Ensuring Access to Behavioral Health Providers

Surveys and studies have documented that people seeking in-network care for behavioral health conditions encounter serious access problems. This longstanding issue has been exacerbated by an increasing need for these services and shortages of behavioral health providers, particularly in rural areas. Addressing these challenges requires a multipronged approach that includes bolstering provider capacity while also ensuring that the providers who are available are part of plan networks. Indeed, a key barrier to access is the large share of available providers who don’t participate in any network. To improve access and help people get the care they need, state and federal policymakers could begin by creating strong standards for behavioral health networks and ensuring plans are constructing their provider networks in ways that meet federal standards for covering mental health care on par with other care.

Federal Standards Set a Floor

The Affordable Care Act (ACA) sets minimum provider network standards that all marketplace plans must meet to guarantee access to covered services, including behavioral health. Beginning in 2023, federal regulators strengthened standards for plans offered on HealthCare.gov by requiring them to satisfy numerical measures of access — maximum time or distance to travel to an appointment, for example — for certain providers. In addition, those standards were extended to a small subset of behavioral health providers. Recently, federal regulators proposed that these standards should become minimum requirements for all marketplace plans (including those sold through the state-run marketplaces), with states still able to establish rules that do more to protect consumers.

States Have Adopted More Stringent Measures of Network Sufficiency

Some states already have gone further than the federal standards, for example, by setting quantitative standards for a broader range of behavioral health providers. For example, Maryland sets limits on time and distance to travel to certain behavioral health providers and requires wait times for nonurgent behavioral health care appointments to be shorter than those for nonurgent primary and specialty care. Additionally, insurers must conduct quarterly audits to determine whether they are meeting quantitative access standards and carry out twice-yearly surveys of providers to monitor wait times.

Other states use measures to ensure access to particular services rather than to providers. New Hampshire sets strict time and distance standards for core behavioral health services, including alcohol use assessment and detox and behavioral health counseling. The state also requires shorter appointment wait times for behavioral health services than for other medical services.

States Are Incorporating Mental Health Parity Protections into Network Standards

Federal mental health parity requirements prohibit plans from imposing greater limits on behavioral health care than they do other services. This means, among other things, that insurers can’t make it harder to access in-network behavioral health providers than it is to access other types of providers. Under these rules, a plan’s approach to determining behavioral health provider reimbursement and criteria for providers seeking to participate in a plan’s network cannot be less favorable than the approach used for other providers.

Yet while network adequacy standards traditionally have not incorporated these mental health parity protections, recent state action is changing that. Illinois’s network adequacy rules require insurers to comply with parity rules when they develop their networks and also adhere to time and distance and appointment wait time standards. New Mexico goes further by requiring insurers to show they have met parity requirements for reimbursement rates and credentialing criteria in constructing their networks. The standards also require insurers to “undertake all efforts” to meet network adequacy standards, including by increasing provider reimbursement rates.

Oversight Plays an Important Role

Even with strong network adequacy standards, access problems may remain. Given workforce shortages, regulators will need to make certain that insurers have done all they can to contract with available but out-of-network providers to meet access standards. Data on out-of-network use and provider reimbursement rates can help identify access problems and potential solutions. Oregon requires insurers to report annually on mental health treatment barriers, including reimbursement rates for behavioral health providers compared with those for other providers. Federal regulators are proposing to require health plans to collect and evaluate data on out-of-network use and provider reimbursement rates to demonstrate equal treatment of behavioral health providers and other medical providers when constructing their networks.

Looking Ahead

Improving access to behavioral health providers to meet a growing need will require multiple policy responses. One known problem, workforce shortages, will take a substantial investment of time and money to resolve. Federal policymakers can take immediate steps to strengthen behavioral health networks: first, by finalizing the minimum standards for all marketplace plans, and then by setting numerical access standards that reflect geographic differences in states and that address a full range of behavioral health providers and services. Yet even with a stronger federal floor, states can move ahead with their own policies to better protect consumers. This includes requiring insurers to report additional data to help assess whether specific approaches translate to adequate access for patients who need behavioral health services.