Reports indicate that more and more people are reporting a need for mental health services.[1] Accessing mental health services, however, can often be a frustrating process. Even with comprehensive insurance coverage, consumers may not understand what services are covered and who can provide services. As anyone who has insurance coverage and has had to access services can likely attest, finding a provider can be a difficult task even when the insurance plan covers the service or provider. This difficulty is compounded if the service requires a specialist or is a specialized service such as mental health or substance use disorder treatment. The root cause of this frustration is that access to care is a function of covered services and availability of providers.

Recognizing this connection between coverage and access, in February 2022, CMS released a Request for Information soliciting feedback on issues related to health care access, such as enrolling in and maintaining coverage, accessing health care services and supports, and ensuring adequate provider payment rates to encourage provider availability and quality.[2] This RFI provided opportunities for stakeholders to comment on different policies that impact access to health care. The National Association of Behavioral Healthcare issued a response on behalf of their membership that requested, among other things, a strengthening of network adequacy standards and more sustainable reimbursement structures for behavioral health providers.[3]

The Affordable Care Act (ACA) requires health plans to ensure a sufficient choice of providers and provide information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers which is often referred to as network adequacy.[4] Monitoring network adequacy usually includes quantitative standards such as:

• Time/distance standards: determines if providers are geographically accessible
• Minimum number of providers: measures a minimum provider-to-enrollee ratio
• Appointment wait times: measures the length of time an enrollee would have to wait to get an appointment with a type of provider

Beginning in 2023, federal oversight of network adequacy resumes and CMS has proposed that mental health providers in particular are one of the provider types where appointment wait times are measured. While past metrics have focused only on psychiatric inpatient and outpatient care, the continuum of mental health care services extends well beyond that. It may be prudent for additional types of services or providers to be included in the monitoring and requirements for network adequacy.

Discussions related to access to mental health services often center on mental health parity requirements such as those included in the Mental Health Parity and Addiction Equity Act (MHPAEA). Essentially, mental health parity provides for equal treatment of mental health conditions (and now substance use disorders) in insurance plans. In practice, the laws require that carriers not impose different limitations or dollar limits on mental health and substance use disorder services as compared to services provided for physical health care.[5] However, studies of mental health parity haves not demonstrated a significant growth in utilization of mental health services., underscoring the connection between ensuring that services are covered and the availability of providers to foster  access to care.[6]

States are tasked with demonstrating network adequacy and access to covered services in their Medicaid programs — either those directly operated in a fee-for-service environment or through managed care. Yet this can be a daunting task for states to manage and enforce. There are strategies that track and monitor network standards, such as implementing mid-year reviews, having a health insurance ombudsman able to take complaints from enrollees, greater transparency of provider network data, and close monitoring of quantitative measures on a more frequent basis.

Myers and Stauffer has experience both in the management of state mental health and Medicaid programs as well as extensive experience helping states to assess true access to services and develop strategies to address needs. If you would like more information about how Myers and Stauffer can support your state’s behavioral health system initiatives, please contact one of our contributors listed below.

Find out more about mental health services and funding on our Insights page.

[1] Kaiser Family Foundation. “Mental Health and Substance Use State Fact Sheets.” KFF, 21 Apr. 2022, www.kff.org/statedata/mental-health-and-substance-use-state-fact-sheets.

[2] Centers for Medicare and Medicaid Services. “Biden-Harris Administration Announces Request for Information on Access to Care and Coverage for People Enrolled in Medicaid and CHIP | CMS.” 17 Feb. 2022, www.cms.gov/newsroom/press-releases/biden-harris-administration-announces-request-information-access-care-and-coverage-people-enrolled.

[3] National Association of Behavioral Healthcare. “NABH Response to RFI on Access to Coverage and Care in Medicaid and CHIP – NABH.” www.nabh.org/nabh-response-to-rfi-on-access-to-coverage-and-care-in-medicaid-and-chip. Accessed 5 May 2022.

[4] Kaiser Family Foundation. “Network Adequacy Standards and Enforcement.” KFF, 3 Feb. 2022, www.kff.org/health-reform/issue-brief/network-adequacy-standards-and-enforcement.

[5] Centers for Medicare and Medicaid Services. “The Mental Health Parity and Addiction Equity Act (MHPAEA) | CMS.” www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet. Accessed 5 May 2022.

[6] Barry, Colleen L., et al. “The Costs of Mental Health Parity: Still an Impediment?” Health Affairs, May 2006.

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