States and major insurance plans are mostly on board with a new rule to improve coverage for mental or substance-abuse treatment in Medicaid managed-care plans. But they want more time and flexibility to implement changes that would affect millions of Medicaid beneficiaries.
The CMS received 160 letters this week as it closed out its comment period on proposed changed to a rule released in April meant to provide the same amount of coverage for mental- and substance-abuse treatment as there is for surgical and medical 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. Critics of the way managed-care plans deal with mental illness say they don't authorize outpatient services or allow access to the most effective drugs.
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.
Once the rule is finalized, states and plans will have 18 months to comply with the new standards. Payers and states say the timeline is too ambitious because the changes are administratively complex.
UnitedHealthcare representatives suggested an implementation timeline of up to 30 months.
State officials agreed that 18 months may be too quick a turnaround. It will take some time to review services, pull patient and claims data, and develop a compliance documentation on the individual state level, said Lisa Hettinger, Idaho's Medicaid administrator. There would also need to be contract changes with the plans and an amendment process for the state's Medicaid plan as it's currently written on file at the CMS.
“If the final rule were published today, it would be very difficult to develop the rules in time for the 2016 legislative session,” Hettinger said. “Two years would allow time to complete all the necessary activities to show compliance.”
There was also some concern over whether the CMS pushes states hard enough to develop new rates for plans that would take into account that they must now offer enhanced behavioral health benefits.
“The proposed language encourages, but does not require, states to re-assess the actuarial soundness of their rates after changes to benefits have been made to create parity,” according to comments from the Blue Cross and Blue Shield Association. “We are concerned about the potential for states' lack of transparency and predictability in the rate-setting process to lead to insufficient rates.”
The CMS should require states to conduct an analysis of past and projected claims experience, in light of any additional benefits that will be provided as a result of the final rule, and not require managed-care plans to cover additional mental health benefits until appropriate rates are in place, the association says.
Some states are concerned as they don't have interest in adding managed mental-health services into their Medicaid program and it appears that they could be penalized in some way if they don't do so. The rule provides guidelines for provider participation standards, payment rates, and methods to determine medical need and formulary design.
“Standardizing all of these fundamental tools will suppress competition in the market and will take away the flexibility that is necessary for innovation and quality improvement,” said Marie Zimmerman, Minnesota's Medicaid director. “We strongly suggest that CMS work with states and other interested parties to find alternative means to ensuring quality and access to mental-health services in states that have chosen to provide those services outside of a managed-care product.”
Some say these rules aren't enough to fix the problem of access to mental-health services because most Medicaid beneficiaries currently receive behavioral care from not-for-profit or public sector providers. Some wonder whether there the workforce is there, particularly psychiatrists.
Shirley Ann Higuchi, associate executive director of legal and regulatory affairs for the American Psychological Association has previously told Modern Healthcare that her group is working on ways to make it financially viable to treat Medicaid patients.