For the first time, states will be able to expand beneficiary access to specialty consultations, which can improve quality of care and outcomes for physical and behavioral health
The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), today issued guidance that creates an easier path to specialty care for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries. For the first time ever, state Medicaid and CHIP programs will be able to pay specialists directly when a beneficiary’s primary health care provider asks for advice. For example, if a pediatrician consults with a specialty behavioral health provider about a specific patient’s needs, both providers may be reimbursed for their care – even if the patient is not present. This move “links” routine care with specialty care, allowing more people to benefit from practitioners with specialized knowledge.
Today’s announcement delivers on a priority action laid out in President Biden’s Strategy to Address Our National Mental Health Crisis.
“The Biden-Harris Administration is committed to expanding access and improving quality of care for millions of families who have health insurance through Medicaid and CHIP,” said HHS Secretary Xavier Becerra. “With today’s action, more families will be able to access the specialty care they need – including specialty care for children and adults with mental health needs. This is a key step forward in President Biden’s plan to address the nation’s mental health crisis by ensuring that mental health care is as accessible as physical health care.”
“This common-sense change makes good on our commitment to forge better connections to high-quality, person-centered, affordable health care coverage,” said CMS Administrator Chiquita Brooks-LaSure. “Now, care for people who have complex health concerns with Medicaid or CHIP coverage can be informed by expert insights faster – reducing wait times and administrative paperwork, and increasing the prospect of better health.”
Interprofessional consultations, which occur when a person’s physician or other qualified health professional requests advice from a specialist, link “routine care” to unique expertise for complex concerns. Because Medicaid and CHIP beneficiaries often have higher rates of chronic diseases, these services are not just useful – they can often be life-saving.
While access to specialty care has long been a challenge across a range of specialties, access to specialty care for mental health and substance use disorders remains particularly challenging. For example, in 2019 more than 55% of adults with mental illnesses and nearly 35% of those with serious mental illnesses did not receive care. Rates are even lower for Black, Hispanic, and other underserved communities.
Interprofessional consultations are also especially important for improving access to providers who specialize in child and adolescent behavioral health. Children residing in states with statewide psychiatric consultation programs are significantly more likely to receive mental health services than children residing in states without such programs.
This new policy will expand and expedite access to specialty care, allowing beneficiaries to benefit from experts with knowledge of their particular health condition. The new policy eliminates the need for consulting providers to coordinate payment via separate agreements with the treating practitioner, giving Medicaid and CHIP agencies the flexibility to develop payment methods to reimburse consulting practitioners directly for their services. Importantly, these consultations can occur when the beneficiary is not physically present, ensuring personal and geographic barriers do not stand in the way of connections to care.
This new policy aligns Medicaid and CHIP with standards of practice across health care, including in Medicare, which has had a similar policy since 2019. For additional information, consult the State Health Official Letter available on Medicaid.gov.
The Biden-Harris Administration is committed to addressing the nation’s behavioral health crises and strengthening the mental health of all Americans. As part of President Biden’s whole-of-government strategy to transform mental health services for all Americans – a key part of the President’s Unity Agenda – HHS Secretary Xavier Becerra kicked off the HHS National Tour to Strengthen Mental Health to address the mental health challenges that have been exacerbated by the COVID-19 pandemic, including substance use, youth mental health, and suicide. Since kicking off the tour, Secretary Becerra and HHS leaders have been traveling across the country to hear directly from Americans about the mental health challenges they are facing and engage with local leaders to strengthen the mental health and crisis care system in our communities. For more information, consult the fact sheet available here.
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