Adult Behavioral Health Benefits in Medicaid and the Marketplace
Appendix B: Additional Information on Study States’ Medicaid Programs
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.1 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.2
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.3 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.
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.4
Colorado’s ABP includes the same services as those available in traditional Medicaid, plus additional preventive services and habilitative services.5 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.6
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.7 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.8 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).9 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.10 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.11
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.12 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.13 MCOs are not required to provide inpatient or outpatient primary diagnosis substance use disorder services; instead, these services are provided FFS or through PIHPs.14 Medicaid beneficiaries with SMI who require benefits exceeding those provided by the FFS or MCOs receive specialty services delivered by PIHPs.15
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.16 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.