Adult Behavioral Health Benefits in Medicaid and the Marketplace

Medicaid plays a key role in financing behavioral health care, including mental health and substance use disorder services. As of 2014, many previously uninsured adults are newly eligible for Medicaid in states that choose to implement the Affordable Care Act’s (ACA) coverage expansion or for subsidized coverage through a Marketplace qualified health plan (QHP). People with behavioral health diagnoses will need clear information about which services specifically are and are not covered to make meaningful comparisons among plans when shopping for coverage.

This issue brief analyzes specific specialty behavioral health services covered by state Medicaid programs and Marketplace QHPs in four states: Arizona, Colorado, Connecticut, and Michigan. We analyzed a total of 8 Medicaid program benefit packages and 105 Marketplace QHPs. We identify similarities and differences in Medicaid and Marketplace coverage of behavioral health services across the four study states as well as similarities and differences in behavioral health coverage between Medicaid and Marketplace QHPs generally within each state and between different QHPs within each state.

Key findings are summarized in Executive Summary Table 1 and include the following:

• While a large portion of the behavioral health services in this analysis are covered by both state Medicaid programs and Marketplace QHPs, Medicaid coverage of these services is generally more comprehensive than QHPs. Overall, Medicaid coverage of specialty behavioral health services in the four study states is very comprehensive, even though particular services may not be covered by every state’s Medicaid program. For example, all four states’ Medicaid programs covered psychiatric hospital visits, case management, day treatment, psychosocial rehabilitation, psychiatric evaluation, psychiatric testing, medication management, individual therapy, group therapy, family therapy, inpatient detoxification, methadone maintenance, and smoking and tobacco cessation services. By contrast, the only services covered by all Marketplace QHPs in the 4 study states were psychiatric hospital visits and smoking and tobacco cessation services. No QHPs covered psychosocial rehabilitation or adult group home services (the latter are covered by 2 states’ Medicaid programs).
• Medicaid coverage of behavioral health services for newly eligible adults in the four study states generally aligns with coverage for other Medicaid beneficiaries. Behavioral health coverage is comparable – mostly by state design – for beneficiaries eligible for traditional Medicaid and those newly eligible under the ACA’s Medicaid expansion.
• Marketplace QHPs in the four study states provide behavioral health coverage but are generally less clear about the specific services covered as compared to Medicaid. Across the four study states, Marketplaces QHPs explicitly cover many specialty behavioral health services, but QHPs provide general coverage statements rather than an exhaustive list of covered services. In addition, QHPs are silent about coverage for a number of specialty behavioral health services, and several QHPs exclude or limit important behavioral health services, such as residential treatment, treatment of chronic conditions, and substance use disorder medication management.
• Coverage of behavioral health services in Marketplace QHPs in the four study states varies by insurer, but this coverage does not vary by metal tier in QHPs offered by a given insurer within a state’s Marketplace.

Looking Ahead

The information presented in this analysis can help insurance shoppers, particularly those eligible for Marketplace QHPs and those transitioning between Medicaid and Marketplace coverage, and policymakers to better understand the scope of coverage and information available when choosing plans. It will be important to monitor coverage of specialty behavioral health services in QHP plan documents and in the actual experience of plan enrollees seeking services as well as the impact on consumers who move from Medicaid to Marketplace coverage as their income increases in terms of their ability to access necessary specialty behavioral health services and any gaps in access to needed services on which beneficiaries rely to support their recovery and ability to work. The relative newness of the Marketplace QHP coverage option, coupled with a lack of information in QHP documents about coverage of specific services, increases the potential for confusion or misunderstanding about the scope of benefits available for adults with behavioral health needs. This may be especially important as this population needs certain specialty behavioral health services that historically have not been covered by typical private insurance plans. More QHPs than noted in our analysis may in fact cover certain services, but the lack of explicit coverage statements in publicly available plan documents in many cases made it difficult to determine whether a specific service was or was not covered. As policymakers and beneficiaries gain more experience with the new ACA coverage options, further study in this area could examine questions such as the extent of behavioral health needs among newly eligible Medicaid adults and QHP enrollees, which behavioral health services are used by these populations, and the impact of cost-sharing obligations on access to necessary services.

Behavioral health encompasses both mental illnesses and substance use disorders. In 2013, an estimated 10 million adults (or 4.2 percent of all adults) had a mental illness that seriously impaired their functioning (serious mental illness, SMI),¹  and an estimated 20.3 million adults (8.5 percent) had a substance use disorder involving alcohol or illicit drugs in the past year.²  There is some overlap between these groups, with 2.3 million adults (23.1 percent of adults with SMI in the past year) experiencing SMI co-occurring with a substance use disorder.³  SMI includes a range of conditions, such as anxiety disorders, bipolar disorder, major depression, schizophrenia, and post-traumatic stress disorder.

Medicaid plays a key role in financing behavioral health services, accounting for 26% of spending on behavioral health care nationally.⁴  Examples of behavioral health services include psychotherapy, prescription drugs, day treatment, case management, crisis intervention, peer support, assertive community treatment, and supported employment. Prior to the implementation of the Affordable Care Act’s (ACA) coverage expansion, in 2009, 35 percent of non-elderly adult Medicaid beneficiaries had a chronic behavioral health condition, likely reflecting Medicaid eligibility rules that extend coverage to people with substantial health needs.⁵ 

However, not all adults with behavioral health diagnoses receive treatment services. In 2013, 11 million adults (4.6 percent of all adults) reported an unmet need for mental health care in the past year, with 5.1 million of these adults receiving no mental health services during that time. Of these 5.1 million adults, the most common reason cited for foregoing services was the inability to afford the cost.⁶  Also in 2013, 22.7 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem (8.6 percent of persons aged 12 or older). Of these individuals, 20.2 million persons (7.7 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive treatment in the past year. The most common reason cited for not receiving substance use treatment was no health care coverage and inability to afford cost of the treatment.⁷ 

People may be unable to afford the cost of health care because they are uninsured. While lower than the prevalence among Medicaid beneficiaries, a sizeable share — 13 percent — of low-income non-elderly uninsured adults had a chronic behavioral health condition in 2009.⁸  The actual rate of behavioral health conditions among uninsured adults may be even higher, as this population is more likely than those with coverage to have undiagnosed chronic illnesses.⁹ 

As of 2014, many previously uninsured adults may be newly eligible for Medicaid in states that choose to implement the ACA’s coverage expansion or for subsidized coverage through a qualified health plan (QHP) in the Marketplace.¹⁰  As additional people become insured under the ACA, policymakers and other stakeholders can be helped by a better understanding of the benefits and challenges that adults with behavioral health needs are likely to experience when applying for coverage through Medicaid, selecting an individual plan on the Marketplace, or moving between Medicaid and Marketplace coverage as their income changes. People with behavioral health diagnoses will need clear information about which services specifically are and are not covered to make meaningful comparisons among plans when shopping for coverage.

This issue brief analyzes specific specialty behavioral health services covered by state Medicaid programs (including the benefit packages for adults newly eligible for Medicaid under the ACA’s expansion) and Marketplace QHPs in four states: Arizona, Colorado, Connecticut, and Michigan. We identify similarities and differences in Medicaid and QHP coverage of behavioral health services across these states as well as similarities and differences in behavioral health coverage between Medicaid and QHPs generally and between different QHPs within each state. Detailed coverage information for all plans analyzed in each study state is included in Appendix A, and Appendix B provides brief background about each state’s Medicaid program.

Medicaid Behavioral Health Services

Behavioral health benefits are not a specifically enumerated service required to be provided by states to adult¹¹  Medicaid beneficiaries under the state plan benefit package.¹²  Nevertheless, states can and do cover behavioral health services under various mandatory and optional Medicaid state plan benefit categories, such as inpatient, outpatient, physician, other licensed practitioner, federally qualified health center, pharmacy, clinic, case management, and health home services.¹³  (Due to a long-standing payment exclusion in federal law, Medicaid reimbursement is unavailable for inpatient services provided in “institutions for mental disease” (IMD) for adults ages 22-64.¹⁴ ) Medicaid’s rehabilitation services option is a major source of behavioral health coverage, with all states offering some amount of behavioral health services through this state plan category as of 2013.¹⁵  In FY 2011, 78% of beneficiaries receiving Medicaid rehabilitation services had a mental health diagnosis, and 76% of spending for Medicaid rehabilitation services was devoted to those with a mental health diagnosis.¹⁶ 

Adults newly eligible for Medicaid under the ACA’s expansion must receive an alternative benefit plan (ABP), which, at state option, may or may not include all of the services covered by the traditional Medicaid state plan benefit package.¹⁷  ABP coverage is based on a commercial health insurance plan or otherwise approved by the Health and Human Services Secretary. Unlike Medicaid state plan benefit packages, ABPs must cover all of the ACA’s essential health benefits, including behavioral health services.¹⁸  Beneficiaries who are “medically frail,” including newly eligible adults, are exempt from mandatory ABP enrollment and instead must have access to the full Medicaid state plan benefit package, to the extent that it differs from the new adult ABP; however, medically frail beneficiaries may choose to enroll in the ABP.¹⁹  The federal definition of “medically frail” includes “individuals with disabling mental disorders (including. . . adults with serious mental illness) [and] individuals with chronic substance use disorders.”²⁰  Many states are offering their traditional Medicaid state plan benefit package to newly eligible adults to avoid having to determine which new adults qualify as medically frail.²¹ 

States provide behavioral health services either through a fee-for-service (FFS) or managed care delivery system. If beneficiaries are required to enroll in capitated managed care, they generally must have a choice of at least two managed care organizations (MCOs). States also may carve-out behavioral health services (beyond simple physician services) to a specialty behavioral health managed care entity. For example, in our analysis, Arizona, Colorado, and Michigan use pre-paid inpatient health plans (PIHPs) to deliver specialty behavioral health services on a capitated basis (see Appendix B for additional detail).

The ACA requires that Medicaid ABPs provide behavioral health services in parity with physical health services, consistent with the Mental Health Parity and Addiction Equity Act.²²  Specifically, quantitative treatment limitations, cost-sharing obligations, medical necessity criteria, and out-of-network coverage standards for behavioral health benefits must be no more restrictive than those for medical/surgical benefits when both types of services are covered by a health plan. Current federal mental health parity requirements apply to Medicaid MCOs and to Medicaid ABPs but not to other Medicaid services delivered on a FFS basis. Previously, CMS had encouraged, but not required, states to apply mental health parity to PIHPs and PAHPs.²³  In proposed regulations issued in April 2015, CMS would require parity for state Medicaid programs’ MCO enrollees, across all delivery systems that provide services to MCO enrollees, including PIHPs, PAHPs, and FFS. CMS also proposed regulations to implement parity for ABP enrollees, regardless of delivery system.²⁴  CMS continues to encourage, but not require, parity in FFS benefits that are not delivered to MCO or ABP enrollees. Consequently, there may be different utilization limits or other restrictions on services that affect parity depending on the type of delivery system through which services are provided.

Marketplace Behavioral Health Services

The ACA provided for the creation of Marketplaces to facilitate the purchase of QHPs by individuals and small businesses. The Marketplace in each state may be operated by the state or the federal government or in partnership between the state and federal government. Marketplaces allow consumers to compare and shop for health plans and are the mechanism through which premium tax credits (for people with income from 100-400% of the federal poverty level (FPL), $11,770-$47,080 per year for an individual in 2015) and cost-sharing reductions (for people with income from 100-250% FPL, $11,770-29,425 per year for an individual in 2015) (for silver-level plans) are administered. (People with income between 100-138% FPL ($11,770-$16,243 per year for an individual in 2015) who qualify for Medicaid are ineligible for Marketplace subsidies.)

Behavioral health services are one of the ACA’s 10 categories of essential health benefits and thus must be included in QHP benefit packages.²⁵  (EHB requirements also apply to health plans sold in the individual and small group markets outside the Marketplace.) Federal regulations require the selection of a benchmark plan to define EHBs in each state and to which a QHP’s covered benefits must be substantially equivalent.²⁶  States had the option to select a benchmark plan from among the largest small-group plan by enrollment, one of the three largest health plans offered to state employees, one of the three largest federal employee health plans, or the health maintenance organization with the largest commercial non-Medicaid enrollment in the state.²⁷  If states did not make a selection, the benchmark plan defaulted to the largest small group plan. States have broad leeway to further define the scope of services required to be covered by QHPs. In addition, federal mental health parity requirements (described above) apply to all QHPs.²⁸ 

This project analyzed specific specialty behavioral health services available in state Medicaid programs and Marketplace QHPs in the individual market in four states: Arizona, Colorado, Connecticut, and Michigan. (Our analysis excludes small-group policies available on the Marketplaces.) These four states represent various geographic regions of the country and span the variety of Marketplace models, including State-based Marketplaces (Colorado and Connecticut), Federally-facilitated Marketplace (Arizona), and state Partnership Marketplace (Michigan). All four states have expanded Medicaid to newly eligible adults under the ACA (with Michigan’s expansion effective in April 2014). Additional detail about the methodology is provided at the end of this brief.

We examined particular specialty behavioral health services in the four study states as these are the services that adults with behavioral health needs are most likely to require, and these services may vary by coverage type (Medicaid vs. Marketplace) and among QHPs, may differ by plan or insurer. They include services that are specifically designed to treat behavioral health conditions; providers in this sector include physicians, such as psychiatrists, and non-physician mental health providers, such as psychologists, social workers, counselors, and psychiatric nurses.²⁹  We did not focus on general service categories that have overlap between physical and behavioral health care (e.g., physician services, prescription drugs, home health services) and that may be provided by non-mental health providers, such as primary care physicians. We analyzed each state’s Medicaid program and 105 Marketplace QHPs. We examined benefits information to determine similarities and differences in behavioral health services coverage in Medicaid and the Marketplace across the four states. We also identified similarities and differences in specialty behavioral health services within a given state, both between Medicaid and Marketplace QHPs generally and between different QHPs offered in a given state’s Marketplace. Our findings are illustrative of the similarities and differences in behavioral health coverage across and within states, and specifics in other states will vary. Our analysis does not focus on any utilization limitations on coverage of specific services or on any required cost-sharing, which particularly for QHPs, may limit access to services even if services are covered.

The four states in this analysis all provide behavioral health services to all Medicaid beneficiaries (including newly eligible adults), although the particular services offered differed across the states. In states that have not opted to align their new adult ABP with their Medicaid state plan benefit package, there may be differences in specific services covered depending on the beneficiary’s Medicaid coverage pathway.³⁰ 

Our analysis classifies adult specialty behavioral health services into four categories: institutional and intensive services, outpatient facility services, outpatient provider services, and substance use disorder treatment services. Numerous discrete behavioral health services are mapped to these four categories, as listed in Table 1.

Medicaid Coverage of Behavioral Health Services

Overall, Medicaid coverage of specialty behavioral health services in the four study states is very comprehensive, even though particular services may not be covered by every state. (This observation refers to a state’s overall Medicaid program, without distinguishing the particular delivery system in which one system for part of a state’s Medicaid population, such as a PIHP, may cover one service listed here, while another system for another segment of the population, such as FFS, may not.) Medicaid benefits are largely determined by state policy choices as outlined in the state’s Medicaid plan, within the minimum requirements provided in federal law. In the institutional care and intensive services category, all four states covered psychiatric inpatient hospital visits (in non-IMD settings for most adults), and three states (all but Michigan) covered psychiatric residential services. Connecticut and Michigan allowed for 23-hour observation, and Arizona and Connecticut covered adult group home services. Most states covered the majority of outpatient facility services (e.g., case management, day treatment, psychosocial rehabilitation, partial hospitalization), although it appears that Arizona does not cover two particular relatively common services in this category: partial hospitalization and intensive outpatient mental health services. All four states covered all of the outpatient provider services (e.g., individual and family therapy, psychiatric testing) in our analysis. In the substance use disorder treatment category, all four states covered inpatient detoxification, methadone maintenance, and smoking and tobacco cessation services. However, Arizona did not explicitly cover outpatient detoxification or Suboxone treatment, and Colorado did not explicitly cover residential rehabilitation or chemical dependency intensive outpatient services.

All four states covered the following services in their Medicaid programs:

• Psychiatric hospital visits
• Case management services
• Day treatment (community behavioral health program)
• Psychosocial rehabilitation
• Psychiatric services – evaluation and testing
• Medication evaluation, prescription and management
• Psychological testing
• Individual, group and family therapy
• Inpatient detoxification
• Methadone maintenance
• Smoking and tobacco use cessation counseling.

These findings are summarized in Table 2 below and state-specific coverage details are included in the tables in Appendix A.

Behavioral health coverage is comparable – mostly by state design – for beneficiaries eligible for traditional Medicaid and those newly eligible under the ACA’s Medicaid expansion. The four study states chose to align their traditional Medicaid state plan behavioral health benefits and their new adult ABP behavioral health coverage, often intentionally to reduce the effects of churning between different Medicaid coverage groups.

Marketplace Coverage of Behavioral Health Services

Across the four study states, Marketplaces QHPs explicitly cover many specialty behavioral health services. In the four study states, all QHPs analyzed provide inpatient psychiatric hospital services and inpatient substance use services. Most plans explicitly cover individual and group therapy. Many of the plans specifically cover intensive outpatient services, partial hospitalization, residential treatment, and substance use disorder residential rehabilitation services.

However, QHPs provide general coverage statements rather than an exhaustive list of covered services. The QHPs in all four study states include general coverage statements in their plan documents. For example, the documents for a given plan generally state that the QHP covers inpatient and outpatient mental health and substance use disorder services. As plan documents are the most detailed publicly available information about which services will or will not be covered, these general coverage statements make it difficult to determine whether specific services are covered without submission and disposition of an actual claim. Although the QHPs in our analysis mention some specific services, such as partial hospitalization (Arizona, Colorado) and intensive outpatient (Connecticut, Michigan), the plans lack an exhaustive list of covered services, which could prove especially problematic for adults with behavioral health needs seeking to compare QHPs, as it is important for these individuals to know whether their chronic health needs will be met by a given plan.

QHPs are silent about coverage for a number of specific specialty behavioral health services. For example, in Arizona, Colorado, and Connecticut, none of the QHPs explicitly covers or excludes from coverage the following mental health services: 23-hour observation, group home services, mental health rehabilitation, and individual testing. In addition, QHPs in Arizona and Colorado are silent about coverage for inpatient rehabilitation for substance use disorder treatment. In Michigan, QHPs are silent about coverage for psychosocial rehabilitation. Without an explicit coverage statement, it is difficult to determine whether specific services necessary for adults with behavioral health needs will or will not be covered.

Across the four study states, several QHPs exclude or limit important behavioral health services, such as residential treatment, treatment of chronic conditions, and substance use disorder medication management. Four of thirty QHPs in Arizona explicitly exclude coverage for residential treatment and treatment of chronic conditions not subject to favorable modification for those with mental illness. In Colorado, a few plans exclude counseling for those who do not respond to “therapeutic treatment” as stated, but not defined, in the plan document. The determination about whether a beneficiary will respond to therapeutic treatment is left to the discretion of the plan physician. In addition, multiple plans in Colorado exclude coverage of residential treatment, and one plan explicitly excludes coverage of substance use disorder residential treatment including rehabilitative services. In Michigan, two of twenty-eight plans cover residential treatment only for mental health conditions that are likely to show improvement during the admission. Five plans also exclude from coverage treatment for antisocial personality disorder. Further, two plans do not cover treatment for chronic substance abuse conditions. Across the study states, a number of plans limit substance use medication management services. For example, these services only are available during an inpatient stay or for the treatment of withdrawal symptoms. Excluding and/or limiting these important behavioral health services reduces access to care and is likely to negatively impact plan enrollees who need these services.

QHP coverage for behavioral health services varies by insurer; however, coverage does not vary by metal tier in plans offered by a given insurer within the Marketplace. In all four study states, behavioral health coverage and exclusions, as described in the plan documents, for a given insurer often were the same across all plans offered within the state’s Marketplace. Coverage of specific services did, however, vary by insurer, as expected due to rules permitting substitution of actuarially equivalent services within EHB categories. Our findings about QHP coverage of behavioral health services are summarized in Table 3.

Medicaid and Marketplace Coverage of Behavioral Health Services Compared

In general, a large portion of the four categories of behavioral health benefits identified in this analysis are covered through both Medicaid programs and at least some Marketplace QHPs; however, across the four study states, Medicaid coverage of behavioral health services is generally more comprehensive than in QHPs. For example, all four states’ Medicaid programs covered psychiatric hospital visits, case management, day treatment, psychosocial rehabilitation, psychiatric evaluation, psychiatric testing, medication management, individual therapy, group therapy, family therapy, inpatient detoxification, methadone maintenance, and smoking and tobacco cessation services. By contrast, the only services covered by all Marketplace QHPs in the 4 study states were psychiatric hospital visits and smoking and tobacco cessation services. No QHPs covered psychosocial rehabilitation or adult group home services (the latter are covered by 2 states’ Medicaid programs).

Medicaid benefit packages are more specific about which benefits are covered, while QHPs tend to provide general coverage statements instead of a list of specific covered services. Consequently, it appears that state Medicaid programs offer more comprehensive behavioral health coverage. However, there are a few exceptions. For example, some QHPs in Arizona specify substance use disorder treatment coverage for partial hospitalization, outpatient detoxification, and residential rehabilitation services whereas the state Medicaid program does not. Therefore, it seems that Arizona QHP coverage for substance use services is more comprehensive than Arizona’s Medicaid program. Further, some Michigan QHPs specify coverage of more services than the state Medicaid program (e.g., residential treatment facility, intensive outpatient, individual testing, family therapy).

As noted above, QHP behavioral health coverage is generally less clear about which specific services are covered than that available in Medicaid, with QHPs generally lacking an exhaustive list of covered services. While QHPs cover many general categories of specialty behavioral health services, it is difficult to determine definitively which specific services are covered. General coverage statements, silence about coverage of certain services, and the lack of an exhaustive benefit coverage list make it almost impossible to determine whether specific services are covered by a given QHP without submission and disposition of an actual claim.

Moving forward, the information presented in this analysis can help insurance shoppers, particularly those eligible for Marketplace QHPs and those transitioning between Medicaid and Marketplace coverage, and policymakers to better understand the scope of coverage and information available when choosing plans. As the state Medicaid plan benefit packages in this analysis seem to be more comprehensive in their coverage of specialty behavioral health services than QHPs, it will be important to monitor the impact on consumers who move from Medicaid to Marketplace coverage as their income increases in terms of their ability to access necessary specialty behavioral health services and any gaps in access to services on which beneficiaries rely to support their recovery and ability to work.

In addition, it will be important to monitor coverage of specialty behavioral health services in QHP plan documents and in the actual experience of plan enrollees seeking services. The relative newness of the Marketplace QHP coverage option, coupled with a lack of information in QHP documents about coverage of specific services, increases the potential for confusion or misunderstanding about the scope of benefits available for adults with behavioral health needs. This may be especially important as this population needs certain services that historically have not been covered by typical private insurance plans. More QHPs than noted in our analysis may in fact cover certain services, but the lack of explicit coverage statements in publicly available plan documents in many cases made it difficult to determine whether a specific service was or was not covered.

The lack of transparency about QHP coverage of specialty behavioral health services also may be reflected in QHP coverage of other specialty health care services, which could impact enrollees with other chronic diseases that may require specialized treatment (e.g., Parkinson’s disease, kidney disease and cancer). Marketplace navigators and application counselors/assistors in particular may receive questions from consumers about whether certain services are covered by a QHP or Medicaid, which they may not be able to answer.

As policymakers and beneficiaries gain more experience with the new ACA coverage options, it will be important to study this area further, examining questions such as the extent of behavioral health needs among newly eligible Medicaid adults and QHP enrollees, which behavioral health services are used by these populations, and the impact of cost-sharing obligations on access to necessary services.

To determine which services were covered in each state’s Medicaid program, five primary sources were reviewed: each state Medicaid agency’s website, each state’s Medicaid plan (where available electronically), state plan amendments, applicable waiver documentation available on Medicaid.gov and state Medicaid department websites, state Medicaid policy and provider manuals, and provider covered procedure codes (e.g., CPT and HCPCS), where available by state.

To determine the available QHPs in a state, three primary sources were reviewed: the healthcare.gov website, the respective insurer’s website, and each state’s System for Electronic Rate and Form Filing (SERFF) portal (where available). A representative sample of plans was then selected based on their Marketplace premium. Platinum and gold plans with the highest actuarial values of 90 and 80 percent, respectively; silver plans with 70 percent actuarial value;³¹  and bronze plans with 60 percent actuarial value were selected for review. The health insurance plan documents and summary of benefits were analyzed for behavioral health (including mental health and substance use) benefit coverage for adults ages 21-64. Each plan was examined for both inpatient and outpatient behavioral health service coverage.

ARIZONA

Colorado

CONNECTICUT

MICHIGAN

Arizona

Most Medicaid beneficiaries in Arizona receive acute care services through a capitated managed care organization (MCO). (One exception is for those who receive services through a long-term care contractor for seniors and people with developmental or physical disabilities.) MCO primary care providers may prescribe psychotropic medications and provide medication adjustment and monitoring services for MCO enrollees with depressive, anxiety, or attention deficit hyperactivity disorders.³²  Otherwise, Medicaid beneficiaries must receive behavioral health services through regional behavioral health authorities, which carve out these services from the acute care MCOs and are the primary delivery system for Medicaid behavioral health care in Arizona.³³ 

Overall, minimum coverage of behavioral health benefits in Arizona’s Medicaid program is very specific. State documents detail coverage by provider type (e.g., hospital, provider office) and by procedure code.

Arizona intentionally provides its newly eligible adults with the same Medicaid benefit package that other categorically eligible Medicaid beneficiaries receive to minimize disruptions for individuals moving among different Medicaid coverage groups.³⁴  The benchmark plan for purposes of essential health benefits (EHBs) in both the Marketplace and the Arizona Medicaid ABP for newly eligible adults is the State’s employee health benefit plan.

Colorado

With few exceptions, all Colorado Medicaid beneficiaries must obtain behavioral health services through their assigned behavioral health organization (except for Medicare-covered mental health services and emergency care), which is a capitated prepaid inpatient health plan.³⁵ 

Colorado’s ABP includes the same services as those available in traditional Medicaid, plus additional preventive services and habilitative services.³⁶  Colorado uses the same base benchmark plan (i.e., Kaiser Deductible/Coinsurance HMO 1200D) to determine EHBs in its new adult ABP and in the Marketplace, to ease transitions between Medicaid and Marketplace coverage.³⁷ 

Connecticut

Connecticut’s Medicaid program provides all behavioral health services on a fee-for-service basis and contracts with an administrative services organization (ASO) to oversee and coordinate these services. All Medicaid coverage groups receive essentially the same services.³⁸  Broadly categorized, these include inpatient mental health, inpatient substance use disorder treatment, institutional treatment, outpatient mental health, and outpatient substance use disorder treatment. Overall, behavioral health coverage in Connecticut’s Medicaid program is quite thorough and detailed by treatment setting (e.g., hospital, provider office) and by procedure code.³⁹  Some services require prior authorization from the ASO.

In addition, Connecticut was awarded a five year grant under the CMS Medicaid Incentives for Prevention of Chronic Diseases program to provide tobacco cessation services and participation incentives to beneficiaries who smoke and have SMI (among other target groups).⁴⁰  Connecticut is the only study state participating in this grant program, although other states outside our analysis are participating in the program and targeting beneficiaries with SMI and another chronic condition.

Connecticut chose Secretary-approved coverage as the basis for its new adult ABP and used duplication and substitution to align the new adult ABP with the state plan benefit package.⁴¹  For purposes of EHBs in the Marketplace, Connecticut used the Blue Cross and Blue Shield Service Benefit Plan—Basic Option as its benchmark, a Federal Employee Health Benefit Plan option.⁴² 

Michigan

Michigan provides behavioral health services through its traditional FFS program, Medicaid managed care organizations (MCOs), and PIHPs. Generally speaking, the delivery system through which a beneficiary accesses services depends on the severity of behavioral health condition. The MCOs and FFS program provide outpatient services to treat mild and moderate conditions.⁴³  MCOs are required to cover up to 30 outpatient mental health visits per calendar year, although they may contract with PIHPs to provide these services.⁴⁴  MCOs are not required to provide inpatient or outpatient primary diagnosis substance use disorder services; instead, these services are provided FFS or through PIHPs.⁴⁵  Medicaid beneficiaries with SMI who require benefits exceeding those provided by the FFS or MCOs receive specialty services delivered by PIHPs.⁴⁶ 

Michigan’s Medicaid behavioral health benefits are outlined in the state’s Medicaid provider manual, which lists covered services and types of providers allowed to bill for specified services. The covered services are essentially equivalent for new adults and traditional Medicaid populations.⁴⁷  For purposes of determining EHBs, Michigan chose the largest small group insurance plan in the State, the Priority Health HMO, for both its new adult ABP and Marketplace benchmark.

1. Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings at 12 (2013), available at http://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf. ↩︎
2. Id. at 50. ↩︎
3. Id. ↩︎
4. Mark TL, Levit KR, Yee T, and Chow CM, “Spending on mental and substance use disorders projected to grow more slowly than all health spending through 2020.” 33 Health Affairs 1407-15 (Aug. 2014), available at http://content.healthaffairs.org/content/33/8/1407.abstract?sid=1e1a3e1e-7024-4836-bfab-bc68f1f32277. ↩︎
5. Kaiser Commission on Medicaid and the Uninsured, The Role of Medicaid for People with Behavioral Health Conditions at 2 (Nov. 2012), available at https://modern.kff.org/health-reform/fact-sheet/the-role-of-medicaid-for-adults-with/. ↩︎
6. Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings at 24 (2013), available at http://www.samhsa.gov/data/sites/default/files/NSDUHmhfr2013/NSDUHmhfr2013.pdf. ↩︎
7. Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings at 93 (2013), available at http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf. ↩︎
8. Kaiser Commission on Medicaid and the Uninsured, The Role of Medicaid for People with Behavioral Health Conditions at 2 (Nov. 2012), available at at https://modern.kff.org/health-reform/fact-sheet/the-role-of-medicaid-for-adults-with/. ↩︎
9. Id. (internal citation omitted). ↩︎
10. One study predicted that Medicaid enrollment for non-elderly adults with SMI would nearly double with implementation of the ACA’s expansion (estimated 24.5% of Medicaid beneficiaries in 2019, compared to 12.8% in 2006), with 31% of previously uninsured adults with SMI becoming newly eligible for Medicaid. However, this study pre-dates the Supreme Court’s ruling on the ACA’s constitutionality, which effectively made implementation of the Medicaid expansion a state option (Kaiser Commission on Medicaid and the Uninsured, A Guide to the Supreme Court’s Decision on the ACA’s Medicaid Expansion (Aug. 1, 2012), available at https://modern.kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-decision/).   To date, 30 states (including DC) have implemented the ACA’s Medicaid expansion (Kaiser Commission on Medicaid and the Uninsured, Status of State Action on the Medicaid Expansion Decision (April 29, 2015), available at https://modern.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/). The same study predicted that 28% of previously uninsured adults with SMI would become eligible for private insurance under the ACA. Rachel Garfield, Judith Lave, and Julie Donohue, Health Reform and the Scope of Benefits for Mental Health and Substance Use Disorder Services, 61 Psychiatric Services, 1081-1086 (Nov. 2010). ↩︎
11. Medicaid beneficiaries from birth through age 21 qualify for comprehensive coverage, including behavioral health services, under the mandatory Early Periodic Screening Diagnosis and Treatment benefit. 42. U.S.C. § § 1396a(a)(43), 1396d(r)(5). ↩︎
12. Cf. 42 C.F.R. § § 440.210, 440.220. ↩︎
13. 42 U.S.C. § 1396a(a)(1); 1396d(a); see generally Kaiser Commission on Medicaid and the Uninsured, Medicaid Enrollment and Expenditures by Federal Core Requirements and State Options (Jan. 2012), available at https://modern.kff.org/medicaid/issue-brief/medicaid-enrollment-and-expenditures-by-federal-core/. States also may provide behavioral health services through § 1915(c) home and community-based services waivers, which are outside the scope of this analysis. ↩︎
14. CMS recently proposed that states may make capitation payments to MCOs and PIHPs for enrollees receiving services of no more than 15 days per month in an IMD that is an inpatient hospital facility or sub-acute facility providing crisis residential services. Proposed 42 C.F.R. § 438.3(u). CMS proposes this change in the capitated managed care context to address difficulties with beneficiary access to short-term inpatient behavioral health treatment and to recognize managed care plans’ flexibility in providing care in alternate settings in lieu of those covered by statute. 80 Fed. Reg. _____ (June 1, 2015), available at https://federalregister.gov/a/2015-12965. ↩︎
15. See, e.g., SAMHSA, Medicaid Handbook: Interface with Behavioral Health Services at 3-5 (2013), available at http://store.samhsa.gov/shin/content/SMA13-4773/SMA13-4773_Mod1.pdf. ↩︎
16. Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2011 MSIS and CMS-64 reports. 2010 data was used for FL, KS, ME, MD, MT, NM, NJ, OK, TX, and UT and then adjusted to 2011 spending levels. ↩︎
17. 42 U.S.C. § 1396a(k)(1). The statute uses the former terminology, “benchmark benefits.” In its July 2013 final rule, CMS began using the term “ABP.” 78 Fed. Reg. 42160 (July 15, 2013); see generally 42 U.S.C. § 1396u-7; 42 C.F.R. § § 440.300-440.390. ↩︎
18. 42 C.F.R. § 440.345(d). ↩︎
19. 42 U.S.C. § 1396a(k)(1); 42 C.F.R. § 440.320. Technically, beneficiaries in the new adult expansion group who meet an ABP exemption “must be given the option of an Alternative Benefit Plan that includes all benefits available under the approved State plan” instead of being required to receive the ABP that the state has selected for the expansion group. 42 C.F.R. § 440.315. ↩︎
20. 42 C.F.R. § 440.315(f). ↩︎
21. HHS, Office of the Assistance Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy, How the Affordable Care Act Can Support Employment for People with Mental Illness at 3 (May 2014), available at http://www.aspe.hhs.gov/daltcp/reports/2014/ACAmiesIB.cfm. ↩︎
22. 42 C.F.R. § 440.345(c); see also CMS, State Health Official Letter re: Application of the Mental Health Parity and Addiction Equity Act to Medicaid MCOs, CHIP, and Alternative Benefit (Benchmark) Plans (Jan. 16, 2013), available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-001.pdf. ↩︎
23. CMS, State Health Official Letter re: Application of the Mental Health Parity and Addiction Equity Act to Medicaid MCOs, CHIP, and Alternative Benefit (Benchmark) Plans (Jan. 16, 2013), available at http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-001.pdf. ↩︎
24. 80 Fed. Reg. 19420 (April 10, 2015), available at. https://www.federalregister.gov/articles/2015/04/10/2015-08135/medicaid-and-childrens-health-insurance-programs-mental-health-parity-and-addiction-equity-act-of; see also Kaiser Commission on Medicaid and the Uninsured, Behavioral Health Parity and Medicaid (forthcoming, 2015). ↩︎
25. 45 C.F.R. § 147.150(a); see also 42 U.S.C. § 18022(b). ↩︎
26. 45 C.F.R. § 156.100. ↩︎
27. 45 C.F.R. § 156.100(a). ↩︎
28. 45 C.F.R. § 147.160; see also ACA § 1311(j). ↩︎
29. See Kaiser Commission on Medicaid and the Uninsured, Mental Health Financing in the United States: A Primer at 3 (April 2011), available at https://modern.kff.org/medicaid/report/mental-health-financing-in-the-united-states/. ↩︎
30. See, e.g., Kaiser Commission on Medicaid and the Uninsured, Benefits and Cost-Sharing for Working People with Disabilities in Medicaid and the Marketplace (Oct. 2014), available at https://modern.kff.org/medicaid/issue-brief/benefits-and-cost-sharing-for-working-people-with-disabilities-in-medicaid-and-the-marketplace/. ↩︎
31. This measure was selected due to the availability of subsidies. ↩︎
32. Arizona Health Care Cost Containment System, Medical Policy Manual, ch. 300, Policy 310, p. 310-2. ↩︎
33. CMS, Special Terms and Conditions, Arizona Health Care Cost Containment System Section 1115 Demonstration at 11, available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/az/Health-Care-Cost-Containment-System/az-hccc-stc-10012011-09302016-amended-042013.pdf. ↩︎
34. CMS, Letter to Tom Betlach, Director, AHCCCS (April 1, 2014) and State Plan Amendment AZ-14-0006, available at www.medicaid.gov. ↩︎
35. Colorado Dep’t of Health Care Pol’y & Financing, Community Behavioral Health Services Program, available at http://www.colorado.gov/cs/Satellite?c=Page&cid=1212398231156&pagename=HCPR%2FHCPFLayout; Colorado Medical Assistance Program, Colorado 1500 Specialty Manuals at p. 5, available at http://www.colorado.gov/cs/Satellite?c=Document_C&childpagename=HCPF%2FDcoument_C%2FHCPFAddLink&cid-1210237704667&pagename=HCPFWrapper. ↩︎
36. CMS, Colorado SPA CO-13-0055, (February 10, 2014), available at medicaid.gov. ↩︎
37. CMS, Letter to Susan E. Birch, Executive Director, Dep’t of Health Care Pol’y and Financing (Feb. 10, 2014) and SPA CO-13-0055, available at www.medicaid.gov. ↩︎
38. See http://www.ctbhp.com/about.htm. ↩︎
39. See, e.g., http://www.ctbhp.com/providers/covrdsrvcs/CTBHP_Covered_Services.pdf. ↩︎
40. See http://innovation.cms.gov/initiatives/MIPCD/MIPDC-The-States-Awarded.html. ↩︎
41. Connecticut SPA 14-008, available at www.medicaid.gov. ↩︎
42. Id. at 7. ↩︎
43. Michigan Dep’t of Comm’y Health, Medicaid Provider Manual: Mental Health/Substance Abuse, p. 3-4 (April 1, 2014), available at http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf. ↩︎
44. Michigan Dep’t of Comm’y Health Medicaid Provider Manual: Medicaid Health Plans, p. 7 (April 1, 2014), available at http://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf.). Medicaid health plans are required to cover inpatient hospitalization due to complications of a substance use disorder, where substance use is a secondary diagnosis. Id. at 8. ↩︎
45. Id. at 8. ↩︎
46. Id. at 1. ↩︎
47. CMS, Michigan SPA 14-0001 (April 30, 2014), available at www.medicaid.gov. ↩︎