Has your state set network adequacy standards for behavioral health services offered by Medicaid Managed Care plans yet? If not, now is the time to work with your state to develop strong standards. On July 1, federal regulations will require states to ensure that their Medicaid Managed Care plans provide specific network adequacy for their behavioral health services. Advocates should act now to ensure their states comply with the federal rules and use the best possible network adequacy standards for behavioral health.
The new network adequacy requirement stems from two recent federal rules. The modernized Medicaid Managed Care Final Rule, published in May 2016, requires states to adopt network adequacy requirements — including time and distance standards — for many services provided by managed care plans starting next month (although CMS has indicated it would not require strict adherence to the deadline). The Mental Health Parity Final Rule requires most Medicaid programs to ensure that the rules that apply to mental health and substance use disorder Medicaid benefits, including network adequacy, are not more restrictive than those that apply to medical and surgical benefits. Taken together, these regulations require states to adopt network adequacy rules that apply to Medicaid behavioral health benefits and to ensure the rules are comparable to those that apply to medical/surgical benefits.
The Medicaid Act has long required plans to ensure that all covered services are available and accessible to enrollees. Under Medicaid regulations, if a plan cannot provide adequate access to a needed service in its network, it must allow an enrollee to access the service from an out-of-network provider.
Maintaining network adequacy standards is key to insuring timely and appropriate access to behavioral health services. Twenty percent of individuals with mental illness rely on Medicaid for their insurance, including twenty-six percent of those with serious mental illness. Inadequate access to behavioral health services has both economic and health related consequences. The economic impact of inadequate access stems from both the cost of treating increasingly more complex health issues and the loss of productivity from unemployment. Untreated mental illness is one of the leading causes of mortality worldwide and linked to higher risks of developing cardiovascular disease, respiratory disease, and other chronic diseases. This is in addition to the physical and mental burden of mental illness itself. Network adequacy standards help address delays in treatment and barriers to can lead to higher instances of morbidity and mortality, a rise in co-morbid physical and psychological conditions, productivity loss, and a lower quality of life.
Starting July 1, states will have to establish time and distance standards for various services provided by Medicaid plans, including behavioral health services. States should be developing and implementing these standards now. For example, starting in July, a new California law will require Medi-Cal plans to provide access to outpatient mental health and substance use disorder within a maximum travel time of 30 minutes or 15 miles in urban areas, or 90 minutes or 30 miles in rural areas. Similarly, Florida Medicaid requires in its contract that plans ensure access to behavioral health providers, including psychiatrists, other licensed practitioners, and licensed substance use treatment centers within 30 minutes travel time or 20 miles in urban counties, and within 60 minutes travel time or 45 miles in rural counties.
While states must set time and distance standards for Medicaid plans, we recommend that they also use other methods to monitor network adequacy for their behavioral health services. For example, the new California law also sets waiting times for appointments for various service types, including a requirement that plans provide access to most outpatient mental health and substance use disorder treatment services within 10 business days. Florida’s contract requires plans to maintain a ratio of 1:1,500 adult psychiatrists to adult enrollees, 1:1,500 other licensed practitioners to enrollees, and two substance use treatment centers per county.
As the time for compliance draws nearer, advocates should work with their states to ensure that they are adopting robust network adequacy measures and regularly monitoring plans’ compliance.