As mental health coverage expands, providers not always there

At the start of the year, before the state’s health insurance exchange was enrolling people in earnest, California rolled out a huge new addition to its Medicaid benefits.

Following the Affordable Care Act’s passage, Medi-Cal, the state’s Medicaid program, expanded coverage to those with mild and moderate mental health problems. The benefits previously were limited to very select groups and the most severely ill patients.

To deliver the new benefits, managed care plans have been charged with pulling together “adequate” networks of mental health providers in every county, from psychologists and psychiatrists to social workers and marriage and family therapists.

Complete provider networks must be submitted to the state by the end of next month, according to the Department of Health Care Services. But despite assurances from the state and managed care organizations that networks will be robust enough to meet the needs of nearly 11.5 million beneficiaries, some caregivers see a different reality.

“The [provider] lists are inadequate for the need,” said Christopher Reilly, director of behavioral services at Clinica Sierra Vista, the third-largest federally qualified health center (FQHC) in the nation. “It’s a nightmare in Kern County,” Reilly said. “We are short providers all the time.”

Clinica Sierra Vista provides services in Kern County, a rural region whose Medi-Cal plans are handled in part by Health Net, one of the nation’s largest managed care companies. The insurer coordinates a portion of Sierra Vista’s behavioral health referrals, and insists it’s ready to meet rising demand.

“We had our behavioral health network in place and ready to go on January 1,” said Health Net spokesman Brad Kieffer.

According to Kieffer, Health Net is leaning on its existing commercial network to provide care for patients on Medi-Cal plans in its service areas. “We did go through these providers first and ask if they would take Medi-Cal patients and the majority of them did,” Kieffer said. He said the insurance provider’s mental health network is “strong,” but also pointed out that Health Net is still recruiting providers where needed.

Reilly of Clinica Sierra Vista is the first to point out that rural areas face greater challenges in attracting and retaining health care providers. However, he argues that the state could make one simple change to improve access to care for all Medi-Cal patients, regardless of region: Let marriage and family therapists practice at federally qualified health centers and bill Medi-Cal.

“We have 29 community health centers, and I run behavioral health out of two of those centers,” Reilly said. “If I could get marriage and family therapists, I could get behavioral health workers in 16 of those 29 clinics.”

According to the California HealthCare Foundation, state law has historically prohibited marriage and family therapists from serving as Medi-Cal providers. Only recently has this sector of the mental health care workforce – the largest segment in California by far – been reimbursed by Medi-Cal.

The twist? Marriage and family therapists must work in private practice, not in FQHCs, where the majority of Medi-Cal beneficiaries will be seen.

That leaves clinics like Sierra Vista struggling to meet the behavioral health needs of patients.

“The ACA caused a wonderful change in the accessibility to mental health care for Medi-Cal beneficiaries long overdue,” said Reilly. “Now we have to build the infrastructure up to meet that challenge … That’s the hard part.”

Starting in 2014, Medi-Cal beneficiaries on managed care plans gained coverage for individual and group therapy, psychiatric consultations, outpatient services for monitoring drug therapy, and outpatient lab work.

Medi-Cal primary care doctors also gained the ability to refer patients with non-severe conditions to licensed mental health professionals.

The expansion in coverage is unprecedented, but it’s still too soon to tell just how meaningful the new benefits will be for Medicaid patients. A number of experts have echoed Reilly’s concern that there aren’t enough mental health professionals to meet the rising demand for care.

With nearly one in three Californians covered by Medi-Cal, the demand for mental health providers is greater than ever before.

This blog post is the second in our series on mental health and substance use disorder coverage under the Affordable Care Act. Read the first story – a primer on the changes and expansions in benefits – here.

Photo by R via Flickr.