Health care providers say changes put 'poorest of poor' at-risk

Behavioral health providers across Nebraska say a change intended to expand federal health insurance coverage of mental health care has instead put vulnerable patients at risk of losing services.

In expanding Medicare's coverage to some behavioral health services like licensed independent mental health practitioners, providers say the reimbursements they were receiving through Nebraska's Medicaid program have been slashed dramatically.

That has produced a 50% loss in payments for individuals that qualify for both Medicare and Medicaid — so-called "dual eligible" individuals — resulting in losses of thousands of dollars to providers across the state.

In turn, those providers have been forced to reduce the number of times they see dual eligible patients, put those individuals on waiting lists or cut off services to them altogether.

"Especially for our rural providers, this is a hit to their finances, which is causing many to reevaluate how they will be able to continue serving this population," said Annette Dubas, the executive director of the Nebraska Association of Behavioral Health Organizations.

Many of the providers struggling most are working in rural areas of Nebraska, often with the "poorest of the poor" who cannot otherwise get the help they need, said Dubas, a former state senator from Fullerton.

The problem with how providers are able to be reimbursed was identified more than a year ago, Dubas said, although federal officials chalked it up to "unintended consequences."

Beginning in January 2024, Medicare expanded the number of behavioral health providers it would reimburse to make those services more accessible to a greater number of people nationwide.

But in Nebraska, adding more masters-level counselors to the services it would reimburse for ended up having the opposite effect for individuals enrolled both in Medicare and Medicaid when the program took effect in the state on July 1.

Nebraskans who were "dual eligible" — those over the age of 65 or with a qualifying disability who are also low income found their reimbursements for behavioral health services were roughly half of what they were before.

For example, before the federal change took effect on Jan. 1, a licensed independent mental health practitioner would bill Medicaid $187 for one hour of therapy provided to a patient enrolled in both safety net programs.

Since Jan. 1, those providers are now required to first bill Medicare, which pays roughly 80% of a maximum reimbursement of $95 for one hour of therapy. The provider can then bill Medicaid, which picks up the remaining 20% of the cost.

Taken together, the provider is paid a total of $95, well below the $187 they were receiving per patient in prior years, providers say.

The change in how behavioral health services were reimbursed for dual eligible Nebraskans came as a shock to Mandy Price, a licensed independent mental health provider and owner of Inspirit Counseling in Chadron, who said it was not communicated clearly to providers.

After continuing to bill Nebraska Medicaid for services rendered to dual eligible patients, Price said she learned through a July 15 letter that she should have first sent the bills to federal Medicare.

Medicaid demanded Price repay nearly $10,000 that was paid out in error for dual eligible Nebraskans seeking treatment at her business as she worked to jump through the hoops in order to be able to submit reimbursements to Medicare over the next three months.

"I worked really hard to get credentialed with Medicare, and as soon as I was able to get credentials, I tried to rebill all of those claims," Price explained, "but they did not get repaid."

To compound matters, Price said Inspirit Counseling had to make difficult decisions about the 30-35 patients who were dual eligible. Some providers decided to keep seeing patients on a pro bono basis, while others had to terminate their patients' treatment.