Appendix EExploring Strategies to Improve Access to Behavioral Health Care Services Through Medicare and Medicaid: Proceedings of a Workshop—in Brief

ADULTS WITH LIVED EXPERIENCE USING PUBLIC INSURANCE PROGRAMS

To better understand the experience of individuals who are past or present beneficiaries of public insurance programs, the webinar heard from three individuals who summarized their experiences and perspectives. Keris Jän Myrick, the vice president of partnerships at Inseparable, said not having a navigator at the beginning of her mental health troubles was a huge challenge when she was a Medicaid beneficiary. When discharged from a locked psychiatric unit after being diagnosed with schizophrenia, she was left to navigate Medicaid benefits on her own. She floundered and had no idea what to do, how to do it, or even how to find a provider who accepted Medi-Cal¹ and specialized in treating individuals with schizophrenia without first having to go through the community mental health system. Today, she said, Medicaid beneficiaries receive a welcome letter with the name of a navigator they can contact who can help the individual use and maximize their Medicaid benefits.

The community health system, Myrick said, focused on medication and professional care, but not on providing services such as the supported employment and supported education she wanted to pursue. There was also no emphasis on prevention or early intervention, which would have kept her from deteriorating to where she required hospitalization.

Myrick’s family was not aware that they were eligible to receive support themselves. Myrick explained that families of beneficiaries can receive family support services (family or parent peer support/psychoeducation, etc.) as collateral to the member and paid for by Medicaid. Peer support was important for her, given the shortage of providers of color, but only 18 states’ Medicaid programs allow for billing youth peer support services for members under the age of 18. Though many state Medicaid programs now allow billing for telehealth services, Myrick raised questions about access to digital therapeutics, apps, and evidence-based digital tools. She said there is a need to include digital literacy training and support for beneficiaries as a billable service.

Advocating for a holistic approach to health, Myrick said mental health should not exist in isolation but should be part of achieving complete physical, mental, and social well-being. For her, the four pillars of recovery are health, home, purpose, and community, many of which happen in systems that do not communicate with mental health. For example, the housing system may not be aware that the Medicaid beneficiary it serves is receiving services in the public mental health system. This can lead to individuals not getting the integrated support they need. “As a Medicaid beneficiary, I did not want my mental illness to exist in a silo,” she said. “I wanted to be seen as a whole person.”

Myrick spoke of the challenge of facing society’s perceived low expectations for people with a severe mental illness on public assistance and Medicaid. The treatment and support an individual receives can align with low expectations, affecting the individual’s belief in his or her own capabilities. She pointed out how valuable the therapeutic alliance with one’s provider can be, so picking a provider cannot be a “willy-nilly thing.”

Audrey Levine, a faculty member at Fountain House, said that being eligible for both Medicaid and Medicare came with the stigma of being both a “dual eligible” and having a dual diagnosis. In New York, she said, she perceives that people with dual diagnoses receive less attention from the mental health system and are often relegated to “young and inexperienced clinicians” or clinicians who are “burned out and about to retire.” Levine expressed a desire to find a provider with whom she can grow.

Laura Van Tosh, a convener for the Mental Health Policy Roundtable, said that when she moved to Washington to be with her family until she was well enough to live on her own, she was put on a 2-month waitlist to see a specialist at Kaiser Permanente who treats patients with her disorder. Until there was an opening, she saw an out-of-network psychiatrist to manage her medications, which at the time were causing intense side effects. She also hired an out-of-network case manager to help with her care while she reintegrated into society. During this time, she paid out of pocket for both psychiatric and community-based services, along with medication co-payments.

Today, Van Tosh’s Medicare Advantage program pays for her medication and psychiatric services, though she pays for her out-of-network psychotherapy. She has qualified and is grateful for medical financial assistance through Kaiser that has kept her from being financially vulnerable, as well as for the integrated care Kaiser provides that has made a huge difference in her health and quality of life. “Services integration is paramount and matters more than I ever imagined,” she said.

In 2022, Van Tosh had a mental health crisis and used publicly funded crisis services, inpatient care, and peer support services which enabled her to seek recovery-oriented care. While insurance covered the majority of her inpatient care, there were still unexpected expenses. She now lives independently and has enrolled with Seattle Club house, a Medicaid-reimbursable, psychosocial rehabilitation, community support program. She said that peer support has played a large role in helping her avoid repeated hospitalizations.

CAREGIVERS TO CHILDREN WITH EXPERIENCE USING PUBLIC INSURANCE PROGRAMS

In 2010, Lisa Butler, who today is director of family support services at the Oregon Family Support Network, and her husband were suffering from substance use disorder and had their three children (while pregnant with their fourth child) placed in foster care. Both adults recovered and reunited with their children. At the time, Butler said, she was a scared parent navigating a system that considered her a problem parent. The family engaged in wraparound services² for her older son, but she was overwhelmed by the many services and supports the program imposed on her without asking for her input. At one point, the family was dealing with eight providers, and she did not feel the system was welcoming or supportive.

Butler said there needs to be a paradigm shift in thinking about how providers view families and that families need to be approached with some humility. It is easy to find someone to blame for an issue, she said, but her family takes the attitude that nothing is wrong and that something that needs to change will emerge. This attitude, she said, is destigmatizing and reframes challenges as opportunities for growth rather than as inherently negative. She wondered what the mental health system would look like if it viewed families in that way and if there was a better balance between professional outcome-based therapies and engaging with a family and getting to know it better before trying to address needs and problems.

When her younger son was diagnosed with bipolar disorder with psychosis, the family entered the system again. The local youth and family crisis center handed her a long list of providers, but she could not find one with the capacity to accept another client. Instead, the family used the crisis center often. Her son could call any time of day, and someone from the crisis center would be there for him. After her son was seen at the crisis center, the provider who saw her son would call to check in on both her and her son. “That was the first time I had ever had a provider call and check on me as the parent caregiver rather than the identified youth,” Butler said. “That was probably the most beneficial and supportive thing that could have happened for me.”

When Butler’s daughter had a suicide attempt, the safety plan the crisis center gave her was like nothing she had ever seen. “It was something I could follow,” she said. She commented that the system does a good job once a family gets connected with professional services and supports, and she noted that what families often need at first is help meeting basic needs such as sleep, food, and financial support. Providing those basic needs can set a family in crisis up to do the work that lies ahead to support their child. She added she wants every family navigating the youth and family mental health system to have family peer support to help them find a provider. A family peer support partner could walk alongside the parents, empower them, offer them hope, normalize their situation, and reduce the isolation the family may experience.

Laura Marshall, co-founder of Advocates for Mental Health of Michigan Youth, spoke about her family’s challenges navigating the mental health system as it sought mental health treatment for her son. Adopted at age 14 months, her son began showing signs of significant mental health challenges almost immediately and was diagnosed with reactive attachment disorder, attention deficit hyperactivity disorder, oppositional defiant disorder, and pediatric bipolar disorder. By the time her son was 6 years old, the family was involved with community mental health. Though Marshall was employed and had private health insurance, the few times she tried to use her insurance to access any service or assistance, the claim was denied.

When the family first sought help from community mental health, they had a “phenomenal” therapist who tried to understand the challenges Marshall’s son was facing. Despite trying many therapeutic approaches, none seemed to help her son overcome his anger and aggression issues. When this “experienced, knowledgeable” therapist moved on to work with adults, her son had a succession of therapists “who always assumed that she and her husband must be doing something wrong as parents rather than looking for the root cause of her son’s problems.”

Marshall’s son did qualify for a serious emotional disturbance waiver, which meant his behavioral and mental health challenges were severe enough that he could qualify for hospitalization. The waiver also made him and his family eligible to receive a variety of services and supports that would enable him to stay at home and in his community. Marshall said that studies show this had the best chance of producing a good outcome for him. The family tried working with these services, but with unsatisfactory results. For example, the family was promised respite care, but all they were offered was group respite that required driving an hour into town for 2 hours of care for their son. Marshall said her experience differed from what the Medicaid provider manual promised.

By the time Marshall’s son was 12, his aggression and destructive behavior had reached a point where he was causing thousands of dollars of damage to the family’s home and car. The crisis line did not meet the family’s needs, leaving the family no choice but to call the police regularly. This resulted in him being placed in the juvenile detention system. There, he sat for 6 months until a judge ordered him released to a residential program in Wyoming, far from his family in Michigan.

Marshall said she wants to emphasize the value the services that experienced social workers can provide and added there are so few psychiatrists left who accept Medicaid that often the only option for seeing a psychiatrist is via telehealth, and, while it is better than nothing, telehealth is not for everyone. She said that her family has struggled finding a therapist who was culturally competent. For example, her Black teenage son is more comfortable sharing his story and challenges with someone who looks like him, rather than young White females assigned to him. Even when he was matched with a Black therapist born in Kenya, the fit was poor because he did not have the lived experience to understand the challenges her son was having.

Eboni Dabney, founder of A Mom Like Me, discussed the challenges she faced accessing behavioral health services for both her and her son. One challenge was finding a provider who would accept Medicaid or Blue Cross Blue Shield when it became a Medicaid add on. Despite having a list of providers who reportedly accepted Medicaid, none she called actually did. She said that when she and her son lived in Iowa, she could call the mobile crisis support hotline during a crisis, but in Chicago, where they now live, accessing crisis support involves calling 911, potentially leading to police involvement.

Dabney recalled that as a Black woman living in Iowa, she never had an established relationship with a therapist, in part because no one she saw looked like her. Since moving to Chicago, the only services she has accessed are through an organization for at-risk boys that also offers services to their parents. When her son was 10, he told Dabney he wanted to speak with a behavioral health professional. The list of providers for children was scant, and finding one who had the cultural background and experience to relate to her son was challenging. Eventually, she found a therapist who was a good fit for her son.

Dabney expressed frustration with the process of navigating through various providers, especially during a crisis when urgent assistance is needed. However, her navigator had no better luck than she did finding a provider who would accept Medicaid. A simple place to start, she said, would be for Medicaid to keep the provider list updated. She has heard from providers that they are choosing not to deal with Medicaid because of the difficulty of getting paid. She also learned that Medicaid does not cover things such as cognitive or neurodivergent tests in Illinois.

She also voiced frustration with the overemphasis on medication as a first solution for her own mental health challenges. At one point, Dabney was placed on a 72-hour hold at a behavioral health facility, and when discharged she was told to learn her triggers and stay away from them, with no follow up. She supported the idea that addressing basic needs should be included as a component of behavioral health services and that focusing on root causes can contribute to more effective and holistic support for individuals and families.

EXPERIENCES OF BEHAVIORAL HEALTH CARE PROVIDERS WITH PUBLIC INSURANCE PROGRAMS

Warren Ng, the medical director of outpatient behavioral health at New York-Presbyterian/Columbia University Irving Medical Center, said that the perception among psychiatrists is that lower payment and reimbursement rates often affect how systems of care invest in mental services and are barriers to addressing the nation’s mental health crisis, particularly in under-resourced communities and communities of color. Without addressing these barriers, the limited number of mission-minded psychiatrists will continue going instead to places with fewer barriers and administrative burdens. Moreover, trainees working in this setting see the difficulties in managing care for Medicare and Medicaid beneficiaries, a disincentive to work in public health. Ng said that without a value-based payment system that reimburses for this work, this will continue to be a problem.

Ng said that many psychiatrists are interested in providing psychotherapy and other interventions beyond prescribing medications, but the current payment structure and prior authorization requirements make that difficult. He said the medication shortage of attention-deficit/hyperactivity disorder medications during and after the COVID-19 pandemic was challenging because of the difficulties in securing prior authorization for alternative medicines from Medicaid and the Children’s Health Insurance Program. By the time Medicaid authorized one medication, it was often unavailable, requiring him to seek prior authorization for another drug. This took away from the time he could provide care and delayed access to care. While some organizations have a practice management system that handles prior authorization and reimbursement issues, public health settings lack such administrative support.

Another challenge is that the individuals seeking mental health care in the public health setting tend to present with more complex and more acute cases. Often, Ng said, obtaining prior authorization for intensive outpatient treatment can be a burden. Processing claim denials in the different reimbursement systems creates a significant administrative burden that has some health systems considering whether providing mental health services is too much trouble, he added.

The variability in reimbursement policies across Medicaid, Medicare, Marketplace, and managed care settings creates another challenge, Ng said. For example, there is a difference between the Medicare and Medicaid reimbursement for telehealth services in primary care setting and the reimbursement in a mental health setting which results in telehealth services being reimbursed when delivered in an outpatient setting but not when delivered in a primary care setting. Consistency in Medicaid and Medicare rates is important for the sustainability within the public health care system, Ng said.

These challenges create recruitment and retention issues, Ng continued. The new requirement for individuals to renew their Medicaid status annually creates an administrative burden resulting from the need to check each individual’s status before providing care. It also creates a burden for Medicaid beneficiaries, particularly those with cultural or linguistic needs. Medicaid also requires new clinicians to go through a laborious enrollment and credentialing process before they provide services, which can delay when a clinician can start work.

New York’s Medicaid program recently approved reimbursements for its school-based mental health programming at 125 percent of the normal Medicaid rate, though this positive development came only after the billing and collection structure was changed for this one service in this one setting. The state did not raise the reimbursement rate for the same services delivered in its primary care settings. In Ng’s imagined ideal world, Medicare, Medicaid, and Marketplace plans would all cover a full menu of options that would provide clinicians with the flexibility to treat their patients without today’s administrative burdens, and behavioral care would be integrated into primary care.

Margaret Adam, the medical director at Iora/One Medical, said that her organization works with seniors and accepts original Medicare, some Medicare Advantage managed care plans, and dual-eligible individuals, though not Medicaid alone. The largest barrier her team faces in providing counseling services is the lack of behavioral health counselors who accept Medicare, particularly those who accept Medicare and have experience in geriatric psychiatry, comorbid conditions, and the complicated medication interacts that can occur. Poor reimbursement rates are to blame for this shortage, she said. In one New York county, only four psychiatrists accept Medicare, most of whom work part time. Options for patients who need services are to join a wait list, skip therapy altogether and wait until they deteriorate to where they require hospitalization, or pay out of pocket to see a private psychiatrist. Few if any of her patients have the resources to take the third course.

This problem is compounded by the fact that Medicare restricts reimbursement for counseling services to those who have the proper licensure. Adam said that there are many licensed mental health counselors who could work with patients, but Medicare does not recognize that licensure. Medicare has acknowledged this problem and is considering some policy changes, but the current policy limits access to care and can delay a patient connecting with services for as much as 6 months.³

Often, patients struggling with severe, chronic mental illness who cannot get care immediately will appear at her office pleading for a prescription for a medication that has benefited them previously, Adam said. If the drug requires prior authorization, the amount of information required about past treatments can be almost impossible to provide, making the odds of getting prior authorization “slim to none,” she added.

In her organization’s integrated behavioral health model, the financial limitations have restricted the organization’s ability to staff according to need, resulting in the limited number of behavioral health providers handling large panels. In an ideal world, if Adam was seeing a patient for high blood pressure and realized that depression was the major barrier to the patient taking the medication as prescribed, she would introduce her patient to a behavioral health provider in a warm handoff.⁴ If treated effectively, the patient would have his or her depression under control, take the prescribed high blood pressure medication, and avoid having a stroke and being hospitalized. However, the current reimbursement structure makes the ideal situation difficult to achieve, even though it could reduce expenses overall.

One significant administrative burden, Adam said, is the need to negotiate rates with each individual Medicare Advantage plan and then determine if a patient is eligible for care given the patient’s specific plan. In addition, this situation makes it difficult to tell a patient ahead of time how much care will cost. For many seniors, this uncertainty is not acceptable, and it increases the likelihood that they will forgo treatment.

Step one to address this situation is to increase reimbursement rates, Adam said. Step two is establishing more community health clinics that accept Medicare and Medicaid beneficiaries. Step three is getting more behavioral health providers into the field and having both Medicare and Medicaid recognize a broader range of licensures⁵. Step four, a larger issue, is changing society’s perspective about the importance of behavioral health care. “It impacts everything we do, and yet we continue to pigeonhole it,” she said. “It is a carve-out on insurance and does not get covered when it is integral to health.”

Rakhee Patel, the clinical director for regional adult services at Coastal Horizons Center, said that there is a shortage of providers in her region of North Carolina who will accept Medicare and Medicaid beneficiaries. Perceived administrative burden, the need for additional training and having the right credentials to be Medicaid or Medicare certified, challenges with prior authorizations, and low reimbursement rates that have not changed in over 12 years are largely to blame for this shortage, even in the private practice community. In North Carolina, Patel added, clinicians need to get reauthorization for their Medicaid beneficiaries after every eighth session.

In addiction counseling, the regulatory burdens are significant and usually involve dealing with multiple federal and state-level regulations, Patel said. She acknowledged the need for regulation but said there could be a better balance that ensures there are enough clinicians to provide the care individuals dealing with an addiction treatment need. She wants the Centers for Medicare & Medicaid Services (CMS) to communicate better before changing a clinical coverage policy.

Tyler Vermillion, the community outreach coordinator at Ideal Option, said that dealing with the administrative and regulatory burdens associated with addiction treatment requires at least two full-time employees at his organization. The documentation required for an individual to gain admission to care for a behavioral health and substance use disorder poses a significant challenge. The mandate to adopt a certified electronic health record (EHR) incurred exorbitant costs and has been problematic because most EHRs are not tailored for behavioral health. Integrating a behavioral health module into an EHR represents an additional and ongoing expense and administrative burden, he added.

Vermillion said that managed care organizations wield excessive power to dictate with which providers they will contract. Opening a new facility and commencing the contracting process requires an agency to be fully operational, including facilities and staff. His organization endured 18 months of employing staff despite not yet being eligible for reimbursement, and it recently had to remove behavioral health care from 90 percent of its addiction treatment clinics because of contracting issues. Medicare, he added, requires more highly credentialed providers to cater to enrollees in an outpatient setting, but it can cost twice as much to employ such a provider. This is not feasible for many stand-alone agencies.

Vermillion wants Medicare to allow for a provisional diagnosis and level of care that meets the American Society of Addiction Medicine (ASAM) recommendations so that an individual could access needed services quickly. New Mexico’s Treat First model does just that.⁶ Instead of prioritizing extensive diagnostic exploration before even establishing rapport with a client, Treat First provides a mechanism to form a relationship with an individual within four visits. The idea is to help people first and then conduct the full assessment required for Medicare and Medicaid reimbursement.

Heather Jefferies, the executive director of the Oregon Council for Behavioral Health, said Oregon launched 17 community-governed managed care organizations (CCOs) in 2012, which, along with commercial insurance, has created a complicated system that providers must deal with for prior authorizations. The CCO model increased immunization rates and improved access to chronic disease care. However, behavioral health is lagging, in part because obtaining reimbursement for behavioral health services delivered outside of the physical health benefit is hampered by a failure to adjust historical payment schedules which disadvantages community-based providers. There is more emphasis at the federal level on achieving parity with physical health, but progress has been slow. One problem stemming from having 17 CCOs is that behavioral health clinics must endure 7 to 12 audits a year. An ongoing problem in Oregon is that addiction treatment services delivered before a provider performs a full assessment with the patient/client (Oregon uses ASAM) are not reimbursable, leaving early engagement services and other services rendered unfunded while still critical to engaging individuals in care, particularly those with barriers such as houselessness. Workforce shortages have placed Oregon among the worst states for providing behavioral health services. Without the ability to pay a living wage, organizations in Oregon have difficulty recruiting employees, particularly persons of color. “We do not want to continue unintentional institutional racism by offering poor wages,” Jefferies said. Yes, she added, individuals drawn to work in community-based behavioral health and substance use treatment are mission driven, but it is wrong to have them bear the burden of delivering care without providing them with a respectable salary. The problem is that addiction treatment services in Oregon are not reimbursable unless a provider has undergone an extensive ASAM assessment.

Going forward, Jefferies would like to see parity between mental health and substance use disorder services and physical health care. She said community-based behavioral health systems cannot take financial risks because revenues have been so lean for too many years. A recent modest increase in Oregon health plan reimbursement rates, averaged at 30 percent, gave the resources needed for provider organizations to increase available behavioral health provider wages in Oregon. This was demonstrated in reducing the number of empty job positions reported within these organizations from 40–65 percent to 18–25 percent. This was a significant and immediate improvement occurring within 7 months after providers were able to increase wages. She wants CMS to modernize its rules to reflect current behavioral health care practices and interventions, to offer guidance to help states streamline and improve their operations, and to provide states with the resources needed to collect and report data on compliance. She would also have CMS work with Marketplace and commercial plans to standardize coverage requirements for behavioral health and addiction treatment.

STATE-LEVEL INNOVATIONS TO IMPROVE MENTAL HEALTH AND SUBSTANCE USE DISORDER ACCESS IN MEDICARE, MEDICAID, AND MARKETPLACE INSURANCE PLANS

Cara Cheevers, the director of behavioral health programs at the Colorado Division of Insurance, said there are several approaches that her office takes to enforce parity in behavioral health coverage, starting with rule making. Colorado’s regulation about mental health parity mandates annual reporting requirements regarding quantitative treatment limitations such as financial requirements and cost-sharing for behavioral health services compared with physical health services. It also includes nonquantitative treatment limitations such as prior authorization, step therapy, and other usage-management requirements. The latter includes network adequacy and how a plan develops and retains provider networks. A second regulation details similar reporting requirements for medication-assisted treatment (MAT) for substance use disorders coverage, addressing opioid use, opioid overdose, nicotine dependence, and alcohol dependence.

A third regulation sets standards related to network adequacy. Cheevers said that these reporting requirements aim to assess how hard or easy it is for a consumer to get the behavioral health care and substance use disorder treatment they need. This regulation also mandates that individuals must be able to get care within seven calendar days from when they first attempt to make an appointment. Cheevers office also examines mental health parity from the perspective of rates and forms, which provides information on what insurers say they do, as well as market regulation and conduct, which provides information on how insurers cover care in practice.

Cheevers said that Colorado has different robust and dynamic processes to collect complaints from consumers and providers. Hearing directly from consumers and providers about what is working and what is not helps her office adjust its policy approaches to parity and behavioral health coverage in general. From the consumer experience, her office gains insights into how easy or hard it is to get medication prescribed by their providers, how much it will cost to receive care, how clients find a provider who accepts their insurance, how far they have to travel to get to that provider, and if the provider directory is accurate.

Colorado’s usage-management protocols dictate that insurers may not require prior authorization or step therapy for MAT and that they place at least one covered Food and Drug Administration-approved drug for MAT on the lowest drug formulary tier. The protocols also mandate that insurers comply with Mental Health Parity and Addiction Equity Act cost-sharing financial requirements. Recent enforcement actions found that many insurance companies were overcharging for their copays and coinsurance for behavioral health coverage and were out of compliance compared with their coverage of physical health care. Cheevers said her office checks to ensure that the cost share of any plan sold in Colorado is appropriate and complies with state and federal law prior to annual rate approval. It has also created resources to help consumers with complaint navigation and insurance literacy.

As part of its efforts to protect consumers, Cheevers’s office works to ensure that there are adequate provider networks. It cannot require that providers accept commercial insurance, but it tries to mitigate the challenges that it hears about and to understand what it can fix. This work includes making sure that the credentialing process and timeline are clear and transparent, understanding how carriers set their reimbursement rate, and ensuring that the steps a provider must take to be admitted to a network are clear. There are also several statutes and requirements about claim handling, post-payment audits, and delays in paying claims. Cheevers noted that while telehealth is a valuable modality for patients, Colorado states that telehealth cannot supplant in-person requirements for network adequacy.

Brooke Hall, a senior health care policy analyst for the Oregon Department of Consumer and Business Services (DCBS), said that Oregon’s behavioral health parity law requires every insurer offering plans providing behavioral health benefits to report to DCBS annually on nonquantitative treatment limitations (NQTLs) for behavioral health benefits. NQTLs include medical management standards that limit or exclude benefits based on whether a treatment is considered experimental formulary design and any other criteria that may limit the scope or duration of benefits. The law also requires DCBS to evaluate and report on whether insurers are treating behavioral health services at parity with medical services.

The DCBS reports show that there were similar denial rates for behavioral health and medical-surgical services, Hall said, but that notable variation among insurance carriers indicates potential biases. The reports also revealed inconsistences in the application of NQTLs and more claims from out-of-network behavioral health providers. The latter suggests there are access challenges or patient preference for out-of-network care. However, in-network claims for behavioral health have increased, suggesting improved availability of in-network services or increased consumer confidence in in-network providers.

Hall said that the DCBS reports indicate that reimbursement rates for behavioral health services are generally lower than for medical-surgical services and that reimbursement rates for out-of-network services are lower than for in-network rates. They also detail significant geographic variations in reimbursement rates for behavioral health services that may affect consumer access.

Responding to these findings, DCBS has developed comprehensive templates and guidance for insurers to streamline reporting—focusing on quantitative data and NQTLs—and improve the quality and consistency of insurer-provided data, Hall said. It has also refined its data collection process to more accurately assess mental health parity. Going forward, Oregon is considering adding quantitative standards around time and distance to providers and appointment wait times. It is also looking to streamline the credentialing process to enable more providers to enter the state’s networks. Hall noted that, as in Colorado, Oregon’s network adequacy statute prohibits the use of telehealth to meet network adequacy requirements.

Paula Stone, the director of the Arkansas Department of Human Services’ Office of Substance Abuse and Mental Health, noted that Medicaid provides 65 percent of all mental health services in Arkansas, with much of the remaining funded through Substance and Mental Health Services Administration block grants. She explained that Arkansas handled Medicaid expansion by making premium payments for Marketplace plans rather than by adding more people to its Medicaid roles. This allowed the state to get a new provider group to provide behavioral health services and to increase reimbursements for and access to substance user disorder services.

When Stone’s office looked at its traditional Medicaid population, it found that the office was paying for more services than commercial insurers were, particularly for home and community-based services to address functional deficits related to mental health conditions. While Medicaid pays for some of those services for children, it does not for adults. Rather than have Medicaid managed care plans provide care, Arkansas developed a new type of organized care model that requires Medicaid-enrolled providers to own at least 51 percent of the service provider. This program targets individuals ages 4 and up with significant intellectual and developmental disabilities or behavioral health conditions.

To get enough providers in place to meet the behavioral health care needs of its traditional Medicaid population, Stone said that Arkansas began paying independent, licensed, master’s degree therapists in addition to those employed by health care agencies. By paying them the same rate as agency providers, the state enticed independent therapists to provide services to lower-needs Medicaid beneficiaries. In addition, the state lifted requirements for prior authorization for its lower-needs population. This could have made the program unsustainable financially, but when people could access services quickly, they would use services for a shorter time. The state has since eliminated its requirement for a primary care referral, too. Arkansas has also lifted its certification requirements and allowed behavioral health care to be co-located in new places so that private practitioners need not open their own clinics and primary care physicians can hire their own behavioral health care providers and bill for their services. In addition, it changed its credentialing rules so that providers need not be recredentialed when joining a new organization.

NATIONAL PERSPECTIVE ON INNOVATIONS TO IMPROVE MENTAL HEALTH AND SUBSTANCE USE DISORDER ACCESS IN MEDICARE, MEDICAID, AND MARKETPLACE INSURANCE PLANS

Sean Robbins, the executive vice president and chief corporate affairs officer at the Blue Cross Blue Shield (BCBS) Association, said that in BCBS’s experience, raising Medicaid payment rates is not a silver bullet for getting more behavioral health care providers to accept Medicaid beneficiaries. While payment policy is important, it does not do enough to build the broad networks that can deliver mental health services where they are most needed. One issue is that many providers already have a full roster of clients. Another issue is the perception that participating in a network comes with an administrative burden.

That said, BCBS has expanded its behavioral health networks by over 55 percent over the past 4 years and provides coverage in all 50 states. It did this, Robbins explained, by forming partnerships with management services organizations to identify gaps, fill the gaps based on geography, and contract with new providers in those areas. BCBS has also increased the number of primary care providers in networks, given that primary care may deliver as much as 25 percent of outpatient behavioral health care. Another tactic to entice providers has been to speed and even automate credentialing processes and automate prior authorization.

Robbins said that BCBS has increased access to care by establishing over 250 community-based behavioral health programs across the nation. BCBS also launched a $10 million, 4-year effort to partner with Boys and Girls Clubs in some 5,000 locations nationwide. This program will provide training on trauma-informed care for all 48,000 of the organization’s frontline staff to enable them to identify, triage, and potentially direct youth who need care to the appropriate place in the health care system. BCBS of Rhode Island has been testing the idea that eliminating prior authorization for both in-network and out-of-network behavioral health services will increase access.

A third focus for BCBS is public policy regarding workforce development, diversity in the workforce pipeline, and telehealth. Telehealth, Robbins said, is an important link for providing behavioral health services, particularly in rural communities that cannot build large provider networks. Building a diverse behavioral health workforce is important to meeting the needs of the different populations needing care.

Lindsey Browning, the director of Medicaid programming at the National Association of Medicaid Directors, noted that Medicaid pays for 24 percent of all spending on behavioral health and substance use treatment, with 40 percent of Medicaid enrollees living with a mental health or substance use disorder. Medicaid is the only insurer for children with complex medical health needs, and at least some states are developing innovative programs to expand residential youth services and expand access to other services for children and adolescents. She said there are four levers that Medicaid programs have to address behavioral health provider supply: network adequacy and access standards, payment policies, reducing administrative burden, and expanding and extending the workforce.

Browning said that nearly 75 percent of Medicaid beneficiaries are in risk-based managed care plans accountable for ensuring that there are sufficient provider networks to meet the demand for services. States have leverage here because they include network adequacy and access standards in Medicaid contracts. For many Medicaid leaders, a big question is whether their increased investment in certified community behavioral health clinics is improving care delivery and access.

To reduce administrative burden, states are aligning or centralizing certain processes such as credentialing, prior authorization, and processing claims rather than having a separate process for each managed care plan. Some states are processing claims more promptly to help providers who may have cash flow issues. Telehealth has been an important method for extending the behavioral care workforce, and Medicaid has been a leader in employing peer supporters and community health workers to augment the traditional workforce. Reiterating Robbins’s comment that payment is but one lever to increase provider participation, Browning said that state and federal partnerships are essential because the states are not well positioned to address some of the underlying infrastructure gaps.

Douglas Jacobs, the chief transformation officer for the Center for Medicare at CMS, said that CMS’s behavioral health goals focus on coverage and access to care, quality of care, equity and engagement, and data analytics for action and impact. He said that, over time, more psychiatrists have been dropping their Medicare participation. This is one reason Medicare has expanded network adequacy requirements to include marriage and family therapists and has recently proposed including mental health counselors, clinical psychologists, and licensed clinical social workers.

He then discussed some changes in traditional Medicare and Medicare Advantage that focus on expanding access to behavioral health. These changes include:

• allowing a physician or nurse practitioner to provide general rather than direct supervision of behavioral health providers.
• creating new billing codes to support integrating behavioral health into primary care; providing bundled services for individuals with chronic pain and substance use disorder; allowing social workers, marriage and family therapists, and mental health counselors to bill for health behavior assessment and intervention; enabling reimbursement for services delivered by community health workers, peer support workers, and care navigators; and addressing social determinants of health risk assessment.
• implementing a new benefit category for marriage and family therapists, mental health counselors, and intensive outpatient program services in settings such as federally qualified health centers, community mental health centers, and regional health centers.
• allowing addiction counselors to enroll in Medicare, paying for crisis psychotherapy outside of clinical settings.
• allowing upfront funding for new accountable care organizations in underserved areas and allowing them to invest in new staff, including behavioral health providers.
• requiring Medicare Advantage organizations to establish care coordination programs.
• making the telehealth benefit permanent for behavioral health services.

Box 1 summarizes suggestions to improve access to behavioral health care services that were made by speakers at the three webinars.

BOX 1

Suggestions from Individual Webinar Participants to Improve Access to Behavioral Health Care.

REFERENCES

• Bureau of Health Workforce. Designated health professional shortage areas statistics: First quarter of fiscal year 2024 designated HPSA quarterly summary. 2023. [March 28, 2024]. https://data​.hrsa.gov​/Default/GenerateHPSAQuarterlyReport .
• Guth M, Saunders H, Niles L, Bergefurd AG, Kennedy RE. Findings from a survey of state Medicaid programs. 2023. [March 28, 2024]. How do states deliver, administer, and integrate behavioral health care. https://www​.kff.org/mental-health​/issue-brief​/how-do-states-deliver-administer-and-integrate-behavioral-health-care-findings-from-a-survey-of-state-medicaid-programs/
• SAMHSA (Substance Abuse and Mental Health Services Administration). Key substance use and mental health indicators in the United States: Results from the 2021 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2021. [March 28, 2024]. (HHS Publication No. PEP22-07-01005, NSDUH Series H-57). https://www​.samhsa.gov​/data/report/2021-nsduh-annual-national-report .