Advancing Medicaid Mental Healthcare in the Colorado General Assembly
2023 Medicaid Behavioral Health Workforce Solutions
2022 Medicaid Behavioral Health Workforce Solutions
COMBINE, Colorado Medicaid Behavioral Healthcare Network, organizes contracted Medicaid counselors, social workers, and clinic directors. Our members provide statewide frontline care for outpatient counseling and are informed by participation through RAE contracts with:
United Healthcare (Rocky Mtn HP, Ft Collins and Western counties)
Anthem/Elevance (CCHA Boulder/Golden/Colorado Springs)
Anthem/Elevance/Beacon (NE and SE Colorado)
Colorado Access (Denver/Aurora)
Attracting, training, and keeping skilled workers.
Title 25.5 Medicaid covers over a million Coloradans. Depression, anxiety, and PTSD are at epidemic proportions. The 17 Community Mental Health Centers cannot meet the need without contracted Medicaid clinics and counselors.
As stigma decreases and demand increases, the private counseling market is thriving, where fees are higher than Medicaid reimbursement, and paperwork is minimal. Providers are leaving the network as conditions are variable and administrative costs increase.
The solution is a supported workforce.
While 90% of expansion population care is funded by the feds, money is not the whole story. Counselors want predictability and clarity from the RAEs, from HCPF, and from the legislators who oversee the public health system.
This packet offers eight solutions to the workforce challenge that are practical, work with the RAE framework, and are fiscally prudent: Prior Authorization Guardrails, Regulated Clawbacks, Parity Governance, Pre-Licensure Apprenticeships, Contracting Timelines, Continuity of Care, Network Adequacy Reports and Ratios, and Rate Setting Parity.
New prior authorization programs for outpatient counseling are confounding providers and cause more provider exodus.
Extending HB 19-1211 to Title 25.5 (Medicaid) could provide for some regulation of prior authorization:
Readily available clinically based clinical criteria.
Reporting of approval and denials.
Timelines for decisions (5 days for non-urgent care) and appeals.
Ensures prior authorizations requests are reviewed by licensed professionals.
Relaxation of PARs for providers with a history of adherence.
Set minimum duration of authorization to 6 months.
“Clawbacks” name the circumstance where Payers decide to reduce current payouts in order to recoup previously paid money.
Payers have a variety of reasons for recoupment, and should have the right to recoup, within a reasonable time period.
While counselors and clinics are limited to filing claims within 120 days, payers routinely contract clawback periods as long as seven years in Colorado.
With exceptions for fraud, federal rules, and some others, these states regulate the clawback period:
Model bills are referenced here: https://www.cga.ct.gov/2007/rpt/2007-R-0205.htm
In brief, “Parity” means decision processes that limit treatment must be similar between medical and behavioral health realms. Parity concerns are not just about benefits. The federal government has included credentialing, prior authorization processes, reimbursement determination processes, and other provider-side concerns as parity issues.
HB19-1269 incorporated federal MHPAEA (Parity) language into Title 25.5 (Medicaid).
Currently that state has no mechanism to hear, adjudicate, and respond to Medicaid parity concerns. HB19-1269 requires HCPF to answer letters from the Behavioral Health Ombudsman. This process contrasts sharply with commercial insurance.
Colorado has rules for parity for Title 10 commercial insurance. See “Regulation 3 CCR 702-4-2-64 - CONCERNING MENTAL HEALTH PARITY IN HEALTH BENEFIT PLANS”
These rules have teeth: “Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspensions or revocation of license.”
Both New York and Massachusetts legislatures have passed parity governance measures with features like: “traditional elements of a compliance program that are specifically focused on behavioral health parity, including designating a compliance officer; implementing board and management reporting; implementing written policies and procedures; creating a mechanism for reporting, identifying and remediating noncompliance; and annual training of all employees, management, board members and agents.”
Title 25.5 could be amended to include parity governance.
Counseling is a highly complex skill, ranging in applicability across populations, and requires lengthy training and mentorship to achieve independent competency.
Counselors in Colorado walk a long path to licensure, including 2 or more years of graduate coursework, 1 year of professional internship, and then a minimum of 2 years practicing under supervision, along with nationally recognized exams.
This pre-licensure phase of early career therapists is actually longer than what’s required of medical doctors, who can be licensed to practice independently in Colorado one year after graduation.
Short of importing licensed providers from out of state, reimbursed supervised pre-licensure counseling is the only way the workforce can grow. Early career counselors want opportunities to work, and want diverse, competent supervision.
Currently Colorado carriers support supervised pre-licensure counseling variably, which creates a bottleneck on service.
Some commercial carriers reimburse for supervised pre-licensure work. All of the RAEs will cover services provided by supervised therapists.
Colorado could require all carriers and managed care organizations under both Title 10 and Title 25.5 to reimburse for supervised pre-licensure work.
This session saw the introduction of SB21-126, which regulates credentialing and contracting time for physicians. These excellent rules however only apply to physicians contracting with carriers regulated by Title 10, the commercial carriers. This leaves behavioral health care providers in the commercial space, along with both medical and behavioral health care providers on the Medicaid side, without these valuable protections.
Medicaid counselors have routinely experienced delays in initiating treatment as long as a year while contracting with HCPF and the RAEs. Reducing contracting time will help recruitment as providers are easily dissuaded from participating by long waits on the front end.
SB21-126 could be a model for a bill that would extend protections beyond commercial contracts for physicians.
On the path toward independent practice, and even after licensure, there are several points where continuity of care is impacted because of administrative processes. Smoothing out these transitions would decrease provider exits and client abandonment.
For Title 25.5 Medicaid participation, counselors need licensure, insurance, and credentials with both HCPF (‘validation’) and RAE contracts. Pre-licensure supervised work is typically billed through the credentialed supervisor.
Essentially there are four transitions of concern:
From university internship to graduate licensure candidate
From licensure candidate to licensed professional
From employee at a Center to independent professional
From employee or contractor with one organization to another
Thankfully DORA created a process where all counseling students can receive their LPCC (licensed professional counselor candidate) credential before graduating. This excellent policy assures continuity of care when interns continue working with their caseload after graduation, under supervision.
LPCCs practice as Center workers or under supervision in clinics. During this time, LPCCs gain licensure. Once licensed they can apply for HCPF validation and RAE contracts. The Center or clinic will add the newly licensed person to their RAE contracts. When the counselor changes their employment context, their credentials could be portable, and counselors’ clients could always have the option to continue with the counselor.
Counseling is relational, and most research puts the relationship as the primary factor for efficacy. Medicaid members could be entitled to keep their counselor.
The most important statistic for network adequacy analysis is the count of participating providers. RAE and HCPF network adequacy reports need additional legislated standards including time frames for posting data and requirements to disaggregate the data. For instance, HCPF received Oct-Dec 2020 data on January 31, 2021. That data was finally posted in May of 2021.
The lack of disaggregated data makes necessary comparisons over time impossible. Reports could include Providers for Adults per County and Providers for Children per County, and providers who are accepting new clients.
For example, the only data in the 2020 Oct- Dec RAE 6 (CCHA) report for provider count suggests over 6,000 providers are available to Boulder and Golden members, when only two providers are listed in CCHA’s directory as accepting new child clients.
Accurate, standardized reporting of provider counts is necessary to evaluate impacts of changes to policy. For instance, Medicaid counselors contracted with CCHA saw a 20% cut to the rate for all services January 2020. Between October 2019 and October 2020, contracted provider participation dropped by a third from 364 to 240. This is only known because of the quarterly reports , which no longer give county level data.
The current provider to member ratio of 1:1,800 written into RAE contracts is lower than the lowest state, Alabama, and deserves reform. According to statistics from Mental Health America’s 2020 report
“...in Massachusetts, there is a mental health provider for every 180 residents (1:180), which marks the best ratio in the nation. On the other end of the spectrum is Alabama, which has the nation’s worst ratio at 1,100 residents for every one mental health provider (1:1,100). Texas, West Virginia, Georgia, Arizona, Tennessee, Mississippi and Iowa are the other states that have ratios of 1:700 or worse.”
Colorado could strive for a better Medicaid provider to member ratio.
For rate setting processes to be in compliance with parity, they must be similar between medical and behavioral health domains.
In Colorado, for Medicaid, the rate setting processes are sharply different, which needs correction according to the spirit and letter of parity compliance.
The MPRRAC has set rates for all behavioral health service codes, and Medicaid RAEs are out of parity compliance by using a different process to set rates. Requiring RAEs to reimburse at MMPRAC rates would comply with parity.
Legislation providing for minimum rates would at least reassure the provider community that there is some protection against further rate cuts.
Larger clinics that see real benefits from COMBINE efforts please donate 1/10th of 1% of Medicaid revenue. (e.g. $500 on $500,000)