HHS, CMS Guidance Boosts Access to Specialty Behavioral Healthcare

The US Department of Health and Human Services (HHS), through the Centers for Medicare and Medicaid Services (CMS), has expanded access to specialty behavioral healthcare for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries.

The department issued guidance detailing how state Medicaid and CHIP programs will be able to reimburse specialists directly when primary care providers seek advice on behalf of a beneficiary.

For example, if a pediatrician consults with a specialty behavioral health provider about a beneficiary’s needs, both providers may receive payment for the care. This policy aims to link routine care with specialty care and increase access to specialty providers.

“The Biden-Harris Administration is committed to expanding access and improving quality of care for millions of families who have health insurance through Medicaid and CHIP,” HHS Secretary Xavier Becerra said in the press release.

“With today’s action, more families will be able to access the specialty care they need – including specialty care for children and adults with mental health needs. This is a key step forward in President Biden’s plan to address the nation’s mental health crisis by ensuring that mental healthcare is as accessible as physical healthcare.”

The policy eliminates the need for consulting providers to coordinate payment through separate agreements with the treating provider and allows Medicaid and CHIP agencies to create payment methods to reimburse consulting providers directly. The consultations can occur and be reimbursed for even when the beneficiary is not physically present.

The policy aligns Medicaid and CHIP with other practice standards across the healthcare industry, including Medicare, which implemented a similar policy in 2019.

Connecting primary care physicians with specialists can be especially beneficial for Medicaid and CHIP beneficiaries, as these populations tend to have high rates of chronic diseases.

“This common-sense change makes good on our commitment to forge better connections to high-quality, person-centered, affordable health care coverage,” said CMS Administrator Chiquita Brooks-LaSure. “Now, care for people who have complex health concerns with Medicaid or CHIP coverage can be informed by expert insights faster – reducing wait times and administrative paperwork, and increasing the prospect of better health.”

Accessing specialty care for mental health and substance use disorders has been difficult for those who need care. In 2019, more than 55 percent of adults with mental illnesses and almost 35 percent of those with serious mental illnesses did not receive care. These rates were even lower for Black, Hispanic, and other underserved communities, the press release noted.

As the country faces an ongoing youth mental health crisis, interprofessional consultations can help boost access to providers specializing in child and adolescent behavioral health. According to HHS, children living in states with statewide psychiatric consultation programs are more likely to receive mental healthcare services than children in states without these programs.

Public and private payers have been increasing their efforts surrounding mental and behavioral healthcare access, as the majority of Americans believe that health insurers are responsible for ensuring access to affordable, high-quality mental healthcare.

Aetna’s Medicaid plan in West Virginia recently granted $9.3 million to local community-based organizations to support behavioral health and social care needs for children in foster care.

In addition, payers have prioritized telehealth, mental healthcare workforce training, and new payment models to help members manage their mental health needs.