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Medicaid Managed Care Plans and Behavioral Health Carve-ins

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Medicaid is transitioning to Managed Care plans more and more every year. More states are on board than ever before as they aim to reduce the cost of care for beneficiaries. In order to achieve low utilization, states have been discussing new methods of partnering with Managed Care Organizations (MCOs). The rising popularity of risk-sharing and quality incentives are leading more states to “carve-in” behavioral health. 

The Kaiser Family Foundations reports that 39 states have risk-based MCOs as of 2019. That number is only expected to rise as we finish 2021 and enter the next year.

What is Risk Sharing?

Risk sharing in health insurance is growing in popularity. In the healthcare setting, this model enables everyone involved in care (providers, pharmaceutical companies, etc.) to share the associated risk and opportunities when it comes to the complicated world of Medicaid Reimbursements. 

When a managed care organization enters a risk-sharing arrangement, they agree to share profit or losses if aggregate spending goes above or below the threshold in that contract. 

Up until this point, managed care organizations were carved out of risk-bearing arrangements. Now, more states are carving comprehensive behavioral health MCOs into these agreements.

Medicaid and Carve-Out Plans

In 2018, there were only two states that had implemented a carve-in approach to MCO risk-sharing agreements. Just one year later, that number jumped to eleven states entering carve-in plans. According to the National Council for Behavioral Health, 30 states now cover behavioral health services for adults under comprehensive MCO contracts. 

Many reasons were cited in this NCBH report for why states are integrating more comprehensive carve-in behavioral health plans. Some of the main reasons include the following: 

Lowering Costs

Research has shown that patients with behavioral health conditions often encounter higher physical healthcare costs. In an effort to mitigate the overarching cost of services, many states have looked to carve in plans as the best option.

Whole Person Care

As information surfaces and society gains more insight into the field of mental and behavioral health, it has become more apparent that whole-person care needs to be a priority and not just physical medical care. Some states have cited this as a reason to pursue carve-in behavioral health plans. 

The idea behind managed care organizations is that they can offer holistic care to their patients in one place. Total care coordination between medical care and behavioral health care leads to improved outcomes that both lower costs for state Medicaid providers and improves the quality of life for patients.

States Without Carve-In Plans

There are a number of reasons why a state might opt out of comprehensive behavioral health carve-in plans. Regardless of those reasons, this does not mean that their Medicaid policies carve out every single BH service. 

On average, specialty mental health outpatient services are more likely to be carved out. Several states always carve out these services, others depend on the situation that is prompting the need for those services, and others carve out based on statewide data and geographical location. These carve-outs do not usually include substance use disorder services, which are likely to be carved into state plans.

A Quality Billing Partner Can Help Your Behavioral Health Organization Tackle Carve-Outs

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The healthcare industry, as a whole, seems to be transitioning toward comprehensive behavioral health carve-in plans. Providers need to pay close attention to the changes in regulation that happen on a regular basis to figure out where they stand and what they need to do to keep up. While providers may be able to benefit greatly from these changes, actually laying hands on those rewards can be tricky. Logik can improve how providers navigate through changes in regulation and act as their one source of truth when it comes to billing. Schedule a consultation now to learn more about how your practice can maximize reimbursements

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