Advocating for access to psychological and Neuropsychological services within Medicaid

Boots on the ground

Each state has wide latitude in its implementation of Medicaid, and the Medicaid rules are evolving rapidly in most states as healthcare reform designs are taking shape. Therefore, advocacy for inclusion of neuropsychological and psychological services within the Medicaid system must occur on a state by state level. This is not an issue that National Organizations can address "for us" without the boots on the ground leadership of state/ regional psychological and neuropsychological associations and dedicated clinicians.

Barriers to Psychologists' participation in Medicaid

APA practice organization has put together a very helpful document outlining state by state barriers to full participation in Medicaid, along with a set of challenges/ opportunities for advocacy. Barriers in many states include:

•Physician order required for services

•Limited scope of service: assessment only or no independent therapy

•No mechanism for trainees to bill

•Health and Behavior CPT codes not recognized

•Same day billing restrictions

•Limits on telemedicine

Clinicians in all 50 states have a vested interest in engaging in advocacy at the state level to address these barriers. Otherwise, as the Medicaid population expands, psychologists and neuropsychologists' services will be inaccessible to large segments of the population.

First hand accounts from the trenches

As more state and regional psychological/ neuropsychological associations gather experience advocating for inclusion of neuro/ psychological services within Medicaid, we will post first hand accounts of the advocacy agendas, experiences, and advice from clinicians in the trenches. If you have had experience in your state, please contact us.

New York

Milke Santa Maria, Ph.D., ABPP-CN, former president of the New York State Neuropsychological Association, describes his successful advocacy efforts to include neuropsychologists as Medicaid approved providers

What were the Medicaid rules for Psychologist and Neuropsychologist participation before you started your advocacy work?

Before I took up the issue with NY Medicaid the (old) code for neuropsychological testing (96117) was restricted to physicians (MDs, DOs). I made a couple of calls and was able to find someone at NY Medicaid who agreed with me in principle that neuropsychologists should be able to bill for neuropsychological testing.

There was willingness on the part of NY Medicaid to make a change to this. A key concern expressed by the party with whom I dealt was who is a neuropsychologist and how is a neuropsychologist differentiated from a psychologist. I failed to find any objective answers from within our field though many expressed the concern that board-certification is too stringent a criterion.

So what I did back in about 2004 was to create what I now call the NY Medicaid model. NY Medicaid agree to pay the neuropsychological testing to PhDs who were either board-certified (initially only with ABCN, but now by ABCN or ABN or ABPdN) or who provided a letter to NY Medicaid from any 1 of these 3 boards stating that they had passed phase 1 of the board process (credential review). In other words, either board-certified persons or persons who had been determined by peer review to meet the training requirements for a neuropsychologist were permitted to bill neuropsychological testing codes. Basically, in the interest of privacy of candidates, none of the boards will release information on persons currently in the board process, and none of the other neuropsychology organizations (INS, NAN, D40) felt comfortable accepting the responsibility of credential review and certification. So I circumvented the barrier our own field was posing to reimbursement, and now we are able to be paid by NY Medicaid.

How is the Medicaid program currently handling neuropsychological services?

Presently, NY Medicaid will reimburse up to 3 units of 96118, and 1 unit of 96116 or 90801, but will not pay 96119.

Tell me about your advocacy team? What organizations are involved?

I did this on my own, during the period that I was president of NYSAN.

What are the goals of your Medicaid advocacy- what are you all trying to accomplish?

I would still like to get 96119 covered and would like to increase # of units of 96118 that are covered.

How is it going so far?

I has a recent email exchange with Ed Barnoski (NYSAN president) and with Tim Wynkoop and Tresa Roebuck Spencer about possibly pushing NY Medicaid to add 96119. There currently is hesitation among NYSAN members to push on this given the long lingering technician issue in NY.

How did you come to be the one to step up to the plate? What is the history of your willingness to dive in?

It was what was right and what was in the best interest of my patients and my personal reimbursement.

Do you have some advice for others in states who do not currently have a team of psychologist and neuropsychologist advocates working to ensure Medicaid participants have adequate access to psychological and neuropsychological services?

Yes. Go out and do it. You don't need a team.

Mississippi

Edward Manning, Ph.D., is a professor of Neurology at University of Mississippi Medical Center. He has shared his experience advocating for greater Medicaid access to neuropsychological services in Mississippi.

What were the Medicaid rules for Psychologist and Neuropsychologist participation in Mississippi before you started your advocacy work?

Medicaid covers services by Psychology and Neuropsychology for kids – with some restrictions. A plan of care (POC) has to be submitted after the initial visit, and further testing will only be covered once that POC is approved. Psychological testing (LD, ADHD, etc.) is limited at 4 total units for 96101. Neuropsychological testing is allowed up to 10 units of 96118. No testing by technicians/psychometrists, etc., is covered.

For adults, some services by Psychology are covered only through the community mental health center system for diagnostic interview and treatment. No testing codes are authorized.

How is the Medicaid program in Mississippi responding to healthcare reform? (e.g. are they moving towards Medical homes? Bundled payments? Keeping with fee for service?)

This is still being determined. The governor is resisting Medicaid expansion. The Director of Medicaid is providing revised models for expansion. The legislature is mixed on expansion.

Tell me about your advocacy team? What organizations are involved?

The task force is comprised of several psychologists who are members of the Mississippi Psychological Assocation (MPA). APA has provided a small grant to fund services for a lobbyist, who was instrumental in setting up meetings with the director of the Division of Medicaid.

What are the goals of your Medicaid advocacy- what are you all trying to accomplish?

Expansion of services for adults for services to include any relevant diagnostic and treatment issues – for behavioral health, for patients with medical conditions (i.e., TBI, stroke, epilepsy, etc.).

Allowing use of technicians for Psychological and Neuropsychological testing across kids and adults. Greater flexibility for number of hours for Psychological testing.

How is it going so far?

The Director of the Division of Medicaid, Dr. David Dzielak, has been receptive. Apparently some of the restrictions are legislative and some are administrative. He expressed a willingness to consider modifications, which is considerably more than two of his predecessors. However, all is in a holding pattern given the current issue of Medicaid expansion.

How did you come to be the one to step up to the plate? What is the history of your willingness to dive in?

I have tried, unsuccessfully, as an individual, over the years to lobby for change with previous Medicaid directors. Our state association has expressed interest, but this is the first time the executive committee formed a task force to try to effect change.

I think this will require an ongoing, active effort across individuals, state and national associations and will most likely need to involve some method for enlisting the assistance of consumers.