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DHS Axes Prior Approval for Some Mental Health Treatment

Friday, October 20, 2017  
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October 10, Wisconsin Health News

The state’s Medicaid program won't have to give prior approval for patients to receive outpatient mental health and substance abuse treatment in excess of 15 hours or $825 a year, effective at the start of the month.

Under the new policy, Medicaid will also no longer require prior authorization for outpatient mental health and substance abuse assessments in excess of eight hours per year.

The federal government has confirmed the authority of Medicaid programs to use a prior authorization process to evaluate medical necessity, according to a September update from the Department of Health Services. DHS revised its rules to ensure mental health and substance abuse parity is applied for all Wisconsin Medicaid members, the update noted.

Michael Heifetz, state Medicaid director, said that Gov. Scott Walker and the Legislature have focused on providing and improving access to behavioral healthcare in recent years.

“This is really a piece of that larger puzzle, but a very significant one for our providers and our patients and our members,” he said.

Heifetz said that as of last week, the department had received about 7,000 requests for outpatient behavioral healthcare. They approved about 6,000 of them, roughly 82 percent.

“We anticipate it impacting thousands of our members, but it’s difficult to say,” he said. “In some regards, we’d be trying to prove a negative of what prior authorization is doing and I don’t want to do that.”

Heifetz said they’re looking at other changes to improve access to mental healthcare, including requesting the federal government cover residential substance abuse treatment. They’re also looking at updating policy surrounding medication-assisted treatment.

“This is one step in what could be a few more, but we also want to make sure this step is implemented smoothly with our members and providers,” he said.

They also want to measure its impact and are expecting a slight, incremental increase in costs. He said they anticipate saving "money on the backend" if the programs work.

Joanne Alig, Wisconsin Hospital Association senior vice president of policy and research, said that reforming prior authorization requirements was a key recommendation coming from the association’s Medicaid policy work group.

“WHA has long supported reducing regulatory burdens on healthcare providers in a number of areas, including Medicaid,” Alig said in a statement.