This article is part of the HHCN+ membership
Providing behavioral health services in patients' homes can make services more effective and make patients more comfortable, but the already complicated regulatory and reimbursement situation for these services is set to be even more challenging.
With the Senate considering cutting large portions of Medicaid, there is a greater possibility that states will cut funding for home and community-based services. This puts home behavioral healthcare reimbursement at even greater risk. Advocates of home care are pushing to wipe out regulatory reforms to protect access and ensure critical services are meeting increasing demand.
“Behavioral health needs are escalating nationwide, particularly between Medicaid and dual-qualified groups, but the reimbursement and policy frameworks do not meet the demands of working from home.”
Based in Medford, Massachusetts, Innovive offers home health services to patients with multiple medical comorbidities with behavioral health conditions. Innovive offers skilled nursing designed to support mental and physical health, wounds and behavioral health and coordination of care.
Each year, one in five Americans experience behavioral health. Among Medicare beneficiaries, the rates are even higher, affecting one in four.
Despite how common behavioral health concerns are, even large home health institutions may not be fully equipped to address the behavioral health needs of patients. In a recent HHCN survey, none of the five respondents reported that they are 100% confident that the organization can connect or provide the behavioral health care they need to have to connect or provide patients with the behavioral health care they need.
Home-based healthcare availability has fluctuated over time, according to Dallas Star, regional director of Behavioral Health at Bayada Home Health Care. Currently, the availability of Applied Behavior Analysis (ABA) services is shifting in favour of intraclinical care.
“Clinic-based care offers unique benefits, but it is important to meet the needs of diverse clients, as supported by standards like the Autism Council (CASP),” Starr said. “Organisations like Bayada aim to close this gap by providing services in a variety of settings, including homes, communities, schools, clinics, and more, to provide care wherever their clients need it most.”
Pensau Kentownship, New Jersey is a nonprofit home health provider that provides skilled and skilled home health services for adults, pediatric home health, hospice home care, home rehabilitation and assisted care.
The transition to in-clinical behavioral healthcare severely limits access to care for people with deep autism who need home-based care and care in a residential setting.
Must follow regulations and policies of home providers of behavioral health
Organizations that provide behavioral healthcare must comply with both federal regulations and state-specific policies. This can vary widely from state to state.
For example, Palumbo says innovations operate in Massachusetts, Colorado and Iowa, with each state having a “clear” regulatory environment. To maintain compliance, Innovive maintains localized, centralized compliance and clinical teams from each state.
Some of the innovative regulations require compliance with the inclusion of CMS conditions, state licensing rules, Medicaid regulations, and privacy standards under HIPAA and 42 CFR Part 2.
According to STAR, some states have additional requirements for home environments, such as electronic visit verification (EFF).
“Inconsistent across the state's Medicaid program complicates the operation of providers serving multiple states,” Starr said.
Regulations vary not only by state-by-state variations, but also by payer. Medicaid coverage for ABA Care is usually limited to individuals under the age of 21, Starr said, and Medicare does not currently cover ABA services and is restricting access to care for these beneficiaries.
The future of home behavioural health
Funding for home and community-based services for people with mental illnesses in Medicaid is “lagging behind,” published by Ellen Breslin, principal of the national health care consulting firm Health Management Associates (HMA), according to an article published by Dennis Heffey, a researcher and policy analyst at the Boston Disability Policy Consortium.
Funding for home and community-based behavioral health services is delayed due to institutional bias, HEPHY told HHCN.
“Institutional bias requires states to fund institutionalization, whether nursing homes or other institutions, but home and community-based services are optional, even if they are cheap,” Heaphy says. “In most cases, states still choose to institutionalize because they are basically simple or easy.”
According to Medicaid and Tip Payment and Access Commission (MACPAC) data, 28 exemptions and authorities are used to fund home and community-based services for people with mental illness or severe emotional disorders, while three to four times more states are using these exemptions for other groups.
Already underfunded, behavioral healthcare home providers are increasing pressure from a tenuous regulatory environment.
“The current secretary of the Department of Health regarding proposed Medicaid budget cuts and autism treatment has sparked concerns among health care providers,” Starr said. “Budget cuts can have a serious impact on our ability to attract and retain qualified staff for ABA services, which are already thinning. Paying fewer people to these skilled people could be forced to pay more in other industries, such as retail.
According to Heaphy, potential Medicaid budget cuts will not affect institutional care, but home and community-based services will suffer.
“The challenge (states) currently facing under the new administration is that states face significant cuts in their Medicaid budget,” Heafy said. “They cannot cut care budgets for their facilities, so they need to cut HCBS budgets. We are concerned that this could disproportionately affect people with mental health diagnosis or substance use disorders due to discriminatory practices and lack of understanding of population needs.”
Advocacy initiatives to improve access
To ensure long-term access to much-needed home-based behavioral health support, providers advocate for higher reimbursement rates and increased provider support. All of this could be driven by the increased adoption of value-based refund arrangements.
Innovive supports policies that promote workforce development for behavioral health professionals in community-based roles, encourages value-based models that explain behavioral health needs and complexity, and ensures parity in psychiatric and health services.
“Policymakers have the opportunity to reconfigure their homes as a treatment environment and viable alternatives to institutional care,” Palumbo said. “By recognizing the full range of care provided at home, including case management and care coordination, future policies can better support patient outcomes, system sustainability, and health equity.”
According to STAR, there is a need for mandatory reimbursement for all essential care adjustment activities and appropriate funding for complex cases involving adults and deep needs, and appropriate funding for adults and people with deep needs.
The wish list of regulatory changes that support access to integrated home behavioral health care includes making telehealth access permanent, removing any restrictions like approved years, and fully funding the services needed for patients with complex needs.
It is also necessary to address the age gap in coverage, Starr said. Medicaid often stops ABA services at age 21, but Medicare generally does not cover ABA services at all and leaves patients through patients who can benefit from these services.
Starr said that services that were made behind the scenes also need a refund.
“Now, our clinicians spend a lot of time caring for other providers (voice therapists, occupational therapists, primary care physicians, etc.) and manage cases, but services are not refundable,” Starr said. “This makes it difficult to truly integrate care and build a strong team around patients. You need unbound code so that you can compensate for all the important tasks they do when you're not in person with the client.”
According to Palumbo, value-based arrangements can help improve access to health care for home behavior, but according to STAR, standardization of behavioral conditions is difficult because each person's goals are unique.
“We want to avoid increasing the risks of people institutionalised value-based care,” Heafy said. “What really matters is that service fees are broken because they are not responsible.
