Medicaid Coverage of Behavioral Overall health Solutions in 2022: Findings from a Survey of State Medicaid Applications

Medicaid plays a crucial role in covering and financing care for individuals with behavioral well being situations. Almost 40% of the nonelderly adult Medicaid population (13.9 million enrollees) had a mental well being or substance use disorder (SUD) in 2020. Most enrollees with behavioral well being situations qualify for Medicaid mainly because of their low incomes. Behavioral well being services are not a especially defined category of Medicaid advantages: some may well fall beneath mandatory Medicaid advantage categories (e.g., psychiatrist solutions may well be covered beneath the “physician services” category), and states may well also cover behavioral well being advantages by means of optional advantage categories (e.g., case management solutions, prescription drugs, and rehabilitative solutions). Behavioral well being solutions for young children are especially complete due to Medicaid’s EPSDT advantage for young children: young children diagnosed with behavioral well being situations obtain any service accessible beneath federal Medicaid law important to right or ameliorate the situation. Nonetheless, the exact same is not expected for adults.

To improved recognize the variation in access to behavioral well being solutions for adults in Medicaid, KFF surveyed state Medicaid officials about behavioral well being advantages covered for adult enrollees in their charge-for-service (FFS) applications. These concerns have been portion of KFF’s Behavioral Overall health Survey of state Medicaid applications, fielded as a supplement to the 22nd annual budget survey of Medicaid officials performed by KFF and Overall health Management Associates (HMA). A total of 45 states (like the District of Columbia) responded to the behavioral well being advantages survey. This concern short utilizes the survey information to describe the landscape of behavioral well being service coverage across states, like themes across and inside service categories. More state-by-state detail is accessible in KFF’s Medicaid Behavioral Overall health Solutions information collection. Additional policy context is accessible in a series of behavioral well being briefs that can be accessed in the “Behavioral Overall health Supplemental Survey” section on this web page.

Medicaid coverage of behavioral well being solutions varied moderately across states, with the median quantity of covered solutions at 44 of the 55 solutions queried (Figure 1). We offered state Medicaid officials with a list of 55 behavioral well being advantages and asked them to indicate which have been covered beneath their FFS Medicaid applications for adults, as of July 1, 2022 (for extra data on survey procedures, see Appendix A). We grouped the advantages queried by service category: institutional care/intensive, outpatient, SUD, naloxone (devoid of prior authorization), crisis, integrated care, and other solutions. Notably, all but one particular state (SC) reported coverage of at least half of all solutions queried, with a median coverage price of 4-fifths of all solutions (44 of 55). These higher prices of coverage reflect state trends in current years to expand Medicaid solutions across the behavioral well being care continuum—however, coverage of solutions may well not translate into access to care, especially provided workforce shortages that make accessibility a challenge for Medicaid enrollees (as effectively as individuals with private insurance coverage). We also asked states that reported coverage of each and every service to indicate any copay needs as effectively as notable limits on the solutions (such as day limits or other utilization controls, like prior authorization needs). Across solutions, most states reported no copay needs, but limits have been extra frequent.

These findings are restricted to FFS Medicaid and do not comprehensively capture variation in coverage for managed care organizations (MCOs) or Section 1115 waivers. Inside each and every service category, we asked states to note variations in coverage for populations getting solutions from MCOs or by means of Section 1115 waivers. Most states continue to rely on MCOs to provide inpatient and outpatient behavioral well being solutions, and these MCOs may well present solutions to their adult enrollees that differ from these accessible on a FFS basis. States also may well use Section 1115 waivers to operate their Medicaid applications in methods that differ from what is expected by federal statute these can include things like “comprehensive” waivers that make broad modifications in Medicaid advantages and other plan guidelines or extra targeted demonstrations. For state-particular data on behavioral well being advantage coverage variation in MCOs or Section 1115 waivers as reported by states, see footnotes on indicators in the information collection. See also Appendix A for a summary of survey procedures.

Across responding states, coverage prices have been highest for SUD and outpatient solutions and lowest for crisis solutions (Figure two). As indicated in Figure two, for each and every service category, the majority of responding states covered extra than 50% of the solutions queried, with at least a handful of states reporting coverage of one hundred% of solutions queried. Some states reported higher coverage prices across service categories, like six states that cover extra than 90% of all solutions queried: NY, AZ, OR, MI, NJ, and WV. Every single of these states cover all solutions in many of the categories: for instance, MI and OR each and every cover one hundred% of the solutions queried in the institutional, outpatient, SUD, and integrated care categories.

More detail on definitions of and trends inside each and every service category, like copays and limits, is integrated in the bullets beneath. For a detailed table displaying the quantity of states with coverage of each and every person advantage, see Appendix B.

• Institutional care and intensive solutions are commonly reserved for scenarios that need a larger level of care and monitoring, such as behavioral well being emergencies or lengthy-term therapy for these with ongoing desires. Though a substantial majority of responding states report coverage of inpatient psychiatric hospital solutions and 23-hour observation, fewer than half of states report coverage of psychiatric residential therapy and adult group properties. Inside this category, limits and copays are most frequent for psychiatric inpatient care, with extra than one particular-third of covering states reporting limits and almost one particular-fifth reporting copays. In states devoid of Section 1115 waivers of the IMD payment exclusion, the quantity of psychiatric or residential care facilities that accept Medicaid may well be restricted.
• Outpatient solutions include things like a wide variety of psychiatric solutions offered in outpatient settings. Solutions in this category variety from psychiatric testing—which may well be employed to inform diagnosis of mental well being conditions—to extra intensive solutions, like partial hospitalization services—a extra intensive therapy that happens many occasions a week on an outpatient basis. Whilst all or almost all states cover evaluation and testing solutions as effectively as person, loved ones, and group therapy, there is extra variation in coverage of ADL/Capabilities instruction, case management, and day therapy solutions. Inside this category, states have been most probably to report limits for case management and copays for therapy (person, loved ones, or group).
• Solutions to treat SUD have been queried in categories that adhere to the level of care criteria from the American Society of Addiction Medicine (ASAM), ranging from early intervention to extra intensive solutions, such as medically monitored intensive inpatient solutions (which may well be topic to the IMD exclusion). Most states reported the highest coverage prices for SUD solutions compared to the other categories, probably bolstered by provisions in the Help Act. Inside this category, almost all states cover outpatient SUD therapy, although states have been least probably to cover clinically managed higher intensity residential solutions. As solutions develop in intensity, the quantity of states putting limits on the service also increases. Also inside this service category, all or almost all states reported coverage of medicines for SUD therapy, like buprenorphine, naltrexone, and methadone. About one particular-third of states report limits for buprenorphine, but fewer limits are reported for naltrexone, which is not a controlled substance. For most SUD medicines, about one particular-quarter of states report copay needs (whereas fewer states report copays for solutions across the ASAM levels).
  • We also asked states to report coverage of naloxone (devoid of prior authorization needs), which is employed to reverse an opioid overdose and is prescribed to individuals with opioid use disorder, but may well be accessible more than the counter in the future. Almost all states cover at least one particular formulation of naloxone devoid of a prior authorization. A handful of states location other limits on these prescriptions and fewer than one particular-third of states need copays. (Information for this service category is not shown in Figure two, but can be discovered in Appendix B.)
• Crisis solutions supply specialized responses to enrollees experiencing behavioral well being emergencies. These solutions aim to minimize the reliance on law enforcement specialists, emergency departments, and other organizations staffed by individuals who are not behavioral well being specialists. States have been much less probably to cover crisis solutions compared to other categories: for most states, crisis solutions was the category for which the state reported the lowest coverage price, like many states that reported covering none of the crisis solutions queried. In contrast, 4 states (AZ, NM, NY, and TN) reported covering every single crisis service queried. The wide variety of coverage across states may well reflect the emerging nature of crisis management in behavioral well being. Inside this category, states most often covered mobile crisis solutions (about 3-quarters of responding states). This reasonably larger coverage price could be in portion connected to the American Rescue Strategy Act’sprovision of a new option and enhanced funding for states to supply neighborhood-primarily based mobile crisis intervention solutions.
• Integrated care solutions supply behavioral well being care in conjunction with physical well being care. Examples include things like mental well being screening in key care settings and psychiatric evaluation with health-related solutions. Traditionally, physical and behavioral well being solutions have been delivered separately, but a expanding physique of proof supports their integration. Coverage of solutions in this category varies collaborative care model solutions are covered least often and psychiatric evaluations with health-related solutions, as effectively as Medicaid person/loved ones counseling, are covered most typically. For most integrated care solutions, handful of states reported copays, and limits have been somewhat extra frequent (fewer than one particular-fifth of states).

We also asked states to report coverage of a handful of more behavioral well being advantages in an “other” category. For instance, extra than 4-fifths of responding states cover peer assistance solutions, which are offered by men and women who have personally skilled behavioral well being challenges. These specialists may well support enrollees with emotional assistance or navigation of well being care or other social solutions. Peer supports has been identified as one particular technique that states are utilizing to extend the Medicaid behavioral well being workforce.

Seeking ahead, states may well continue the trend of expanding Medicaid behavioral well being advantages and may well also boost access to behavioral well being care by means of other applications or policies. Because FY 2016, behavioral well being advantages have been the most frequent category of service expansions reported on KFF’s annual Medicaid price range survey. For instance, in FY 2022 and/or FY 2023, a quantity of states reported expanding coverage of crisis solutions and/or of solutions aimed to boost the integration of physical and behavioral well being care. As access to behavioral well being care is a crucial Medicaid priority at each the state and federal levels, these trends are probably to continue into the future. Notably, complete coverage of behavioral well being solutions has been linked to larger Medicaid acceptance prices by providers. In addition to additional expanding coverage of behavioral well being solutions, states may well take more policy actions to raise access and boost outcomes for enrollees with behavioral well being situations. For instance, states may well pursue initiatives to address behavioral well being workforce shortages, such as by adopting permanent expansions of behavioral well being telehealth policy to facilitate access to care. State Medicaid agencies may well also play a function in establishing, implementing, and assisting to fund a statewide crisis technique, like 988 crisis hotline solutions. KFF surveyed states on these and other behavioral well being policies, with the outcomes to be published in a series of briefs that can be accessed in the “Behavioral Overall health Supplemental Survey” section on this web page. Lastly, in addition to state Medicaid policy, federal legislation could continue to shape the behavioral well being landscape for Medicaid enrollees.

This operate was supported in portion by Nicely Getting Trust. KFF maintains complete editorial manage more than all of its policy evaluation, polling, and journalism activities.

This short draws on operate completed beneath contract with Overall health Management Associates (HMA) consultants Angela Bergefurd, Gina Eckart, Kathleen Gifford, Roxanne Kennedy, Gina Lasky, and Lauren Niles.

Appendix A: Methodology

KFF contracted with Overall health Management Associates (HMA) to survey Medicaid directors in all 50 states and the District of Columbia to determine these behavioral well being solutions covered for adult beneficiaries in their applications. The survey instrument captured data about solutions covered, copay needs, and notable limits on these solutions as of July 1, 2022. The survey information is summarized in this short and published on a state-by-state basis in KFF’s Medicaid Behavioral Overall health Solutions information collection. This information reflects what the states reported on the survey responses differ in level of detail and have been not verified by means of yet another supply.

The survey asked states to report coverage of solutions in their charge-for-service (FFS) applications for categorically needy (CN) regular Medicaid adults ages 21 and older. The survey did not ask about service coverage for medically needy (MN) coverage groups, which may well differ from the state’s CN advantage package. Youngsters have been excluded from the survey mainly because all young children beneath age 21 enrolled in Medicaid by means of the categorically needy pathway are entitled to the Early and Periodic Screening, Diagnostic, and Therapy (EPSDT) advantage, which calls for states to cover all screening solutions for young children as effectively as any solutions “necessary… to right or ameliorate” a child’s physical or mental well being situation (regardless of whether or not the service is covered for adults). All but six states (AR, DE, GA, MN, NH, UT) submitted survey responses, although in some situations a responding state may well have left a distinct service row blank. The territories are not integrated in the information.

We offered states with a list of 55 optional Medicaid behavioral well being solutions. For each and every service, the state chosen from a yes/no dropdown menu on the survey to indicate whether or not the service was covered. The list of behavioral well being solutions integrated in this survey was primarily based on the solutions queried by KFF in a comparable 2018 survey the 2018 information is accessible in the information collection. Whilst we have posted information for each years, the information really should not be compared across years as a trend due to modifications in query phrasing more than time.

Note that although this survey focused on coverage in FFS, most states continue to rely on MCOs to provide inpatient and outpatient behavioral well being solutions, and these MCOs may well present solutions to their adult enrollees that differ from these accessible on a FFS basis. States had an chance on the survey to note variations in expected minimum advantages for MCOs, as effectively as variations in advantage coverage beneath Option Advantage Plans (advantage plans that Medicaid expansion states are expected to design and style, in line with federal suggestions, for newly eligible ACA expansion adults) or Section 1115 waiver applications. To the extent that they have been reported, these notes are integrated in the information collection as state-particular footnotes. Nonetheless, the level of comprehensiveness of states’ responses in capturing these variations varies, and the level of data offered is probably inconsistent across states. For that reason, although the state-particular footnotes may well supply beneficial context about coverage in an person state, they really should not be taken as a comprehensive list of variations in advantage coverage beneath managed care, Option Advantage Plans, or Section 1115 waiver applications nationally.

More data on Medicaid coverage of behavioral well being solutions is accessible right here and right here.

Appendix B: Summary Table