Telehealth can be an essential element of facilitating entry to look after Medicaid enrollees, notably the practically 4 in ten enrollees with behavioral well being wants (psychological well being situations and/or substance use dysfunction (SUD)). In the course of the COVID-19 pandemic, states took benefit of broad authority to broaden Medicaid telehealth insurance policies, leading to excessive telehealth utilization throughout populations. Specifically, states report that telehealth has helped keep and broaden entry to behavioral well being care in the course of the pandemic. Certainly, in state fiscal yr (FY) 2022, behavioral well being, particularly psychological well being, remained a prime service class with excessive telehealth utilization amongst Medicaid enrollees. Equally, CMS knowledge signifies that behavioral well being providers delivered by way of telehealth elevated dramatically in the course of the pandemic; this discovering is in keeping with different evaluation of outpatient visits (together with however not restricted to Medicaid sufferers). Nonetheless, CMS additionally notes that this improve was not sufficient to completely offset the decline within the price of in-person utilization of psychological well being outpatient providers.
Given ongoing supplier workforce challenges that current obstacles to enrollees’ entry to behavioral well being care, Medicaid telehealth coverage might proceed to function an essential software 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 concern steerage 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 providers, and digital peer psychological well being helps. Sooner or later, Congress may move extra laws prompt in a Senate Finance Committee draft on psychological well being and telehealth.
In opposition to 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 providers. These questions have 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 diverse by query. This concern 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 look at wanting 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, using telehealth in Medicaid was changing into extra widespread; particularly, most states provided some protection of behavioral well being providers delivered by way of telehealth, and the vast majority of telehealth utilization was for behavioral well being providers and prescriptions. Nonetheless, Medicaid insurance policies concerning allowable providers, suppliers, and originating websites diverse broadly, and telehealth fee insurance policies have been unclear in lots of states. To extend well being care entry and restrict threat of viral publicity in the course of the pandemic, all 50 states and DC expanded protection and/or entry to telehealth providers in Medicaid. We requested states to point particular behavioral well being Medicaid coverage actions taken to broaden telehealth in response to COVID-19 and any applied or deliberate adjustments to those insurance policies.
Almost all responding states took not less than one specified Medicaid coverage motion to broaden entry to behavioral well being care by way of telehealth (Determine 1). States mostly reported including audio-only protection of behavioral well being providers, which may also help facilitate entry to care, particularly in rural areas with broadband entry challenges and for older populations who might wrestle to make use of audiovisual expertise. Additionally, practically all states reported increasing behavioral well being providers allowed to be delivered by way of telehealth, reminiscent of to newly permit telehealth supply of group remedy or medication-assisted remedy (MAT). Many states famous that just about all behavioral well being providers have been eligible for telehealth supply in the course of the pandemic. Lastly, most states reported increasing the supplier sorts that could be reimbursed for telehealth supply of behavioral well being providers, reminiscent of to permit specialists with completely 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 in the course of the pandemic.
As of July 2022, states have been extra prone to permit audio-only protection of behavioral well being providers in comparison with different providers. As reported on KFF’s 2022 Medicaid price range survey, practically 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 (not less than generally) throughout service classes, with psychological well being and SUD providers probably the most steadily coated classes (Determine 2).
Many states reported completely adopting some or all of those behavioral well being Medicaid telehealth coverage expansions. According to responses to KFF’s 2022 Medicaid price range survey, many states reported everlasting (i.e. non-emergency) adoption of telehealth coverage expansions that have been initially enacted in the course of the pandemic on a short lived foundation. Specifically, states steadily famous that every one or most expansions of behavioral well being suppliers and/or providers allowed for telehealth could 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 might restrict protection of audio-only telehealth for behavioral well being providers, in keeping with issues in regards to 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 raised perceive the impacts of behavioral well being telehealth coverage adjustments in the course of the pandemic, we requested states to point whether or not they monitor behavioral well being telehealth utilization in Medicaid and, if that’s the case, to report utilization tendencies by geography, demographics, and different components.
Almost all responding states monitored utilization of behavioral well being providers 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 might 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 components.
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, reminiscent of:
- Geographic tendencies, with states mostly reporting notably excessive behavioral well being telehealth utilization in rural areas in comparison with city areas. Telehealth could possibly be an essential software for facilitating entry to behavioral well being look after Medicaid enrollees in rural areas with fewer supplier and hospital assets.
- Demographic tendencies, which have 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) have been almost 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 shade. A small variety of states reported that feminine enrollees have been extra prone to make the most of telehealth in comparison with male enrollees.
- Temporal tendencies, with states steadily 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 adjustments, reminiscent of to additional broaden or to restrict telehealth flexibilities, might 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 providers.
The tendencies summarized above are usually in keeping 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 providers in comparison with SUD providers (this pattern seemingly displays the upper prevalence of psychological well being situations in comparison with SUD situations amongst Medicaid enrollees). Just a few states reported that demographic utilization tendencies diverse by service or supplier kind. For instance, New York indicated that feminine enrollees have been extra seemingly than male enrollees to obtain psychological and psychiatric providers by way of telehealth, however that male enrollees have been extra prone to obtain SUD providers by way of telehealth. Colorado reported that utilization tendencies by race/ethnicity have 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 numerous populations.
What are key points to look at wanting forward?
Key points which will affect states’ future behavioral well being Medicaid telehealth coverage choices embody evaluation of utilization and different knowledge in addition to federal steerage:
- Knowledge and high quality: As states proceed and broaden their monitoring of behavioral well being telehealth utilization, the outcomes of those analyses might present info that may inform coverage choices. Additionally, the Authorities Accountability Workplace (GAO) has really useful that CMS gather info to evaluate the impression of telehealth on high quality of look after Medicaid enrollees, and most states report questions and/or issues in regards to the high quality of providers delivered by way of telehealth that could be addressed via ongoing knowledge evaluation.
- Federal steerage and laws: States additionally report waiting for additional steerage from the federal authorities associated to Medicaid telehealth insurance policies. The Bipartisan Safer Communities Act signed into regulation in June 2022 directs CMS to concern steerage to states on choices and greatest practices for increasing entry to telehealth in Medicaid, together with methods for evaluating the impression of telehealth on high quality and outcomes. CMS should concern this steerage by the tip of 2023. The Consolidated Appropriations Act handed in December 2022 approved extra telehealth provisions, reminiscent of necessities for Medicaid supplier directories to incorporate info on telehealth protection and for CMS to concern steerage on how states can use telehealth to ship disaster response providers. The Act additionally approved grants for nonprofits to broaden and enhance digital peer psychological well being help providers, in addition to different non-Medicaid telehealth provisions (reminiscent of 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 Could 2022 as a part of a collection of drafts related to its psychological well being care initiative. Wanting forward, Congress may take up extra insurance policies prompt within the draft, reminiscent of to require public consciousness campaigns on the supply of behavioral well being telehealth protection.
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 steerage—could also be an essential element of sustaining entry to behavioral well being look after enrollees.
This work was supported partly by Effectively Being Belief. KFF maintains full editorial management over all of its coverage evaluation, polling, and journalism actions.
This transient attracts on work completed underneath contract with Well being Administration Associates (HMA) consultants Angela Bergefurd, Gina Eckart, Kathleen Gifford, Roxanne Kennedy, Gina Lasky, and Lauren Niles.