Medicaid plays a essential role in covering and financing care for people today with behavioral overall health circumstances. Practically 40% of the nonelderly adult Medicaid population (13.9 million enrollees) had a mental overall health or substance use disorder (SUD) in 2020. Most enrollees with behavioral overall health circumstances qualify for Medicaid simply because of their low incomes. Behavioral overall health services are not a especially defined category of Medicaid positive aspects: some could fall below mandatory Medicaid advantage categories (e.g., psychiatrist solutions could be covered below the “physician services” category), and states could also cover behavioral overall health positive aspects by means of optional advantage categories (e.g., case management solutions, prescription drugs, and rehabilitative solutions). Behavioral overall health solutions for kids are specifically complete due to Medicaid’s EPSDT advantage for kids: kids diagnosed with behavioral overall health circumstances acquire any service readily available below federal Medicaid law needed to appropriate or ameliorate the situation. Having said that, the similar is not expected for adults.

To greater have an understanding of the variation in access to behavioral overall health solutions for adults in Medicaid, KFF surveyed state Medicaid officials about behavioral overall health positive aspects covered for adult enrollees in their charge-for-service (FFS) applications. These queries had been aspect of KFF’s Behavioral Well being Survey of state Medicaid applications, fielded as a supplement to the 22nd annual budget survey of Medicaid officials performed by KFF and Well being Management Associates (HMA). A total of 45 states (which includes the District of Columbia) responded to the behavioral overall health positive aspects survey. This situation short makes use of the survey information to describe the landscape of behavioral overall health service coverage across states, which includes themes across and inside service categories. More state-by-state detail is readily available in KFF’s Medicaid Behavioral Well being Solutions information collection. Additional policy context is readily available in a series of behavioral overall health briefs that can be accessed in the “Behavioral Well being Supplemental Survey” section on this web page.

Medicaid coverage of behavioral overall health solutions varied moderately across states, with the median quantity of covered solutions at 44 of the 55 solutions queried (Figure 1). We supplied state Medicaid officials with a list of 55 behavioral overall health positive aspects and asked them to indicate which had been covered below their FFS Medicaid applications for adults, as of July 1, 2022 (for extra information and facts on survey strategies, see Appendix A). We grouped the positive aspects queried by service category: institutional care/intensive, outpatient, SUD, naloxone (without having 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 overall health care continuum—however, coverage of solutions could not translate into access to care, specifically provided workforce shortages that make accessibility a challenge for Medicaid enrollees (as properly as people today with private insurance coverage). We also asked states that reported coverage of every single service to indicate any copay specifications as properly 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 had been extra 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 overall health solutions, and these MCOs could give solutions to their adult enrollees that differ from these readily available on a FFS basis. States also could use Section 1115 waivers to operate their Medicaid applications in methods that differ from what is expected by federal statute these can consist of “comprehensive” waivers that make broad adjustments in Medicaid positive aspects and other system guidelines or extra targeted demonstrations. For state-certain information and facts on behavioral overall health 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 strategies.

Across responding states, coverage prices had 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 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, which includes six states that cover extra than 90% of all solutions queried: NY, AZ, OR, MI, NJ, and WV. Every of these states cover all solutions in many 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 beneath. 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 ordinarily reserved for conditions that need a larger level of care and monitoring, such as behavioral overall health emergencies or extended-term remedy for these with ongoing demands. Despite the fact that a huge 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 extra than one particular-third of covering states reporting limits and practically one particular-fifth reporting copays. In states without having Section 1115 waivers of the IMD payment exclusion, the quantity of psychiatric or residential care facilities that accept Medicaid could be restricted.
• Outpatient solutions consist of a wide variety of psychiatric solutions supplied in outpatient settings. Solutions in this category variety from psychiatric testing—which could be employed to inform diagnosis of mental overall health conditions—to extra intensive solutions, like partial hospitalization services—a extra intensive remedy that happens many instances a week on an outpatient basis. Although all or practically all states cover evaluation and testing solutions as properly as person, family members, and group therapy, there is extra variation in coverage of ADL/Abilities instruction, case management, and day remedy solutions. Inside this category, states had been most most likely to report limits for case management and copays for therapy (person, family members, or group).
• Solutions to treat SUD had been queried in categories that stick 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 could be topic to the IMD exclusion). Most states reported the highest coverage prices for SUD solutions compared to the other categories, most likely bolstered by provisions in the Help Act. Inside this category, practically all states cover outpatient SUD remedy, whilst states had been least most likely 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 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 drugs, about one particular-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 (without having prior authorization specifications), which is employed to reverse an opioid overdose and is prescribed to people today with opioid use disorder, but could be readily available more than the counter in the future. Practically all states cover at least one particular formulation of naloxone without having a prior authorization. A handful of states spot 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 give specialized responses to enrollees experiencing behavioral overall health emergencies. These solutions aim to lower the reliance on law enforcement pros, emergency departments, and other organizations staffed by people today who are not behavioral overall health pros. States had been significantly less most likely 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 numerous 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 could reflect the emerging nature of crisis management in behavioral overall health. Inside this category, states most regularly covered mobile crisis solutions (about 3-quarters of responding states). This somewhat larger coverage price could be in aspect connected to the American Rescue Program Act’sprovision of a new option and enhanced funding for states to give neighborhood-primarily based mobile crisis intervention solutions.
• Integrated care solutions give behavioral overall health care in conjunction with physical overall health care. Examples consist of mental overall health screening in key care settings and psychiatric evaluation with health-related solutions. Traditionally, physical and behavioral overall health solutions have been delivered separately, but a developing 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 health-related solutions, as properly as Medicaid person/family members counseling, are covered most generally. For most integrated care solutions, handful of states reported copays, and limits had been somewhat extra prevalent (fewer than one particular-fifth of states).

We also asked states to report coverage of a handful of added behavioral overall health positive aspects in an “other” category. For instance, extra than 4-fifths of responding states cover peer assistance solutions, which are supplied by men and women who have personally knowledgeable behavioral overall health challenges. These pros could enable enrollees with emotional assistance or navigation of overall health care or other social solutions. Peer supports has been identified as one particular approach that states are working with to extend the Medicaid behavioral overall health workforce.

Hunting ahead, states could continue the trend of expanding Medicaid behavioral overall health positive aspects and could also improve access to behavioral overall health care by means of other applications or policies. Because FY 2016, behavioral overall health positive aspects have been the most frequent category of service expansions reported on KFF’s annual Medicaid spending budget 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 strengthen the integration of physical and behavioral overall health care. As access to behavioral overall health care is a essential Medicaid priority at each the state and federal levels, these trends are most likely to continue into the future. Notably, complete coverage of behavioral overall health solutions has been linked to larger Medicaid acceptance prices by providers. In addition to additional expanding coverage of behavioral overall health solutions, states could take added policy actions to enhance access and strengthen outcomes for enrollees with behavioral overall health circumstances. For instance, states could pursue initiatives to address behavioral overall health workforce shortages, such as by adopting permanent expansions of behavioral overall health telehealth policy to facilitate access to care. State Medicaid agencies could also play a part in establishing, implementing, and assisting to fund a statewide crisis technique, which includes 988 crisis hotline solutions. KFF surveyed states on these and other behavioral overall health policies, with the final results to be published in a series of briefs that can be accessed in the “Behavioral Well being Supplemental Survey” section on this web page. Lastly, in addition to state Medicaid policy, federal legislation could continue to shape the behavioral overall health landscape for Medicaid enrollees.

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

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

Appendix A: Methodology

KFF contracted with Well being Management Associates (HMA) to survey Medicaid directors in all 50 states and the District of Columbia to determine these behavioral overall health solutions covered for adult beneficiaries in their applications. The survey instrument captured information and facts 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 Well being Solutions information collection. This information reflects what the states reported on the survey responses differ in level of detail and had 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) classic Medicaid adults ages 21 and older. The survey did not ask about service coverage for medically needy (MN) coverage groups, which could differ from the state’s CN advantage package. Young children had been excluded from the survey simply because all kids below 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 needs states to cover all screening solutions for kids as properly as any solutions “necessary… to appropriate or ameliorate” a child’s physical or mental overall health situation (regardless of regardless of whether 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 could have left a unique service row blank. The territories are not integrated in the information.

We supplied states with a list of 55 optional Medicaid behavioral overall health solutions. For every single service, the state chosen from a yes/no dropdown menu on the survey to indicate regardless of whether the service was covered. The list of behavioral overall health solutions integrated in this survey was primarily based on the solutions queried by KFF in a related 2018 survey the 2018 information is readily available in the information collection. Although we have posted information for each years, the information should really not be compared across years as a trend due to adjustments in query phrasing more than time.

Note that whilst this survey focused on coverage in FFS, most states continue to rely on MCOs to provide inpatient and outpatient behavioral overall health solutions, and these MCOs could give solutions to their adult enrollees that differ from these readily available on a FFS basis. States had an chance on the survey to note variations in expected minimum positive aspects for MCOs, as properly as variations in advantage coverage below 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 had been reported, these notes are integrated in the information collection as state-certain footnotes. Having said that, the level of comprehensiveness of states’ responses in capturing these variations varies, and the level of information and facts supplied is most likely inconsistent across states. As a result, whilst the state-certain footnotes could give valuable context about coverage in an person state, they should really not be taken as a total list of variations in advantage coverage below managed care, Option Advantage Plans, or Section 1115 waiver applications nationally.

More information and facts on Medicaid coverage of behavioral overall health solutions is readily available right here and right here.

Appendix B: Summary Table