Roughly 75% of States Are Missing Core Behavioral Health Crisis Response Services in Medicaid

Most state Medicaid programs don’t cover all of the three core behavioral health crisis response services recommended by federal guidelines.

Crisis response services play a vital role in alleviating constituencies that have heretofore struggled to address increasing rates of behavioral health crises, notably busy emergency departments and law enforcement. And the evolution of these services has accelerated in recent years after concentrated congressional and executive actions by the federal government.

The three services that the Substance Abuse and Mental Health Services Administration (SAMHSA) prescribe are crisis hotlines, mobile crisis units and crisis stabilization units. SAMHSA further suggests that states cover and act as a coordinating force between all three services to prevent fragmentation. 

As part of a newly released report, the Kaiser Family Foundation garnered poll responses to 45 state Medicaid programs about crisis response services to assess the status of Medicaid coverage and crisis response services. Medicaid is the largest payer of behavioral health services in the U.S. 

About three-quarters of responding states don’t cover all three services through Medicaid, according to KFF.

“Despite this generally lower coverage, the landscape of crisis response systems is evolving across states, driven in part by the opportunity for enhanced federal matching funds for qualified mobile crisis services,” the KFF report states

Only 12 states, including Washington, D.C., cover all three services via fee-for-service Medicaid; 29 states cover one or two core crisis response services; and four state Medicaid programs cover none of the services.

The Centers for Medicare & Medicaid Services (CMS) and its state Medicaid plan partners have seen funding for new and expanded crisis response services to meet the severe behavioral health issues — especially among the Medicaid population — of local communities.

Other KFF data finds 39% of Medicaid enrollees have a mental illness or substance use disorder. The latest omnibus funding bill from Congress put billions of dollars into several behavioral health initiatives including mobile crisis services and hotlines. That also included over $500 million for the 988 Suicide & Crisis Lifeline. 

It also formed the Behavioral Health Crisis Coordinating Office. As part of SAMHSA, the office will oversee and develop plans for best practices for crisis response services. 

And there may be continued interest in expanding crisis services. The Biden administration’s proposed budget for fiscal 2024, largely a symbolic document, would add more funding to these efforts.

“Despite recent advances in crisis services, uncertainties persist, including questions of how to integrate services across the crisis continuum and how to secure long-term sustainable funding,” the KFF report states.

State action is required to take advantage of added federal funding. Further, states would be required to supplement that funding with state tax dollars in many instances.

This is notably true for crisis response hotlines. Only about half of state Medicaid programs polled cover crisis hotlines, the lowest rate of coverage among the three core crisis response services. While these are free to callers, these hotlines often need to bill Medicaid to continue operations.

Administratively, this can be difficult, the report states. Gathering insurance information in a time of crisis may not be possible.

Further, not all hotlines are a part of the 988 network. Over 200 local crisis call centers operate through the 988 hotline. But there remain “numerous” independent hotlines, according to the report.

About three-quarters of state Medicaid programs cover mobile crisis response for adults while roughly two-thirds cover crisis stabilization units.

Just over half (28 of 44) of respondents report intent to or have already planned to use funds from the 2022 American Rescue Plan Act (ARPA) to improve mobile crisis services. Sixteen states have no plans to use those funds.

Most states also report plans to add peer services, or services from trained individuals with experiences with behavioral health issues, to their mobile crisis services.

Almost all responding states (38 of 44) pointed to funding, workforce shortages and geographic issues as their top concerns in developing and implementing crisis response services.

In terms of geography, rural communities tend to have fewer behavioral health professionals in the first place. So, staffing 24/7 teams is a daunting prospect. This is further complicated by the vast space in most rural communities that providers would need to traverse to reach folks.  

“When we asked states to identify their biggest challenge, they overwhelmingly pointed to the shortage of a qualified workforce as their most significant obstacle,” the report states.