CHP Article re: Medicaid Managed Care

November 8, 2023

The article below is (as I understand it) one of several that Crain’s has published/will publish on our request for a carve out of behavioral health services from Medicaid managed care.

Although not stated here, our specific request is to return the scarce resources paid to insurers (many of which are for profit companies) to the mental health and substance use disorder systems of care so we can manage and expand the availability of our services, and address our workforce crisis.  Reinvestment.

It is so typical of the leadership of the Health Plan Association to blame providers for submitting claims with errors.  The reality is that NYS conducted a root cause analysis and found that the Plans were the guilty parties, denying claims inappropriately, failing to pay the state mandated APG government rate, and failing to oversee the third party vendors they hire to manage reimbursement (think Beacon).

Again, thank you to all of the agencies that took the time to complete our Survey.

Crain’s Health Pulse, 11/8

Behavioral health agencies call managed care a ‘failed experiment’ that ups costs, cuts care

Behavioral health providers across New York say they face financial challenges related to participating in Medicaid managed care, resulting in difficulties hiring staff and meeting patient demand, according to a survey conducted by the NYS Council for Community Behavioral Healthcare.

New York transitioned behavioral health into the Medicaid managed care program from a traditional fee-for-service model in 2015. The transition was recommended by the Medicaid Redesign Team implemented under former Gov. Andrew Cuomo, which had a goal of restructuring Medicaid to improve outcomes and control costs.

Now providers say that the shift to managed care has created financial strains that have hampered their ability to provide care amid worsening mental health and substance use disorder crises. Many of these financial challenges, they say, result from delayed or lacking payments from health plans.

Collectively, health plans owe behavioral health agencies in New York $10 million from outstanding claims that have been due for more than 90 days, according to the council’s survey, which was shared with Crain’s. The smallest amount owed was $80,000 and the largest was $3 million.

Health plans’ rejections of claims force agencies to hire staff to track down payments. The survey found that 84% of agencies employ numerous staff for the sole purpose of addressing issues related to the shift of behavioral health services into managed care.

Lauri Cole, executive director of the NYS Council for Community Behavioral Healthcare, said that the responsibility of holding health plans accountable for missing payments is on the provider.

“That reduces their ability to keep the front door open and increase the availability of care,” Cole said. “Some providers get stuck waiting six, nine months for hundreds of thousands of dollars that they can’t afford to wait for.”

Just under half of providers that operate licensed mental health clinics said they had waiting lists for services, and a third had to pause new intakes at some point last year, the survey showed.

The survey, conducted in September, includes responses from 60 behavioral health agencies across the state that are members of the NYS Council for Community Behavioral Healthcare. The Council represents 130 community-based behavioral health providers across the state.

Eric Linzer, president and CEO of the New York Health Plan Association, said in a statement to Crain’s that “health plans place a high priority of having a broad network of providers to meet the behavioral health needs of their members and have worked tirelessly with individual providers to resolve issues – including billing issues – as they arise.”

“However, plans cannot pay for services when providers submit claims that include billing errors, and plans report that some providers continue to struggle with that process,” Linzer added, noting that the association welcomes the opportunity to speak with providers about billing concerns.

Cole said that the challenges providers face with Medicaid managed care are a result of poor state oversight of managed care plans. The Department of Health released a “root cause” analysis of health plans in the state in 2021 due to behavioral health providers’ complaints about payments, aiming to address systemic problems within Medicaid managed care. The state determined several deficiencies related to health plans’ routine failure to pay government-mandated rates and inappropriate denials of behavioral health claims.

Danielle DeSouza, a spokeswoman for the agency, said that the state “is continually evaluating the managed care program and will continue to do so to ensure the highest quality care and outcomes for all managed care members.”

Because of the continued challenges for behavioral health providers related to Medicaid managed care, Cole said that her organization is calling for the state to return behavioral health services to a traditional, fee-for-service model under Medicaid—effectively carving out behavioral health benefits from the managed care program.

Linzer said that “the previous fee-for-service structure under which Medicaid members were forced to seek services was ineffective, uncoordinated and did not provide good outcomes for individuals in need of behavioral health care.” He added that a carve-out would undermine efforts to make the Medicaid program more “accountable and effective” than the previous fee-for-service model.

But Cole said that removing behavioral health services from managed care will improve providers’ ability to provide care.

“This is a failed experiment—one we didn’t ask for and one we didn’t have a decision about,” Cole said. She said the conditions outlined in the survey including long waitlists and workforce shortages are getting worse, calling on the state to reconsider the inclusion of behavioral health in managed care as it considers budget priorities for the next fiscal year. —Amanda D’Ambrosio