State Policies Expanding Access to Behavioral Health Care in Medicaid

Key Takeaways

Behavioral well being circumstances—together with psychological diseases and substance use dysfunction (SUD)—are  particularly widespread amongst Medicaid enrollees and have worsened throughout the COVID-19 pandemic. Efforts to handle these points have been a spotlight in Medicaid on the federal degree, together with within the 2018 SUPPORT Act and extra lately within the 2021 American Rescue Plan Act (ARPA), which supplied enhanced Medicaid funding for sure behavioral well being suppliers and cell disaster companies. The proposed Build Back Better Act (BBBA) handed by the Home of Representatives on November 19, 2021 would construct on each ARPA provisions and in addition develop funding for neighborhood psychological well being companies. Additionally, CMS underneath the Biden Administration has identified behavioral well being coverage and investments as a key federal Medicaid precedence.

States are profiting from new federal coverage choices to handle behavioral well being points in Medicaid and are additionally creating different initiatives to enhance psychological well being and substance use outcomes. Outdoors of Medicaid, other state agencies can also take steps to handle behavioral well being outcomes, generally together with Medicaid populations however typically broader. On KFF’s 21^st annual Medicaid budget survey, all responding states reported not less than one initiative to develop behavioral well being care in Medicaid in state fiscal yr (FY) 2021 and/or 2022, together with disaster service and different profit expansions, initiatives to develop telehealth and deal with fairness, and managed care modifications. This temporary summarizes knowledge from this survey, with key findings together with:

• Greater than half of states reported plans to take up the brand new ARPA community-based cell disaster intervention service possibility and about two-thirds reported one other disaster service initiative. States are additionally increasing a variety of different Medicaid behavioral well being companies akin to screening.
• Many states expanded telehealth to extend entry to care throughout the COVID-19 pandemic, and as of July 1, 2021, almost all states lined telehealth supply of behavioral well being companies. Many states plan to proceed this protection post-pandemic. States additionally reported different access-related behavioral well being initiatives together with to handle disparities and to advertise co-location.
• Most states proceed to depend on managed care organizations (MCOs) to ship behavioral well being companies. Most permit MCOs to make use of “in lieu” of authority to cowl sure behavioral well being companies, notably to permit protection of companies supplied in establishments for psychological illness (IMDs).

Some states reported behavioral well being initiatives throughout many areas, typically as a part of wide-ranging statewide initiatives recognized as high priorities for his or her Medicaid applications—examples embrace California, Colorado, Massachusetts, Montana, and Washington. Trying forward, greater than one-third of responding states talked about behavioral well being initiatives as a future precedence, and a number of other recognized behavioral well being companies as an upward spending stress in FY 2022. Continued efforts on the federal degree could have an effect on the extent of enhanced Medicaid funding accessible to states for expanded behavioral well being companies. Moreover, it’s unclear how behavioral well being service patterns could change within the aftermath of the COVID-19 pandemic and whether or not or how states could modify or undertake new initiatives on this space.

Introduction

Medicaid performs a key function in overlaying and financing behavioral health care: in 2020, Medicaid lined 23% of nonelderly adults with psychological sickness, 26% of nonelderly adults with severe psychological sickness (SMI), and 22% of nonelderly adults with SUD; as compared, Medicaid lined 18% of the overall nonelderly grownup inhabitants (see Appendix A). The COVID-19 pandemic and ensuing financial recession have negatively affected mental health and substance use outcomes and exacerbated obstacles to care.

Efforts to handle the opioid epidemic and broader behavioral well being points have been a focus in Medicaid in recent years, together with by way of federal laws such because the 2018 SUPPORT Act. Extra lately, ARPA supplied enhanced Medicaid funding that may very well be used to assist behavioral well being home and community-based services (HCBS) suppliers and to supply community-based cell disaster intervention companies; the proposed BBBA (passed by the Home of Representatives on November 19, 2021) would construct on each of those choices. The BBBA would additionally develop funding for a neighborhood psychological well being companies Medicaid demonstration program for states to implement Licensed Group Behavioral Well being Clinics.

This temporary attracts on knowledge from KFF’s 21^st annual Medicaid budget survey to evaluate how states are utilizing new federal coverage choices and implementing different revolutionary behavioral well being initiatives. We give attention to efforts to develop behavioral well being advantages, enhance entry to behavioral well being care and fairness, and leverage MCOs to ship behavioral well being advantages.

How are states increasing behavioral well being advantages?

Federal legislation mandates Medicaid protection of many behavioral well being advantages, and states can also cowl further non-compulsory behavioral well being advantages. Behavioral well being companies for youngsters are notably complete because of Medicaid’s Early, Periodic Screening, Prognosis, and Remedy (EPSDT) profit for youngsters (see Appendix A). Within the years prior to the COVID-19 pandemic, states have been more and more increasing non-compulsory behavioral well being advantages and profiting from federal choices within the SUPPORT Act. Hostile results of the COVID-19 pandemic on psychological well being and substance use outcomes have introduced additional focus to behavioral well being points and prompted the Substance Abuse and Psychological Well being Companies Administration (SAMHSA) to issue a number of COVID-19 grants, accessible to state businesses to handle psychological well being and SUD outcomes. Different current federal coverage choices extra instantly goal Medicaid, akin to ARPA’s enlargement of cell disaster response companies, which aim to attach Medicaid enrollees experiencing psychological well being crises to applicable community-based care (an possibility which the proposed BBBA would make everlasting).

On the time of survey completion, greater than half of states indicated they may or in all probability will take up the brand new possibility underneath ARPA to supply community-based cell disaster intervention companies. ARPA supplies 85% federal matching funds for these disaster intervention companies for the primary three years, with these further funds to complement, not supplant, the extent of state spending for these companies. The ARPA mannequin dispatches multidisciplinary cell disaster groups to supply Medicaid-covered companies to enrollees experiencing a psychological well being or SUD disaster exterior a hospital or different facility setting. These cell disaster companies usually should not have to be supplied statewide and could be focused to particular teams of enrollees (quite than be accessible to all Medicaid enrollees). States could restrict enrollees’ alternative of supplier for these companies. Underneath ARPA, this new possibility is out there to states for 5 years, starting April 1, 2022; nonetheless, a provision within the proposed BBBA would make this selection accessible completely. ARPA additionally approved $15 million for state planning grants; these have been awarded to twenty states in September 2021 (nonetheless, underneath ARPA, all states are eligible to take up this selection starting April 1, 2022, together with those who didn’t obtain planning grants).

About two-thirds of responding states indicated they produce other, non-ARPA-related disaster service initiatives in place in or deliberate for FY 2022. A few of these initiatives are restricted to Medicaid enrollees and funding, however others have a broader focus. Generally reported initiatives embrace cell disaster response and repair initiatives (separate from the ARPA possibility); disaster hotlines; and disaster diversion, stabilization, and/or receiving facilities. Disaster hotlines embrace 988 hotlines, which have been designated by the Federal Communication Fee as the brand new telephone quantity to attach people with suicide prevention and psychological well being disaster counselors. One state (New Hampshire) is planning implementation of a Critical Time Intervention model to supply assist to people with SMI throughout susceptible durations of transition (e.g., discharge from a psychiatric hospital).

States are additionally increasing a variety of Medicaid behavioral well being companies, some focused to particular populations or wants (Determine 1). States reported service expansions throughout the care continuum, together with institutional, intensive, outpatient, and residential and community-based behavioral well being companies. Continued state give attention to SUD profit expansions is per past years and goals to focus on the substance use disaster that has worsened throughout the COVID-19 pandemic. States reported approaches to concentrating on SUD together with new or expanded residential/inpatient SUD advantages, protection of opioid therapy applications, and enhanced care administration. States are additionally implementing different focused profit expansions to handle mental health and different wants which were adversely affected by the COVID-19 pandemic, akin to publicity to gun violence (addressed by a profit enlargement in Illinois). Total, on the 2021 price range survey, 10 states reported new or expanded psychological well being and/or SUD advantages in FY 2021 and 14 states reported such expansions deliberate for FY 2022 (see Determine 1 for examples). These embrace expanded protection of intensive outpatient companies, clinic companies, school-based companies, and supportive employment companies. Some behavioral well being profit expansions are focused to particular populations akin to children or pregnant/postpartum girls.

Greater than four-fifths of states reported initiatives in place associated to screening enrollees for behavioral well being wants, in fee-for-service (FFS) and/or by way of MCO contract necessities. Behavioral well being screenings are one strategy for Medicaid to attach people with behavioral well being must the suitable companies. Most responding states that contract with MCOs (31 of 37) reported FY 2021 contract necessities associated to behavioral well being screening, and two MCO states reported plans to implement such necessities in FY 2022. About half of all responding states reported non-MCO initiatives associated to behavioral well being screening in FY 2021 and FY 2022.

What initiatives are states adopting to enhance entry to behavioral well being care and fairness?

The COVID-19 pandemic has created new obstacles to take care of individuals already experiencing behavioral well being circumstances and had disproportionate unfavorable impacts on behavioral well being outcomes for individuals of shade. Telehealth—which was changing into extra widespread in Medicaid applications previous to the pandemic—could  be an necessary element of facilitating entry to behavioral well being companies for children and adults, particularly throughout the pandemic, and ARPA included funding accordingly to assist behavioral well being professionals’ utilization of telehealth. States have broad flexibility to find out whether or not and easy methods to cowl companies (together with behavioral well being) delivered by way of telehealth of their Medicaid applications.

As of July 1, 2021, all responding states cowl audio-visual telehealth supply of behavioral well being companies, and nearly all additionally cowl audio-only supply of those companies (Determine 2). All responding states (47) reported that they generally or all the time lined audio-visual supply of FFS psychological well being and SUD companies. Nearly all reported overlaying audio-only supply of FFS psychological well being (45 states) and SUD companies (44 states). Almost all MCO states reported requiring MCOs to cowl the identical companies by way of telehealth as lined in FFS. Throughout service classes, most states are contemplating post-pandemic telehealth insurance policies, with many weighing expanded entry in opposition to high quality considerations particularly for audio-only telehealth. States have been extra prone to report plans to keep up audio-only protection for psychological well being and SUD companies in comparison with different, non-behavioral well being companies.

States report that telehealth helped keep and develop entry to behavioral well being care throughout the pandemic. Thirty-one states (out of 45 responding) reported that telehealth, particularly expanded audio-only protection, had specific worth in sustaining or bettering entry to behavioral well being companies. The survey additionally requested states to establish the highest two or three classes of behavioral well being companies that had the very best telehealth utilization throughout FY 2021; states most often recognized psychotherapy, counseling (for psychological well being circumstances and/or SUD), and affected person evaluations.

Eight states reported present or deliberate initiatives to handle racial/ethnic disparities in behavioral well being in Medicaid. Previous to the pandemic, Black and Hispanic individuals have been less likely to obtain wanted behavioral well being companies in comparison with the overall inhabitants, and during the pandemic, Black and Hispanic adults have been extra prone to report signs of hysteria and/or depressive dysfunction. The current uptick in substance use issues can also be disproportionately affecting many individuals of shade. Of the states that recognized any initiatives addressing racial/ethnic well being disparities, eight reported initiatives to particularly deal with disparities in behavioral well being care and outcomes. These embrace managed care necessities and/or initiatives, efforts to enhance knowledge assortment and stratification, and eligibility or profit expansions that will deal with behavioral well being disparities. For instance:

• California’s value-based fee program directs MCOs to handle well being disparities by making enhanced funds that concentrate on SMI, SUD, and homelessness.
• Connecticut’s current procurement for behavioral well being Administrative Companies Group (ASO) companies requires bidders to establish particular, actionable methods to enhance fairness, with an emphasis on race and ethnicity.
• Since FY 2020, Michigan has used capitation withholds to incentivize reductions in racial disparities in behavioral well being metrics.

Many states reported a necessity to enhance knowledge assortment to allow identification of racial/ethnic well being disparities, and future initiatives to handle behavioral well being disparities could emerge as knowledge turns into higher identified.

Almost half of states reported initiatives to advertise bodily and behavioral well being co-location in place in or deliberate for FY 2022. A few of these initiatives are restricted to Medicaid enrollees and funding, however others have a broader focus. Many people receiving take care of behavioral well being circumstances even have bodily well being circumstances that require medical consideration, and the inverse can also be true. One strategy to handle care fragmentation and higher integrate physical and behavioral health care is co-location of each forms of care on the similar web site. Reported initiatives have been most often at Licensed Group Behavioral Well being Clinics (CCBHCs), neighborhood psychological well being facilities (CMHCs), federally certified well being facilities (FQHCs), and well being properties. For instance, state legislation in Kansas directs the state to determine an authorized CCBHC mannequin in FY 2022, which can encourage CMHCs to start providing bodily well being companies. A number of states reported plans to cowl new built-in care companies, whereas others reported permitting for fee of a behavioral well being encounter on the identical day as a medical encounter and/or different administrative modifications. A couple of states talked about incentive funds for suppliers or MCOs who promote built-in care.

Different notable co-location initiatives in place or deliberate embrace:

• California is proposing to implement its CalAIM initiative in January 2022, which can integrate the administration and financing of specialty psychological well being and SUD companies underneath a single state/county contract. The purpose is to enhance outcomes for enrollees by way of extra coordinated therapy and to permit suppliers to reply in a extra patient-centered method. Distinct from this behavioral well being integration effort, CalAIM additionally features a plan to check the full integration of bodily well being, behavioral well being, and oral well being underneath one contracted managed care entity.
• Missouri goals to extend co-location by increasing its care integration program—which at present entails collaboration between FQHCs and CMHCs—to incorporate collaboration between FQHCs and SUD suppliers.
• New Hampshire is continuous to implement ProHealth Grants to work with three CMHCs and three FQHCs to develop built-in well being properties for individuals ages 16 to 35. The purpose of this program is to combine FQHC companies (akin to screening, detection, and therapy of bodily well being circumstances) throughout the CMHCs to enhance and stop future well being circumstances.

How are states utilizing MCOs to ship behavioral well being companies?

States use a mix of FFS and managed care preparations to ship behavioral well being care to Medicaid beneficiaries, with these companies more and more being supplied by MCOs in recent times (see Appendix A). Underneath federal Medicaid rules, states could permit MCOs to supply companies or settings that substitute for these which are lined underneath the state plan. These in lieu of companies (ILOS) have to be recognized within the MCO contract and enrollees is probably not required to make use of them. In recent years, states have more and more used MCO “in lieu of” authority to cowl companies supplied to nonelderly adults in “institutions for mental disease” (IMDs) that in any other case can be ineligible for federal Medicaid funding. The 2018 SUPPORT Act codified the present Medicaid managed care regulation permitting capitation funds to incorporate IMD companies as much as 15 days monthly utilizing “in lieu of” authority.

Most states proceed to depend on MCOs to ship inpatient and outpatient behavioral well being companies (Determine 3 and Appendix B). Though MCOs present complete companies, states could carve particular companies out of MCO contracts to FFS or restricted profit pay as you go well being plans (PHPs). Companies often carved out embrace behavioral well being, pharmacy, dental, and long-term companies and helps (LTSS). Nonetheless, there was vital motion throughout states to carve these companies in to MCO contracts. In line with outcomes from past years, nearly all of MCO states reported that particular behavioral well being service varieties have been all the time carved into their MCO contracts (i.e., nearly all companies lined by the MCO); fewer states reported that companies have been all the time carved out (to PHP or FFS) or that carve-in standing varies by geographic or different elements. Additionally, 5 states reported focused carve-outs of behavioral well being drugs, akin to psychotropic medicines, from MCO capitation funds (knowledge not proven).

Eleven states reported making current modifications to how behavioral well being advantages are delivered underneath MCO contracts: three states in FY 2021 solely, 4 states in FY 2022 solely, and 4 states in each FY 2021 and 2022. For instance:

• California, by way of its CalAIM Part 1115 waiver initiative, reported a set of modifications to streamline service supply in each FY 2021 and FY 2022 to enhance coordination of psychological well being care between Medi-Cal MCOs managing non-specialty psychological well being companies and county-operated psychological well being PHPs managing specialty psychological well being companies and SUD therapy.
• Ohio is implementing a specialised managed care entity—a pay as you go inpatient well being plan—accountable for offering behavioral well being companies, with restricted exceptions, to youth with advanced wants enrolled in each MCOs and FFS in FY 2022.
• West Virginia eliminated an MCO community requirement in FY 2021 that required MCOs to contract with all SUD suppliers; MCOs could now make contracting choices primarily based upon supplier high quality.

Most states permit MCOs to make use of “in lieu of” authority to cowl sure behavioral well being companies, notably to permit protection of companies supplied in IMDs. Thirty of 37 responding MCO states indicated allowing not less than one ILOS as of July 1, 2021; of those, 23 reported that the permitted ILOS included sure behavioral well being companies. By far, probably the most generally cited ILOS was companies supplied to nonelderly adults in IMDs, that are in any other case ineligible for Medicaid funding besides by way of in lieu of or waiver authority (21 states). 9 states additionally talked about different authorised behavioral well being companies (together with psychological well being and SUD companies). Lastly, two states talked about plans so as to add behavioral well being ILOS in FY 2022.

Trying Forward

Throughout the 2021 budget survey questions mentioned on this temporary, all responding states reported not less than one initiative to develop entry to behavioral well being care in Medicaid. Some states reported initiatives throughout many areas, typically as a part of wide-ranging statewide initiatives recognized as high priorities for his or her Medicaid program—examples embrace California’s CalAIM initiative, Colorado’s behavioral well being care coordination efforts, Massachusetts’ Roadmap for Behavioral Health Reform, Montana’s pending HEART Part 1115 demonstration and parallel service additions, and Washington’s efforts to construct an efficient neighborhood behavioral health system. Additional info is required to grasp in additional element how these reported behavioral well being initiatives function and the extent to which states are selling referrals and treatment or receipt of different advantages following screenings.

Total, greater than one-third of responding states talked about behavioral well being initiatives as a priority for FY 2022 and past, and a number of other recognized behavioral well being companies as an upward spending stress in FY 2022. This development tracks with the Biden Administration’s identification of behavioral well being coverage and investments as a key federal Medicaid precedence. Continued efforts on the federal degree—together with the proposed BBBA—could have an effect on the extent of enhanced Medicaid funding accessible to states and their take-up of expanded behavioral well being companies. For instance, further states could take up the ARPA cell disaster companies possibility if it turns into everlasting underneath BBBA. The impression of the ARPA enhanced federal Medicaid funding for HCBS (starting April 2022) on behavioral well being HCBS suppliers additionally stays to be seen. Moreover, it’s unclear how behavioral well being service patterns—akin to utilization of telehealth—could proceed to evolve within the aftermath of the COVID-19 pandemic and whether or not or how states could modify or undertake new behavioral well being initiatives. States additionally could pursue and CMS underneath the Biden administration could promote Section 1115 demonstration waivers to develop entry to behavioral health care throughout the care continuum.