Proposed regulations ensuring mental health parity in Medicaid managed-care plans promise better coverage for important services like substance-abuse counseling—at least for beneficiaries who have providers. But the CMS rules won't guarantee more providers will participate.
“One of the questions that still remains in terms of access to care is whether there is the workforce to care for these people, particularly psychiatrists," said Dr. Tara Bishop, an assistant professor in the public health and medicine department at Weill Cornell Medical College. Out of all medical specialties, psychiatrists “are the least willing to take any type of insurance, including Medicaid.”
The proposed rule, released Monday, requires Medicaid and Children's Health Insurance Program managed-care plans to provide the same level of benefits for mental or substance-abuse treatment that they provide for medical and surgical care. States and health plans often have placed limits on mental-health coverage in terms of the number of covered days of service or visits. In many cases, coverage has been denied due to murky medical necessity rules. Under the CMS' new parity proposal, states would be required to tell enrollees the reason for any coverage denials.
The proposed rule applies provisions of the Mental Health Parity and Addiction Equity Act of 2008 to managed-care plans contracting with Medicaid and CHIP. It would ensure beneficiaries have access to mental health and substance abuse benefits regardless of whether services are provided through the managed-care organization or another service delivery system. The parity provisions would not, however, apply to beneficiaries in traditional Medicaid programs. Officials note in the regulation that they hope the policy will encourage states to modify their Medicaid benefits consistent with it.
The use of managed care is growing quickly in state Medicaid programs. Currently, 37 states and the District of Columbia contract with managed-care plans to administer benefits to at least some of their beneficiaries.
About 21.6 million Medicaid beneficiaries and 850,000 CHIP beneficiaries are expected to benefit from the coverage parity rule. The services are estimated to cost the federal government and states about $1 billion between fiscal 2015 and fiscal 2019.
The implications are huge for a population that often struggles to get the care they need, especially for substance abuse issues, experts say. “Sadly, (beneficiaries) are frequently denied access to the services that not only could assist them in gaining a quality of life and permit them to be a productive citizen but even save their lives,” said Kent Runyon, executive director of Novus Medical Detox Center in New Port Richey, Fla.
“There's this stigma that the cause of substance abuse was willful misconduct, so we shouldn't use federal dollars to help these people,” said Cynthia Moreno Tuohy, executive director of NAADAC, which represents addiction services providers. “Now more people can actually access treatment.”
Officials from state Medicaid agencies in Delaware, Kentucky and Louisiana said they already have made or were about to make changes to their Medicaid managed-care programs that would put them in compliance with the proposed CMS rule.
But Sheila Schuster, a clinical psychologist and executive director of the Advocacy Action Network, an umbrella organization that includes several health advocacy organizations, said health plans in Kentucky have continued to limit behavioral health coverage. “There's been lots of battles with managed-care organizations over access to services,” she said. “They're not authorizing outpatient services or allowing beneficiaries access to the most effective drugs. They're creating all kinds of hoops for providers and beneficiaries to jump through.” She hopes this will stop once the CMS rule is finalized.
America's Health Insurance Plans, the Association for Community Affiliated Plans, and Medicaid Health Plans of America all declined to comment on the proposed rule, saying they are still reviewing it.
Mental health stakeholders agree Medicaid and CHIP beneficiaries will be helped by the rule. But they were mixed in their assessment of whether more providers will join managed-care networks and treat program beneficiaries. “If you're a private practitioner, I don't think this will lead to much of a change for you,” said Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disability Directors.
Most Medicaid beneficiaries currently receive behavioral care from not-for-profit or public sector providers. Manderscheid said beneficiaries tend to respond well to practitioners at these facilities, as they have the most experience working with low-income patients.
Others agreed. “Very few Medicaid beneficiaries with mental illness are out there trying to find providers themselves. They tend to have case managers for that," said Andrew Sperling, director of legislative advocacy at the National Alliance on Mental Illness. "The problem has been, do they have access to appropriate care?”
Others were hopeful that more providers would accept Medicaid patients. “Our membership is very interested in participating in Medicaid,” said Shirley Ann Higuchi, associate executive director of legal and regulatory affairs for the American Psychological Association. Her group has worked with its members on strategies to make it financially viable to treat Medicaid patients given the program's low payment rates.