Across state agencies, people speak different languages. It can be a hindrance to cross-sectoral collaboration between Medicaid and offices of behavioral health, says Lindsey Browning, program director at the National Association of Medicaid Directors. “There’s sometimes a hesitancy, on both sides, to step into each other’s world and get the language wrong,” she notes. In addition, the focus in behavioral health is often on specific programs and initiatives, while in Medicaid, it’s populations and coverage. As states prepare for 988, Browning says bridging the cultural and language gap between Medicaid and behavioral health is a critical component.
Also, Browning points out two other layers of complication—the perception by those in behavioral health that Medicaid is immensely intricate and Medicaid’s lack of resources to prioritize all areas that need attention. “Medicaid directors have so many fires to put out and so few people to put out those fires,” she says. “It can be challenging for them to focus on what’s coming down the pike.”
Throughout the United States, Medicaid’s resources are spread thin as it prepares for the Covid public health emergency to end. The 90-day increment extensions made by Xavier Becerra, the health and human services secretary, have extended vital flexibility for providers, like telehealth. However, once the emergency ends, Medicaid will have to determine whether to expand or roll back these temporary waivers. While taxing, Browning points out this isn’t unfamiliar terrain for Medicaid. “There are known processes to work through those flexibilities and decide what to keep or not,” she says.
What is taking up a lot of time and energy at Medicaid is that soon it will have to do a complete redetermination of eligibility for every single one of its 84 million members. Member redetermination is a process that typically happens annually. However, during the pandemic, people enrolled as of March 18, 2020, or who enrolled during the public health emergency have been able to keep their Medicaid benefits, despite potential changes in circumstances. Members will continue to be covered by Medicaid until after the public health emergency is over.
“The redetermination effort is sucking the capacity and attention of state Medicaid directors because it’s such a complex, unprecedented task,” says Browning. “But we also know that behavioral health needs are increasing.”
State Medicaid agencies are trying to balance the imminent demands of the redetermination process with the imminent need to prepare for 988. The latter is the three-digit number for mental health, substance use, and suicide crisis that telecom companies must direct to the National Suicide Prevention Lifeline by July 16. Most recently, on January 14, Becerra renewed the Covid public health emergency declaration for another 90 days, effective January 16. That means it will be up for renewal in mid-April. At which point, Browning expects Becerra will renew the emergency for another 90-days before declaring the crisis over in mid-July. “That’s not great timing for those thinking about 988,” she says.
Browning points out that a long-standing Medicaid priority has been to build out a more comprehensive approach to behavioral health treatment and integrative care. “Medicaid is the largest payer of behavioral health services in the nation,” she says. Nevertheless, Medicaid directors are less likely to know the nuances of 988. Browning says this creates an opportunity for state behavioral health leaders to bring them up to speed. “That includes talking about the realities of the hotline going live and the capacity needed to answer those calls,” she says, “as well as the infrastructure and capacity needed in the community to respond to those who require in-person care.”
The first step of cross-agency collaboration between Medicaid and behavioral health, notes Browning, is sitting down together to look at and map out the state’s current crisis care system. “In most communities, that involves an existing patchwork of systems and services,” she says. Some states have already done this work, using the Sequential Intercept Model or Stepping Up, which Medicaid and behavioral health partners can build upon. Despite their differences, the two agencies have a common goal: helping people get the care they need. “This helps ground the partnership and can help overcome potential cultural or language differences,” says Browning.
The focus on a shared goal is precisely the approach Virginia’s Department of Medical Assistance Services, the agency that administers Medicaid, and the Department of Behavioral Health and Developmental Services have taken. Last May, assistant commissioner Heather Norton shared with #CrisisTalk that building out mental health community services could only be successful if the two partnered. Otherwise, gaps would remain. Dr. Alyssa Ward, DMAS’ behavioral health clinical director, agreed. She said that while there are often competing priorities in cross-agency collaborations, the partners have focused on the people they support and their vision for services.
As they work together, Medicaid and behavioral health partners will have to bridge differences in approach. Throughout the nation, behavioral health has been shifting to “care first” and “no wrong door,” where crisis facilities accept everyone who comes. However, Medicaid pays a specific provider to deliver a particular service. “Medicaid doesn’t historically operate like a firehouse model, while behavioral health first responds to a person in crisis and figures out who pays on the backend,” says Browning. “That way, they’re not asking a person in crisis, ‘Do you have Blue Cross Blue Shield or Medicaid?’”
This safety net model requires braided and blended funding, including federal grants and sustainability through state telecom fees, Medicaid, Medicare, and private commercial insurers. However, Medicaid and behavioral health partners will have to be creative to determine how Medicaid can take part in a “care first, figure out billing later” approach.
Browning says partners can look at what other states are doing and turn to CMS’ Medicaid guidance on the scope of and payment for community-based mobile crisis intervention services. “Starting April 1, there’s enhanced federal Medicaid funding for states to do mobile crisis,” she says, “which pairs up nicely with 988 soon going live.” Partners can also turn to CMS guidance on other Medicaid initiatives to expand their community-based crisis system, including the revised 2017 substance use disorder-focused section 1115 initiative (“Strategies to Address the Opioid Epidemic”) and the 2018 serious mental illness-serious emotional disturbance initiative. The latter focuses on decreasing psychiatric boarding and hospital readmissions and improving community-based care, care coordination, and crisis stabilization services, including call centers, mobile crisis teams, intensive outpatient services, and acute short-term crisis stabilization.
However, Browning points out that the language in CMS’ Medicaid guidance can be confusing, especially for behavioral health leaders. She hopes CMS and SAMHSA partner together to help state agency partners navigate CMS guidance. “SAMHSA and CMS jointly coming together to talk to Medicaid leaders and behavioral health agency leaders about the guidance would be really helpful,” she says. Each brings to the table their own set of expertise; together, they can address both best practices and funding. “CMS will have answers that SAMHSA can’t answer and vice versa,” says Browning.
For example, SAMHSA can answer questions about evidence-based models, best practices, and delivery structures. While CMS can talk through financing, explaining what Medicaid can and can’t pay for and what states have to report for Medicaid to pay for crisis services, and what policy changes must be made for them to do so. Browning notes SAMHSA can also inform states on how to use additional funding, like block grant dollars, to wrap around Medicaid payments. “To prepare for 988, we have to think creatively about how funding sources can work together,” she says.
“Right now, Medicaid covers one in four people in this country.” “That’s a massive role and opportunity to ensure a quarter of the U.S. population can have their behavioral health needs met.”