Adult Behavioral Health Benefits in Medicaid and the Marketplace

Key Findings

Medicaid Coverage of Behavioral Health Services

Overall, Medicaid coverage of specialty behavioral health services in the four study states is very comprehensive, even though particular services may not be covered by every state. (This observation refers to a state’s overall Medicaid program, without distinguishing the particular delivery system in which one system for part of a state’s Medicaid population, such as a PIHP, may cover one service listed here, while another system for another segment of the population, such as FFS, may not.) Medicaid benefits are largely determined by state policy choices as outlined in the state’s Medicaid plan, within the minimum requirements provided in federal law. In the institutional care and intensive services category, all four states covered psychiatric inpatient hospital visits (in non-IMD settings for most adults), and three states (all but Michigan) covered psychiatric residential services. Connecticut and Michigan allowed for 23-hour observation, and Arizona and Connecticut covered adult group home services. Most states covered the majority of outpatient facility services (e.g., case management, day treatment, psychosocial rehabilitation, partial hospitalization), although it appears that Arizona does not cover two particular relatively common services in this category: partial hospitalization and intensive outpatient mental health services. All four states covered all of the outpatient provider services (e.g., individual and family therapy, psychiatric testing) in our analysis. In the substance use disorder treatment category, all four states covered inpatient detoxification, methadone maintenance, and smoking and tobacco cessation services. However, Arizona did not explicitly cover outpatient detoxification or Suboxone treatment, and Colorado did not explicitly cover residential rehabilitation or chemical dependency intensive outpatient services.

All four states covered the following services in their Medicaid programs:

• Psychiatric hospital visits
• Case management services
• Day treatment (community behavioral health program)
• Psychosocial rehabilitation
• Psychiatric services – evaluation and testing
• Medication evaluation, prescription and management
• Psychological testing
• Individual, group and family therapy
• Inpatient detoxification
• Methadone maintenance
• Smoking and tobacco use cessation counseling.

These findings are summarized in Table 2 below and state-specific coverage details are included in the tables in Appendix A.

Behavioral health coverage is comparable – mostly by state design – for beneficiaries eligible for traditional Medicaid and those newly eligible under the ACA’s Medicaid expansion. The four study states chose to align their traditional Medicaid state plan behavioral health benefits and their new adult ABP behavioral health coverage, often intentionally to reduce the effects of churning between different Medicaid coverage groups.

Marketplace Coverage of Behavioral Health Services

Across the four study states, Marketplaces QHPs explicitly cover many specialty behavioral health services. In the four study states, all QHPs analyzed provide inpatient psychiatric hospital services and inpatient substance use services. Most plans explicitly cover individual and group therapy. Many of the plans specifically cover intensive outpatient services, partial hospitalization, residential treatment, and substance use disorder residential rehabilitation services.

However, QHPs provide general coverage statements rather than an exhaustive list of covered services. The QHPs in all four study states include general coverage statements in their plan documents. For example, the documents for a given plan generally state that the QHP covers inpatient and outpatient mental health and substance use disorder services. As plan documents are the most detailed publicly available information about which services will or will not be covered, these general coverage statements make it difficult to determine whether specific services are covered without submission and disposition of an actual claim. Although the QHPs in our analysis mention some specific services, such as partial hospitalization (Arizona, Colorado) and intensive outpatient (Connecticut, Michigan), the plans lack an exhaustive list of covered services, which could prove especially problematic for adults with behavioral health needs seeking to compare QHPs, as it is important for these individuals to know whether their chronic health needs will be met by a given plan.

QHPs are silent about coverage for a number of specific specialty behavioral health services. For example, in Arizona, Colorado, and Connecticut, none of the QHPs explicitly covers or excludes from coverage the following mental health services: 23-hour observation, group home services, mental health rehabilitation, and individual testing. In addition, QHPs in Arizona and Colorado are silent about coverage for inpatient rehabilitation for substance use disorder treatment. In Michigan, QHPs are silent about coverage for psychosocial rehabilitation. Without an explicit coverage statement, it is difficult to determine whether specific services necessary for adults with behavioral health needs will or will not be covered.

Across the four study states, several QHPs exclude or limit important behavioral health services, such as residential treatment, treatment of chronic conditions, and substance use disorder medication management. Four of thirty QHPs in Arizona explicitly exclude coverage for residential treatment and treatment of chronic conditions not subject to favorable modification for those with mental illness. In Colorado, a few plans exclude counseling for those who do not respond to “therapeutic treatment” as stated, but not defined, in the plan document. The determination about whether a beneficiary will respond to therapeutic treatment is left to the discretion of the plan physician. In addition, multiple plans in Colorado exclude coverage of residential treatment, and one plan explicitly excludes coverage of substance use disorder residential treatment including rehabilitative services. In Michigan, two of twenty-eight plans cover residential treatment only for mental health conditions that are likely to show improvement during the admission. Five plans also exclude from coverage treatment for antisocial personality disorder. Further, two plans do not cover treatment for chronic substance abuse conditions. Across the study states, a number of plans limit substance use medication management services. For example, these services only are available during an inpatient stay or for the treatment of withdrawal symptoms. Excluding and/or limiting these important behavioral health services reduces access to care and is likely to negatively impact plan enrollees who need these services.

QHP coverage for behavioral health services varies by insurer; however, coverage does not vary by metal tier in plans offered by a given insurer within the Marketplace. In all four study states, behavioral health coverage and exclusions, as described in the plan documents, for a given insurer often were the same across all plans offered within the state’s Marketplace. Coverage of specific services did, however, vary by insurer, as expected due to rules permitting substitution of actuarially equivalent services within EHB categories. Our findings about QHP coverage of behavioral health services are summarized in Table 3.

Medicaid and Marketplace Coverage of Behavioral Health Services Compared

In general, a large portion of the four categories of behavioral health benefits identified in this analysis are covered through both Medicaid programs and at least some Marketplace QHPs; however, across the four study states, Medicaid coverage of behavioral health services is generally more comprehensive than in QHPs. For example, all four states’ Medicaid programs covered psychiatric hospital visits, case management, day treatment, psychosocial rehabilitation, psychiatric evaluation, psychiatric testing, medication management, individual therapy, group therapy, family therapy, inpatient detoxification, methadone maintenance, and smoking and tobacco cessation services. By contrast, the only services covered by all Marketplace QHPs in the 4 study states were psychiatric hospital visits and smoking and tobacco cessation services. No QHPs covered psychosocial rehabilitation or adult group home services (the latter are covered by 2 states’ Medicaid programs).

Medicaid benefit packages are more specific about which benefits are covered, while QHPs tend to provide general coverage statements instead of a list of specific covered services. Consequently, it appears that state Medicaid programs offer more comprehensive behavioral health coverage. However, there are a few exceptions. For example, some QHPs in Arizona specify substance use disorder treatment coverage for partial hospitalization, outpatient detoxification, and residential rehabilitation services whereas the state Medicaid program does not. Therefore, it seems that Arizona QHP coverage for substance use services is more comprehensive than Arizona’s Medicaid program. Further, some Michigan QHPs specify coverage of more services than the state Medicaid program (e.g., residential treatment facility, intensive outpatient, individual testing, family therapy).

As noted above, QHP behavioral health coverage is generally less clear about which specific services are covered than that available in Medicaid, with QHPs generally lacking an exhaustive list of covered services. While QHPs cover many general categories of specialty behavioral health services, it is difficult to determine definitively which specific services are covered. General coverage statements, silence about coverage of certain services, and the lack of an exhaustive benefit coverage list make it almost impossible to determine whether specific services are covered by a given QHP without submission and disposition of an actual claim.