HHS, CMS: New Policy Allows Medicaid, CHIP Plans to Reimburse Specialists Directly for Consultations

The US Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), announced a new policy to expand access to specialty consultations for beneficiaries enrolled in state Medicaid and Children’s Health Insurance Program (CHIP) plans.

According to a CMS press release, the policy will permit Medicaid and CHIP plans to pay specialty providers directly for interprofessional consultations, eliminating the need to coordinate payment through additional paperwork. For instance, if a pediatrician seeks advice from a specialty behavioral health care provider, both providers can be reimbursed directly for the patient’s care, even if the patient did not attend an in-person appointment with the specialist.

The policy is intended to link routine care with specialty care and bolster patient access to providers with specialized knowledge, the press release said.

Of particular concern is members’ access to specialty care for behavioral health needs and substance use disorders, the press release said. More than half of adults with mental illnesses did not receive care in 2019, and rates are worse among underserved communities.

“With today’s action, more families will be able to access the specialty care they need­—including specialty care for children and adults with mental health needs,” said HHS Secretary Xavier Becerra.

Additionally, Medicaid and CHIP beneficiaries often experience higher rates of chronic disease. Expanded access to specialty services could improve outcomes for those with complex conditions, the press release said.

“Now, care for people who have complex health concerns with Medicaid or CHIP coverage can be informed by expert insights faster—reducing wait times and administrative paperwork, and increasing the prospect of better health,” said CMS Administrator Chiquita Brooks-LaSure.

Through the new policy, Medicaid and CHIP plans will have more flexibility to develop reimbursement models for consulting providers. Medicare has had a similar policy in place since 2019.

Reference:
Centers for Medicare & Medicaid Services. HHS expands access to essential specialty care for millions of Medicaid and CHIP beneficiaries. News release. January 5, 2023. Accessed January 6, 2023. https://www.cms.gov/newsroom/press-releases/hhs-expands-access-essential-specialty-care-millions-medicaid-and-chip-beneficiaries