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Adult Behavioral Health Benefits in Medicaid and the Marketplace

Looking Ahead

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.

Key Findings Methodology

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.