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.
Executive Summary Table 1:
|Category||Services Explicitly Included||Arizona||Colorado||Connecticut||Michigan|
|Institutional care and intensive services||Psychiatric hospital visit||Yes||All||Yes||All||Yes||All||Yes||All|
|23-hour observation||No||None Specified||No||None Specified||Yes||None Specified||Yes||Some|
|Adult group homes||Yes||None Specified||No||None Specified||Yes||None Specified||No||None Specified|
|Outpatient facility services||Case management||Yes||None Specified||Yes||Some||Yes||Some||Yes||Some|
|Day treatment||Yes||Some||Yes||None Specified||Yes||None Specified||Yes||Some|
|Psychosocial rehabilitation||Yes||None Specified||Yes||None Specified||Yes||None Specified||Yes||None Specified|
|Intensive outpatient||No||Some||Yes||Some||Yes||All||For SUD||Some|
|Mental health rehabilitation||No||None Specified||No||None Specified||Yes||Some||No||None Specified|
|Outpatient provider services||Psychiatric services – evaluation||Yes||Some||Yes||Some||Yes||None Specified||Yes||Some|
|Psychiatric services – testing||Yes||Some||Yes||Some||Yes||None Specified||Yes||Some|
|Medication evaluation, prescription and management||Yes||Some||Yes||Some||Yes||None Specified||Yes||Some|
|Psychological testing||Yes||None Specified||Yes||Some||Yes||None Specified||Yes||Some|
|Individual therapy||Yes||Some||Yes||Some||Yes||None Specified||Yes||All|
|Group therapy||Yes||Some||Yes||Some||Yes||None Specified||Yes||Some|
|Family therapy||Yes||None Specified||Yes||Some||Yes||None Specified||Yes||Some|
|Substance use disorder services||Inpatient detoxification||Yes||Some||Yes||Some||Yes||None Specified||Yes||Some|
|Residential rehabilitation||Yes||Some||No||None Specified||Yes||Some||Yes||Some|
|Outpatient detoxification||No||Some||Yes||Some||Yes||None Specified||Yes||Some|
|Methadone maintenance||Yes||Some||Yes||Some||Yes||None Specified||Yes||Some|
|Suboxone treatment||No||Some||Yes||Some||Yes||None Specified||Yes||Some|
|Smoking and tobacco use cessation counseling||Yes||All||Yes||All||Yes||All||Yes||All|
|NOTE: The QHPs in all four study states include general coverage statements in their plan documents. Some of the above services may be covered by QHPs, but without an explicit coverage statement, it is difficult to determine whether specific services will or will not be covered without submission of an actual claim.|
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.