Our work shaping and reporting on national mental health policy is made possible through a capacity grant from the Perigee Fund.
In late April, the Centers for Medicare and Medicaid Services (CMS) published final rules (CMS-2439-F) related to Medicaid and Children’s Health Insurance Program (CHIP) managed care.
The new rules address “new standards to help states improve their monitoring of access to care by requiring the establishment of new standards for appointment wait times, use of secret shopper surveys, use of enrollee experience surveys, and requiring states to submit a managed care plan analysis of payments made by plans to providers for specific services, to monitor plans’ network adequacy more closely.”
In a related fact sheet about the regulations, the following areas are noted as being impacted by the regulations: The regulations go into effect on July 9, 2024, though some regulation implementation dates are delayed, as outlined in the fact sheet.
The regulations address:
- Access
- State Directed Payments
- Medical Loss Ratio
- In Lieu of Service and Setting (ILOS)
- Quality (Quality Strategy and External Quality Review (EQR))
- Quality (Medicaid and CHIP Quality Rating System (MAC QRS))
- CHIP
Our analysis focuses on the appointment wait time standards.
APPOINTMENT WAIT TIME STANDARDS
Network adequacy requirements generally focus on time/distance standards – where a provider is located in relation to the patient/plan population, such as the miles or travel time between patients and providers. The new rules include “Appointment Wait Time Standards” (Section 438.68(e)). Under this new section, Medicaid agencies will need to develop and enforce wait time standards for routine appointments in four areas with the following wait times:
- Outpatient mental health and substance use disorder (SUD) – adult and pediatric – 10 days
- Primary care – adult and pediatric – 15 days
- Obstetrics and gynecology (OB/GYN) – 15 days
- One other type of service selected by the state – Not specified
The regulations note the state-developed appointment wait times must be no longer than 10 business days for routine outpatient mental health and substance use disorder appointments and no longer than 15 business days for routine primary care and OB/GYN appointments.
- The standards don’t differ for maternity care and don’t address midwifery appointments specifically, though it’s a reasonable expectation that the same rules would apply for contracted midwives.
- CMS indicates states may utilize telehealth balancing the availability of providers that can provide in-person care and enrollees’ preferences for receiving care.
Should a state have requirements that are more stringent, those state rules will apply.
WAIT TIME SECRET SHOPPER SURVEYS
In addition to adding a new requirement of appointment wait times, CMS will also now require states to conduct secret shopper surveys. A secret shopper is typically someone who will pretend to be a patient to determine if the plan provides a network that complies with the appointment wait time standards.
According to the Center for Connected Health Policy’s analysis of the regulations, plans will not be able to contract with telehealth companies that do not also provide services in person as a means of meeting the appointment wait time requirement unless those states have laws that require health plans to cover services regardless of whether they are provided in-person or via telehealth. In other words, plans need to have enough in-person services available to meet the appointment wait time standards.
WHAT THIS MEANS FOR MATERNAL MENTAL HEALTH
These new CMS rules will have a significant impact on our field in several ways:
- For the first time, provide teeth to the Federal Mental Health Parity requirements, which address, among other things, equal access between medical and mental health and substance use benefits. We are working with state advocates and state agencies to remind them of the need to monitor behavioral health network adequacy by provider subspeciality (in our case PMH-Cs and the forthcoming reproductive psychiatry MD certification), not just provider licensure (MD, LCSW, etc.). Arizona is the first state Medicaid agency to explore monitoring PMH-C network adequacy, using our model legislation/regulation framework.
- However, for both Mental Health and OB/Gyn appointment wait times, there are not enough providers to meet the need, regardless of these standards and requirements of insurers. So practically speaking, it’s critical that insurers and government look to creative solutions, like:
- A federal telepsychiatry consultation program that fills the gaps where states don’t have such programs, supporting obstetric providers (OBs/Midwives/Family Practice providers who deliver babies) in managing preliminary diagnosis and treatment for maternal depression and anxiety.
- The Federal Health and Human Services Administration (HRSA) should be provided additional authority to implement a strategy by which mental health providers are trained and placed in mental health care shortage areas to close these gaps. HRSA should also prioritize training and placement of therapists of the same racial and ethnic backgrounds in these communities. (Learn more about maternal mental health shortage areas through our county-level “risk and resource” map, which juxtaposes perinatal population risk for maternal mental health disorders against PMH-C, Reproductive Psychiatry, and MMH community-based organizations (CBOs).
- CMS should address coverage of digital therapeutics, and likewise, state Medicaid Agencies should cover FDA-approved digital therapeutics, devices and drugs specific to maternal mental health.
The Policy Center will continue to provide these insights to CMS, state Medicaid and insurance leaders, and federal and state lawmakers.
Learn more about the other requirements in the rule from The Georgetown University McCourt School of Public Policy’s Center for Children and Families.
Read the complete CMS final rules and the fact sheet to learn about the breadth of the new rules.
