Medicaid plays a important role in covering and financing care for men and women with behavioral wellness situations. Practically 40% of the nonelderly adult Medicaid population (13.9 million enrollees) had a mental wellness or substance use disorder (SUD) in 2020. Most enrollees with behavioral wellness situations qualify for Medicaid mainly because of their low incomes. Behavioral wellness services are not a particularly defined category of Medicaid advantages: some may perhaps fall beneath mandatory Medicaid advantage categories (e.g., psychiatrist solutions may perhaps be covered beneath the “physician services” category), and states may perhaps also cover behavioral wellness advantages by means of optional advantage categories (e.g., case management solutions, prescription drugs, and rehabilitative solutions). Behavioral wellness solutions for young children are especially complete due to Medicaid’s EPSDT advantage for young children: young children diagnosed with behavioral wellness situations acquire any service accessible beneath federal Medicaid law important to appropriate or ameliorate the situation. Nonetheless, the very same is not necessary for adults.
To greater recognize the variation in access to behavioral wellness solutions for adults in Medicaid, KFF surveyed state Medicaid officials about behavioral wellness advantages covered for adult enrollees in their charge-for-service (FFS) applications. These concerns have been aspect 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 (which includes the District of Columbia) responded to the behavioral wellness advantages survey. This concern short utilizes the survey information to describe the landscape of behavioral wellness service coverage across states, which includes 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 wellness briefs that can be accessed in the “Behavioral Overall health Supplemental Survey” section on this web page.
Medicaid coverage of behavioral wellness 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 wellness advantages and asked them to indicate which have been covered beneath their FFS Medicaid applications for adults, as of July 1, 2022 (for far more details on survey solutions, 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 1 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 wellness care continuum—however, coverage of solutions may perhaps not translate into access to care, especially offered workforce shortages that make accessibility a challenge for Medicaid enrollees (as effectively as men and women with private insurance coverage). We also asked states that reported coverage of every single service to indicate any copay specifications as effectively as notable limits on the solutions (such as day limits or other utilization controls, which includes prior authorization specifications). Across solutions, most states reported no copay specifications, but limits have been far more prevalent.
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 every single 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 wellness solutions, and these MCOs may perhaps provide solutions to their adult enrollees that differ from these accessible on a FFS basis. States also may perhaps use Section 1115 waivers to operate their Medicaid applications in methods that differ from what is necessary by federal statute these can involve “comprehensive” waivers that make broad modifications in Medicaid advantages and other system guidelines or far more targeted demonstrations. For state-precise details on behavioral wellness 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 solutions.
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 every single service category, the majority of responding states covered far more than 50% of the solutions queried, with at least a couple of states reporting coverage of one hundred% of solutions queried. Some states reported higher coverage prices across service categories, which includes six states that cover far more than 90% of all solutions queried: NY, AZ, OR, MI, NJ, and WV. Each and every of these states cover all solutions in several of the categories: for instance, MI and OR every single cover one hundred% of the solutions queried in the institutional, outpatient, SUD, and integrated care categories.
More detail on definitions of and trends inside every single service category, which includes copays and limits, is integrated in the bullets under. For a detailed table displaying the quantity of states with coverage of every single person advantage, see Appendix B.
- Institutional care and intensive solutions are usually reserved for circumstances that demand a larger level of care and monitoring, such as behavioral wellness emergencies or extended-term remedy for these with ongoing desires. While a massive 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 remedy and adult group houses. Inside this category, limits and copays are most prevalent for psychiatric inpatient care, with far more than 1-third of covering states reporting limits and practically 1-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 perhaps be restricted.
- Outpatient solutions involve a wide variety of psychiatric solutions offered in outpatient settings. Solutions in this category variety from psychiatric testing—which may perhaps be utilised to inform diagnosis of mental wellness conditions—to far more intensive solutions, like partial hospitalization services—a far more intensive remedy that happens several occasions a week on an outpatient basis. Whilst all or practically all states cover evaluation and testing solutions as effectively as person, family members, and group therapy, there is far more variation in coverage of ADL/Abilities education, case management, and day remedy solutions. Inside this category, states have been most probably to report limits for case management and copays for therapy (person, family members, or group).
- Solutions to treat SUD have been queried in categories that comply with the level of care criteria from the American Society of Addiction Medicine (ASAM), ranging from early intervention to far more intensive solutions, such as medically monitored intensive inpatient solutions (which may perhaps 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, practically all states cover outpatient SUD remedy, though 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 practically all states reported coverage of drugs for SUD remedy, which includes buprenorphine, naltrexone, and methadone. About 1-third of states report limits for buprenorphine, but fewer limits are reported for naltrexone, which is not a controlled substance. For most SUD drugs, about 1-quarter of states report copay specifications (whereas fewer states report copays for solutions across the ASAM levels).
- We also asked states to report coverage of naloxone (devoid of prior authorization specifications), which is utilised to reverse an opioid overdose and is prescribed to men and women with opioid use disorder, but may perhaps be accessible more than the counter in the future. Practically all states cover at least 1 formulation of naloxone devoid of a prior authorization. A handful of states location other limits on these prescriptions and fewer than 1-third of states demand copays. (Information for this service category is not shown in Figure two, but can be identified in Appendix B.)
- Crisis solutions offer specialized responses to enrollees experiencing behavioral wellness emergencies. These solutions aim to lessen the reliance on law enforcement specialists, emergency departments, and other organizations staffed by men and women who are not behavioral wellness 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, which includes many states that reported covering none of the crisis solutions queried. In contrast, 4 states (AZ, NM, NY, and TN) reported covering each crisis service queried. The wide variety of coverage across states may perhaps reflect the emerging nature of crisis management in behavioral wellness. Inside this category, states most regularly covered mobile crisis solutions (about 3-quarters of responding states). This fairly larger coverage price could be in aspect connected to the American Rescue Strategy Act’sprovision of a new option and enhanced funding for states to offer neighborhood-primarily based mobile crisis intervention solutions.
- Integrated care solutions offer behavioral wellness care in conjunction with physical wellness care. Examples involve mental wellness screening in main care settings and psychiatric evaluation with healthcare solutions. Traditionally, physical and behavioral wellness 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 regularly and psychiatric evaluations with healthcare solutions, as effectively as Medicaid person/family members counseling, are covered most normally. For most integrated care solutions, couple of states reported copays, and limits have been somewhat far more prevalent (fewer than 1-fifth of states).
We also asked states to report coverage of a couple of further behavioral wellness advantages in an “other” category. For instance, far more than 4-fifths of responding states cover peer help solutions, which are offered by men and women who have personally knowledgeable behavioral wellness challenges. These specialists may perhaps assistance enrollees with emotional help or navigation of wellness care or other social solutions. Peer supports has been identified as 1 strategy that states are applying to extend the Medicaid behavioral wellness workforce.
Hunting ahead, states may perhaps continue the trend of expanding Medicaid behavioral wellness advantages and may perhaps also improve access to behavioral wellness care by means of other applications or policies. Given that FY 2016, behavioral wellness 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 wellness care. As access to behavioral wellness care is a important Medicaid priority at each the state and federal levels, these trends are probably to continue into the future. Notably, complete coverage of behavioral wellness solutions has been linked to larger Medicaid acceptance prices by providers. In addition to additional expanding coverage of behavioral wellness solutions, states may perhaps take further policy actions to raise access and boost outcomes for enrollees with behavioral wellness situations. For instance, states may perhaps pursue initiatives to address behavioral wellness workforce shortages, such as by adopting permanent expansions of behavioral wellness telehealth policy to facilitate access to care. State Medicaid agencies may perhaps also play a part in building, implementing, and assisting to fund a statewide crisis program, which includes 988 crisis hotline solutions. KFF surveyed states on these and other behavioral wellness policies, with the benefits to be published in a series of briefs that can be accessed in the “Behavioral Overall health Supplemental Survey” section on this web page. Ultimately, in addition to state Medicaid policy, federal legislation could continue to shape the behavioral wellness landscape for Medicaid enrollees.
This operate was supported in aspect by Effectively Getting Trust. KFF maintains complete editorial manage more than all of its policy evaluation, polling, and journalism activities.
This short draws on operate performed 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 wellness solutions covered for adult beneficiaries in their applications. The survey instrument captured details about solutions covered, copay specifications, 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 a different supply.
The survey asked states to report coverage of solutions in their charge-for-service (FFS) applications for categorically needy (CN) conventional Medicaid adults ages 21 and older. The survey did not ask about service coverage for medically needy (MN) coverage groups, which may perhaps differ from the state’s CN advantage package. Kids 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 Remedy (EPSDT) advantage, which calls for states to cover all screening solutions for young children as effectively as any solutions “necessary… to appropriate or ameliorate” a child’s physical or mental wellness situation (regardless of no matter whether the service is covered for adults). All but six states (AR, DE, GA, MN, NH, UT) submitted survey responses, even though in some situations a responding state may perhaps have left a certain service row blank. The territories are not integrated in the information.
We offered states with a list of 55 optional Medicaid behavioral wellness solutions. For every single service, the state chosen from a yes/no dropdown menu on the survey to indicate no matter whether the service was covered. The list of behavioral wellness 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 ought to not be compared across years as a trend due to modifications in query phrasing more than time.
Note that though this survey focused on coverage in FFS, most states continue to rely on MCOs to provide inpatient and outpatient behavioral wellness solutions, and these MCOs may perhaps provide 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 necessary minimum advantages for MCOs, as effectively as variations in advantage coverage beneath Option Advantage Plans (advantage plans that Medicaid expansion states are necessary to design and style, in line with federal recommendations, 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-precise footnotes. Nonetheless, the level of comprehensiveness of states’ responses in capturing these variations varies, and the level of details offered is probably inconsistent across states. For that reason, though the state-precise footnotes may perhaps offer beneficial context about coverage in an person state, they ought to 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 details on Medicaid coverage of behavioral wellness solutions is accessible right here and right here.
Appendix B: Summary Table