Telehealth can be an essential element of facilitating entry to look after Medicaid enrollees, significantly the almost 4 in ten enrollees with behavioral well being wants (psychological well being situations and/or substance use dysfunction (SUD)). Through the COVID-19 pandemic, states took benefit of broad authority to develop Medicaid telehealth insurance policies, leading to excessive telehealth utilization throughout populations. Specifically, states report that telehealth has helped preserve and develop entry to behavioral well being care throughout the pandemic. Certainly, in state fiscal yr (FY) 2022, behavioral well being, particularly psychological well being, remained a high service class with excessive telehealth utilization amongst Medicaid enrollees. Equally, CMS knowledge signifies that behavioral well being companies delivered by way of telehealth elevated dramatically throughout the pandemic; this discovering is in step with different evaluation of outpatient visits (together with however not restricted to Medicaid sufferers). Nonetheless, CMS additionally notes that this enhance was not sufficient to totally offset the decline within the charge of in-person utilization of psychological well being outpatient companies.
Given ongoing supplier workforce challenges that current obstacles to enrollees’ entry to behavioral well being care, Medicaid telehealth coverage could proceed to function an essential device for extending the workforce and facilitating improved entry to behavioral well being care, even past the COVID-19 pandemic. The 2022 Bipartisan Safer Communities Act requires CMS to challenge steering on Medicaid and telehealth by the tip of 2023. The Consolidated Appropriations Act handed in December 2022 approved extra telehealth provisions, together with necessities or funding associated to supplier directories, disaster companies, and digital peer psychological well being helps. Sooner or later, Congress may go extra laws urged in a Senate Finance Committee draft on psychological well being and telehealth.
Towards this backdrop of state and federal coverage exercise, KFF surveyed state Medicaid officers about insurance policies and tendencies associated to telehealth supply of behavioral well being companies. These questions had been a part of KFF’s Behavioral Well being Survey of state Medicaid packages, fielded as a complement to the 22nd annual price range survey of Medicaid officers performed by KFF and Well being Administration Associates (HMA). A complete of 44 states (together with the District of Columbia) responded to the survey, however response charges diversified by query. This challenge transient makes use of this survey knowledge to reply three key questions:
- How have states expanded behavioral well being telehealth coverage in response to COVID-19?
- What tendencies have states noticed in behavioral well being telehealth utilization?
- What are key points to observe trying forward?
How have states expanded behavioral well being telehealth coverage in response to COVID-19?
States have broad authority to cowl telehealth in Medicaid with out federal approval. Previous to the pandemic, the usage of telehealth in Medicaid was turning into extra widespread; particularly, most states provided some protection of behavioral well being companies delivered by way of telehealth, and nearly all of telehealth utilization was for behavioral well being companies and prescriptions. Nonetheless, Medicaid insurance policies concerning allowable companies, suppliers, and originating websites diversified broadly, and telehealth fee insurance policies had been unclear in lots of states. To extend well being care entry and restrict danger of viral publicity throughout the pandemic, all 50 states and DC expanded protection and/or entry to telehealth companies in Medicaid. We requested states to point particular behavioral well being Medicaid coverage actions taken to develop telehealth in response to COVID-19 and any applied or deliberate modifications to those insurance policies.
Practically all responding states took no less than one specified Medicaid coverage motion to develop entry to behavioral well being care by way of telehealth (Determine 1). States mostly reported including audio-only protection of behavioral well being companies, which may also help facilitate entry to care, particularly in rural areas with broadband entry challenges and for older populations who could battle to make use of audiovisual expertise. Additionally, almost all states reported increasing behavioral well being companies allowed to be delivered by way of telehealth, akin to to newly permit telehealth supply of group remedy or medication-assisted remedy (MAT). Many states famous that just about all behavioral well being companies had been eligible for telehealth supply throughout the pandemic. Lastly, most states reported increasing the supplier varieties that could be reimbursed for telehealth supply of behavioral well being companies, akin to to permit specialists with totally different licensure necessities (e.g. marriage and household therapists, dependancy specialists, and peer specialists). A small variety of states famous extra behavioral well being Medicaid coverage actions past these specified; for instance, Washington reporting offering expertise to enrollees and suppliers to enhance entry to behavioral well being care throughout the pandemic.
As of July 2022, states had been extra prone to permit audio-only protection of behavioral well being companies in comparison with different companies. As reported on KFF’s 2022 Medicaid price range survey, almost all states added or expanded audio-only telehealth protection in Medicaid in response to the COVID-19 pandemic. As of July 1, 2022, a majority of states reported offering audio-only protection (no less than typically) throughout service classes, with psychological well being and SUD companies essentially the most regularly coated classes (Determine 2).
Many states reported completely adopting some or all of those behavioral well being Medicaid telehealth coverage expansions. In line with responses to KFF’s 2022 Medicaid price range survey, many states reported everlasting (i.e. non-emergency) adoption of telehealth coverage expansions that had been initially enacted throughout the pandemic on a brief foundation. Specifically, states regularly famous that every one or most expansions of behavioral well being suppliers and/or companies allowed for telehealth can be maintained after the general public well being emergency. Nonetheless, some states additionally reported limiting or including guardrails to pandemic-era behavioral well being telehealth flexibilities. Mostly, states reported that they’d restrict protection of audio-only telehealth for behavioral well being companies, in step with considerations concerning the high quality of audio-only telehealth reported on the price range survey.
What tendencies have states noticed in behavioral well being telehealth utilization?
To higher perceive the impacts of behavioral well being telehealth coverage modifications throughout the pandemic, we requested states to point whether or not they monitor behavioral well being telehealth utilization in Medicaid and, in that case, to report utilization tendencies by geography, demographics, and different elements.
Practically all responding states monitored utilization of behavioral well being companies delivered by way of telehealth in FY 2022 or plan to start doing so in FY 2023 (Determine 3). Telehealth utilization knowledge may also help states assess the impacts of expanded telehealth coverage. These assessments could inform future high quality and different analyses. Some states that already monitor behavioral well being telehealth utilization reported future plans to extend this monitoring and/or to stratify utilization knowledge by extra demographic or different elements.
Many states reported excessive utilization of telehealth for behavioral well being care throughout all or most Medicaid populations, although some states famous utilization tendencies amongst sure subgroups of Medicaid enrollees, akin to:
- Geographic tendencies, with states mostly reporting significantly excessive behavioral well being telehealth utilization in rural areas in comparison with city areas. Telehealth might be an essential device for facilitating entry to behavioral well being look after Medicaid enrollees in rural areas with fewer supplier and hospital assets.
- Demographic tendencies, which had been mostly captured by race/ethnicity and age. These tendencies usually mirror general knowledge indicating that behavioral well being situations are most prevalent amongst younger adults and White individuals. Specifically, some states reported that youthful enrollees (together with youngsters and non-elderly adults) had been most certainly to make the most of telehealth for behavioral well being care. A number of states reported greater telehealth utilization amongst White people in comparison with individuals of coloration. A small variety of states reported that feminine enrollees had been extra prone to make the most of telehealth in comparison with male enrollees.
- Temporal tendencies, with states regularly reporting that behavioral well being telehealth utilization has declined from its peak earlier within the pandemic, however stays excessive in comparison with the pre-pandemic interval. Future coverage modifications, akin to to additional develop or to restrict telehealth flexibilities, could impression ongoing utilization. For instance, South Carolina reported anticipating a rise in behavioral well being telehealth utilization amongst youngsters in FY 2023 as a part of an initiative to extend entry for school-based psychological well being companies.
The tendencies summarized above are usually in step with general Medicaid telehealth utilization tendencies reported on KFF’s 2022 price range survey. Moreover, a number of states reported that telehealth utilization was greater for psychological well being companies in comparison with SUD companies (this development possible displays the upper prevalence of psychological well being situations in comparison with SUD situations amongst Medicaid enrollees). A number of states reported that demographic utilization tendencies diversified by service or supplier kind. For instance, New York indicated that feminine enrollees had been extra possible than male enrollees to obtain psychological and psychiatric companies by way of telehealth, however that male enrollees had been extra prone to obtain SUD companies by way of telehealth. Colorado reported that utilization tendencies by race/ethnicity had been associated to supplier kind, as group psychological well being facilities are likelier to make use of telehealth and are additionally likelier to serve extra racially/ethnically various populations.
What are key points to observe trying forward?
Key points that will affect states’ future behavioral well being Medicaid telehealth coverage selections embrace evaluation of utilization and different knowledge in addition to federal steering:
- Knowledge and high quality: As states proceed and develop their monitoring of behavioral well being telehealth utilization, the outcomes of those analyses could present info that may inform coverage selections. Additionally, the Authorities Accountability Workplace (GAO) has really useful that CMS accumulate info to evaluate the impression of telehealth on high quality of look after Medicaid enrollees, and most states report questions and/or considerations concerning the high quality of companies delivered by way of telehealth that could be addressed by means of ongoing knowledge evaluation.
- Federal steering and laws: States additionally report expecting additional steering from the federal authorities associated to Medicaid telehealth insurance policies. The Bipartisan Safer Communities Act signed into legislation in June 2022 directs CMS to challenge steering to states on choices and finest practices for increasing entry to telehealth in Medicaid, together with methods for evaluating the impression of telehealth on high quality and outcomes. CMS should challenge this steering by the tip of 2023. The Consolidated Appropriations Act handed in December 2022 approved extra telehealth provisions, akin to necessities for Medicaid supplier directories to incorporate info on telehealth protection and for CMS to challenge steering on how states can use telehealth to ship disaster response companies. The Act additionally approved grants for nonprofits to develop and enhance digital peer psychological well being help companies, in addition to different non-Medicaid telehealth provisions (akin to telehealth insurance policies for veterans and for Medicare enrollees). A number of of those federal Medicaid telehealth insurance policies handed in 2022 comply with from a Senate Finance Committee dialogue draft on guaranteeing entry to telehealth, launched by the Committee in Might 2022 as a part of a sequence of drafts related to its psychological well being care initiative. Trying forward, Congress may take up extra insurance policies urged within the draft, akin to to require public conscious
As states emerge from the COVID-19 pandemic and grapple with behavioral well being workforce shortages, the continuation of expanded telehealth coverage—knowledgeable by knowledge evaluation and federal steering—could also be an essential element of sustaining entry to behavioral well being look after enrollees.
This work was supported partially by Properly Being Belief. KFF maintains full editorial management over all of its coverage evaluation, polling, and journalism actions.
This transient attracts on work finished beneath contract with Well being Administration Associates (HMA) consultants Angela Bergefurd, Gina Eckart, Kathleen Gifford, Roxanne Kennedy, Gina Lasky, and Lauren Niles.
