7Recommendations

RECOMMENDATIONS

Goal 1: Grow the pie. Bolster state and federal efforts to promote and ease entry into Medicare and Medicaid along the behavioral health care workforce continuum by reducing credentialling, enrollment, and licensing barriers and by focusing training programs and telehealth support where Medicare, Medicaid, and Marketplace beneficiary access gaps are greatest.

The workforce and funding for training from both CMS and SAMHSA presently support care delivery sites or institutions (examples: CMS: graduate medical education (GME) funding; SAMHSA: certified community behavioral health centers). This funding is ongoing, year-after-year, and dependable. However, there are no requirements for institutional recipients of funds to report on workforce pathways after training is completed, so it is not possible to assess either the positive or negative effects of a training environment on long-term career choice. Psychiatrist training, like other physician training, is supported by CMS GME funding, but psychiatrists are the physician specialty least likely to accept patients with Medicare and Medicaid plans. In this context, CMS should predicate ongoing funding of workforce training with consistent reporting of post-trainee career trajectories to facilitate institutional comparisons among grantees. SAMHSA has similar opportunities with its grants that support environments where training occurs, largely supporting the non-physician behavioral health care workforce. Programs can then be developed to support training environments in which more trainees care for populations covered by Medicare, Medicaid, and Marketplace plans.

CMS could pilot alternative GME payment methods, award new Medicare-funded GME training positions in priority disciplines and geographic areas and develop models within the CMS Center for Medicare and Medicaid Innovation to add other behavioral health care professions to the educational funding aspects of these programs that increase access to care. Medically underserved areas and underrepresented and minoritized communities should be prioritized, with strong consideration given to modeling these CMS and SAMHSA pilots after existing HRSA programs with this focus, such as the National Health Service Corps, Behavioral Health Workforce and Education Training Program, Graduate Psychology Education Program, Health Careers Opportunity Program, and Nursing Workforce Diversity Program. These HRSA programs have a proven track record of increasing the supply of behavioral health care providers in underserved areas and diversifying the behavioral health care workforce to better reflect the communities served, including under-resourced populations, based on patient needs, race, ethnicity, and lived experience. This approach has been shown to increase access to care for all Medicaid beneficiaries.

Much of the funding for training presently supports care delivery sites or institutions rather than directly supporting the workforce required to care for beneficiaries and individuals in these funded settings. This creates a more extreme challenge in behavioral health care because while CMS allows for physicians in training to bill for services under the supervision and license of a preceptor, similar parity does not exist for other behavioral health care professionals. This limits non-physician behavioral health trainee exposure to caring for Medicare and Medicaid beneficiaries and has a strong potential to influence which patients these care providers serve when they finish training.

RECOMMENDATION 1: CMS and SAMHSA should restructure current workforce and training mechanisms and their funding to better incentivize robust training environments that support career choices that will more directly impact care for Medicare and Medicaid beneficiaries.

• 1-1 The CMS and SAMHSA restructuring of the current workforce and training mechanisms should have two interrelated priorities: first, a focus on the providers serving populations with the highest need for greater access to behavioral health provision in Medicaid, such as rural, child/adolescent, and racial/ethnic minoritized populations; second, a focus on workforce demographic diversity, modeled after and aligned with existing HRSA programs that have successfully grown and diversified the behavioral health care workforce in underserved areas.
• 1-2 CMS should predicate ongoing funding of the workforce training with consistent reporting of post-trainee career trajectories to facilitate institutional comparisons among grantees and ultimately provide a mechanism for greater accountability between CMS funding of training and the rate at which trained providers serve Medicare and Medicaid beneficiaries.
• 1-3 CMS should allow for behavioral health care trainees to bill for services under the supervision of a licensed care provider, as already exists for physician trainees.

(T)here is a whole provider enrollment and credentialing process. That is also an additional barrier and burden. And sometimes we will hire someone, but their Medicaid enrollment is several months delayed because it takes time to be able to get them enrolled. . . . (W)e do not actually have them start work until . . . (we) get all that paperwork done.

—Warren Ng, webinar 2 panelist

Experiences of Behavioral Health Care Providers with Public Insurance Programs

A lengthy, repetitive, and burdensome credentialing process discourages behavioral health care providers from enrolling with multiple payers. Credentialing delays also delay the ability to bill and receive payments. Behavioral health care providers are less likely than other care providers to have an administrative support system that enables them to navigate unnecessary complexities. Adopting certain technological and administrative tools would eliminate many of these difficulties.

RECOMMENDATION 2: CMS should use its regulatory authorities over Medicare (including Medicare Advantage) and provide assistance to state Medicaid programs and Marketplaces plans to streamline behavioral health provider credentialing and enrollment processes.

• 2-1 CMS should develop guidance for states on funding mechanisms and provide models for developing, implementing, and operating a single state-wide platform for care provider credentialing and enrollment. For instance, states could use available funding mechanisms to upgrade their Medicaid Management Information System provider enrollment modules, creating a single, state-wide platform for Medicaid, its managed care organizations (MCOs), or other Medicaid payers to use for credentialing, enrollment, renewals, and licensure checks.
• 2-2 CMS should allow states to include connectivity to state and federal licensing entities as part of the allowable costs of implementing the system.
• 2-3 CMS should encourage states to accept Medicare credentialing and enrollment for Medicaid purposes, and Medicare should reciprocate.
• 2-4 CMS should work with states to modify Medicare’s and Medicaid’s enrollment systems and processes to check ex parte information sources before requiring additional information from behavioral health care providers for initial enrollment or renewal as a care provider. This would allow behavioral health care providers to keep their enrollment information current in either a state Medicaid or a state Medicare system, and it would facilitate more rapid initial enrollment.
• 2-5 Whenever possible, CMS should impose time limits on the credentialing process, or support enforcement if there are existing time limits, employing a centralized database to streamline this process. CMS should encourage state regulators to do the same.

We need regulations, but having that balance is really important. (H)ow do we ensure individuals . . . are getting seen, and this redundancy (and licensing and regulations) is not going to get in the way of more providers doing the work (because that is what we really need)[?] We need more providers working with the underserved populations that we see nationwide.

—Rakhee Patel, webinar 2 panelist

Experiences of Behavioral Health Care Providers with Public Insurance Programs

As a field, behavioral health has had the largest sustained use of telehealth and continues to drive innovation in telehealth for all of health care. In this context, CMS has a key opportunity to use telehealth as one tool to improve access to behavioral health care services in Medicare, Medicaid, and Marketplace as it offers a mechanism to address the documented maldistribution of behavioral health providers across geographies and populations. In addition, the rapidly evolving nature of telehealth applications in behavioral health, recommendations to support the next generation of telehealth applications are also critical. While 90 percent of Americans today already have access to a smartphone or computer able to connect to audio or video telehealth (synchronous telehealth), inequities in broadband access and digital literacy limit the applicability and reach of telehealth. In addition, the effects of telehealth and new technology-powered tools on clinicians are unknown. The recommendation seeks to balance the opportunity for telehealth to address geographic maldistribution of behavioral health care providers with the considerations that support equitable access to high-quality behavioral health care services.

RECOMMENDATION 3: CMS should develop an agile and flexible interagency strategy to set guidelines for coverage and payment for telehealth for behavioral health needs across settings, modalities, and care providers. This strategy should include:

• 3-1 Efforts to establish coverage consistency of telehealth across states in order to simplify cross-state telehealth health care provider engagement.
• 3-2 Development of processes to reimburse telehealth based on a thoughtful consideration of the value provided and the cost of delivery—as is done with in-person care. Flexibility on the use and reimbursement of these services will be essential to maximizing the benefit to patients and the system at large. Given the rapid changes in modalities for telehealth, these policies should be evaluated regularly.
• 3-3 Establishing skill needs and promoting digital skills training for clinicians and digital health literacy skills for patients that will increase equitable adoption.

I rode a bicycle to the community mental health center to get my services, which back then were medication management until I could get housing and leave the shelter. So there were gaps around security, ability to have safe housing. The environment I lived in played a big role in the pace of recovery.

—Laura Van Tosh, webinar 1 participant

Lived Experiences in Accessing Behavioral Health Care Services through Public Insurance Programs

Expediting the process of cross-state and cross-territory professional licensure will increase the number of behavioral health care professionals who practice across jurisdictional boundaries and provide services in underserved communities across the lifespan. Occupational interstate compacts should be developed and adopted for all behavioral health professions across all states and territories.

RECOMMENDATION 4: The Department of Health and Human Services (HHS) and its agencies should develop a uniform strategy to promote and adopt evidence-based approaches to reduce multi-state licensure barriers as a mechanism to expand access to behavioral health providers in Medicare, Medicaid, and the Marketplace.

• 4-1 HHS should actively collaborate with organizations such as the Department of Defense, the Council of State Governments, and its National Center for Interstate Compacts; the relevant national professional associations; and states to create and adopt interstate compacts for those behavioral health care professions not currently covered in an occupational interstate compact. Provisions for telehealth across state and jurisdictional lines should be included.
• 4-2 HHS should actively collaborate with organizations such as the Department of Defense, the Council of State Governments, and its National Center for Interstate Compacts; the relevant national professional associations; and states to ensure that states join existing occupational interstate compacts.
• 4-3 HRSA should incentivize states by including language in its request for proposals grantmaking process to join existing occupational licensure interstate compacts.
• 4-4 HHS should encourage states to review existing occupational professional interstate compacts to allow for the provision of telehealth across state and jurisdictional lines.

Goal 2: Make participation worthwhile. Strengthen support structures for behavioral health care providers and alleviate administrative and financial impediments to participation.

There are a lot of challenges and barriers that we are facing day to day . . . there are prior authorizations and reauthorization requests. Care providers of course are taking into consideration the time it takes to complete these sorts of documentations to get approval for the services for the clients that they see. And oftentimes there is lag time here too. We submit the prior authorizations, or the reauthorizations, and it takes a couple of weeks or so if not longer to get approvals. That again can be really cumbersome and oftentimes sometimes frustrating for health care providers who really want to continue to see individuals get the ongoing services that they need.

—Rakhee Patel, webinar 2 panelist

Experiences of Behavioral Health Care Providers with Public Insurance Programs

Based upon patient and care provider pressure, negative feedback, and state legislative and regulatory actions, gradual and fragmented efforts are underway to streamline health plan prior authorization processes. To accomplish Recommendation 5, a coordinated, comprehensive, and expeditious effort is called for, including the active participation of stakeholders, particularly states since Medicaid is a joint federal/state program. There is likely sufficient interest in this topic to attract private grant support for the data analysis and convening of stakeholders, which will be prerequisites for the CMS rulemaking on this topic.

A critical focus on cost-containment necessitates MCO and health plan use of prior authorization and other cost management tools. Data exist on the substantial cost savings associated with applying prior authorization for specific services and medications. Likewise, there are some services and treatments where data shows that imposition of prior authorization is of little cost-saving value. These data should be used to identify the low-cost-savings (“low-value prior authorization”) applications. Policies recently adopted by some states and CMS and voiced by the broad-based participants in the January 2018 “Consensus Statement on Improving the Prior Authorization Process” provide guidance for achieving reform. Implementing these policies expeditiously will take a concerted effort by CMS and states, given the changes each payer will need to make to data analytics, clinical criteria reviews, process automation, and other medical care coordination and processes. A process for ongoing monitoring of prior authorization reforms will be needed to respond to evolving consequences. This process should require continual data analysis and periodic assessments of whether revisions are needed.

RECOMMENDATION 5: CMS should use its authority to adopt policies and issue rules and guidance, and to monitor managed care plan access standards to quickly reduce provider administrative burdens and related adverse patient impacts associated with low-value prior authorization and other medical usage review instruments applied to behavioral health care services.

• 5-1 CMS should use its authority to identify and, to the fullest extent possible, disallow low-value prior authorization practices within Medicare plans. CMS should provide states with technical assistance to similarly eliminate and monitor for low-value prior authorization practices within Medicaid managed care.
• 5-2 CMS should adopt policies and the standards that require or incentivize insurers to focus behavioral health prior authorization only where high-cost waste and misuse are evident. These policies and rules should articulate clear responsibilities and guidelines for the mechanisms of rigorous regulatory oversight of insurer prior authorization review activities by state and federal agencies.

(A)t one point, (I) had a therapist that had to leave because he couldn’t support his family. So he went to work for a bank to pay the bills. And then worked as a CLS worker in the evenings and weekends to kind of fill that personal need he had.

—Laura Marshal, webinar 1 panelist,

Lived Experiences in Accessing Behavioral Health Care Services through Public Insurance Programs

Inadequate reimbursement negatively affects care provider participation in insurance plans, particularly in public and publicly subsidized payer markets. This, in turn, affects access to behavioral health care for vulnerable populations, including older adults, persons with disabilities, the rural population, and racial and ethnic minoritized individuals. CMS is well positioned to be a federal leader on reimbursement policies across public and publicly subsidized insurance markets and can play a critical role in guiding behavioral health reimbursement and coverage policies. CMS has recently proposed a 19 percent increase over 4 years in the “work value” component of the resource-based relative value scale (RBRVS). While this is a positive start, CMS has not yet addressed the practice cost component of the RBRVS.

CMS has several potential avenues to ensure that reimbursement rates and coverage of services are sufficient to support behavioral health care providers across a range of core behavioral health services and health care provider types and are, where appropriate, in accordance with the Mental Health Parity and Addiction Equity Act.

RECOMMENDATION 6: CMS should provide guidance on setting Medicare and Medicaid fee-for-service reimbursement rates to ensure adequate access to a full continuum of behavioral health care services, which includes accounting for the actual costs of care and adjusting for past and current undervaluation of work efforts of behavioral health care providers. To address this undervaluation, CMS should continue to revisit and revise the RBRVS.

• 6-1 CMS should conduct an updated cost study to remedy the acknowledged bias in the current RBRVS formulation. Improving the formulation of the Medicare fee schedule may also help to influence Medicaid fee-for-service rates.
• 6-2 Within Medicaid fee-for-service, CMS should encourage state Medicaid agencies to adopt regular rate reviews to adjust for inflation and account for market forces that could be discouraging behavioral health providers from enrolling in Medicaid fee-for-service. CMS should encourage consideration of rate differentials in underserved areas where there is an inadequate workforce within Medicaid and ensure proposed rates are sufficient to support access to behavioral health providers consistent with the general population. CMS should provide comparison rate and provider access information to states for Medicare, Medicare Advantage, Marketplace, and private plans to assist states in developing access monitoring review plans (AMRP) for behavioral health services that better determine whether state payment rates are sufficient to ensure access to care for beneficiaries at least comparable to the general population.

I think the other piece is around some of the prompt pay policies that we’ve seen in Medicaid programs . . . . (T)hat’s probably a more commonly used strategy . . . . [The Medicaid programs are] setting expectations and requirements with the managed care plans to conduct prompt payment to the behavioral health providers who may need that cash flow, [that] may not have a lot of reserves.

—Lindsey Browning, webinar 3 panelist

Innovations to Improve Mental Health and Substance Use Disorder Access in Medicare, Medicaid, and Marketplace Insurance Plans

A concerted effort to improve the cash flow for behavioral health care providers through an efficient revenue cycle infrastructure, including prompt payment and claims management, by all parties should result in marked improvement in the participation of behavioral health providers in these plans. A broad-based approach will have a greater effect than individual insurance plans making their own adjustments, which could add complexity and confusion. Developing effective billing and payment processes will take collaboration and cooperation across all payers and regulators, including CMS, state Medicaid agencies, state insurance commissioners, and managed care organizations serving Medicare, Medicaid, and Marketplace beneficiaries. By prioritizing prompt pay and charging the oversight to state Medicaid programs and insurance regulators, CMS will be able to help reduce financial strain on behavioral health providers who participate in Medicare, Medicaid, and Marketplace plans.

RECOMMENDATION 7: CMS should use its regulatory and incentive structures to ensure prompt payment and eliminate inappropriate claims denials of behavioral health care services.

• 7-1 To adequately enforce prompt pay laws and regulations, CMS should use its monitoring authority over state Medicaid programs and state Marketplace plans to ensure that plans are in compliance with prompt pay laws. Specifically, state Medicaid agency single audits should include monitoring of prompt payment of Medicaid managed care plan behavioral health claims. State insurance regulators should include similar monitoring of prompt payment in Marketplace plans.
• 7-2 CMS, in consultation with state Medicaid officials, should ensure that Medicare and Medicaid provider claims are not rejected or denied for non-substantive reasons (such as using Dr. instead of Drive in an address). This may necessitate updating claims payment systems, manuals, managed care contracts, or other actions to ensure that payments are received in a timely manner following claims submission. Medicare and Medicaid payers should be required to provide regular training opportunities for behavioral health care providers on billing and claims submission and clear, accurate, and up-to-date instructions to participating care providers.
• 7-3 CMS should develop a common set of behavioral health diagnostic codes that qualify for reimbursement. CMS, through its federal authority, and Medicaid and insurance regulators, through their state authority, would hold responsibility for enforcing compliance.
• 7-4 CMS should develop policies that address the findings of the HHS Office of Inspector General report related to Medicare Advantage plans’ inappropriate payment denials for services provided that meet Medicare coverage rules and medical assistance organizations’ billing rules.

Goal 3: Optimize performance and accountability. Improve opportunities for care providers to increase care delivery capacity and to provide more person-centered care, while strengthening MCO accountability for access and care delivery and provider accountability for performance.

[M]y pie in the sky dream is that . . . every child, youth and family navigating the . . . system would have . . . [a] family support specialist to accompany them through finding providers. . . . We never just call and somebody says, oh, hello, thank you for calling our office, how can we help you?

—Lisa Butler, webinar 1 panelist

Lived Experiences in Accessing Behavioral Health Care Services through Public Insurance Programs

Managed care organizations have the responsibility to deliver a care provider network sufficient to ensure access to beneficiaries. Managed care organizations have greater flexibility to address barriers to care provider participation and improve behavioral health care access among their beneficiaries compared with traditional Medicare and Medicaid. Beneficiary access entails more than an adequate network of available behavioral health providers. Plans are not financially accountable for beneficiaries accessing the services they need when they need them. Access to care is affected by payment arrangements, hassle factors, and the quality of care providers. That is, access requires that the individual receive timely behavioral health services to achieve the best possible outcome. The following recommendation is designed to maximize the flexibilities that managed care plans have to address market forces and barriers inhibiting behavioral health care provider availability as well as barriers to beneficiary access such that timely, appropriate behavioral health services are made available to beneficiaries.

RECOMMENDATION 8: CMS should develop behavioral health care access outcome standards, along with significant financial penalties and bonuses, for managed care organizations participating in Medicare. CMS should work with states to develop similar standards and financial models to incentivize behavioral health care access in Medicaid managed care.

• 8-1 Both Medicare and Medicaid increasingly rely on third-party managed care organizations to deliver health care services to beneficiaries. CMS should work with states to establish an outcome-based behavioral health care access standard for payment, which can be adopted widely in a contract model.
• 8-2 CMS should convene Medicare and state Medicaid leadership to develop a model managed care contract for behavioral health services that establishes quality metrics for access, measuring the managed care organization’s delivery of timely, appropriate behavioral health care services to enrollees, and that is enforced through financial incentives (e.g., penalties and bonuses). In establishing quality metrics, CMS and states should recognize that meeting access outcome standards will require managed care organizations to build a full continuum of behavioral health providers and services, culturally aligned with the beneficiary population, and establish bi-directional integration of behavioral and physical health. It will also require addressing beneficiary barriers to seeking, receiving, and benefiting from services.
• 8-3 CMS and SAMHSA should implement a technical assistance function to support states and managed care organizations (Medicare Advantage and Medicaid MCOs) in implementing these access measures and to help plans adopt additional efforts to support and build the behavioral health workforce and improve beneficiary access to care.
• 8-4 SAMHSA should work with states to align state grant funds to supplement managed care investments in building the continuum of care providers and services needed for MCOs to meet quality metrics for access.

I was very keen on moving forward in my education and employment, but I was told no, those aren’t the things you’re going to do. . . . They pushed those aside rather than looking at things like supported employment and supported education.

—Keris Myrick, webinar 1 panelist

Lived Experiences in Accessing Behavioral Health Care Services through Public Insurance Programs

Value-based payment and alternative payment models in Medicare, Medicaid, and Marketplace plans are increasingly prevalent and represent the direction that an evolving health care delivery system is taking in the U.S. One implication of this trend is that health care professional will be delivering care under arrangements that measure performance and demand accountability. At the core of accountability for value is the measurement of performance towards desired goals of care and tying these measures to payment. Those measures need to be accompanied by consequences related to performance. Unfortunately, the current set of measures in behavioral health are inadequate in that they do not fully capture the desired goals and can be burdensome. Even coding for the behavioral health risk is inadequate, as it misaligns rewards for the managed care plans that embrace care for behavioral health because they are paid risk-adjusted per-member, per-month rates for beneficiaries. As a result, value-based arrangements for behavioral health care do not create incentives for health plans to ensure access to appropriate-high quality care. As a result, too often the supply of professionals that can address the needs of people covered by Medicare, Medicaid and Marketplace plans is insufficient.

RECOMMENDATION 9: CMS should invest in the development of improved quality and risk adjustment measures for behavioral health care. These measures should improve the measurement of performance of care toward desired goals of care and be linked to payment. These measures should carefully consider the administrative measurement burden that would fall on care providers.

• 9-1 CMS should lead in the development of new performance metrics. CMS should coordinate with states and MCOs to agree on a limited set of measures that apply across Medicare, Medicaid, and the Marketplace. Measures should offer insight into whole-person health by considering social (e.g., educational attainment, employment levels, housing stability) and emotional (e.g., quality of life, loneliness, self-efficacy) needs. Without this emphasis, value-based models in behavioral health run the risk of perpetuating disparities and leaving vulnerable populations behind.
• 9-2 CMS and states should work with MCOs and CMS-supported, value-based payment programs to incentivize care providers based on these newly developed measures. These efforts should include sunsetting legacy measures and aligning measures across insurance segments to reduce the burden to care providers participating in these programs.
• 9-3 CMS should create targeted financial support for practice transformation costs, recognizing that behavioral health care providers need technical assistance for developing new operations, reporting, billing, and health record systems.
• 9-4 In its development of new measures, CMS should also consider modifying the existing measures for behavioral health risk adjustment.

This report is based on the best available scientific evidence and input from individuals with firsthand experience trying to provide or access behavioral health services. As such, the urgency with which the nation must move to take action may not be apparent on every page of the report. However, the committee cannot understate the importance of seeing these recommendations as requiring immediate attention to stop the problems that people enrolled in Medicare, Medicaid, and Marketplace plans face daily in accessing even the most basic behavioral health care.

Outside of uncertainties from the recent Supreme Court decision in the Loper Bright Enterprises v. Raimondo case, which overturned the longstanding “Chevron deference” that allowed agencies to interpret ambiguous language applicable to their work, statutory authorities are likely sufficient for these recommendations (Turrentine, 2024)^1,2. Some recommendations can be implemented in the short term and put into action within a year or two, especially those that apply to existing systems. These focus on immediate actions within current frameworks. The recommendations that can be implemented in the short term are Recommendation 1-3; Recommendations 2-1, 2-2, and 2-3; Recommendation 3; Recommendation 4; Recommendation 5; Recommendation 6-1; Recommendations 7-1 and 7-4; Recommendations 8-1 and 8-2; and Recommendation 9-3. All recommendations have at least one aspect that can be implemented in the short term. The remaining recommendations primarily address systemic changes, which may take longer to fully implement.

Regardless of the timeframes for full implementation, these recommendations provide specific actions that should be set in motion with a sense of urgency. This work is not intended to be a plan that “sits on a shelf,” but rather a guide to how Medicare, Medicaid, and Marketplace programs can improve behavioral health provider participation in the context of the current dysfunctional, inequitable, under-resourced, and stigmatized disarray of policies and structures which have lost sight of the individuals, children, and families unable to get the health care they need and deserve.

REFERENCE

• Turrentine J. The Supreme Court ends Chevron deference—What now. 2024. [June 18, 2024]. https://www​.nrdc.org​/stories/what-happens-if-supreme-court-ends-chevron-deference .