CMS New Rule MedicaidThe Centers for Medicare and Medicaid Services (CMS) have announced the finalization of a new rule that will help strengthen access to mental health and substance-use services for individuals who receive Medicaid benefits though managed care organizations and those who have Children’s Health Insurance Program (CHIP) coverage. According to CMS’ press release, this “final rule strengthens access to mental health and substance use disorder benefits for low-income Americans.” The new provisions of this rule will benefit the over “23 million people enrolled in Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and CHIP.”

Sylvia M. Burwell, the HHS Secretary, said in a press release: The Affordable Care Act provided one of the largest expansions of mental health and substance use disorder coverage in a generation. 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.” Burwell went on to address the a very important healthcare industry issue, the opioid epidemic. She touched on how this rule will help those in need of recovery services; stating: “This rule will also increase access to evidence-based treatment to help more people get the help they need for their recovery and is critical in our comprehensive approach to addressing the serious opioid epidemic facing our nation.”

Right now states have the flexibility to provide services through “the managed care delivery mechanism using entities other than Medicaid managed care organizations, such as prepaid inpatient health plans or prepaid ambulatory health plans” and this rule will not limit this flexibility. The CMS stated in its press release that the rule “maintains state flexibility in this area while guaranteeing that Medicaid enrollees are able to access these important mental health and substance use services in the same manner as medical benefits.”

One of the important changes this rule implements is that health plans will now need to disclose mental health and substance use information on request, and include the medical necessity criteria applied. States will also now be required to disclose reasons for denial of “reimbursement or payment for services with respect to mental health and substance use disorder benefits.”

CMS hopes that this rule will help to increase access to and improve the quality of mental health services for low income individuals. With the opioid abuse epidemic in the forefront of many people’s minds,  this is a crucial time for CMS to address these issues. CMS has also implemented other initiatives to help states close the behavioral health gap and increase integration and access to behavioral health services.

The key provisions below are as outlined by the National Council for Behavioral Health:

  • Parity Applies to Both Carve-In and Carve-Out Arrangements – Thanks in part to the hundreds of comments submitted by National Council members, CMS maintained the proposed language of ensuring parity applies to Medicaid managed care beneficiaries even in states where behavioral health services have been carved out of managed care contracts. In such cases, states are responsible for ensuring that the entire package of Medicaid services for managed care enrollees complies with the parity law, regardless of whether the services are delivered in a managed care organization, fee-for-service Medicaid or other delivery arrangement.
  • Plans Must Meet Disclosure Requirements – CMS finalized its proposal requiring Medicaid managed care plans, alternative benefit plans and CHIP plans to make their criteria for medical necessity determinations available to enrollees or contracting providers upon request. Plans must also make available to enrollees the reason for any denial of services. Additionally, states must publicly post documentation of their compliance with the parity requirements outlined in the rule.
  • States, Managed Care Entities Share Responsibility for Compliance – In states where all services are fully included within managed care contracts, managed care organizations are now responsible for ensuring their compliance with parity, even if doing so means covering services beyond the scope of those outlined in the state Medicaid plan. Managed care organizations may include the cost of these services in their calculations of actuarial soundness when contracting with Medicaid, meaning that any additional cost of covering services needed to comply with parity falls squarely on the state.
  • Effective Date – States will have up to 18 months to comply with the finalized provisions.

The final rule was published March 30, 2016 and can also be viewed here:

See the full press release here.

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