Behavioral Health: Options for Low-Income Adults to Receive Treatment in Selected States
Released: 2015-07-20T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: Research has shown that low-income individuals disproportionately experience behavioral health conditions and may have difficulty accessing care. Expansions of Medicaid under PPACA raise questions about states' capacity to manage the increased demand for treatment. Additional questions arise about treatment options for low-income adults in non-expansion states.

GAO was asked to provide information about access to behavioral health treatment for low-income, uninsured, and Medicaid-enrolled adults. This report examines (1) how many low-income, uninsured adults may have a behavioral health condition; (2) options for low-income, uninsured adults to receive behavioral health treatment in selected non-expansion states; and (3) how selected Medicaid expansion states provide behavioral health coverage for newly eligible enrollees, and how enrollment in coverage affects treatment availability.

GAO obtained estimates of low-income adults who may have a behavioral health condition from the Substance Abuse and Mental Health Services Administration. GAO also selected four non-expansion and six expansion states based on, among other criteria, geographic region and adult Medicaid enrollment. GAO reviewed documents from all selected states, and interviewed state Medicaid and BHA officials to understand how uninsured and Medicaid-enrolled adults receive behavioral health treatment. The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate.

section_title: What GAO Found
paragraphs: Nationwide, estimates using 2008-2013 data indicated that approximately 17 percent of low-income, uninsured adults (3 million) had a behavioral health condition, defined as a serious mental illness, a substance use condition, or both. Underlying these national estimates is considerable variation at the state level.

The estimated number of low-income, uninsured adults with behavioral health conditions was divided evenly between states that did and did not subsequently expand Medicaid under the Patient Protection and Affordable Care Act (PPACA).

Behavioral health agencies (BHA) in four selected non-expansion states offered various treatment options for low-income, uninsured adults, focusing care primarily on those with the most serious behavioral health needs. To do so, BHAs in all four selected states established priority populations of those with the most serious behavioral health needs. Also, BHAs in three of the four states maintained waiting lists for adults with less serious behavioral health needs.

Six selected states that expanded Medicaid generally managed behavioral health and physical health benefits separately for newly eligible enrollees, and state officials reported increased availability of behavioral health treatment, although some access concerns continue. Four of the six selected states explicitly chose separate contractual arrangements for behavioral health and physical benefits. Officials from all six selected states said that enrollment in Medicaid increased the availability of behavioral health treatment for newly eligible enrollees. Officials also reported some ongoing access concerns, such as workforce shortages.

section_title: Letter
paragraphs: Behavioral health conditions—mental health and substance use  conditions—affect a substantial number of adults in the United States. In  2013, an estimated 43.8 million adults (18.5 percent) had a mental health  condition—including 10 million adults (4.2 percent) with a serious mental  illness—and 20.3 million (8.5 percent) had a substance use condition.  Concerns about the availability of behavioral health treatment, particularly  for low-income individuals, have been longstanding. Medicaid, a joint  federal-state program that finances health care coverage for low-income  and medically needy individuals, is the largest payer for behavioral health  treatment in the nation. However, research has shown that individuals  enrolled in Medicaid experience a higher rate of behavioral health  conditions than those with private insurance, and may have difficulty  accessing treatment. Moreover, the demand for behavioral health  treatment is likely to increase as 29 states have chosen to expand  eligibility for Medicaid as allowed by the Patient Protection and Affordable  Care Act (PPACA). Under PPACA, states are permitted to expand  eligibility for Medicaid to certain adults with incomes up to 138 percent of  the federal poverty level (FPL). PPACA requires states that expand  Medicaid to provide newly eligible enrollees with health care coverage  that includes behavioral health benefits. Expansions of Medicaid,  coupled with high rates of need among low-income individuals, raise  questions about the capacity of states that expanded Medicaid to handle  the increased demand for behavioral health treatment. For states that  have not expanded Medicaid, additional questions arise about what  treatment options states are able to provide for low-income, uninsured  adults with behavioral health conditions.

Given the potential challenges states may face in providing behavioral  health treatment to low-income adults, you asked us to provide  information about access to and utilization of behavioral health treatments  among low-income adults newly eligible for Medicaid, as well as options  for behavioral health treatment for low-income, uninsured adults not  eligible for Medicaid in states that have not expanded the program. This  report describes (1) what is known about how many low-income,  uninsured adults may have a behavioral health condition; (2) what options  exist for low-income, uninsured adults to receive behavioral health  treatment in selected states that have not expanded Medicaid; and   (3) how selected Medicaid expansion states provide behavioral health  coverage for newly eligible enrollees, and how enrollment in coverage  affects treatment availability.

To describe what is known about how many low-income, uninsured adults  may have a behavioral health condition, we obtained national and state- level estimates of low-income, nonelderly adults who may have a  behavioral health condition from the Substance Abuse and Mental Health   Services Administration (SAMHSA). Low-income refers to individuals  who are at or below 138 percent of the FPL, which reflects those who  may be newly eligible for Medicaid in states that chose to expand their  programs under PPACA. However, these estimates are based on the  total low-income population in the state and do not differentiate between  previously eligible and newly eligible adults. Furthermore, the methods  used to produce the estimates do not account for variation in uptake rates  for the Medicaid program, which is the proportion of eligible individuals   After reviewing the data sources and  who ultimately choose to enroll.methods used to produce these estimates and checking for obvious  errors, we determined that the estimates were sufficiently reliable for our  purposes. For these estimates, we limited behavioral health conditions to  substance use conditions and serious mental illnesses, as opposed to the  more inclusive definition of behavioral health conditions used for the  remainder of this report, which comprise substance use conditions and all  mental health conditions. To examine the options that exist for low- income, uninsured adults to receive behavioral health treatment in  selected states that have not expanded Medicaid, we selected four states  (Missouri, Montana, Texas, and Wisconsin) to obtain variation among  states in total population size, adult Medicaid enrollment, percent change  in Medicaid enrollment from 2013 to 2014, per capita number of  behavioral health professionals, and geographic region. We reviewed  documentation and conducted interviews with officials from state  behavioral health agencies (BHA), which also play a role in funding   To determine how states that expanded  behavioral health treatment.Medicaid provided behavioral health coverage and the extent to which  Medicaid coverage affected the availability of treatment, we selected six  states (Connecticut, Kentucky, Maryland, Michigan, Nevada, and West  Virginia). We chose to select more expansion states than non-expansion  states because of the greater policy and enrollment changes taking place  in those states as they implemented the expansion of Medicaid. We  selected expansion states to achieve variation in the same characteristics  we used to select non-expansion states, with one additional  characteristic, which was the delivery system (e.g., fee-for-service (FFS)  or managed care) used in their Medicaid programs. For each state, we  reviewed documentation regarding their state Medicaid programs, and  conducted interviews with Medicaid and state BHA officials. The reported  experiences of expansion and non-expansion states cannot be  generalized to all states. To obtain contextual information about  behavioral health treatment in both expansion and non-expansion states,  we interviewed representatives from behavioral health professional and  advocacy groups, and spoke with a behavioral health benefits manager,  an organization that manages benefits for state Medicaid programs.

We conducted this performance audit from July 2014 through June 2015  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Behavioral Health Treatment
paragraphs: Access to behavioral health treatment—services and prescription drugs to  address behavioral health conditions—is important because of the  harmful consequences of untreated conditions, which may result in  worsening health, increased medical costs, negative effects on  employment and workplace performance, strain on personal and social  relationships, and possible incarceration. Behavioral health treatment can  help individuals reduce their symptoms and improve their ability to  function. However, research suggests that a substantial number of  individuals with behavioral health conditions may not receive any  treatment or less than the recommended treatment, even among those  with serious conditions. For example, in 2013, SAMHSA estimated that  there were 3.9 million adults aged 18 or older with a serious mental  illness who perceived an unmet need for mental health care within the  last 12 months. This number includes an estimated 1.3 million adults with  a serious mental illness who did not receive any mental health services.  One potential barrier to accessing treatment is shortages of qualified  behavioral health professionals, particularly in rural areas. SAMHSA  noted that more than three-quarters of counties in the United States have  a serious shortage of mental health professionals.

Behavioral health treatment includes an array of options ranging from less  to more intensive, and may include prevention services, screening and  assessment, outpatient treatment, inpatient treatment, and emergency  services for mental health and substance use conditions. Prescription  drugs may also be included as part of treatment for either substance use  or mental health conditions. See table 1 for information on select  behavioral health treatments.

In addition to these treatments, other supportive services exist for  behavioral health conditions that are designed to help individuals manage  mental health or substance use conditions and maximize their potential to  live independently in the community. These supportive services are  multidimensional—intended to address not only health conditions, but  also employment, housing, and other issues. For example, they include  recovery housing—supervised, short-term housing for individuals with  substance use conditions or co-occurring mental and substance use  conditions that can be used after inpatient or residential treatment.

section_title: Medicaid
paragraphs: The Centers for Medicare & Medicaid Services (CMS)—a federal agency  within the Department of Health and Human Services (HHS)—and states  jointly administer the Medicaid program, which finances health care,  including behavioral health care, for low-income individuals and families.  States have flexibility within broad federal parameters for designing and  implementing their Medicaid programs. States may use Medicaid  waivers—which allow states to set aside certain, otherwise applicable  federal Medicaid requirements—to provide health care, including  behavioral health treatment, to individuals who would not otherwise be  eligible for those benefits under the state’s Medicaid program. For  example, states may use waiver programs to target residents in a  geographic region or to target individuals with particular needs, such as  those with serious mental illness. States may also choose different  delivery systems to provide benefits including behavioral health treatment  to Medicaid enrollees, such as FFS or managed care. Some states with  managed care delivery systems may elect to “carve out” behavioral health  benefits, i.e., contract for them separately from physical health care  benefits. For example, some states contract with limited benefit plans,  which are managed care arrangements designed to provide a narrowly  defined set of services. Similarly, states with FFS delivery systems may  choose to contract with separate companies to administer behavioral health benefits than those administering physical health care benefits.Our previous work has noted that while using a separate plan to provide  mental health services may control costs, it can also increase the risk that  treatment for physical and mental health conditions will not be  coordinated.

section_title: Medicaid and Other Funding Sources for Public Behavioral Health Programs
paragraphs: A variety of sources provide funding for behavioral health treatment in  public programs. Medicaid is the largest source of funding for behavioral  health treatment, with spending projected to be about $60 billion in  2014. Another significant source of revenue for state BHAs is state  general revenues. In contrast to Medicaid, for which payment of benefits  to eligible persons is required by law, state general funding for the  treatment of uninsured and underinsured residents is discretionary. The  extent to which state-funded treatment is provided may depend on the  availability of funding. States may also use SAMHSA mental health and  substance use block grants to design and support a variety of treatments  for individuals with behavioral health conditions. See figure 1 for  information on sources of state BHA revenues for mental health in 2013.  (Similar figures for substance use were not available.)

section_title: Patient Protection and Affordable Care Act
paragraphs: The number of states that have expanded Medicaid includes the District of Columbia,  which we refer to as a state of for the purposes of this report.

section_title: State Behavioral Health Agencies
paragraphs: State BHAs are the agencies responsible for planning and operating state  behavioral health systems, and they play a significant role in  administering, funding, and providing behavioral health treatment. State  BHAs manage behavioral-health-related federal grants and may work  with other state agencies—such as state Medicaid agencies—to identify  and treat mental health and substance use conditions. State BHAs may  contract directly with providers to deliver behavioral health treatments or  may contract with county or city governments, which are then responsible  for the delivery of treatments within their local areas. State BHAs may  also play a role in providing Medicaid enrollees with wraparound  services—that is, services that state Medicaid programs do not cover, but  that may aid in recovery, such as supportive housing.

section_title: An Estimated 3 Million Low-Income Uninsured Adults Had a Behavioral Health Condition, with Half Living in States that Have Not Expanded Medicaid
paragraphs: Nationwide, estimates using data from 2008 to 2013 indicated that of   17.8 million low-income, uninsured adults, approximately 3 million   (17 percent) had a behavioral health condition prior to the Medicaid  expansion in 2014. Specifically, about 1 million low-income, uninsured  adults (5.8 percent) were estimated to have a serious mental illness,  while nearly 2.3 million low-income, uninsured adults (12.8 percent) were  estimated to have a substance use condition. Underlying these national  estimates was considerable variation at the state level. In particular, the  percentage of low-income, uninsured adults with a behavioral health  condition ranged from 6.9 percent to 27.5 percent. Similarly, the  percentage of low-income uninsured adults with serious mental illness  ranged from 1.3 percent to 13 percent, while the percentage with a  substance use condition ranged from 5.9 percent to 23.5 percent. See  figure 3 for the states with the highest and lowest estimated percentages  of low-income, uninsured adults with a serious mental illness or  substance use condition. See appendix I for state-by-state estimates.

Of the 3 million low-income, uninsured adults estimated to have a  behavioral health condition, nearly half—approximately 1.4 million people,  or about 49 percent—lived in the 22 states that had not expanded  Medicaid as of February 2015, compared with the approximately   1.5 million people in the remaining 29 states that had expanded Medicaid.  The estimated prevalence of behavioral health conditions overall among  low-income, uninsured adults was about 17 percent, on average, in both  expansion and non-expansion states.

section_title: Selected Non- Expansion States Offered Treatment Options for Uninsured Adults, but Primarily Provided Treatment to Those with the Most Serious Behavioral Health Needs
paragraphs: State BHAs in the non-expansion states we examined offered a variety of  behavioral health treatments for low-income, uninsured adults. These  states identified priority populations to focus care on adults with the most  serious conditions and used waiting lists for those with more modest  behavioral health needs.
subsections: section_title: States Offered a Variety of Behavioral Health Treatments for Uninsured Adults
paragraphs: The non-expansion states we examined—Missouri, Montana, Texas,  and Wisconsin—offered a range of behavioral health treatments— inpatient and outpatient services and prescription drugs—for low-income,  uninsured adults. These states used community mental health centers,  state institutions, and contracts with providers to deliver treatments, and  used a variety of sources, such as state general funds, federal block  grants, and Medicaid to fund them. For mental health and substance  use conditions, outpatient services that these states offered included  evaluation and assessment, visits with medical providers, and individual,  family, and group counseling. Treatments also included emergency care,  and in most of these states, partial hospitalizations and inpatient  psychiatric care for mental health conditions. For substance use  conditions, these states also offered detoxification and residential  treatment. These states generally made prescription drugs available to  uninsured adults as part of the treatment for behavioral health conditions.

For example, Missouri, Texas, and Wisconsin included medication- assisted treatment for substance use conditions, and all four of the  selected non-expansion states offered prescription drugs for mental  health conditions. In addition to treatment, the non-expansion states also  offered some supportive services, such as peer support or housing  services, for uninsured adults.

For two of the states we examined—Wisconsin and Texas—the  availability of specific services for behavioral health may vary throughout  the state. In particular, the responsibility for administering and providing  treatment was divided between the state BHA and local entities, which  receive both state and local funding to provide behavioral health  treatment. funding for behavioral health, which they can use to fund services of their  choosing. The Wisconsin BHA identified a core list of 30 services for  behavioral health that it promotes and encourages counties to provide,  but the official noted that it may be difficult for a single county to provide  all of the services on the list. For example, the Wisconsin BHA reported  that about a quarter of counties provided medication-assisted treatment  for individuals with substance use conditions in 2013. As another  example, Texas offers opportunities for local mental health authorities to  compete for funding for specific types of services, such as housing.

Local entities are counties for Wisconsin and local mental health authorities in Texas. In  contrast, the state BHA is solely responsible for administering behavioral health treatment  in Missouri and Montana. coverage. In addition, Wisconsin obtained a Medicaid waiver effective  January 2014 that made certain childless adults up to 100 percent of the  FPL eligible for Medicaid, which gave them access to Medicaid-covered  services and prescription drugs, including behavioral health treatments.

Officials from the non-expansion states we examined noted initiatives  relevant to low-income, uninsured adults, such as improving crisis  response and coordinating care for individuals involved with law  enforcement.

Texas officials noted that 24 of the 33 local mental health authorities  have a facility-based crisis option to treat individuals experiencing a  crisis and that they would like to provide the remaining local mental  health authorities with similar facilities, which are intended to avoid  inpatient care.

In Wisconsin, behavioral health treatment includes mobile crisis  services to respond to individuals in the community experiencing a  crisis. A Wisconsin official told us that there were legislative efforts  underway to expand these services, particularly in rural areas.

Missouri has hired community mental health liaisons to facilitate  access to behavioral health services for individuals who are in  frequent contact with law enforcement.

section_title: States Set Priorities to Focus Care on Those with the Most Serious Behavioral Health Needs and Used Waiting Lists for the Remaining Individuals
paragraphs: The selected non-expansion states established priority populations for  providing behavioral health treatment to those with the most severe  behavioral health needs. For the states we examined, priority populations  for mental health treatment included individuals with serious mental  illness and those presenting in crisis. Similarly, all the non-expansion  states we examined identified priority populations for receiving treatment  for substance use conditions. Specifically, pregnant women and  individuals abusing drugs intravenously were among the priority groups  that the states identified to receive treatment.

As part of setting priorities for those with the most serious behavioral  health needs, the non-expansion states included specific eligibility  requirements based on diagnosis or impairment, in addition to financial  status, for behavioral health treatment for the uninsured.

In Montana, individuals aged 18 to 64 diagnosed with a severe,  disabling mental illness, and incomes up to 150 percent of the FPL  may qualify for the state-funded Mental Health Services Plan.  Montana officials told us that their Mental Health Services Plan does  not provide treatment to individuals with more moderate behavioral  health needs, but that these individuals may get some treatment  through community-based “drop-in” centers.

In Texas, local mental health authorities are required to provide  services to adults with diagnoses of schizophrenia, bipolar disorder, or  clinically severe depression, and may, to the extent feasible, provide  services to adults experiencing significant functional impairment due  to other diagnoses. Individuals who are not members of the identified  priority groups are generally not eligible to receive treatment.

Three of the states we examined maintained waiting lists for individuals  with more modest needs for behavioral health treatment.

Texas officials said that they triage individuals eligible for behavioral  health treatment, and those with less urgent needs may have to wait.  In some cases, individuals may receive a lower level of care than  recommended while waiting for treatment due to resource limitations.  For example, an individual might receive medication-related services  and crisis services as needed, but not recommended rehabilitation  services. Texas officials told us that there were over 5,000 individuals  waiting for behavioral health treatment as of February 2013, although  they were able to move most individuals off waiting lists when they  received additional state funding for fiscal years 2014 and 2015. They  described this additional funding as “historic,” and they reduced the  number of individuals waiting to fewer than 300 as of May 2014. In  addition to reducing the waiting list, Texas moved 1,435 adults from  lower levels of care to more appropriate levels in 2014.

A Wisconsin official told us if county agencies run out of funding, they  are permitted to establish waiting lists or may only serve clients with  Medicaid coverage. The official said there were 1,656 individuals  waiting for substance use treatment and 242 individuals waiting for a  specific mental health service in 2013, prior to Wisconsin extending  Medicaid coverage to certain low-income adults through a Medicaid  waiver.all services if they run out of funding, but must always provide  emergency care.

The official said that county agencies do not have to provide

Missouri officials said there were 3,723 individuals on the waiting list  for substance use treatment as of January 2015.

Missouri state BHA officials noted that Missouri does not maintain a waiting list for  mental health services.

section_title: Selected Expansion States Generally Managed Behavioral Health Separately from Other Benefits, Reporting Increased Treatment Availability, but Some Continuing Access Concerns
paragraphs: Selected states generally managed behavioral health benefits for newly  eligible Medicaid enrollees separately from physical benefits through  carve-outs or separate contracts. Health plans for these enrollees were  generally aligned with Medicaid state plans, resulting in comparable  behavioral health benefits for newly eligible and existing Medicaid  enrollees. According to state officials, expanding Medicaid has increased  the availability of behavioral health treatment, although some access  concerns continue.
subsections: section_title: Selected States Generally Managed Behavioral Health Coverage for Newly Eligible Enrollees Separately from Other Benefits
paragraphs: The expansion states we examined generally managed behavioral health  benefits separately from other benefits through carve-outs or separate  contracts. Four of the six states included in our study—Connecticut,  Maryland, Michigan, and West Virginia—explicitly carved out or  contracted for the administration of behavioral health services or  prescription drugs separately from other services and drugs. For  example, in Maryland, specialty mental health services have been carved  out of its contracts with managed care organizations (MCO) since 1997  and are paid for on an FFS basis. Michigan carved behavioral health  services out of its MCO contracts and moved them to a limited benefit  plan in 1998. Connecticut, which has an FFS delivery system for newly  eligible enrollees, contracted with a behavioral health benefits manager to  administer behavioral health services. The other two states contracted  with MCOs to provide both physical and behavioral health coverage, but  several of these MCOs chose to subcontract with behavioral health  benefits managers. See table 2 for information on the expansion states’  coverage designs for behavioral health services and prescription drugs.

State officials cited various reasons for separately managing behavioral  health benefits, including concerns about access, ensuring appropriate  expertise, and state law.

Maryland officials told us they chose to carve out mental health  services and pay for them on an FFS basis through a behavioral  health benefits manager due to concerns about beneficiary access  under managed care, particularly for more intensive services  generally not covered by commercial insurance plans. Maryland also  separately carved out mental health prescription drugs on an FFS  basis, which officials said was so that the state could align policies for  these drugs with the behavioral health benefits manager administering  the mental health services carve-out.

In Kentucky, three of the five Medicaid MCOs subcontracted  behavioral health benefits to a behavioral health benefits manager.  Kentucky officials told us that one of the MCOs decided to subcontract  these benefits due to a lack of expertise in managing behavioral  health prescription drugs.

Michigan and Connecticut officials told us that state laws prohibit their  Medicaid programs from using certain utilization management  techniques for some types of behavioral health prescription drugs.  Michigan officials told us that given the lack of utilization management  tools available, they decided to pay for behavioral health prescription  drugs on an FFS basis rather than to include these drugs in the  state’s limited benefit plan contracts.

Providers have raised concerns about managing behavioral health  benefits separately from medical benefits, and some states reported  making efforts to make sure care is coordinated. Behavioral health  physician groups we spoke with told us that paying for physical and  behavioral health care separately makes it difficult to assess the total cost  of care for individuals with behavioral health conditions, and does not  provide adequate incentives to make investments in one type of care that  may reduce costs for another type of care. For example, provider groups  said that lack of investment in substance use services could lead to  additional costs for emergency medical care. In addition, one physician  group raised concerns about managing behavioral health services  separately from prescription drugs because of the potential for conflicting  utilization management policies to create barriers to care. For example, a  pharmacy benefits manager may require outpatient counseling as a  condition for receiving medication-assisted treatment for substance use,  but such counseling may not be covered by the managed care company  that authorizes behavioral health services. The four states we spoke with  that explicitly manage behavioral health care separately—Connecticut,  Michigan, Maryland, and West Virginia—noted that they were engaged in  care coordination efforts.

Connecticut officials said that although they have multiple contracts  for benefits administration, all claims are processed through a single  vendor and the state uses these data to help identify individuals in  need of care management.

Michigan officials said that the state has implemented claims sharing  between the MCOs managing physical health care and the limited  benefit plans that manage behavioral health benefits. Michigan is  currently working on a demonstration program with CMS that would  allow for real-time sharing of clinical information for individuals dually  eligible for Medicare and Medicaid.

Maryland included financial incentives related to physical health, such  as the number of patients who have an annual primary care visit, in  the contract with its behavioral health benefits manager.

West Virginia officials said that they were working on creating a  comprehensive managed care plan for newly eligible Medicaid  enrollees that would offer both physical and behavioral benefits,  including prescription drugs, under the same plan in order to better  coordinate care.

In addition, Michigan, Maryland, and West Virginia have established  Medicaid health homes to coordinate care for individuals with chronic   As of January 2015,  conditions, including behavioral health conditions.Connecticut was in the process of developing Medicaid health homes for  individuals with behavioral health conditions.

section_title: Selected States Provided Comparable Behavioral Health Benefits for Newly Eligible and Existing Medicaid Enrollees
paragraphs: Five of the six expansion states included in our study chose to align their  alternative benefit plans with their Medicaid state plans—providing at  least the same benefits for newly eligible enrollees as existing enrollees  received under the state plan—and some states made alignment-related  coverage changes.

Connecticut, Kentucky, Maryland, Michigan, and Nevada aligned their  alternative benefit plans with their Medicaid state plans, which  required these states to add to their alternative benefit plans any state  plan benefits that were not already included. For example, Michigan  officials said they added additional recovery-oriented substance use  services, such as peer support services, to the alternative benefit plan  to match existing state plan benefits.

Although not required, states may also choose to add benefits to their  Medicaid state plans to match their alternative benefit plans. As part  of the alignment process, Kentucky chose to extend substance use  treatment—previously limited to children under 21 and pregnant and  postpartum women—to all Medicaid enrollees under its state plan to  match the substance use coverage in its alternative benefit plan.

West Virginia did not align its alternative benefit plan with its Medicaid  state plan, but there were no differences in coverage for behavioral  health services and associated prescription drugs.

section_title: Selected Expansion States Reported Increased Availability of Behavioral Health Treatment, but Cited Some Ongoing Access Concerns
paragraphs: Officials we interviewed from the six expansion states generally reported  that Medicaid expansion had resulted in greater availability of behavioral  health treatment, and changes were greater in states without previous  coverage options for low-income adults. Kentucky, Nevada, and West  Virginia did not have any coverage available for low-income childless  adults prior to expansion and primarily relied on their states’ BHAs to  provide behavioral health treatment for the uninsured.

Kentucky officials reported a substantial increase in the availability of  behavioral health treatment for individuals when they enrolled in  Medicaid, as individuals were no longer limited to what state-funded  community mental health centers could provide, and could access  additional services, such as peer support services.

Nevada officials stated that while the state BHA and the state’s  Medicaid program provide the same array of behavioral health  treatments, some uninsured individuals experienced long delays in  receiving care prior to enrolling in Medicaid coverage under the  expansion.

West Virginia officials cited the increased availability of prescription  drugs. West Virginia’s BHA did not pay for prescription drugs for  uninsured individuals except in limited circumstances, whereas newly  eligible Medicaid enrollees gained access to the full array of covered  drugs under the state’s Medicaid program.

In contrast, Connecticut, Maryland, and Michigan all had limited coverage  available for certain low-income adults prior to expanding Medicaid that  paid for some behavioral health services and prescription drugs. For  example, Maryland’s Primary Adult Care program paid for outpatient  mental health and substance use services and prescription drugs for  adults up to 116 percent of the FPL. Officials from these three states  reported that while the availability of treatment increased when individuals  enrolled in Medicaid, the changes were small; for example, officials from  two states reported that Medicaid beneficiaries had a greater choice of  providers.experienced larger changes; for example, Michigan officials reported that  enrollment in Medicaid had resulted in improved access to substance use  services, including access to case management, which officials said could  help individuals live more successfully in the community.

Individuals not enrolled in these coverage programs  Officials from the expansion states in our study did report some access  concerns for new Medicaid enrollees due to behavioral health  professional shortages, which they attempted to address in a variety of  ways. Officials from all six states cited behavioral health workforce  shortages as a challenge to providing behavioral health treatment for low- income adults in their states. The state officials specifically highlighted  shortages of Medicaid-participating psychiatrists and psychiatric drug  prescribers.

Nevada officials reported conducting a secret shopper study of  psychiatrists in the state’s Medicaid program in 2014 that found only  22 percent of Medicaid-enrolled psychiatrists were accepting new  Medicaid patients.

Maryland and Connecticut officials reported difficulties providing  Medicaid enrollees with access to certain prescription drugs used for  medication-assisted treatment for substance use conditions due to a  lack of physicians willing to prescribe these drugs for Medicaid  enrollees.

States reported taking several steps to address workforce shortages,  such as providing reimbursement for telehealth services, expanding the  types of providers who can receive reimbursement for providing services  in Medicaid, and using peers and other non-licensed providers to deliver  some services under the supervision of licensed providers. Michigan  chose to address behavioral health needs of its new Medicaid enrollees  by leveraging its primary care workforce. The state used a health  assessment tool as part of the enrollment process for its alternative  benefit plan that included questions about potential behavioral health  conditions. Health assessment information was conveyed to each  enrollee’s primary care provider, who could then address any behavioral  health needs or refer for specialty care if needed.

State officials reported additional concerns regarding access to  behavioral health treatment due to expansion-related budget reductions  for state BHAs, which fund treatment for uninsured individuals, as well as  non-Medicaid covered treatments for Medicaid enrollees. Officials from  four of the six expansion states we spoke with—Connecticut, Kentucky,  Michigan, and Nevada—reported that their state’s BHA budget had been  reduced based on the expectation that uninsured individuals would enroll  in Medicaid. For example, Michigan officials reported that the state  reduced its state general fund contribution for its BHA by about   10 percent ($116 million) from fiscal year 2013 to fiscal year 2015, and  Nevada reported a $33 million reduction to its BHA budget over fiscal  years 2014 and 2015 related to the expansion. Some state officials raised  concerns about having enough state BHA funding for individuals who  would remain uninsured or underinsured following expansion, including  individuals who are eligible but do not enroll or re-enroll in Medicaid,  immigrants, and certain individuals under 65 who are enrolled in  Medicare because of a disability. Officials from two states also  expressed concerns about the adequacy of funding for wraparound  services—services that are not covered by their states’ Medicaid  programs, such as supportive housing—for Medicaid enrollees. Officials  from the four states that reported BHA budget reductions noted that there  were subsequent adjustments to their budgets to lessen the impact of the  reductions based on these concerns. For example, Michigan’s BHA  received an additional $25 million for fiscal year 2015 to address  behavioral health needs in certain populations that remain ineligible for  Medicaid. (See appendix II for more information on expansion-related  changes in state BHA budgets.) Despite concerns about budget  reductions, officials from two states noted that when additional Medicaid  funds from the expansion were considered as part of the behavioral  health budget, much more funding was available overall.

Other continuing access problems mentioned by state officials related to  inpatient behavioral health treatment.

Nevada officials said that lack of psychiatric inpatient capacity has led  to patients who were considered a risk to themselves or others being  kept in emergency rooms for up to several days before they could  secure a bed in a psychiatric hospital. Officials said that an average of  90 to 110 patients per day, predominately Medicaid enrollees, were  waiting in emergency rooms. Nevada has made efforts to address the  problem, for example, by sending teams of psychiatrists to emergency  rooms to assess psychiatric patients to determine whether they could  be discharged and treated on an outpatient basis. However, officials  noted that discharging such patients carries risks and has led to poor  outcomes in the past.

Kentucky officials said that they were working to expand capacity for  residential treatment programs for substance use. Officials said that  given Medicaid’s exclusion of payment for treatment for adults at  “institutions for mental disease” with 16 or more beds, they were  encouraging providers to design any new residential substance use  programs to be under that limit. However, they noted that doing so  can prevent providers from taking advantage of economies of scale  and may make it more difficult to operate some residential treatment  programs shown to be effective for substance use conditions. Officials  said that the state was working to develop alternatives to inpatient  care for Medicaid enrollees, such as transitional housing combined  with an intensive outpatient program.

section_title: Agency Comments
paragraphs: We provided a draft of this report to the Department of Health and Human  Services for review. HHS provided technical comments, which we  incorporated as appropriate.

As arranged with your offices, unless you publicly announce the contents  of this report earlier, we plan no further distribution until 30 days after its  issuance date. At that time, we will send copies of this report to the  Secretary of Health and Human Services and other interested parties. In  addition, the report will be available at no charge on the GAO website at  http://www.gao.gov.

If you or your staff members have any questions, please contact me at  (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. Major contributors to this report are listed in appendix III.

section_title: Appendix I: Estimated Number and Percentage of Low-Income, Uninsured Adults with Behavioral Health Conditions
paragraphs: Estimated number of low-income, uninsured adults    Percent   (standard error) Number Total   20.3 (2.6) 68,495 337,414   24.9 (4.6)  20.9 (2.7)  19.4 (2.2)  12.5 (1.2)  12.0 (2.0)  13.0 (3.6)  15.7 (1.2)  12.2 (1.8)  21.1 (4.5)  23.7 (3.6)  16.5 (1.4)  27.5 (3.1)  19.2 (3.1)  15.9 (3.3)  15.8 (2.3)  20.3 (2.4)  19.9 (3.8)  21.2 (1.6)  19.5 (4.4)  16.4 (1.7)  17.2 (2.4)  21.0 (3.2)  20.6 (3.3)  21.5 (3.3)  20.4 (4.2)  6.9 (2.3)  13.2 (2.5)
subsections: section_title: State expanded Medicaid as of
paragraphs: Estimated number of low-income, uninsured adults    Percent   (standard error) Number Total   12.6 (1.6) 85,555 679,004   14.4 (2.1)  27.5 (4.1)  27.4 (2.1)  18.1 (2.7)  20.7 (3.3)  18.9 (2.0)  24.9 (4.0)  22.3 (2.7)  17.5 (3.4)  22.0 (2.5)  13.7 (1.0)  16.6 (3.2)  23.4 (4.6)  23.4 (3.8)  18.1 (2.3)  21.4 (3.8)  19.6 (3.4)

section_title: Total
paragraphs: 16.7 (0.4)  16.9 (0.5)  16.6 (0.5)

State expanded  Medicaid as of  February 2015  error)    9.8 (2.3) error)    11.7 (1.9)

Percent   (standard  error)  1.2 (0.5)

3,251  10.1 (3.5)

21.9 (4.5)

6.3 (1.7)

17.0 (2.3)

2.4 (1.1)

9.8 (1.8)

13.1 (1.9)

3.5 (1.4)

4.0 (0.6)

9.7 (1.0)

1.2 (0.3)

2.8 (1.0)

9.7 (1.9)

0.5 (0.3)

7.4 (2.8)

7.2 (2.4)

6.0 (0.8)

11.9 (1.1)

2.2 (0.5)

3.6 (1.2)

9.4 (1.8)

0.8 (0.5)

6.4 (2.1)

18.1 (4.3)

3.3 (1.7)

11,231  11.3 (2.1)

15.8 (3.3)

3.4 (1.4)

3.9 (0.7)

13.9 (1.3)

1.3 (0.3)

50,730  13.0 (2.7)

19.9 (2.8)

5.4 (1.5)

6.4 (2.3)

13.4 (2.5)

0.7 (0.3)

3.3 (1.3)

12.8 (2.8)

0.2 (0.2)

6.1 (1.5)

13.4 (2.0)

3.7 (1.2)

6.2 (1.5)

16.3 (2.2)

2.2 (0.9)

8.8 (3.0)    6.1 (2.9)

16.0 (3.6)

4.9 (2.2)  1.6 (1.2)

16.0 (1.3)

2.0 (0.5)

11.7 (2.6)

2.1 (1.0)

7.3 (1.0)     7.2 (1.5)

11.1 (1.6)

1.9 (0.7)

6.1 (1.6)

12.9 (2.2)

1.8 (0.7)

6.5 (1.9)

16.3 (2.9)

1.9 (0.8)

5.5 (1.6)

15.8 (3.2)

0.6 (0.3)

State expanded  Medicaid as of  February 2015  error)    6.9 (2.8) error)    16.1 (2.8)

Percent   (standard  error)  1.5 (0.6)

5.2 (1.8)

17.9 (4.0)

2.7 (1.5)

1.3 (0.8)

5.9 (2.1)

0.4 (0.3)

6.1 (1.7)

10.7 (2.1)

3.6 (1.2)

3.1 (0.9)

10.4 (1.5)

0.9 (0.4)

3.1 (1.1)

13.1 (1.9)

1.8 (0.6)

2,688  10.5 (3.1)

19.7 (3.8)

57,470  11.1 (1.5)

20.5 (1.7)

4.2 (0.9)

7.5 (1.7)

12.4 (2.2)

1.7 (0.8)

6.8 (1.9)

15.9 (2.9)

2.0 (0.9)

6.2 (1.3)

15.4 (1.9)

2.7 (0.9)

6.9 (2.5)

23.5 (3.8)

5.5 (2.3)

33,594  10.4 (2.4)

16.0 (2.5)

4.1 (2.0)

5.6 (1.9)

14.5 (3.1)

2.6 (1.3)

8.5 (1.8)

15.9 (2.5)

2.4 (1.0)

4.2 (0.6)

10.5 (0.8)

1.0 (0.3)

7.4 (2.0)

10.6 (2.3)

1.4 (0.7)

1,041  10.2 (3.2)

15.7 (3.9)

2.5 (1.2)

7.3 (2.4)

16.9 (4.2)

0.8 (0.4)

36,787  10.1 (3.0)

18.0 (3.2)

4.7 (1.8)

9.1 (2.1)

12.7 (1.9)

3.6 (1.4)

22,092  11.3 (3.8)

15.4 (3.7)

7.9 (2.4)

12.4 (2.3)

0.7 (0.3)

section_title: Total
paragraphs: 17,750,507  1,029,529  523,286 9,022,176  506,243 8,728,331  5.8 (0.2)    2,272,065  5.8 (0.3)    1,190,927  5.8 (0.3)    1,082,313  12.8 (0.3)    13.2 (0.5)    12.4 (0.5)

1.9 (0.1)  2.0 (0.2)  1.7 (0.2)

Not reported because percentage was estimated with low precision. However, totals include data for  states that are not reported in this table.  For the purposes of this report, we refer to the District of Columbia as a state.  Totals include data for states that are not reported in this table. Numbers of low-income uninsured  adults in expansion and non-expansion states with a given type of behavioral health condition may  not sum to the total because the percentages used to calculate these numbers were rounded.

section_title: Appendix II: State-Reported Information on Effects of Medicaid Expansion on State Behavioral Health Agency Budgets
subsections: section_title: Connecticut
paragraphs: Connecticut officials reported that the budget for its state behavioral health agency (BHA) was reduced in fiscal  years 2014 and 2015. However, amid concerns about the effects on providers, the BHA absorbed some of these  reductions.

section_title: Kentucky
paragraphs: In fiscal year 2014, the BHA’s budget was reduced by $15.2 million, but the agency absorbed this reduction  rather than decreasing the amount of grant funding for providers for the treatment of uninsured and  underinsured individuals.  In fiscal year 2015, there was a $25.5 million reduction in the BHA’s budget. The BHA used a one-time   $10 million appropriation from the Connecticut legislature plus other sources to limit the reduction in grant  funding for providers to $5.4 million.  Kentucky officials reported that the BHA’s budget was reduced by $9 million in fiscal year 2014. However,  one-time funds allowed the BHA to avoid reducing funding for its contracts with community mental health  centers.  In fiscal year 2015, there was a $21 million decrease in the BHA’s budget, which was taken from contracts  with community mental health centers.

section_title: Maryland
paragraphs: Maryland officials reported that the state has not reduced state general fund support for its BHA due to the  expansion of Medicaid.

section_title: Michigan
paragraphs: Michigan officials reported that the state reduced the budget for its state BHA due to the Medicaid expansion, but  then added some funds based on concerns about certain populations that remain ineligible for Medicaid.

Michigan officials reported that state general revenue contributions to its BHA were reduced by $116 million  from fiscal year 2013 to fiscal year 2015 (from $1.153 billion in fiscal year 2013 to $1.037 billion for fiscal  year 2015).

Michigan officials reported that their legislature had appropriated an additional $25 million for fiscal year  2015 to address the needs of individuals ineligible for Medicaid, such as individuals younger than 64 enrolled  in Medicare based on a disability and commercially insured children.

section_title: Nevada
paragraphs: Nevada officials reported that the state reduced the budget for its BHA, but used one-time funds to ease the  transition from state funding to Medicaid reimbursement for substance use providers in fiscal year 2014.

Nevada officials reported a reduction of $33 million in the BHA’s budget in fiscal years 2014 and 2015.

Nevada officials said one-time funds totaling about $690,000 were used in fiscal year 2014 for substance  use service providers to maintain services during the transition from state funding to Medicaid  reimbursement.

section_title: West Virginia
paragraphs: West Virginia officials reported that its charity care fund, which reimburses its network of comprehensive  community behavioral health centers for the care of the uninsured, was funded at about $15.4 million per  year in fiscal years 2013, 2014, and 2015.

Officials said that the governor’s fiscal year 2016 budget had recommended a $3 million reduction in the  charity care fund due to Medicaid expansion.

section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, William Black, Assistant Director;  Manuel Buentello; Hannah Locke; Drew Long; Hannah Marston Minter;  and Emily Wilson made key contributions to this report.


Question-summary annotations: questions: question: How were behavioral health and physical health benefits managed differently within states that expanded Medicaid?
answer: Six selected states that expanded Medicaid generally managed behavioral health and physical health benefits separately for newly eligible enrollees, and state officials reported increased availability of behavioral health treatment, although some access concerns continue. Four of the six selected states explicitly chose separate contractual arrangements for behavioral health and physical benefits.
child_questions: question: What did officials say Medicaid enrollment?
answer: Officials from all six selected states said that enrollment in Medicaid increased the availability of behavioral health treatment for newly eligible enrollees.

question: What concerns remain regarding the expansion of Medicaid within these states?
answer: Officials also reported some ongoing access concerns, such as workforce shortages.

questions: question: What did GAO obtain from the Substance Abuse and Mental Health Services Administration?
answer: GAO obtained estimates of low-income adults who may have a behavioral health condition from the Substance Abuse and Mental Health Services Administration.

question: How did GAO select the states for study?
answer: GAO also selected four non-expansion and six expansion states based on, among other criteria, geographic region and adult Medicaid enrollment.
child_questions: question: From these states, what did GAO review?
answer: GAO reviewed documents from all selected states, and interviewed state Medicaid and BHA officials to understand how uninsured and Medicaid-enrolled adults receive behavioral health treatment.
child_questions: question: How did the Department of Health and Human Services help GAO with the report?
answer: The Department of Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate.