Jan 9, 2024

As a CCLP policy fellow, Milena helps organize and coordinate public policy development, assisting in coalition-building, community outreach, legislation, litigation, and administrative advocacy.

Recent articles

CCLP’s 2024 legislative wrap-up, part 2

CCLP's 2024 legislative wrap-up focused on expanding access to justice, removing administrative burden, supporting progressive tax and wage policies, preserving affordable communities, and reducing health care costs. Part 2/2.

CCLP’s 2024 legislative wrap-up, part 1

CCLP's 2024 legislative wrap-up focused on expanding access to justice, removing administrative burden, supporting progressive tax and wage policies, preserving affordable communities, and reducing health care costs.

Barriers to behavioral health care: survey responses

by | Jan 9, 2024

In March through May of 2023, CCLP released a mental health survey to Colorado residents. While the survey wasn’t a validated instrument, the answers are anecdotal submissions that provide a window into people’s experience. This article will be reviewing those answers submitted, while keeping the individuals who responded anonymous.

 

Intake appointments

All outpatient behavioral health care starts with an intake appointment, whether it be with a therapist, psychologist, or a behavioral health specialist.  Unfortunately, scheduling this first appointment is often a difficult task for many. In our survey we asked individuals, “How long has it/does it take for you to obtain an intake appointment?” The average response indicated six weeks, but we regularly heard wait times as long as two to three months and in some cases even greater than six months.

In one instance a respondent reported that they were able to get an intake appointment for their child that same month they called — however, two days before the scheduled appointment it was cancelled unexpectedly. This family was told there were no providers available, so a new intake appointment was scheduled for three months later.

In Colorado, each Regional Accountable Entity (RAE), is responsible for contracting and supporting a network of care providers in a managed care plan. Their contracts with the state provide timeliness standards that apply to behavioral health services. Non-urgent intake appointments are to be received by the Medicaid member within seven (7) days according to these contracts.[1] Despite this, based on the feedback CCLP received in the survey, individuals and families are not receiving timely access to care. Without regular oversight and enforcement to ensure these timelines are being met, there will continue to be inequities and barriers in accessing mental and behavioral health care.

Waiting for outpatient care

When forced to wait for outpatient care, individuals and families often go to their local emergency department if they are in crisis. While this may be a necessary move for treatment, emergency departments are often only able to provide medication management for two to three days at most, with no ongoing therapy or counseling services while the individual is being treated. And those on Medicaid sometimes face additional hurdles in the hospital, particularly in proving treatment is medically necessary. One respondent in the survey reported that while in the emergency room seeking a higher level of care, Medicaid denied payment for treatment — even though the person had an official behavioral health diagnosis. The definition of what is medically necessary,[2] which guides what care the Medicaid program will ultimately reimburse, is often open to interpretation, putting the Medicaid member at risk of not getting treatment they need.

One family reported that they were denied by Medicaid for residential treatment even after their child had multiple inpatient hospitalizations and several mental health holds. The doctor who had evaluated the child told the parents it was urgent for the child’s safety that she receive a higher level of care. Despite this, she was denied residential treatment services for two months. After waiting for three months in appealing the denial, she was finally approved for residential services, but now they had to wait for a spot to open up. The family reports that they have been, “on a residential waitlist since January 2023.” And that their “daughter almost died in February.” They were still waiting at the time of the survey. As of this publication date, it is unknown whether their child has started residential treatment.

I wish I could say this is the only family who has had this happen, but in my experience, those who do not meet the strict standards for a mental health hold[3] at the time of assessment in the emergency department often get discharged from the hospital without follow-up care in place. Indeed, others reported in the survey that individuals who are not deemed “sick enough” to quality for inpatient services are the ones who do not receive treatment. A behavioral health provider responded in the survey and said that their patients, “get denied a lot even when [they] are justified for receiving the services.” This is true even for children under 21, who would benefit from an expanded definition of medical necessity.[4]

Care Coordination

Care coordination, as shown, has been severely lacking within our behavioral health system, causing harm and creating gaps for individuals and families in receiving appropriate treatment.[5] CCLP is hopeful that these issues will be better addressed as new statutory provisions begin to go into effect next year with the new Behavioral Health Administration (BHA).[6] For example, the new law will provide a requirement that once a Medicaid patient is put on a mental health hold, the hospital has a responsibility to notify the managed care entity (RAE) of the discharge and need for follow-up care.[7] Additionally, the BHA is required to be notified of the mental health hold if the facility cannot locate an appropriate placement for the patient.[8] Once notified, the BHA will be tasked with supporting the facility in locating an appropriate placement option.

 

It is too soon to tell if these changes will have significant impacts for families like the ones who responded to our survey, but CCLP remains committed to improving access to behavioral health care for individuals and families in Colorado.

 

******

[1] Colorado Department of Health Care Policy & Financing, Health First Colorado Managed Care Contracts, Dec 2023. https://hcpf.colorado.gov/health-first-colorado-managed-care-contracts. See Section 9, Network Development and Access Standards, at 9.4.13.5.2. in the contracts.

[2] 10 CCR 2505-10 § 8.076.1.8.  Medical necessity is defined as a “program good or service . . . that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or development effects of an illness, condition, injury or disability.

[3] CRS §27-65-105. A mental health hold is generally involved only when a person “appears to be an imminent danger to others or to himself or herself or appears to be gravely disabled.”

[4] 10 CCR §2505-10, 8.280.1. Early and Periodic, Screening, Diagnosis and Treatment.

[5] See HEDIS [Healthcare Effectiveness Data and Information Set] Measurement Year 2021 Aggregate Report for Health First Colorado (Colorado’s Medicaid Program), produced by Health Services Advisory Group, Inc., available at  https://hcpf.colorado.gov/sites/hcpf/files/Aggregate%20Report%20for%20Health%20First%20Colorado%202022.pdf.

[6]Kim, Boram, Colorado to Make Numerous Reforms to its Behavioral Health Administration to Address Operational Delays, State of Reform, June 2023. https://stateofreform.com/featured/2023/06/colorado-to-make-numerous-reforms-to-its-behavioral-health-administration-to-address-operational-delays/

[7] CRS §27-65-106.8.d.II. [effective January 1, 2024]

[8] CRS §27-65-106.7.a. [effective January 1, 2024]

Recent articles

CCLP’s 2024 legislative wrap-up, part 2

CCLP's 2024 legislative wrap-up focused on expanding access to justice, removing administrative burden, supporting progressive tax and wage policies, preserving affordable communities, and reducing health care costs. Part 2/2.

CCLP’s 2024 legislative wrap-up, part 1

CCLP's 2024 legislative wrap-up focused on expanding access to justice, removing administrative burden, supporting progressive tax and wage policies, preserving affordable communities, and reducing health care costs.

HEALTH:
HEALTH FIRST COLORADO (MEDICAID)

To maintain health and well-being, people of all ages need access to quality health care that improves outcomes and reduces costs for the community. Health First Colorado, the state's Medicaid program, is public health insurance for low-income Coloradans who qualify. The program is funded jointly by a federal-state partnership and is administered by the Colorado Department of Health Care Policy & Financing.

Benefits of the program include behavioral health, dental services, emergency care, family planning services, hospitalization, laboratory services, maternity care, newborn care, outpatient care, prescription drugs, preventive and wellness services, primary care and rehabilitative services.

In tandem with the Affordable Care Act, Colorado expanded Medicaid eligibility in 2013 - providing hundreds of thousands of adults with incomes less than 133% FPL with health insurance for the first time increasing the health and economic well-being of these Coloradans. Most of the money for newly eligible Medicaid clients has been covered by the federal government, which will gradually decrease its contribution to 90% by 2020.

Other populations eligible for Medicaid include children, who qualify with income up to 142% FPL, pregnant women with household income under 195% FPL, and adults with dependent children with household income under 68% FPL.

Some analyses indicate that Colorado's investment in Medicaid will pay off in the long run by reducing spending on programs for the uninsured.

FOOD SECURITY:
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

Hunger, though often invisible, affects everyone. It impacts people's physical, mental and emotional health and can be a culprit of obesity, depression, acute and chronic illnesses and other preventable medical conditions. Hunger also hinders education and productivity, not only stunting a child's overall well-being and academic achievement, but consuming an adult's ability to be a focused, industrious member of society. Even those who have never worried about having enough food experience the ripple effects of hunger, which seeps into our communities and erodes our state's economy.

Community resources like the Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, exist to ensure that families and individuals can purchase groceries, with the average benefit being about $1.40 per meal, per person.

Funding for SNAP comes from the USDA, but the administrative costs are split between local, state, and federal governments. Yet, the lack of investment in a strong, effective SNAP program impedes Colorado's progress in becoming the healthiest state in the nation and providing a better, brighter future for all. Indeed, Colorado ranks 44th in the nation for access to SNAP and lost out on more than $261 million in grocery sales due to a large access gap in SNAP enrollment.

See the Food Assistance (SNAP) Benefit Calculator to get an estimate of your eligibility for food benefits.

FOOD SECURITY:
SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS AND CHILDREN (WIC)

Every child deserves the nutritional resources needed to get a healthy start on life both inside and outside the mother's womb. In particular, good nutrition and health care is critical for establishing a strong foundation that could affect a child's future physical and mental health, academic achievement and economic productivity. Likewise, the inability to access good nutrition and health care endangers the very integrity of that foundation.

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides federal grants to states for supplemental foods, health care referrals, and nutrition information for low-income pregnant, breastfeeding and non-breastfeeding postpartum women and to infants and children up to age five who are found to be at nutritional risk.

Research has shown that WIC has played an important role in improving birth outcomes and containing health care costs, resulting in longer pregnancies, fewer infant deaths, a greater likelihood of receiving prenatal care, improved infant-feeding practices, and immunization rates

Financial Security:
Colorado Works

In building a foundation for self-sufficiency, some Colorado families need some extra tools to ensure they can weather challenging financial circumstances and obtain basic resources to help them and their communities reach their potential.

Colorado Works is Colorado's Temporary Assistance for Needy Families (TANF) program and provides public assistance to families in need. The Colorado Works program is designed to assist participants in becoming self-sufficient by strengthening the economic and social stability of families. The program provides monthly cash assistance and support services to eligible Colorado families.

The program is primarily funded by a federal block grant to the state. Counties also contribute about 20% of the cost.

EARLY LEARNING:
COLORADO CHILD CARE ASSISTANCE PROGRAM (CCCAP)

Child care is a must for working families. Along with ensuring that parents can work or obtain job skills training to improve their families' economic security, studies show that quality child care improves children's academic performance, career development and health outcomes.

Yet despite these proven benefits, low-income families often struggle with the cost of child care. Colorado ranks among the top 10 most expensive states in the country for center-based child care. For families with an infant, full-time enrollment at a child care center cost an average of $15,140 a year-or about three-quarters of the total income of a family of three living at the Federal Poverty Level (FPL).

The Colorado Child Care Assistance Program (CCCAP) provides child care assistance to parents who are working, searching for employment or participating in training, and parents who are enrolled in the Colorado Works Program and need child care services to support their efforts toward self-sufficiency. Most of the money for CCCAP comes from the federal Child Care and Development Fund. Each county can set their own income eligibility limit as long as it is at or above 165% of the federal poverty level and does not exceed 85% of area median income.

Unfortunately, while the need is growing, only an estimated one-quarter of all eligible children in the state are served by CCCAP. Low reimbursement rates have also resulted in fewer providers willing to accept CCCAP subsidies.