Mental health and substance use treatment organizations struggle to meet the increase in demand for services, due in large part to a national workforce shortage. This challenge has been exacerbated due to the Covid-19 pandemic. Demand for behavioral health organizations’ services has continued to increase. At the same time, organizations are having trouble recruiting and retaining employees, and patient waitlists continue to grow. Competition for behavioral health workforce has only grown with new opportunities in telehealth and the entrance of private equity into the behavioral health market. The safety net providers are the most impacted and often have the least flexibility to address underlying factors leading to the shortages in large part due to regulation and administrative burden and underfunded payment models.
HMA, in partnership with the National Council for Mental Wellbeing (NatCon), developed a series of issue briefs outlining state policy and provider steps that can help to address the critical shortage.
HMA is also working with NatCon and the College for Behavioral Health Leadership (CBHL) to engage national partners using a collective impact framework to provide backbone support for organizations to work together in a more structured and action-oriented approach and to leverage various implementers (policy, regulatory, payers, providers, educators, etc.) to move recommendations to action.
Behavioral Health Workforce is a National Crisis: Immediate Policy Actions for States
HMA can help state policy makers and provider organizations with workforce support and problem solving, workforce assessment, strategy and policy design.
Our team of experts includes clinicians with on-the-ground experience as well as previous policy makers. We’ve worked within the certified community behavioral health clinic (CCBHC) model and provide technical assistance to organizations planning for its adoption. We have experience in extending it beyond the demonstration utilizing Medicaid state plan amendments (SPA) or 1115 waivers to enhance the workforce.
HMA capabilities
Identifying effective workforce strategies including training and maximizing of multi-disciplinary teams (e.g., peers, behavioral health providers, nurses, licensed health care providers).
Policy and system design for behavioral health services and workforce expansion
Managed Care Organizations (MCO) strategy and program design as well as strategies to enhance the provider network
Conducting certified community behavioral health clinic (CCBHC) readiness and implementation support.
Maximizing virtual and technology interventions.
Convening stakeholders and building partnerships across sectors.
HMA is positioned to support
State Medicaid agencies
State and local departments of health, public health, behavioral health, and child welfare
Working to integrate services across systems and communities, Paul Fleissner is a seasoned executive who has developed programs and policies … Read more
Allie Franklin is a licensed clinical social worker with decades of experience in public, private, and non-profit behavioral health, healthcare, … Read more
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With the planning and implementation of 988 and mobile crisis teams, as well as co-responder models, state policy makers are working rapidly to advance effective approaches to systemically and effectively address the needs of individuals and families who are experiencing behavioral health crises.
Central to effective implementation is attention to specific community needs. States are working to partner with local communities to build capacity, leverage the knowledge and expertise of local partners, and gain an understanding of how new benefits and system changes fit into existing community frameworks. This local approach is particularly important for rural and frontier communities, and for tailoring models to meet specific priority populations’ needs, while building trust and ensuring crisis services are grounded in equitable access and culturally responsive care.
With more than 25 years of crisis system development, HMA colleagues stand ready to support crisis system community partners in advancing their crisis systems and services.
With our finger on the pulse of the science-backed research and approaches necessary to create integrated and comprehensive systems, we can help identify barriers and explore and implement solutions.
Our HMA crisis system team supports community partners with:
Partnership development
Stakeholder engagement
Crisis system needs assessment – strengths and gaps analysis
Program design and implementation
Crisis service development
Cross-system protocols
Cost modeling and sustainable reimbursement approaches
Health Management Associates (HMA) is a national leader in supporting states with the design, development, negotiation and implementation of Section 1115 demonstration waivers and waiver extensions. HMA has assisted more than 20 Medicaid departments directly with their state plan amendments, waivers, and other demonstration projects – and most recently supported Alaska, Colorado, Delaware, Indiana, Missouri, and Oklahoma.
HMA’s behavioral health team is currently working with multiple Medicaid agencies on the development of substance use disorder (SUD), serious mental illness (SMI), and serious emotional disturbance (SED) specific 1115 waivers.
We pair our behavioral health and Medicaid subject matter experts to support states with:
Developing and applying for SMI/SED and SUD Section 1115 demonstration waivers.
Providing an assessment of the requirements under the Section 1115 demonstration waiver and Medicaid managed care “in lieu of” authorities, including requirements for average length of stay, provider oversight, and monitoring, as well as other considerations.
Reviewing managed care contract requirements and providing applicable Medicaid managed care contract language for states that are utilizing “in lieu of” authority to provide reimbursement for inpatient or residential stays in IMDs.
Technical assistance with developing administrative infrastructure to monitor utilization, including adherence to length of stay requirements under the waiver and “in lieu of” options. CMS’ SMI Section 1115 demonstration waiver guidance prohibits states from receiving Federal Financial Participation (FFP) for any IMD stays that exceed 60 days. In cases where states do not meet this metric, CMS can reduce this maximum length of stay (LOS) to 45 days or less. HMA understands it is important for states to have utilization management (UM) strategies in place to identify these instances and minimize the state’s financial risk, and can therefore provide examples of state UM strategies, as well as incentives to manage inpatient and residential LOS while maintaining access to medically necessary services.
Supporting design of data capture and reporting functions for meeting wavier requirements.
Serving as the independent evaluator for approved SUD and/or SMI/SED 1115 waiver demonstrations.
This week our In Focus section reviews President Joseph R. Biden’s 2023 State of the Union Address (SOTU) to Congress. The President highlighted specific actions that Congress, and the Administration have taken over the last two years to advance his health care priorities.
During his first SOTU address in 2022, President Biden announced the creation of a “Unity Agenda”, which included priority policy areas with potential for bi-partisan support. The President highlighted several steps the Administration has taken to advance the “Unity Agenda” including:
The bipartisan effort to enact the Mainstreaming Addiction Treatment (MAT) Act, which removed the federal requirement for practitioners to have a waiver (known as the X-waiver) to prescribe medications, like buprenorphine, for the treatment of opioid use disorder
The Cancer Moonshot announcements for almost 30 new programs, policies, and resources to close the screening gap, tackle environmental exposure, decrease preventable cancers, advance cutting-edge research, support patients and caregivers, and more.
Addressing mental health needs through the expansion of Certified Community Behavioral Health Clinics and launch of the 988-suicide prevention hotline.
In his SOTU and accompanying White House materials, the President also proposed new policies and initiatives to further advance his health care agenda. These actions include a combination of issues that would require Congressional approval as well as actions regulatory agencies can already advance. Congress and the Administration are expected to build on previous bipartisan achievements to tackle the nation’s dual crises with addiction and mental health.
Notably, the policies outlined in the SOTU foreshadow an active regulatory agenda over the next 18 months as the Administration seeks to solidify key aspects of the President’s health care agenda ahead of the next Presidential election.
The Administration’s planned actions include the following:
Opioids
Calling on Congress to pass legislation to permanently schedule all illicitly produced fentanyl-related substances into Schedule I.
SAMHSA will provide enhanced technical assistance to states who have existing State Opioid Response funds, and will host peer learning forums, national policy academies, and convenings with organizations distributing naloxone beginning this spring.
By this summer, the Federal Bureau of Prisons will ensure that each of their 122 facilities are equipped and trained to provide in-house medication-assisted treatment (MAT).
This spring CMS will provide guidance to states on the use of federal Medicaid funding to provide health care services—including treatment for people with substance use disorder—to individuals in state and local jails and prisons prior to their release. California is the first state to receive approval for a similar initiative.
Mental Health
CDC plans to launch a new campaign to provide a hub of mental health and resiliency resources to health care organizations in better supporting their workforce.
The Department of Education (ED) will announce more than $280 million in grants to increase the number of mental health care professionals in high-need districts and strengthen the school-based mental health profession pipeline.
HHS and ED will issue guidance and propose a rule to make it easier for schools to provide health care to students and more easily bill Medicaid for these services.
The Administration is scheduled to propose new mental health parity rules this spring.
HHS will improve the capacity of the 988 Lifeline by investing in an expansion of the crisis care workforce; scaling mobile crisis intervention services; and developing additional guidance on best practices in crisis response.
HHS also plans to promote interstate license reciprocity for delivery of mental health services across state lines.
HHS intends to increase funding to recruit future mental health professionals from Historically Black Colleges and Universities and to expand the Minority Fellowship Program.
The Department of Veterans Affairs (VA), working with HHS and Defense, will launch a program for states, territories, Tribes and Tribal organizations to develop and implement proposals to reduce suicides in the military and among veterans.
VA will also increase the number of peer specialists working across VA medical centers to meet mental health needs
Cancer Moonshot
The President called on Congress to reauthorize the National Cancer Act to overhaul cancer research and to extend the funding for biomedical research established in the 21st Century Cures Act.
The Administration will take steps to ensure that patient navigation services are covered by insurance. This could require legislation depending on which type on insurance an individual has.
Health care costs
Urging Congress to pass legislation to cap insulin prices in all health care markets. Expanding the $35 insulin cap to commercial markets will require the 60 votes in the Senate.
Home and community services
Working with Congress to approve legislation to ensure seniors and people with disabilities can access home care services and to provide support to caregivers.
HMA and HMA companies are closely monitoring these federal policy developments. We can assist healthcare stakeholders in responding to the immediate opportunities and challenges that arise and contextualize these actions for longer-term strategic business and operational decisions.
If you have questions about these or other federal policy issues and how they will impact your organization please contact Andrea Maresca ([email protected]) or Liz Wroe ([email protected]).
At HMA, our subject matter experts get questions every day from people working in state agencies, counties, health plans and provider groups about how to “right size” the behavioral health continuum to obtain equitable access for growing behavioral health demand. From legislatures to providers, improving access to mental health services is critical to improving overall health outcomes. It is time for behavioral health to create a specific definition of network adequacy that accounts for the complexity and nuance of access to mental health and substance use care. It is time to identify and define the factors that lead to “adequate” provider capacity, to ensure that the right level of care is available to individuals when they need care. Network adequacy in behavioral health needs an overhaul to meet the complexity that is driving access challenges.
Together let’s re-define what “adequate” means in behavioral health to ensure we build systems that meet the needs of communities. At HMA’s quality conference on March 6 in Chicago, the “Developing a Behavioral Health Quality Strategy” working session will engage participants in an in-depth discussion on identifying factors to inform a more accurate definition of behavioral health network adequacy. Speakers will outline some of the core challenges in network adequacy and innovations they have used. Attendees will work collaboratively in a structured exercise on three knotty challenges within network adequacy to identify factors that could improve measurement for states, plans and providers. The goal is for participants to walk away with tangible actions they can implement in their work on behavioral health access.
And follow #HMAtalksQuality on Twitter and LinkedIn for more updates on behavioral health quality efforts throughout the year. View the full agenda and register for HMA’s first annual quality conference on March 6 in Chicago. Registration closes on February 21, 2023.
Join us on Monday, March 6, 2023, at the Fairmont Chicago, Millennium Park, for “Healthcare Quality Conference: A Deep Dive on What’s Next for Providers, Payers, and Policymakers,” where Lee Fleisher, MD, chief medical officer and director of CMS’ Center for Clinical Standards and Quality, will deliver the keynote titled A Vision for Healthcare Quality: How Policy Can Drive Improved Outcomes.
HMA’s first annual quality conference will provide organizations the opportunity to “Focus on Quality to Improve Patients’ Lives.” Attendees will hear from industry leaders and policy makers about evolving health care quality initiatives and participate in substantive workshops where they will learn about and discuss solutions that are using quality frameworks to create a more equitable health system.
In addition to Fleisher, featured speakers will executives from ANCOR, CareOregon, Commonwealth Care Alliance, Council on Quality and Leadership, Intermountain Healthcare, NCQA, Reema Health, Kaiser Permanente, United Hospital Fund, and others.
Working sessions will provide expert-led discussions about how quality is driving federal and state policy, behavioral health integration, approaches to improving equity and measuring the social determinants of health, integration of disability support services, stronger Medicaid core measures, strategies for Medicare Star Ratings, value-based payments, and digital measures and measurement tools. Speakers will provide case studies and innovative approaches to ensuring quality efforts result in lasting improvements in health outcomes.
“What’s different about this conference is that participants will engage in working sessions that provide healthcare executives tools and models for directly impacting quality at their organizations,” said Carl Mercurio, Principal and Publisher, HMA Information Services.
View the Full Agenda
Early Bird registration ends January 30. Visit the conference website for complete details or contact Carl Mercurio at 212-575-5929/[email protected]. Group rates and sponsorships are available.
The holiday season is grounded in gratitude. At HMA, we are grateful for successful partnerships that have fueled change to improve lives.
We are proud to be trusted advisors to our clients and partners. Their success is our success. In 2022 our clients and partners made significant strides tackling the biggest healthcare challenges, seizing opportunities for growth and innovation, and shaping the healthcare landscape in a way that improves the health and wellness of individuals and communities.
HMA partnered with the Colorado Department of Human Services to support the planning and implementation of a new Behavioral Health Administration (BHA). HMA provided technical research and extensive stakeholder engagement, drafted models for forming and implementing the BHA, employed an extensive change management approach, and created a detailed implementation plan with ongoing support. Today the BHA is a cabinet member-led agency that collaborates across agencies and sectors to drive a comprehensive and coordinated strategic approach to behavioral health.
Wakely Consulting Group, an HMA Company, was engaged to support the launch of a Medicare Advantage (MA) joint venture partnership between a health plan and a provider system. Wakely was responsible for preparing and certifying MA and Medicare Part D (PD) bids, a highly complex, exacting, and iterative effort. The Wakely team quickly became a trusted advisor and go-to resource for the joint venture decision makers. The joint venture has driven significant market growth over its initial years, fueled by a competitive benefit package determined by the client product team.
In 2021 Indiana Governor Eric Holcomb appointed a 15-member commission to assess Indiana’s public health system and make recommendations for improvements. The Indiana Department of Health (IDOH) engaged HMA to provide extensive project management and support for six workstreams. HMA prepared a draft report summarizing public input as well as research findings and recommendations. The commission’s final report will form the basis of proposed 2023 legislation, including proposals to substantially increase public health service and funding across the state.
In early 2022 HMA and Wakely Consulting Group, an HMA Company, assisted multiple clients with their applications to participate in the new CMS ACO REACH model. The purpose of this model is to improve quality of care for Medicare beneficiaries through better care coordination and increased engagement between providers and patients including those who are underserved. The team tailored their support depending on each client’s needs. The application selection process was highly competitive. Of the 271 applications received, CMS accepted just under 50 percent. Notably, nine out of the 10 organizations HMA and Wakely supported were accepted into the model.
HMA, and subsidiaries The Moran Company and Leavitt Partners, were selected by a large pharmaceutical manufacturer to analyze the current pipeline of innovative therapies, examine reimbursement policies to assess long-term compatibility with the adoption of innovative therapies and novel delivery mechanisms, and make policy recommendations to address any challenges identified through the process. The project equipped the client with a holistic understanding of future potential impacts and actions to address challenges in a detailed pipeline analysis of innovative therapies.
This week, our In Focus section reviews highlights and shares key takeaways from the 22nd annual Medicaid Budget Survey conducted by The Kaiser Family Foundation (KFF) and Health Management Associates (HMA). Survey results were released on October 25, 2022, in two new reports: How the Pandemic Continues to Shape Medicaid Priorities: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2022 and 2023 and Medicaid Enrollment & Spending Growth: FY 2022 & 2023. The report was prepared by Elizabeth Hinton, Madeline Guth, Jada Raphael, Sweta Haldar, and Robin Rudowitz from the Kaiser Family Foundation and by Kathleen Gifford, Aimee Lashbrook, and Matt Wimmer from HMA; and Mike Nardone. The survey was conducted in collaboration with the National Association of Medicaid Directors (NAMD).
This survey reports on policies in place or planned for FY 2022 and FY 2023, including state experiences with policies adopted in response to the COVID-19 pandemic. The conclusions are based on information provided by the nation’s state Medicaid Directors.
Key Report Highlights
In the following sections, we highlight a few of the major findings from the reports. This is a fraction of what is covered in the 50-state survey reports, which include significant detail and findings on policy changes and initiatives related to delivery systems, health equity, benefits, telehealth, provider rates and taxes, and pharmacy. The reports also look at the opportunities, challenges, and priorities facing Medicaid programs.
Medicaid Enrollment and Spending Growth
The COVID-19 pandemic created significant implications for Medicaid. During this time, Medicaid enrollment has reached record highs due to the Families First Coronavirus Response Act (FFCRA), enacted in March 2020, which authorized a 6.2 percentage point increase in the federal match rate, or Federal Medical Assistance Percentage (FMAP), retroactive to January 1, 2020, and until the Public Health Emergency (PHE) ends. The increase was available to states that meet certain “maintenance of eligibility” (MOE) requirements. Since the survey, the PHE was extended to mid-January 2023, somewhat delaying the anticipated effects described in survey.
Medicaid enrollment growth slowed to 8.4 percent in FY 2022, after a sharp increase in FY 2021 (11.2 percent). Almost all responding states reported that the MOE continuous enrollment requirement was the most significant factor driving FY 2022 enrollment growth. Responding states expect Medicaid enrollment growth to decline (-0.4 percent) in FY 2023, based largely on the assumption that the PHE and the related MOE requirements would end by mid-FY 2023. States anticipate larger declines as Medicaid redeterminations and renewals resume.
In FY 2022, total Medicaid spending is expected to reach a peak growth of 12.5 percent, with enrollment growth as the primary driver. For FY 2023, total spending growth is expected to slow to 4.2 percent, assuming slower enrollment growth after the unwinding of the PHE. State Medicaid spending grew by 9.9 percent in FY 2022 and is projected to increase by 16.3 percent in FY 2023 once enhanced federal fiscal relief expires. If the PHE is extended, state spending increases and enrollment decreases that states anticipated for FY 2023 could occur later.
Figure 1 – Percent Change in Medicaid Spending and Enrollment, FY 1998-23
SOURCE: FY 2022-2023 spending data and FY 2023 enrollment data are derived from the KFF survey of Medicaid officials in 50 states and DC conducted by Health Management Associates, October 2022. 49 states submitted survey responses by Oct. 2022; state response rates varied across questions. Historic data reflects growth across all 50 states and DC and comes from various sources.
Delivery Systems
Capitated managed care remains the predominant delivery system for Medicaid in most states. Forty-six states operated some form of Medicaid managed care (managed care organizations (MCOs) and/or primary care case management (PCCM)). Forty-one states contracted with risk-based MCOs. Of these, only Colorado and Nevada did not offer MCOs statewide. Only five states – Alaska, Connecticut, Maine, Vermont, and Wyoming – lacked a comprehensive Medicaid managed care model.
Thirty-four states, including Distrct of Columbia, operate MCOs only, five states operate PCCM programs only, and seven states operate both MCOs and a PCCM program.
Twenty-seven states contracted with one or more PHPs to provide Medicaid benefits, including behavioral health care, dental care, vision care, non-emergency medical transportation (NEMT), and long-term services and supports (LTSS).
Of the forty-one states that contracted with MCOs, 35 reported that 75 percent or more of their Medicaid beneficiaries were enrolled in MCOs as of July 1, 2022.
Figure 2 – MCO Managed Care Penetration Rates for Select Groups of Medicaid Beneficiaries as of July 1, 2022
SOURCE: KFF survey of Medicaid officials in 50 states and DC conducted by HMA, October 2022.
Medicaid Managed Care and Delivery System Changes
California, Missouri, Nevada, New Jersey, and New York reported expanding mandatory MCO enrollment for targeted populations.
Missouri and Ohio reported introducing specialized managed care programs for children with complex needs.
California, Nevada, and Tennessee indicated that they were carving in certain long-term services and supports (LTSS) into their managed care programs.
California and Ohio reported carving out pharmacy services in FY 2022 or FY 2023, respectively. The District of Columbia carved out emergency medical transportation from its MCO contracts in FY 2022.
Maine, North Carolina, Oregon, and Washington reported changes to their PCCM programs.
Virginia plans to implement Cardinal Care in FY 2023, merging the state’s two existing managed care programs: Medallion 4.0 (serving children, pregnant individuals, and adults) and Commonwealth Coordinated Care Plus (CCC Plus) (serving seniors, children and adults with disabilities, and individuals who require LTSS).
Forty-one states reported at least one specified delivery system and payment reform initiative (e.g. Patient-Centered Medical Home (PCMH), ACA Health Homes, Accountable Care Organization (ACO), Episode of Care Initiatives, All-Payer Claims Database (APCD)).
Health Equity
Twenty-five states reported using at least one specified strategy to improve race, ethnicity, and language (REL) data completeness. Of the 45 responding states, 16 states reported requiring MCOs and other applicable contractors to collect REL data, 12 states reported that eligibility, renewal materials, and/or applications explain how REL data will be used and/or why reporting these data are important, nine states reported linking Medicaid enrollment data with public health department vital records data, and eight states reported partnering with one or more health information exchanges (HIEs) to obtain additional REL data for Medicaid enrollees.
Twelve of 44 responding states reported at least one financial incentive tied to health equity in place in FY 2022. The vast majority of these incentives were in place in managed care arrangements (11 of 13). Within managed care arrangements, states most commonly reported linking or planning to link capitation withholds, pay for performance incentives, and/or state-directed provider payments to health equity-related quality measures. Only two states (Connecticut and Minnesota), reported a FFS financial incentive in FY 2022. Five additional states report plans to implement financial incentives linked to health equity in FY 2023.
Sixteen of 37 responding MCO states reported at least one specified health equity MCO requirement in place in FY 2022. The number of MCO states with at least one specified health equity MCO requirement in place is expected to grow significantly in FY 2023, from 16 to 25 states. Examples of MCO requirements to address health equity include having a health equity plan, designating a Health Equity Officer, and staff training on health equity and/or implicit bias.
Figure 3 – MCO Requirements to Address Health Equity, FYs 2022-23
SOURCE: KFF survey of Medicaid officials conducted by HMA, October 2022; n=37 states.
Benefits
Thirty-three states reported new or enhanced benefits in FY 2022 and 34 states are adding or enhancing benefits in FY 2023. Two states reported benefit cuts or limitations in FY 2022 and no states reported cuts or limitations in FY 2023.
Figure 4 – Select Categories of Benefit Enhancements or Additions, FYs 2022-23
SOURCE: KFF survey of Medicaid officials conducted by HMA, October 2022; Arkansas and Georgia did not respond.
Behavioral Health Services. States reported service expansions across the behavioral health care continuum, including institutional, intensive, outpatient, home and community-based, and crisis services. States reported addressing SUD outcomes, including coverage of opioid treatment programs, peer supports, and enhanced care management. At least ten states are expanding coverage of crisis services, which aim to connect Medicaid enrollees experiencing behavioral health crises to appropriate community-based care, including mobile crisis response services and crisis stabilization centers.
Pregnancy and Postpartum Services. In April 2022, a temporary option under ARPA to extend Medicaid postpartum coverage from 60 days to 12 months took effect. In addition to the states that took advantage of this eligibility change, some states are enhancing coverage of pregnancy and post-partum services. Nine states (California, District of Columbia, Illinois, Maryland, Michigan, New Mexico, Nevada, Rhode Island, and Virginia) are adding coverage of services provided by doulas and seven states (Alabama, Delaware, Illinois, Maryland, Ohio, Oregon, and Vermont) are investing in the implementation or expansion of home visiting programs.
Preventive Services. Sixteen states reported expansions of preventive care in FY 2022 or FY 2023. For example, seven states are expanding services to prevent and/or manage diabetes, such as continuous glucose monitoring. Other reported preventive benefit enhancements relate to asthma services, vaccinations, and genetic testing and/or counseling.
Services Targeting Social Determinants of Health. Many states reported new and expanded benefits targeting social determinants of health. Twelve states reported new or expanded housing-related supports, as well as other services and programs tailored for individuals experiencing homelessness or at risk of being homeless.
Dental Services. Nine states are adding comprehensive adult dental coverage, while additional states report expanding specific dental services for adults.
Telehealth
Most states have or plan to adopt permanent Medicaid FFS telehealth expansions that will remain in place even after the pandemic, though some are considering guardrails on such policies. Nearly all responding states that contract MCOs reported that changes to FFS telehealth policies would also apply to MCOs.
Figure 5 – Changes to FFS Medicaid Telehealth Policy, FY 2022 or FY 2023
SOURCE: KFF survey of Medicaid officials conducted by HMA, October 2022; n=48 states.
Nearly all responding states added or expanded audio-only telehealth coverage in Medicaid in response to the COVID-19 pandemic. Twenty-eight states reported that they newly added audio-only coverage while 19 states expanded existing coverage. Nearly all states reported audio-only coverage of mental health and substance use disorder (SUD) services. States least frequently reported audio-only coverage of home and community-based services (HCBS) and dental services. Two states (Mississippi and Wyoming) reported no coverage of audio-only telehealth for the services in question.
Telehealth utilization by Medicaid enrollees has been high during the pandemic but has decreased and/or leveled off more recently. States noted that telehealth utilization trends over time correspond to COVID-19 outbreaks, with higher utilization during COVID-19 surges and lower utilization when case counts are lower. In general, states reported that telehealth utilization was projected to continue at higher levels than before the pandemic, at least for some service categories.
Thirty-seven states (out of 47 responding) reported that behavioral health services were among those with the highest utilization. Additionally, a majority of states reported high utilization of evaluation and management (E/M) services and/or other physician/qualified health care professional office/outpatient services, including primary care.
States reported ACA expansion adults as one of the groups most likely to use telehealth (about one-third of responding states), followed by children and individuals with disabilities (each identified by about one-sixth of responding states).
Concerns regarding services delivered via telehealth included the quality of diagnoses, whether audio-only telehealth may be less effective, and inadequate access.
Key issues that may influence future Medicaid telehealth policy decisions include analysis of data, state legislation and federal guidance, and cost concerns.
Provider Rates and Taxes
In FY 2022, all 49 responding states reported implementing rate increases for at least one category of provider and 19 states reported implementing rate restrictions. In FY 2023, 48 states reported at least one planned rate increase and the number of states planning to restrict rates increased to 25 states.
States reported rate increases for nursing facilities and home and community-based services (HCBS) providers more often than other provider categories. The survey also found an increased focus on dental rates with about half of reporting states (20 in FY 2022 and 25 in FY 2023) reporting implementing or plans to implement a dental rate increase
Figure 6 – FFS Provider Rate Changes Implemented in FY 2022 and Adopted for FY 2023
SOURCE: KFF survey of Medicaid officials in 50 states and DC conducted by HMA, October 2022.
States continue to rely on provider taxes and fees to fund a portion of the non-federal share of Medicaid costs. All states but Alaska have at least one provider tax or fee in place. Thirty-eight states had three or more provider taxes in place in FY 2022 and eight other states had two provider taxes in place.
The most common Medicaid provider taxes in place in FY 2022 were taxes on nursing facilities (46 states), followed by taxes on hospitals (44 states), intermediate care facilities for individuals with intellectual disabilities (33 states), and MCOs (18 states).
Three states (Alabama, Mississippi, and Wyoming) reported plans to add new ambulance taxes in FY 2023.
Pharmacy
Most states that contract with MCOs report that the pharmacy benefit is carved into managed care (34 out of 41 states that contract with MCOs). Six states (California, Missouri, North Dakota, Tennessee, Wisconsin, and West Virginia) report that pharmacy benefits are carved out of MCO contracts as of July 1, 2022. California was the latest to carve out pharmacy benefits as of January 1, 2022. Two states (New York and Ohio) report plans to carve out pharmacy from MCO contracts in state FY 2023 or later.
In FY 2022, Kentucky began contracting with a single PBM for the managed care population. Louisiana and Mississippi report that they will require MCOs to contract with a single PBM designated by the state in FY 2023 and FY 2024, respectively.
Seven states (Alabama, Arizona, Colorado, Massachusetts, Michigan, Oklahoma, and Washington) have value-based arrangements (VBAs) in place with one or more drug manufacturers.
More than half of responding states reported newly implementing or expanding at least one initiative to contain prescription drug costs in FY 2022 or FY 2023.
Six states (Florida, Kentucky, Massachusetts, Maryland, Nebraska, Nevada) reported recently implemented or planned policies to prohibit spread pricing or require pass through pricing in MCO contracts with PBMs.
Key Opportunities, Challenges, and Priorities in FY 2023 and Beyond
When asked to identify the top challenges for FY 2023 and beyond, Medicaid directors listed the following:
The unwinding of PHE emergency measures and the resumption of redeterminations.
Expiration of emergency authorities.
Lasting focus on COVID-19, including vaccinations, long-COVID, decreased utilization of preventive care services, and future emergency preparedness.
Medicaid directors stated that future priorities shaped by COVID-19 include:
Health equity.
Specific populations and service categories, including behavioral health, long-term services and supports, and maternal and child health.
Health care workforce challenges.
Payment and delivery system initiatives and operations.
IT system modernization.
Social determinants of health.
Medicaid directors note that COVID-19 has presented both new opportunities and challenges and has also shifted and shaped ongoing Medicaid priorities.
Today, the Substance Abuse and Mental Health Services Administration (SAMHSA) released the highly anticipated Cooperative Agreements for Certified Community Behavioral Health Clinic (CCBHC) Planning Grants Notice of Funding Opportunity (NOFO). The NOFO can be found here.
The CCBHC model provides integrated and coordinated community-based care for individuals across the lifespan with and at risk for behavioral health conditions, with a focus on adults with serious mental illness, those with any mental illness, children with serious emotional disturbance, and those with substance use disorders. The model is designed to increase access to behavioral health services; provide a comprehensive range of services, including crisis services, that respond to local needs; incorporate evidence-based practices; and establish care coordination as a linchpin for service delivery. To date, CCBHCs have demonstrated[1]:
Significant reductions in client hospitalizations
Increased access to high quality community-based care, including services like Medication Assisted Treatment and care coordination
Reduced impact of the mental health and substance use care workforce shortage
Innovative and strengthened partnerships with cross-system partners, including law enforcement, schools, and hospitals
About the Planning Grants
These CCBHC Planning Grants are established to support states to develop and implement certification systems for CCBHCs, establish Prospective Payment Systems (PPS) for Medicaid reimbursable services, and prepare an application to participate in a four-year CCBHC Demonstration program. Through this opportunity, SAMHSA anticipates making 15 Planning Grant awards of up to $1 million per award. Awarded states will have 12 months to use their Planning Grant dollars to accomplish the following:
Solicit input for the development of a state CCBHC Demonstration program from consumers (including youth), family members, providers, tribes, and other key stakeholders.
Create and finalize application processes and review procedures for clinics to be certified as CCBHCs.
Assist clinics with meeting certification standards by:
facilitating access to training and technical assistance;
providing workforce supports, including assisting CCBHCs to improve the cultural diversity and competence of their workforce; and
facilitating cultural, procedural, and organizational changes to CCBHCs that will result in the delivery of high quality, comprehensive, person-centered, and evidence-based services that are accessible to the population(s) of focus.
Certify an initial set of clinics as CCBHCs, including those that represent diverse geographic areas, including rural and underserved areas. As an option, states can also develop a process for bringing additional clinics into the State CCBHC Demonstration program to reach the desired geographic spread by the end of the four-year CCBHC Demonstration.
Establish a PPS for behavioral health services furnished by a CCBHC in accordance with the original PPS Methodology Guidelines developed by CMS. A statement indicating that the State agrees to pay for services at the rate established under the PPS during the CCBHC. Demonstration program must be attached with the application.
Develop or enhance statewide data collection and reporting capacity.
Submit a proposal to participate in the CCBHC Demonstration Program no later than March 20, 2024.
The Planning Grant project period is anticipated to begin on March 30, 2023. As a Cooperative Agreement, SAMHSA anticipates having substantial federal programmatic participation, including providing input to selected states in the planning, implementation, and evaluation of the program.
These planning grants are the first phase of a two-phase process of the expansion of the CCBHC Demonstration, authorized by the Bipartisan Safer Communities Act.[2] Beginning July 1, 2024, and every two years thereafter, 10 states that have completed planning grants and submitted successful applications to participate in the CCBHC Demonstration will be eligible to join the program for a four-year period.
Eligibility to Apply
Eligibility for this Planning Grant opportunity is limited to the State Mental Health Authorities, Single State Agencies, or State Medicaid Agencies that are located in the 41 states, including the District of Columbia, that were not previously selected to participate in the CCBHC Demonstration Program. Regardless of which state entity ultimately serves as the applicant, each application must include a signed Memorandum of Agreement between the Director of the State Mental Health Authority, the Director of the Single State Agency, and the Director of the State Medicaid Agency demonstrating a partnership to fulfill the requirements of the award.
Updates to CCBHC Certification Criteria and PPS Guidance Expected but Not Before Application Deadline
Updates are expected to both the CCBHC Certification Criteria and PPS Guidance in the coming months, but the NOFO is clear that these updates will not be available during the application period for these Planning Grants. Specifically:
SAMHSA is in the process of updating the CCBHC Certification Criteria through a process which will include a significant opportunity for public comment. SAMHSA intends to keep the existing framework for the criteria, which is included in the authorizing statute. SAMHSA does not intend to make major changes to the scope and shape of the Certification Criteria.
CMS is also working to update the CCBHC PPS guidance. Any PPS changes will be made available prior to the planning grant execution period and included as part of technical assistance provided to states during the planning grant execution period.
Because neither of these updates will be released prior to the application submission deadline, applicants will use the existing CCBHC Criteria and PPS Guidance to inform their applications.
Next Steps for Interested State Stakeholders
Applications for this opportunity are due December 19, 2022 at 11:59 pm. Each application will be scored on their 30-page narrative submission, which includes significant emphasis on each applicant’s approach to CCBHC planning (including both certifying CCBHCs and establishing the PPS rates) and the state’s experience with the model to date (including the steps already taken to develop a CCBHC program in their state).
HMA and the National Council for Mental Wellbeing will host a joint webinar about this NOFO on Monday, November 7, 2022 at 1-2 pm ET.Register here.
In addition, in anticipation to the NOFO’s release, HMA and the National Council hosted a webinar on October 6, 2022, on “Developing a Strategy for the CCBHC State Demonstration RFP.” During this webinar, we engaged representatives from New York and Michigan to share information about their Demonstration program implementation to date. View the recording.
Should you have questions or want to learn more about HMA’s available support related to this and other CCBHC opportunities, contact Kristan McIntosh at [email protected].
Communities across the country are seeing elevated numbers of adolescents in the Emergency Department due to suicide attempts, self-harm, anxiety, depression, substance use disorder (SUD), and overdose. While this youth mental health crisis predates COVID, it has been greatly exacerbated by the pandemic. According to the Centers for Disease Control and Prevention (CDC), in 2019, 13% of adolescents reported having a major depressive episode, a 60% increase from 2007, and suicide rates rose nearly 60% for youth ages 10 to 24 by 2018[1]. Then it got worse. Last December, the U.S. surgeon general issued a public health advisory about the adolescent mental health crisis as emergency room visits due to suicide attempts rose 51% for adolescent girls in early 2021, compared to the same period in 2019. For boys, the increase was 4%[2].
The surgeon general recommends a “whole-of-society effort,” including a focus on mental health education and prevention, early identification, and access to high-quality mental healthcare.[3] School-based intervention is ideal because only 20% of students in need of more intensive services typically receive needed care when referred to external providers.[4]
The Bipartisan Safer Communities Act has committed $1.7 billion for mental health support in schools and communities via an array of methods including grant programs. The following programs are currently available for a wide array of eligible entities, including states, cities/counties, Local Education Agencies (LEAs), Indian tribes or tribal organizations, health facilities, and nonprofit entities:
Project AWARE (Advancing Wellness and Resiliency in Education). This grant program provides up to $1.8 million per year for up to 4 years to develop a sustainable infrastructure for school-based mental health programs and services. Grant recipients are expected to build collaborative partnerships with the State Education Agency (SEA), LEA), Tribal Education Agency (TEA), the State Mental Health Agency (SMHA), community-based providers of behavioral health care services, school personnel, community organizations, families, and school-aged youth. Grant recipients will leverage their partnerships to implement mental health-related promotion, awareness, prevention, intervention, and resilience activities to ensure that students have access to and are connected to appropriate and effective behavioral health services. Applications are due October 13th.
Resiliency in Communities After Stress and Trauma (ReCAST). This program provides up to $1,000,000 a year for up to 4 years to promote resilience, trauma-informed approaches, and equity in communities that have recently faced civil unrest, community violence, and/or collective trauma within the past 24 months; and to assist high-risk youth and families through the implementation of evidence-based violence prevention, and community youth engagement programs. SAMHSA expects ReCAST to be guided by a community-based coalition of residents, non-profit organizations, and other entities (e.g., health and human service providers, schools, institutions of higher education, faith-based organizations, businesses, state and local government, law enforcement, and employment, housing, and transportation services agencies). Applications are due October 17th.
In addition to these two grants, there will be an expansion of the Certified Community Behavioral Health Center (CCBHC) Demonstration for States that is expected to be released later this month. The Excellence in Mental Health Act[5] established a federal definition and criteria for CCBHCs. These centers are a provider type that delivers a comprehensive range of mental health and SUD services to vulnerable individuals. They meet people where they are, which can include school-based services, and act as a critical partner in ensuring people have access to quality, affordable, and accessible mental health care.
School-based Mental Health Services
School-based mental health services, delivered within a Multi-Tiered System of Supports (MTSS) framework, can be supported by the aforementioned funding opportunities. The MTSS framework is currently used in public schools to target services and supports to students. As shown below, MTSS addresses universal prevention and progressively targeted support for students and families. It also aligns well with partnerships with community providers to establish an authentic community response that addresses the continuum of mental health needs.
Multi-Tiered System of Supports (MTSS) framework
The key to a successfully implemented MTSS framework is a strong partnership between the school staff, parents/guardians, children, and community partners. This partnership works well when anchored to an evidence-based socio-emotional curriculum that is reinforced across all Tiers and familiar to all parties.
Suicide and Self Harm Prevention
Dialectical Behavioral Therapy (DBT) was recently identified by the New York Times as “the Best Tool We Have’ for Self-Harming and Suicidal Teens,” because it is one of the only interventions found to reduce self-harm and suicidal ideation, its effects are maintained at one-year follow-up[6], and it successfully engages young people[7].
Curriculum developers Drs. Lizz Dexter-Mazza and James Mazza worked with Marsha Linehan, the DBT treatment developer, to adapt DBT Skills into a universal school-based social emotional learning curriculum, called DBT-STEPS-A. This approach is designed to help schools intervene and support well-being and resiliency before kids are suicidal or self-harming. It trains existing school personnel to integrate skill-building into the school program, universally or as a stand-alone option for youth in 6-12th grade (an elementary version is in development). As such, it is a viable approach, despite the current shortage of mental health care professionals in school-based settings.
In addition, DBT provides a shared language and strategies across all three MTSS tiers so that everyone (students, school staff, teachers, providers, and parents/guardians) can benefit. Because DBT is also commonly provided in inpatient, outpatient, and residential behavioral health programs, the value of extending this approach into school settings is further magnified for youth who transition from the highest levels of care.
A DBT STEPS-A program taught at the universal level provides the broadest application within school-based settings, supports uptake that leads to peer-to-peer coaching and support, along with shifting the school environment and culture to promote mental wellbeing and reinforce the skills via a shared language and common strategies. In Tier 2, students are supported to practice skills and decision-making strategies in smaller group or individual psychotherapy sessions as needed. The third tier is more intensive support for students experiencing ongoing emotional and behavioral difficulties for whom Tier 2–level support is not sufficient. It is designed to supplement individual psychotherapy for those in need of a higher level of care. Parent/guardian skills-training seminars are recommended, so they can learn about the skills their child is acquiring and how best to support them while they are practicing. Engaging parents/guardians proactively helps to increase adaption of the skills across both home and school contexts.
A matched sample of adolescents who received the DBT STEPS-A curriculum demonstrated lower scores on the BASC-2 Emotion Symptom Index and on the BASC-2 Internalizing Problems, indicating fewer mental health difficulties, compared to peers who did not receive the curriculum (Cohen’s F squared equal to 0.65 and 0.83, respectively[8].
The DBT curriculum is accessible via a $50 manual. All handouts for kids are available in English and Spanish and can be printed from a web-based link for free. An array of trainings are available to support rapid school-based service delivery.
To learn more about current and upcoming funding for enhanced school and community-based mental health care or DBT-STEPS-A, contact:
You can also contact DBT in Schools, LLC for information about DBT-STEPS-A [email protected].
[1] National Vital Statistics reports – Centers for Disease Control and … (n.d.). Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr69/nvsr-69-11-508.pdf
[2] Richtel, M. (2021, December 7). Surgeon general warns of Youth Mental Health Crisis. The New York Times. Retrieved from https://www.nytimes.com/2021/12/07/science/pandemic-adolescents-depression-anxiety.html
[3] Protecting youth mental health – hhs.gov. (n.d.). Retrieved from https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf
[4] Sheryl H. Kataoka, M.D., M.S.H.S., Lily Zhang, M.S., and Kenneth B. Wells, M.D., M.P.H. (2002). Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status. The American Journal of Psychiatry: https://doi.org/10.1176/appi.ajp.159.9.1548
[5] Excellence in Mental Health Act. (2013, February 7). http://www.congress.gov/
[7] Rathus, Jill H. ( 2014). DBT skills manual for adolescents. New York :The Guilford Press,
[8] Elizabeth T. Dexter-Mazza, James J. Mazza, Alec L. Miller, Kelly Graling, Elizabeth Courtney-Seidler, and Dawn Cattuchi (2022). Application of DBT in a School-Based Setting. Pending publication
