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Adult Behavioral Health Benefits in Medicaid and the Marketplace

Project Overview

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.1 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.2

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.

Table 1: Behavioral Health Services Categories
Category Services Included
Institutional care and intensive services Psychiatric hospital visit
23-hour observation
Psychiatric residential
Adult group homes
Outpatient facility services Case management
Day treatment (community behavioral health program)
Partial hospitalization
Psychosocial rehabilitation
Intensive outpatient
Mental health rehabilitation
Outpatient provider services Psychiatric services – evaluation
Psychiatric services – testing
Medication evaluation, prescription and management
Psychological testing
Individual therapy
Group therapy
Family therapy
Substance use disorder services Inpatient detoxification
Residential rehabilitation
Outpatient detoxification
Methadone maintenance
Suboxone treatment
Intensive outpatient (chemical dependency)
Smoking and tobacco use cessation counseling

 

Background Key Findings

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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.