Being Belief. KFF maintains full editorial management over all of its coverage evaluation, polling, and journalism actions.

This transient attracts on work executed underneath contract with Well being Administration Associates (HMA) consultants Angela Bergefurd, Gina Eckart, Kathleen Gifford, Roxanne Kennedy, Gina Lasky, and Lauren Niles.

Appendix A: Methodology

KFF contracted with Well being Administration Associates (HMA) to survey Medicaid administrators in all 50 states and the District of Columbia to establish these behavioral well being providers coated for grownup beneficiaries of their packages. The survey instrument captured details about providers coated, copay necessities, and notable limits on these providers as of July 1, 2022. The survey information is summarized on this transient and revealed on a state-by-state foundation in KFF’s Medicaid Behavioral Well being Providers information assortment. This information displays what the states reported on the survey; responses range in stage of element and weren’t verified by one other supply.

The survey requested states to report protection of providers of their fee-for-service (FFS) packages for categorically needy (CN) conventional Medicaid adults ages 21 and older. The survey didn’t ask about service protection for medically needy (MN) protection teams, which can differ from the state’s CN profit package deal. Youngsters have been excluded from the survey as a result of all kids underneath age 21 enrolled in Medicaid by the categorically needy pathway are entitled to the Early and Periodic Screening, Diagnostic, and Therapy (EPSDT) profit, which requires states to cowl all screening providers for youngsters in addition to any providers “essential… to appropriate or ameliorate” a toddler’s bodily or psychological well being situation (no matter whether or not the service is roofed for adults). All however six states (AR, DE, GA, MN, NH, UT) submitted survey responses, although in some situations a responding state might have left a specific service row clean. The territories will not be included within the information.

We supplied states with an inventory of 55 elective Medicaid behavioral well being providers. For every service, the state chosen from a sure/no dropdown menu on the survey to point whether or not the service was coated. The listing of behavioral well being providers included on this survey was based mostly on the providers queried by KFF in the same 2018 survey; the 2018 information is accessible within the information assortment. Whereas we have now posted information for each years, the information shouldn’t be in contrast throughout years as a pattern as a consequence of modifications in query phrasing over time.

Word that whereas this survey centered on protection in FFS, most states proceed to depend on MCOs to ship inpatient and outpatient behavioral well being providers, and these MCOs might supply providers to their grownup enrollees that differ from these obtainable on a FFS foundation. States had a chance on the survey to notice variations in required minimal advantages for MCOs, in addition to variations in profit protection underneath Various Profit Plans (profit plans that Medicaid enlargement states are required to design, consistent with federal tips, for newly eligible ACA enlargement adults) or Part 1115 waiver packages. To the extent that they have been reported, these notes are included within the information assortment as state-specific footnotes. Nonetheless, the extent of comprehensiveness of states’ responses in capturing these variations varies, and the extent of data supplied is probably going inconsistent throughout states. Due to this fact, whereas the state-specific footnotes might present helpful context about protection in a person state, they shouldn’t be taken as a whole listing of variations in profit protection underneath managed care, Various Profit Plans, or Part 1115 waiver packages nationally.

Further data on Medicaid protection of behavioral well being providers is accessible right here and right here.

Appendix B: Abstract Desk

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