In 1999 58% of products contracted with MBHOs () and specialty contracting remained the most common arrangement in 2003 with increasing prevalence to 72%. This increase was driven by POS and PPO products moving from internal arrangements to specialty contracting. Specialty contracting remained above 80% among HMOs; however there was a small increase in the use of internal arrangements between 1999 and 2003.
Changes in Contracting Arrangements for Behavioral Health Services by Product Type, 1999 to 2003
Most MH/SA treatment services were offered by more than 90% of products in 2003 regardless of contracting arrangement (), although residential treatment was covered less frequently than other services. The picture was similar for 1999 (data not shown). Among all services, outpatient methadone maintenance was least likely to be covered.
Coverage of Mental Health and Substance Abuse Services, by Contracting Arrangement, 2003
Products with internal arrangements were less likely to cover some services than products with specialty contracting. Residential substance abuse rehabilitation services were covered by 52% of products with internal arrangements versus 94% of products with specialty contracting. Outpatient methadone maintenance was offered by 84% of products with comprehensive contracts, 68% of products with specialty contracts and 36% of products with internal arrangements. Residential mental health treatment was covered by 89% of products with specialty contracting, but only 42% of products with internal arrangements.
Prior authorization was required by 80% to 99% of products for inpatient hospitalization; residential treatment, rehabilitation and detoxification; and intensive outpatient MH/SA treatment, among products that covered the service (). Prior authorization was less common, but still usually required, for other services.
Requirements for Prior Authorization among Plans Covering Specific Mental Health and Substance Abuse Services
Prior authorization was most frequently employed by products with specialty contracting. For example, in 2003 63% of products with specialty contracts required prior authorization for mental health outpatient counseling, significantly greater than the 15% of comprehensive products that did so. Similarly, for outpatient detoxification in 2003, 61% of products with specialty contracts required prior authorization versus 41% for products with comprehensive contracts and 38% for products with internal arrangements.
Although prior authorization still predominates, there was a significant decrease in required prior authorization for outpatient mental health counseling, outpatient detoxification, and outpatient substance abuse rehabilitation, although there was a small increase in required prior authorization for both mental health and substance abuse intensive outpatient services. These changes were driven primarily by products with specialty contracting, including a reduction in prior authorization for mental health outpatient counseling from 94% to 63%.
reports on requirements for mental health treatment entry; results for substance abuse were almost identical (data not shown). Products typically had no requirements for entry into specialty mental health treatment (41%), or required that either the health plan member or specialty mental health provider contact the plan, structuring this as a choice of how to meet the requirement (40%). Seven percent of products had the sole requirement that members contact the plan, while another 5% mandated solely that the provider must contact the plan.
Requirements for Entry into Specialty Behavioral Health Treatment, 2003
There were significant differences by contracting arrangement. In 2003, products with comprehensive contracts were more likely (65%) to have no requirements for mental health treatment entry versus plans with specialty contracts (37%). Products with specialty contracts more frequently allowed either the member or provider to contact the plan (48% versus 29% of those with comprehensive contracts and 7% of those with internal arrangements). Nearly all products that required enrollees to call their phone center indicated that at least one outpatient visit was always authorized (data not shown). About 25% of plans with internal arrangements had some other type of requirements, with about one third each requiring PCP referral, allowing but not requiring PCP referral as one way to meet treatment entry requirements, or having a combination of mechanisms.
Organization of Pharmacy Benefits
In 2003 54% of products contracted management of pharmacy benefits out to pharmacy benefit managers (PBM) (). Products that carved out behavioral health services to MBHOs were least likely to use PBMs. The vast majority of products used three-tier formularies to manage pharmacy benefits. This technique was used more frequently by products with specialty contracts.
Organization of Pharmacy Benefits, 2003
The way that products used three-tier formularies varied significantly by contracting arrangement. Ten percent or fewer of products with specialty contracts covered all four of the newer antidepressants asked about on tiers 1 or 2, i.e., tiers with the lowest patient cost sharing. This was also true for the antipsychotic and ADHD medications studied. Plans with comprehensive contracting were most likely (70%) to cover all four antidepressants on tiers 1 or 2, while plans with internal arrangements were most likely to cover all five antipsychotics and all three ADHD medications on tiers 1 or 2 (46% and 56% of products, respectively).
The survey identified shifts in the cost-sharing structures employed by plans between 1999 and 2003 for MH/SA and general medical services. includes results for mental health cost sharing; substance abuse results were almost identical (data not shown). Products reduced their use of coinsurance for behavioral health treatment and increased the use of co-payments. This is related to the increase in specialty contracting; MBHOs typically use co-payments for behavioral health visits, irrespective of whether the product is an HMO where co-payments are most common or a PPO where coinsurance predominates for general health care (data not shown). In contrast, coinsurance for general medical visits became more common, again reflecting the decline in HMOs.
Changes in Cost Sharing for Outpatient Behavioral Health and Medical Visits, 1999 versus 2003
High cost sharing has become more common since 1999 for both behavioral health and general medical services. The proportion of products requiring a higher level of cost sharing (defined as co-payments greater than $20 or coinsurance greater than 20%) increased from 26% to 42% for MH/SA and increased even more substantially for medical care from 4% to 41%. The difference in cost-sharing between medical and behavioral health care has shrunk, but this is due to more health plans falling into the higher cost sharing category for medical care in 2003.