CMS finalizes Medicaid, CHIP parity requirements for mental health services

CMS recently finalized a rule to increase access to mental health and substance use services for individuals with Medicaid or Children’s Health Insurance Program coverage.

“The Affordable Care Act provided one of the largest expansions of mental health and substance use disorder coverage in a generation,” HHS Secretary Sylvia M. Burwell, said in a press release. “Today’s rule eliminates a barrier to coverage for the millions of Americans who for too long faced a system that treated behavioral health as an unequal priority. It represents a critical step in our effort to ensure that everyone has access to the care they need.”

Sylvia M. Burwell

The rule will increase access to evidence-based treatment, helping more individuals receive the care they need, which is critical in addressing the national opioid epidemic, according to Burwell.

Protections within the final rule will benefit more than 23 million individuals enrolled in Medicaid managed care organizations, Medicaid alternative benefit plans and Children’s Health Insurance Program (CHIP).

U.S. states are currently able to provide services through a managed care delivery mechanism through entities other than Medicaid managed care organizations, such as prepaid inpatient health plans or prepaid ambulatory health plans.

The final rule maintains this flexibility at state level and guarantees Medicaid enrollees access to mental health and substance use services comparable to medical benefits.

Victoria Wachino

Key provisions of the final rule, according to the National Council for Behavioral Health, include:

Ensuring parity applies to Medicaid managed care beneficiaries, even in states where behavioral health services are not included in managed care contracts. States are responsible for ensuring the entire package of Medicaid services for managed care enrollees complies with the parity law, regardless of delivery arrangement.
Medicaid managed care plans, alternative benefit plans and CHIP are required to release criteria for medical necessity determinations must be available to enrollees or contracting providers upon request. Reasons for denial of services must be made available and states must publicly post documentation of their compliance with parity requirements.
In states where services are fully included in managed care contracts, managed care organizations must comply with parity, even if that requires covering services beyond those outlined in the state Medicaid plan. Managed care organizations can include cost of services in their calculations of actuarial soundness when contracting with Medicaid, and therefore additional cost of covering services needed to comply falls on the state.
States have 18 months to comply with the final rule.

“The need to strengthen access to mental health and substance use disorder services is clear,” Victoria Wachino, MPP, deputy administrator of CMS and director of the Center for Medicaid and CHIP Services, said in the release. “This final rule will help states strengthen care delivery and support low-income individuals in accessing the services and treatment they need to be healthy.” – by Amanda Oldt

For more information :

The final rule is currently on display and will be published in the Federal Register on March 30, 2016.

Visit http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/mental-health-services.html for further information.