Adult Behavioral Health Benefits in Medicaid and the Marketplace


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 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 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;1 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.

Looking Ahead Appendix A: Explicitly Covered Specialty Behavioral Health Services by State

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