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.
| 4-1: In addition to short-term improvements in behavioral health care provider participation among the existing workforce, strengthening the pipeline of federally subsidized behavioral health providers would build a workforce more likely to continue serving Medicare and Medicaid populations after the end of their training. Bolstering workforce programs and policies, including successful pathway or pipeline programs, would increase the number of people who want to enter the behavioral health field and support care provider retention over time.
4-2: The behavioral health workforce does not reflect the diversity of the population it serves. Increasing historically underrepresented racial and ethnic identities, as well as language and cultural representation, in the behavioral health workforce, is one mechanism to address disparities in access to care facing Medicaid and Medicare programs. Within Medicaid specifically, increased representation of historically underrepresented racial and ethnic identities in the health care workforce could expand access to care for beneficiaries more broadly, regardless of identity.
4-3: Efforts to decrease stigma, dispel historical mistrust, and provide financial incentives associated with behavioral health professions may address recruitment barriers, particularly those affecting communities of color.
4-4: There is a demonstrated inconsistency between the primary source of GME program funding (e.g., Medicare and Medicaid) and participation in public insurance programs among behavioral health providers whose training is funded by GME. While GME program funding primarily comes from Medicare and Medicaid, many trainees do not subsequently participate in these programs.
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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.
| 4-6: Expanding the delivery of behavioral health support specialist (BHSS) services in Medicare and Medicaid has the potential to significantly improve access and outcomes, especially for individuals with complex needs, while also augmenting the reach of licensed behavioral health professionals. Federal intervention is crucial to establish BHSS through model national certification standards and flexible payment models that facilitate the integration of these services into the full continuum of behavioral health care.
5-4: Evidence suggests that administrative burdens, particularly around delayed and denied payments, are at least as important in disincentivizing behavioral health providers from participating in Medicaid, and that similar disincentives exist in Medicare Advantage where inappropriate payment denials have been demonstrated. Given that behavioral health providers are more likely to practice independently and lack administrative support, efforts are needed to simplify and streamline credentialing, billing, and claims processes.
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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.
| 6-5: To maintain health care equity, audio-only behavioral health and SUD telehealth services are essential for serving individuals without adequate internet video access. There is not enough evidence on the relative effectiveness of audio only telehealth, but until the digital divide is addressed, the access to audio-only telehealth for those facing disparities in access may outweigh the uncertainly regarding its relative effectiveness compared to video telehealth for behavioral health services.
6-6: Telehealth is innovating rapidly with many new models coming on board with little evidence on the quality of care across these new modalities. This uncertainly makes it unclear whether future modalities within existing regulatory and payment frameworks will be effective in promoting health care provider access in Medicare, Medicaid, and Marketplace plans. Developing agile and flexible payment and regulatory structures may be needed. For example, hybrid care models that blend synchronous and asynchronous telehealth may increase access to care, but best practices and regulations to protect consumers and ensure integrity of clinical services would be necessary. In addition, payment for these models must balance access with the potential for overuse of low-value care. It is important to explore new regulatory pathways for novel asynchronous telehealth tools that can quickly assess value, build public trust, and increase transparency.
6-7: To improve access to behavioral health care amidst broadband gaps, targeted efforts should identify regions needing both services and broadband. Collaborating with federal agencies such as the Department of Commerce, Treasury, Agriculture, and the Federal Communications Commission can strategically allocate broadband funds. Effective distribution of these resources to underserved areas is crucial for enhancing connectivity and equitable access to essential behavioral health services nationwide.
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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.
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4-7: Occupational licensing compacts can facilitate improved access to care and diminish the maldistribution of the current behavioral health workforce. Revising and updating the interstate licensure agreements or advocating for adjustments in the state law, policy, or regulation could bolster and expand occupational compacts to further ease the provision of telemedicine services across state lines.
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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.
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5-5: Research, regulatory actions, and reported behavioral health provider experience provide compelling evidence that current prior authorization activities demand reform. The time, expense, and patient care delays associated with insurer-applied utilization management tools factor into behavioral health provider participation decisions and decrease care access for patients. Policies recently adopted by some states, CMS, and the broad-based participants in the “Consensus Statement” (referred to above) provide guidance for reform.
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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.
| 5-1: Insufficient and often unstable reimbursement has been identified as a key factor driving low care provider participation in public insurance programs. Low reimbursement is particularly stark when compared to higher out-of-network rates paid in commercial insurance markets and higher cash-pay rates. Across payers, there is often a lack of transparency on how rates for behavioral health services are currently set, with consistent undervaluation of work efforts for behavioral health care providers and inadequate accounting for the costs of care provision.
5-2: There is limited and mixed evidence about the effects of reimbursement rate increases on care provider participation in insurance programs, and existing evidence is lacking on the magnitude and scope of reimbursement required to increase access to behavioral health providers in Medicaid and Medicare. Recent state efforts to modify behavioral health payment, particularly in Medicaid, should be evaluated and monitored closely.
5-3: Evidence suggests that the behavioral health rates for care providers, particularly for the Medicaid and Medicare Advantage plans, have been inadequate to attract and retain behavioral providers in the plan’s networks. In addition, rates do not have parity for the same services with other behavioral health providers. Furthermore, the evidence suggests that because of billing codes, there is a lack of parity between services for substance use disorder and mental health conditions. As a result, the rationale for the existing reimbursement structures must be re-evaluated, revised and subsequently and regularly updated to reflect the full cost of care, including ancillary service provision, administrative requirements, and parity among care providers.
6-3: Studies should explore the role of outcome-based approaches for expanding health care provider participation, results of which may lead to a recommended regulatory approach.
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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.
| 4-5: The lack of billing for services provided by trainees in Medicare and Medicaid is a major barrier to expanding training opportunities for behavioral health specialists more likely to participate in the Medicare and Medicaid programs.
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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.
| 6-2: Various approaches to network adequacy regulations have not been shown to be effective in expanding behavioral health care provider participation or patient access. Nevertheless, they are tools that regulators currently rely on to prevent insurers from selling health plans that are overly restrictive in the supply of behavioral health services offered. Thus, while network adequacy regulation remains a key tool for regulators, current approaches are unlikely to be the avenue for improving health care provider participation in Medicare, Medicaid, and the Marketplace. Strengthening plan accountability for providing adequate supply of behavioral health services based on outcome data would improve regulatory oversight.
6-4: Approaches to measuring access for the purposes of regulating plan networks have largely been health care provider-focused, measuring availability of health care providers. Patient-focused measures, including ease of finding and receiving quality treatment from a culturally appropriate health care provider, are likely to require investments in new and alternative data sources, including patient surveys.
6-8: Quality measurement that can provide more meaningful guidance on the value of care provided and can overcome reporting challenges will better support meaningful improvements in the quality of behavioral health care. It will also enable payment schemes that incentivize investment in behavioral health care by generating new, value-based revenue streams that better support quality care delivery and health care provider recruitment.
6-9: Quality measurement aimed at ultimately improving the accountability of health plans and practices can have the effect of raising costs to both plans and practices. Moreover, behavioral health care providers have frequently opposed performance measurement as an intrusion on professional autonomy. Thus, efforts to bolster accountability may also serve to make clinician balk at participating in health plan networks that are required to report on sophisticated quality metrics.
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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.
| 6-1 Insufficient risk adjustment for those with mental illnesses and substance use disorders contributes to MA, Medicaid MCO, and Marketplace plan strategies that limit access to behavioral health services. These strategies include creating restrictive health care provider networks and using administrative mechanisms such as prior authorization. Risk adjustment, oversight of availability of clinicians, and limits on administrative processes such as prior authorization can attenuate such behavior. Improving access to behavioral health care providers and services through managed care could occur through improvements in behavioral health risk adjustment, regulation of access to care, and thoughtful limits on prior authorization.
5-6: A key barrier for behavioral health provider retention and satisfaction in Medicaid and Medicare, in particular, is the inability to meet patient needs, driven in part by the complexity and fragmentation of the care delivery system and patient navigation challenges. While building behavioral health provider participation in Medicare, Medicaid, and Marketplace programs is important, it is not sufficient to ensure that patients are matched to the right health care providers, according to their clinical, cultural and language needs, at the right time and right place.
6-10 Addressing the technology gap with investments in lower-cost, interoperable EHR systems appropriate for behavioral health and connecting behavioral health records through health information exchanges or other mechanisms is critical for advancing value-based care payments and integrated care models. Managed care tools that allow supplemental or directed payments could provide a mechanism for closing the gap.
6-11: The fragmented organization of publicly supported coverage within and between Medicare, Medicaid, and the Marketplace exacerbates the challenge beneficiaries have in identifying an available behavioral health care provider that can meet behavioral health needs in a timely way. These challenges are heightened for individuals with behavioral health conditions with complex needs. Even if health care provider participation were to improve, the patient experience related to locating suitable services would remain. Addressing care navigation difficulties is a necessary complement to addressing health care provider participation.
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