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.

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[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]