Report “Expanding Behavioral Health Care Workforce Participation in Medicare, Medicaid, & Marketplace Plans” Released

The Centers for Medicare & Medicaid Services and U.S. Department of Health and Human Services should take action to increase the participation of care providers for mental health and substance use disorders in Medicare, Medicaid, and Marketplace health insurance plans, says a new report from the National Academies of Sciences, Engineering, and Medicine, “Expanding Behavioral Health Care Workforce Participation in Medicaid, Medicare, and Marketplace Plans”.

The report, which was sponsored by CMS and SAMHSA, provides recommendations to greatly expand the behavioral health workforce’s participation in Medicare, Medicaid, and Marketplace insurance. It notes that there are many valid reasons why providers are shifting toward a self-pay out-of-pocket model, including being paid less and high administrative burden of participating in managed care. To mitigate this, the report recommends significant reforms that will make the system work better for providers and patients.

Recommendations include:

• Making Provider Participation Worthwhile: The report points to a need to strengthen support structures for behavioral care providers and alleviate the administrative and financial barriers to participating in Medicare, Medicaid, and Marketplace insurance plans.
  • Reimbursement Rates: CMS should provide guidance to states on setting reimbursement rates for behavioral health care that addresses the actual cost of care and adjusts for undervaluation of these services.
  • Prompt Payment & Claims Denials: CMS should use regulations and incentives to ensure prompt payment for behavioral health care services and eliminate inappropriate denial of claims.
  • Prior Authorization & Managed Care Plans: CMS should reduce administrative burdens for behavioral healthcare providers that require them to seek prior authorization before being permitted to deliver behavioral health services.
• Promoting & Easing Entry into Public Insurance: The report recommends reducing credentialing, enrollment, and licensing barriers, and focusing on training programs and telehealth support where gaps are greatest for patients who use Medicare, Medicaid, and Marketplace plans.
  • Streamlining Credentialing and Enrollment: CMS should streamline behavioral health care provider credentialing and enrollment processes, which the report says are lengthy, repetitive, and burdensome, and discourage care providers from enrolling with multiple insurance payers.
  • Guidelines for Telehealth: CMS should develop an interagency strategy to set guidelines for coverage and payment of telehealth services for behavioral health needs. Behavioral health has the largest sustained use of telehealth, and CMS has an opportunity to use this tool to improve patient access to care.
  • Licensing Across State Lines: HHS should develop a uniform strategy to reduce barriers to care provider licensing in multiple states to expand access to these providers as part of public insurance programs.
  • Training: CMS and the Substance Abuse and Mental Health Services Administration should incentivize training programs to better support career choices in behavioral health care, which in turn will benefit more patients enrolled in Medicare and Medicaid.
• Optimizing Performance & Accountability: The report calls for strengthening accountability for managed care plans and improving opportunities for behavioral health care providers to increase their capacity for delivering care.
  • Enforcing Standards for Managed Care: CMS should develop standards for managed care plans participating in Medicare that carry significant financial penalties and bonuses based on behavioral health outcomes. CMS should also work with states to develop similar standards for Medicaid managed care plans.
  • Improved Quality Measures: CMS should invest in improved quality and risk adjustment measures for behavioral health care and link them to payment. These measures should consider the administrative burden that would fall on care providers.

Plans provided through Medicare, Medicaid, and the Health Insurance Marketplace serve a larger population of patients with behavioral health needs when compared with most private insurance plans — and Medicaid is the single largest payer for behavioral health care services in the U.S. Yet, behavioral health care providers participate less in these public insurance plans, and the distribution of these professionals across the U.S. remains misaligned with patient needs. Psychiatrists accept insurance at a rate lower than any other physician specialty, and the acceptance rate of public insurance among psychologists and other mental health professionals is also low.

According to the report, patients with behavioral health conditions are not a homogenous population, and the current system for delivering care is failing to provide them with equitable, appropriate, and accessible care. Increasing the diversity of the workforce and ensuring it can meet the needs of publicly insured populations — for example, children and youth, who face not only growing behavioral health needs but also are one of the largest populations served by public insurance — is an important aim.