For the first time, states will be able to pay specialists directly for consultations about a beneficiary’s physical and behavioral health.
The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), on Thursday issued guidance to create an easier path to specialty care for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries.
The guidance provides the ability for state Medicaid and CHIP programs 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, according to HHS.
“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,” said HHS Secretary Xavier Becerra in the announcement.
CMS Administrator Chiquita Brooks-LaSure described the guidance as a common-sense change that achieves the administration’s vision to forge better connections to high-quality, person-centered, affordable health care coverage. Because Medicaid and CHIP beneficiaries often have higher rates of chronic diseases, these services are not just useful–they can often be lifesaving. The guidance will help reduce wait times and administrative paperwork and lead to better outcomes.
Access to specialty care is a challenge across a range of specialties, but access to care for mental health and substance use disorders is especially difficulty. In 2019 more than 55 percent of adults with mental illnesses and nearly 35 percent of those with serious mental illnesses did not receive care. Rates are even lower for Black, Hispanic, and other underserved communities, HHS said.
The new policy will expand and expedite access to specialty care. It 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. In addition, these consultations can occur when the beneficiary is not physically present, which will ensure that personal and geographic barriers do not stand in the way of connections to care.