States, taking advantage of federal flexibilities and new federal funding, are implementing policy changes that seek to increase availability of and equitable access to behavioral health services. In anticipation of the one-year, 10% increase in the federal medical assistance percentages (FMAP), provided by the American Rescue Plan Act (ARPA), states have submitted spending plans to the Center for Medicare and Medicaid Services (CMS) outlining how they intend to use these one-time funds to invest in home and community-based services (HCBS) that aim to keep individuals out of high cost institutional settings. These proposals reveal priorities across states for investing in home in community based behavioral health services.
Developing and Enhancing Mobile Behavioral Health Crises Response
Through ARPA, states see an important opportunity to improve behavioral health systems, with a particular interest in enhancing crisis response systems. Several state HCBS spending plans propose to use funds to develop and expand the capacity of mobile crisis response, and some states plan to use these funds to bolster supports to specific, underserved populations. West Virginia and New York’s propose expanding existing mobile crisis capacity to better serve individuals with intellectual disabilities, while Michigan and Washington plan to build out crisis response for children. Other states propose using funds to add crisis stabilization units and to use ARPA funds to implement 988, a nationally-accessible hotline for people in suicide and other mental health crisis situations, established by the National Suicide Hotline Designation Act of 2020.
Updating Technology and Data Infrastructure
State HCBS spending plans underscore the need to improve technological capacity in HCBS systems. Several states propose extending facility-based data such as admissions, discharge, and transfer notifications to HCBS providers; others, including Alabama, Maine, New Jersey, and Texas plan to provide grants to providers and/or families for assistive technology and broadband access. Several states, including Colorado, plan to connect and share data across state agencies and/or among providers to better track and coordinate services for the HCBS population. Similarly, Georgia plans to develop a comprehensive case management platform for all HCBS populations that would include a dashboard for outcomes and reporting, streamlining data collection and usage. Georgia also builds in funding to train staff on new technology. New Jersey proposes using funds to develop a public facing registry, to allow members and families to access information on their waitlist status, available services, wait times.
Investing in the Behavioral Health Workforce
State HCBS spending plans reflect widespread and increasing shortages in the behavioral health workforce. States propose multi-faceted approaches: a handful of states seek to implement permanent rate increases for some sectors of the HCBS workforce, and North Carolina, Minnesota, Vermont, New York, and others plan to raise rates for mental health and substance use disorder (SUD) providers specifically. As a shorter-term strategy, other states are taking a specialty pay approach, building in one-time hiring and sign-on bonuses for behavioral health and other direct care workers. States are also planning to allocate funds for training staff to encourage specialization in behavioral health, or to develop specific skills particularly in-demand in the field. For example, Iowa plans to provide training and scholarships for Crisis Response and Behavioral Health Technician certification. Michigan plans to provide loan forgiveness and internships for students in behavioral health who commit to working in behavioral health shortage areas.
COVID-19 and its related risks in institutional settings have heightened the need for care in the community for people with significant behavioral health needs. State ARPA spending plans reflect the tremendous demand for behavioral health services across states, as well as the growing need to address workforce and build more technological capacity for a sector that has long lagged behind physical health systems. Nearly all state HCBS spending plans have been conditionally approved by CMS, final versions are likely to change in response to CMS comment and guidance.