Innovation in Medicaid Behavioral Health Service Delivery During COVID-19
November 5, 2020
The rise of COVID-19 in the United States has increased the need for behavioral health services while necessitating a radical change in how these services are delivered. Behavioral health, which includes mental health and substance use disorders, is a major focus for the Medicaid program, with many Medicaid health plans providing behavioral health coverage as part of their comprehensive benefits packages. In 2015, Medicaid covered 21 percent of adults with mental illness, 26 percent of adults with serious mental illness (SMI), and 17 percent of adults with substance use disorder (SUD), according to a Kaiser Family Foundation analysis. As the COVID-19 pandemic continues, experts are predicting increased rates of relapse of SUDs, related to concerns about high rates of alcohol sales and reduced accessibility of treatment services and supports, including 12-step support group meetings. Simultaneously, the Medicaid population is expected to rise rapidly due to rising rates of unemployment.
The 2019 IMI Annual Medicaid MCO Survey found that fragmentation in program funding and contracting for physical and behavioral health services, and access to behavioral health providers in select regions (e.g., rural, underserved) were top barriers to addressing behavioral health. By highlighting the innovative changes in behavioral health service delivery in Medicaid in response to the COVID-19 pandemic, Medicaid stakeholders can gain a better understanding of best practices and potential changes that may be worth continuing post-pandemic.
Innovation: New Flexibilities Related to Telehealth
At the start of the pandemic, the Centers for Medicare and Medicaid created new flexibilities that adapted and expanded telehealth, including behavioral health services. The time-limited policies have allowed providers and Medicaid managed care organizations to shift in-person care visits to telehealth. Washington D.C. found that behavioral health services accounted for 72 percent of paid telehealth claims for Medicaid enrollees in April 2020. The continuation of the pandemic into the fall of 2020 has necessitated the renewal of certain flexibilities. For example, in August 2020 Pennsylvania issued a memorandum to behavioral health managed care organizations and behavioral health providers in Medicaid with the intention of supporting the continued and uninterrupted delivery of behavioral health services. The suspended provisions included requirements regarding staff supervision, minimum hours of operation, and physician-only services, allowing other licensed practitioners to deliver services within their scope of practice.
While flexibilities related to telehealth are important, there are challenges related to the “digital divide.” These barriers include the absence of technology, digital literacy, and reliable internet coverage. Low income, older, and minority populations are disproportionately affected by this divide. Behavioral health providers seeking to provide care via telehealth should consider interventions such as audio telehealth visits for patients that may not have reliable internet access or a sufficient data plan for video visits. In Washington D.C., 15.9 percent of health center behavioral visits were via audio telehealth (compared to 77. 28 percent over video and 7.53 percent in person) in May 2020. Thinking innovatively about how to best integrate telehealth into one’s practice is an important step to providing care during the COVID-19 pandemic.
Innovation: Addressing the Mental Health Impact of COVID-19
Flexibilities related to the service delivery of behavioral health care may allow for innovations related to behavioral health interventions, as COVID-19 continues to impact the mental health and well-being of a socially distanced nation. The Well Being Trust and Robert Graham Center predicted increased rates of deaths of despair. Nearly half of Americans (48%) are anxious about the possibility of contracting COVID-19, and nearly four in ten Americans (40%) are anxious about becoming seriously ill or dying from the disease. However, far more Americans (62%) are anxious about the possibility of family and loved ones getting coronavirus, according to the American Psychiatric Association. The New England Journal of Medicine noted that those who are diagnosed with COVID-19 may be at risk for depressive and anxiety disorders.
In response to these concerns, Medicaid managed care organizations have quickly developed and implemented innovative behavioral health interventions. For example, AmeriHealth Caritas DC and UPMC For You have launched COVID-19 outreach programs for those who are COVID-vulnerable, at no cost to the member. These programs can connect case managers with those in need behavioral health services. In one instance, a 62-year-old man enrollee of UPMC For You with cardiac history reported anxiety related to his risk of contracting COVID-19. He initially requested education on his risk and advice on appropriate precautions; however, his anxiety persisted. He agreed to participate in a behavioral health telephonic coaching program, where he learned calming techniques that eased his repetitive worry.
It is unclear how or when the COVID-19 pandemic will end. The virus’s impact on behavioral health, particularly for the Medicaid population, is vast, and Medicaid stakeholders will need to be responsive, adaptive, and innovative to respond to the needs of enrollees. However, there is an immediate need to explore how regulatory changes and COVID-19-specific initiatives are addressing the behavioral and mental wellbeing of the Medicaid population, including coverage of services, access to care, and health outcomes.
The authors would like to acknowledge the guidance and support of the IMI behavioral health subcommittee.
 District of Columbia Hospital Association, District of Columbia Primary Care Association, Medical Society of the District of Columbia, & District of Columbia Behavioral Health Association. (2020). Support Audio Telehealth Fact Sheet.