Behavioral Health

More than half of Medicaid managed care organizations have health equity strategies for some of their members, while four in 10 have health equity plans for their entire membership, according to a survey from the Institute for Medicaid Innovation (IMI). The survey found that 48% of MCOs have pursued health equity accreditation from the National Committee for Quality Assurance (NCQA), with 33% “planning to pursue” the accreditation. And 14% have no plans to do so, while 5% didn’t respond. Meanwhile, 86% of MCOs have “programs/policies for health plan internal staff” that are meant to address structural racism or promote racial equity, and 48% have policies for members that do the same. Outside of racial equity concerns, other notable findings from the survey include widespread problems with care coordination and telehealth delivery: 71% of responding MCOs said “access to information from previous providers [is] a key barrier to care coordination,” while 67% said “their information technology systems were a barrier to setting up effective telehealth delivery services.”

Highmark Health recently implemented a medical policy stating the insurer will cover digital prescription therapeutics (DPTs) under certain circumstances. The decision is “incredibly significant for our industry,” Akili Interactive Labs chief executive and co-founder Eddie Martucci, Ph.D., writes in an email to AIS, a division of MMIT.

Highmark’s policy pertains to Akili’s EndeavorRx treatment for children with attention-deficit/hyperactivity disorder as well as the eight other FDA-approved DPTs, which are software-based therapies to treat medical and behavioral conditions. DPTs treat conditions such as substance use disorder, opioid use disorder, irritable bowel syndrome and chronic lower back pain.

Highmark Health recently implemented a medical policy stating the insurer will cover digital prescription therapeutics (DPTs) under certain circumstances. The decision is “incredibly significant for our industry,” Akili Interactive Labs chief executive and co-founder Eddie Martucci, Ph.D., writes in an email to AIS, a division of MMIT.

Highmark’s policy pertains to Akili’s EndeavorRx treatment for children with attention-deficit/hyperactivity disorder as well as the eight other FDA-approved DPTs, which are software-based therapies to treat medical and behavioral conditions. DPTs treat conditions such as substance use disorder, opioid use disorder, irritable bowel syndrome and chronic lower back pain.

While some state officials have had more success than others, most states struggle to enforce mental health parity requirements set by federal law, according to a new report from the Georgetown University Center for Health Insurance Reforms (CHIR) and the Robert Wood Johnson Foundation (RWJF). One of the report’s authors and a mental health patient advocate both say that states need more resources to enforce parity requirements.

State officials have the responsibility of enforcing federal statutes such as the Mental Health Parity and Addiction Equity Act (MHPAEA) in the individual and fully funded employer health plan markets. Many states also have their own parity statutes as well. However, as the report puts it, “federal and state regulators have found that enforcing the complex law is challenging. While insurers’ quantitative barriers to treatment such as cost-sharing or visit limits can be relatively straightforward for regulators to assess, certain ‘non-quantitative’ treatment limits [NQTLs], such as the use of prior authorization, provider reimbursement, and formulary design are much more difficult.”

Recently, the Biden administration approved a pair of wide-ranging Medicaid waiver demonstration programs in Massachusetts and Oregon, granting those states authority to test unique policies such as keeping certain populations enrolled in Medicaid for more than a year and covering clinically tailored housing and nutritional supports. Medicaid managed care plans that serve Massachusetts and Oregon tell AIS Health that they’re planning to play a major role in helping to implement the new waiver programs, which will allow them to expand some of the social-needs-based interventions that they’re already providing and reduce the enrollee churn that can stymie care-management efforts.

Demand for mental health care has ballooned since the onset of the COVID-19 pandemic, and lawmakers from both parties have introduced legislation designed to improve access to such care. But while the idea of increasing access to mental health care is appealing to virtually all members of Congress, there is a tangle of policies that could achieve it, and legislators haven’t been able to agree on which threads should be spun into a high-profile reform bill. One such proposal that is backed by the White House and just passed the House of Representatives — H.R. 7780, the Mental Health Matters Act (MHMA) — was attacked by employer plan sponsors this week.

Congress seems poised to act on mental health issues this year, Joel White, president of Horizon Government Affairs, tells AIS Health, a division of MMIT. White is a veteran lobbyist and a former Republican staffer in the House of Representatives. The House has passed several mental health measures — including, on Sept. 28, H.R. 7780 — but the Senate’s work is moving at a slower pace.

The federal government and patient advocates have directed withering criticism regarding behavioral health coverage toward health plans in recent months. AHIP, the health insurance industry’s largest trade group, responded this week with a statement from its board emphasizing its commitment to equitable access to mental health benefits.

In January, the federal agencies that regulate health plans published a biannual report which found that health insurers have systematically failed to document the level of mental health care access they provide to members. That documentation is part of a yearslong federal effort to make plans comply with mental health care parity laws, which stipulate that health plans are not allowed to impose benefit limitations — non-quantitative treatment limits (NQTLs) — on mental health care that are more severe than limits placed on medical and surgical benefits.

HHS is currently projecting that 17.4% of Medicaid and Children’s Health Insurance Program (CHIP) enrollees — or about 15 million people — will move out of those programs when the COVID-19 public health emergency (PHE) ends. States have been barred from conducting eligibility redeterminations for Medicaid and CHIP during the PHE, as a condition of receiving enhanced federal funding, but those eligibility checks will resume whenever the PHE ends. Of those expected to lose Medicaid/CHIP coverage, almost one third are expected to qualify for premium tax credits to help defray the cost of Affordable Care Act marketplace plans, and among those people, more than 60% can access a zero-premium plan.

HHS on Aug. 16 approved the extension of Medicaid and Children’s Health Insurnace Program (CHIP) coverage for 12 months after pregnancy in Hawaii, Maryland and Ohio. Combined with previously approved state extensions made possible under the American Rescue Plan Act, 21 states and the District of Columbia now offer a full year of postpartum Medicaid/CHIP coverage. Separately, CMS issued a notice of proposed rulemaking on Aug. 18 that aims to require mandatory, annual state reporting of three quality measure sets: the Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP; the behavioral health measures on the Core Set of Adult Health Care Quality Measures for Medicaid; and the Core Sets of Health Home Quality Measures for Medicaid. The quality measures “will allow us not only to identify health disparities but also to implement interventions based on the very data that make those disparities clear,” said CMS Administrator Chiquita Brooks-LaSure.

CMS in a recent bulletin unveiled a “suite of new resources” aimed at guiding states and CMS in their oversight of Medicaid and CHIP programs, including managed care programs. Two items of particular interest to managed care organizations in a July 6 Center for Medicaid and CHIP Services Informational Bulletin (CIB) are templates that provide a standard format for states to report managed care medical loss ratios and network adequacy to determine how well a plan actually delivers its benefits. As plans struggle to meet network adequacy standards, the new template could lead to more intense oversight of network adequacy within managed care, industry experts suggest.