Mental health and substance abuse services that are mandated by state and federal law are being left out of contracts for managed Medicaid behavioral health programs, says a report by the Center of Health Policy Research at George Washington University.
Regardless of whether state officials think itAEs a covered benefit under managed care, if agreements are ambiguous or silent on these issues, states remain legally bound to provide services because managed care plans can argue oitAEs not in the contract.o
A case in point: Many states are surprised to learn that their managed care programs donAEt necessarily cover services ordered by courts, schools, or other social service agencies but which they are obligated to provide. MCOs might deny coverage because they deem the services to be not medically necessary or primarily educational in nature.
In a much-anticipated survey, GW lawyers reviewed agreements on behavioral health between Medicaid agencies and managed care organizations in 37 states. The survey illustrates the power imbalance between the more sophisticated managed care organizations and the less experienced Medicaid agencies. It also points to a cultural gap between commercial insurers and Medicaid agencies, which serve a much needier population. The many ambiguities in health care such as what is omedically necessaryo also cause problems.
Commercial insurers, for example, generally consider medically necessary care to be treatments needed to restore functioning following an acute illness or injury. Medicaid, by contrast, may ocover preventive, ameliorative, and development enhancing services for children and adults with chronic illnesses and disabilities.o The gap is particularly great in pediatric coverage because of the unique standard of medical necessity under the EPSDT (Early Periodic Screening, Diagnosis and Treatment) program.
E. Clarke Ross, executive director of the American Managed Behavioral Healthcare Association (AMBHA), says his association agrees that there needs to be ogreater specificityo in contracts between Medicaid agencies and managed care organizations. ItAEs been largely a matter of state health policy to cover only a traditional, limited benefit structure under managed care and not to integrate block grants and non-Medicaid funding for more comprehensive coverage, according to Dr. Ross.
There needs to be oclear and conciseo information on owhat is being paid for.o If states osay they want to finance 30 days of hospitalization and 20 days of clinic-based, medically necessary care,o then they shouldnAEt ocriticize the lack of vocational rehabilitation services.o
State officials should sort through Medicaid coverage requirements in order to decide which duties are appropriate for managed care and which should continue to be handled by the state, the report says.
In another report, GW researchers reviewed 50 representative agreements between managed care organizations and providers.
oIt was an unpleasant confirmation of what we feared,o says Eric Goplerud, associate administrator for managed care for the Substance Abuse and Mental Health Services Administration (SAMHSA). oIt confirmed our suspicion that provider contracts are as inequitable.o
In many agreements, providers can be terminated at will; the financial terms of their agreements can be unilaterally modified; and the responsibility for eligibility verifications and determinations for the patient and for recovering payments from multiple payers is left to them.
SAMHSA has developed a manual to educate providers about what the provisions in their contracts mean. Other resources include a technical assistance manual on network formation which has similarities to ounion organizing,o Mr. Goplerud says. The manual shows providers how they may legally and jointly negotiate agreements to have more bargaining clout. SAMHSA also is developing materials to educate providers about financial management and risk assessment.
The best avenue to helping MH/SA agencies may be to focus on the contracts between the Medicaid agency and the managed care organization rather than on provider agreements, Mr. Goplerud says.
The study found that contracts with MH/SA agencies commit to the purchasing of only limited services and not the full range of services available and which the state may expect are being offered.
The report recommends that states review provider agreements. Dr. Ross says he takes exception to the bias toward community-based providers in the study. He notes that other providers in managed care networks offer services such as psych-rehab, self-help peer groups, clubhouses, etc. He does not agree that those comprehensive services should be provided by MS/SA agencies.
Contact the GWU Center for Health Policy Research 202-296-6922 Dr. Ross at 202-434-4565. SAMHSA resources can be obtained from the Knowledge Exchange Network at 1-800-789-2647 or from the agencyAEs website, www.samhsa.gov.
