Category: Payers

The 2025 Healthcare Perfect Storm: How Rising Costs and Increased Scrutiny Impact Insurers

The blog post examines the health insurance industry’s challenges in 2025, highlighting rising healthcare costs, increased patient demand, and heightened government scrutiny. Insurers, particularly those focused on Medicare Advantage, must reevaluate strategies to maintain profitability. Despite these hurdles, opportunities for innovation and growth exist through personalized care and strategic partnerships.

This blog post delves into the complex challenges facing the health insurance industry in 2025, a year poised to be a pivotal moment for insurers, particularly those heavily invested in Medicare Advantage plans. Rising healthcare costs, increased patient demand, and heightened government scrutiny are converging to create what we’re calling a “perfect storm.” This confluence of factors threatens profitability and necessitates a critical reevaluation of existing operational strategies. This post expands on the themes discussed in our latest podcast episode, exploring these challenges in greater depth and offering insights into potential solutions for both insurers and healthcare providers.

Rising Healthcare Costs: A Looming Crisis

The escalating cost of healthcare is arguably the most significant challenge facing insurers. Inflation, technological advancements, and the increasing complexity of medical treatments all contribute to this unsustainable upward trend. The post-COVID surge in patient utilization, with many seeking deferred procedures, has exacerbated the problem, placing immense pressure on insurers’ financial reserves. This increased demand is straining existing resources and impacting profitability, pushing medical loss ratios (MLRs) higher than ever before. The implications are profound, forcing insurers to re-evaluate pricing strategies, negotiate more effectively with providers, and explore innovative cost-containment measures.

The Impact on Medicare Advantage

Medicare Advantage (MA) plans, once considered a goldmine for insurers, are particularly vulnerable in this environment. The increased demand for MA plans, coupled with rising healthcare costs, is squeezing profit margins. Major players like Humana and UnitedHealth Group, heavily reliant on MA for revenue, are grappling with these challenges head-on. Their financial performance is becoming increasingly dependent on their ability to manage costs efficiently while maintaining patient satisfaction and adherence to regulatory requirements.

Increased Patient Demand: A Double-Edged Sword

While increased patient demand initially appears beneficial, in the context of rising costs, it becomes a major challenge. Insurers are faced with a difficult balancing act: fulfilling the needs of a growing patient population while simultaneously controlling costs and maintaining profitability. This necessitates a shift towards more proactive and personalized care models that prioritize preventative measures and disease management. Strategic partnerships with providers are crucial for achieving these goals.

The Need for Personalized Care

The sheer volume of patients requires a move beyond traditional, reactive models of care. Personalized care, driven by data analysis and predictive modeling, is becoming essential for identifying high-risk individuals and implementing targeted interventions. This approach not only improves patient outcomes but also helps to manage healthcare costs more effectively, ultimately impacting the MLR and safeguarding insurer profitability.

Increased Government Scrutiny: Navigating Regulatory Hurdles

The health insurance industry is facing unprecedented levels of government scrutiny. Lawmakers are increasingly focused on issues of transparency, affordability, and access to care. This heightened scrutiny translates into stricter regulations, increased audits, and potential penalties for non-compliance. Insurers must navigate this complex regulatory landscape while ensuring they maintain ethical and transparent practices.

Adapting to Regulatory Changes

The regulatory environment is constantly evolving, requiring insurers to be adaptable and proactive. Staying informed about new regulations, investing in compliance programs, and engaging with policymakers are crucial for navigating this challenging landscape. Failure to adapt could lead to significant financial penalties and reputational damage.

Opportunities Amidst the Storm

While the challenges are significant, the current climate also presents opportunities for innovation and growth. Entrepreneurs and healthcare providers can leverage this disruption by focusing on high-cost patient areas and developing innovative solutions that improve efficiency and reduce waste within the healthcare system. New models of care, such as value-based care, offer potential avenues for both improved patient outcomes and reduced costs.

Innovation in Healthcare Delivery

The need for cost-effective and efficient healthcare delivery models has never been greater. Entrepreneurs are stepping up to the plate, developing innovative technologies and solutions to address these challenges. These range from telehealth platforms and remote monitoring devices to AI-powered diagnostic tools and personalized treatment plans. Insurers that embrace these innovations and forge strategic partnerships with these innovators will be better positioned to thrive in the evolving healthcare landscape.

Conclusion

The healthcare industry in 2025 faces a perfect storm of rising costs, increasing patient demand, and intensified regulatory scrutiny. Insurers, especially those heavily reliant on Medicare Advantage, are experiencing significant financial pressure. This necessitates a complete re-evaluation of operational strategies, focusing on cost containment, personalized care, and proactive compliance. However, amidst these challenges lie significant opportunities for innovation and growth. By embracing new technologies, fostering strategic partnerships, and prioritizing patient-centric care models, both insurers and healthcare providers can navigate this turbulent environment and emerge stronger. To delve deeper into this topic and explore potential opportunities, please listen to our podcast episode, “2025 Opportunities in Healthcare: Navigating the Perfect Storm.” This episode provides further insights into the challenges and opportunities discussed in this blog post and offers actionable strategies for navigating the complexities of the 2025 healthcare landscape.

Companies mentioned in this episode:

Research Links:

The Definitive Playbook for Choosing Behavioral Health Markets – Value Based Care Advisory (VBCA) Podcast

Rate sheets don't tell the whole story.In this episode, Alex Yarijanian breaks down the 8-indicator playbook he uses to evaluate any tele-behavioral health market before committing capital — and names the specific states he'd enter today and why.Most operators default to the biggest states: California, Texas, Florida, New York. But population size alone is one of the weakest predictors of a winning market. The real levers live in parity law enforcement, workforce economics, MCO concentration, and infrastructure readiness.WHAT YOU'LL LEARNWhy the biggest states are rarely the best markets for tele-behavioral healthThe 8 indicators that separate win-win markets from cheap-rate miragesHow to build a weighted scoring model before entering a new marketWhat associate-level billing eligibility does to your workforce marginsHow MCO concentration affects contracting speed and rate-cut riskWhich states Alex rates as best all-around, high-risk, and growth-stage betsTHE 8 MARKET INDICATORSMedicaid market size: Total addressable population and realistic capture potentialPayment parity: State-level mental health parity laws and strength of enforcementCost of living index: The single best proxy for labor margin on clinical staffAssociate-level billing: Whether licensed associates can bill independentlyHRSA HPSA demand mapping: Documented unmet need in mental health shortage areasBroadband & 5G coverage: Infrastructure required for reliable telehealth deliveryMCO landscape: Plan count, behavioral carve-outs, any-willing-provider law exposureTax & corporate climate: State-level business environment and regulatory postureMARKET ARCHETYPESBest all-around: Arizona, Nebraska, Delaware, OregonVolume, thin margins: Arkansas, North DakotaHigh rate, high cost niche: AlaskaGrowth stage bets: New Mexico, Montana4 ACTION STEPSBuild a scroll scoring model — layer all 8 indicators into a weighted scorecardValidate demand on the ground — overlay HRSA HPSA maps + FCC broadband gap dataCheck your plan mix — count Medicaid MCOs and behavioral carve-outsRun a payroll stress test — model cost of living vs. your target clinician pay bandRESOURCES MENTIONED HRSA Mental Health HPSA maps: data.hrsa.govFCC broadband coverage maps: broadbandmap.fcc.govNCSL mental health parity law trackerLicensure compact maps: PSYPACT, ASWB Compact, Nurse Licensure Compact State Medicaid rate databases
  1. The Definitive Playbook for Choosing Behavioral Health Markets
  2. Medicare Negotiates Like an Owner. Commercial Doesn’t.
  3. The Rural Health Transformation Fund: What States Are Funding in 2026
  4. Medicare Advantage 2026: How Payers Are Choosing Partners
  5. Digital Health at a Crossroads: The Fallout from a $100M Adderall Fraud Scheme

Understanding State-Level Variation in Medicaid Managed Care Maternity Kick Payments

Understanding State-Level Variation in Supplemental Maternity Kick Payments in Medicaid Managed Care

Introduction

Today, we’re exploring an intriguing study on the state-level variation in supplemental maternity kick payments in Medicaid managed care. This study, conducted by Samantha G. Auty, Jamie R. Daw, and Jacob Wallace, provides valuable insights into how these payments impact delivery costs and care quality.

Post Introduction

In this post, we’ll break down the key findings of the study, understand the implications of kick payments on Medicaid managed care, and discuss how these variations can affect maternal health outcomes across different states. Let’s get started by understanding the basics of Medicaid managed care and why kick payments are essential.

Detailed Story

What is Medicaid Managed Care?

Medicaid managed care (MMC) involves states contracting with private health insurers to provide Medicaid coverage. This model covers about 70% of pregnant Medicaid enrollees and finances approximately 41% of all births in the United States. Under MMC, insurers receive per-member-per-month capitated payments to cover a defined set of benefits. However, covering pregnant individuals poses a higher financial risk due to their increased healthcare needs, which often leads to states implementing one-time “kick payments” to MMC plans triggered by delivery events.

The Role and Variation of Kick Payments

Kick payments are designed to offset the higher costs associated with childbirth. The rates and use of these payments can significantly influence whether MMC plans are incentivized to attract or avoid pregnant enrollees. This study aimed to assess the prevalence and magnitude of these kick payments across different states and how they align with actual delivery costs.

Research Methodology

The researchers conducted a cross-sectional study, abstracting data from state documents and MMC contracts published between 2018 and 2020. They gathered information on whether states used kick payments, the services covered by these payments, and the specific rates.

Additionally, they compared these rates with average state Medicaid fee-for-service (FFS) payments for delivery hospitalizations in 2020 and the Medicaid-Medicare fee index.

Key Findings

The study revealed that out of the 38 states and the District of Columbia using comprehensive MMC, 33 states used maternity kick payments. These payments varied significantly, ranging from $2,838 in New Hampshire to $14,493 in Maryland. Interestingly, the variation in kick payment rates did not correlate with the Medicaid payments to physicians or the actual delivery costs, indicating that in some states, kick payments might exceed delivery costs, while in others, they fall short.

These payments varied significantly, ranging from $2,838 in New Hampshire to $14,493 in Maryland.

Expert Insights

To further explore the implications of these findings, let’s delve into some expert insights.

Potential Implications of Low Kick Payment Rates

When kick payment rates are set too low, MMC plans might attempt to limit services for pregnant enrollees or restrict access to maternity care providers. This can lead to disparities in care quality and access, particularly affecting Black and Indigenous women, who are disproportionately enrolled in Medicaid and face higher risks of maternal mortality and morbidity.

The Need for Aligned Incentives

Aligning kick payment rates with actual delivery costs and care quality is crucial. States need to design Medicaid payment policies that support maternal health and promote health equity. This requires continuous research to understand the effects of these payments on care access, quality, and outcomes.

In-Depth Analysis

The Study’s Limitations

While the study provides valuable insights, it has some limitations. It could not directly associate kick payment rates with MMC plan behavior or maternal health outcomes. Additionally, the comparison was made with Medicaid FFS payments rather than the prices MMC plans paid for delivery services, which were unavailable.

The Path Forward

Further research is essential to evaluate the impact of kick payments on maternal care access and outcomes. Policymakers need comprehensive data to design effective Medicaid payment strategies that ensure equitable and high-quality maternal care.

Practical Tips

For state policymakers and healthcare administrators:

  1. Regular Review of Kick Payment Rates: Ensure that kick payment rates are regularly reviewed and adjusted to reflect actual delivery costs and care quality needs.
  2. Focus on Health Equity: Design payment policies that address disparities in maternal health outcomes, particularly for vulnerable populations.
  3. Data-Driven Decision Making: Use comprehensive data to evaluate the impact of payment policies on maternal care access and outcomes.

FAQ Section

Q1: What are Medicaid managed care kick payments? A: Kick payments are one-time payments made to Medicaid managed care plans to offset the higher costs associated with childbirth.

Q2: Why do kick payment rates vary between states? A: The variation can be due to different state policies, healthcare costs, and the structure of Medicaid managed care contracts.

Q3: How can low kick payment rates affect maternity care? A: Low rates can lead to MMC plans limiting services for pregnant enrollees or restricting access to maternity care providers, affecting care quality and access.

Q4: What can states do to improve kick payment policies? A: States should regularly review and adjust kick payment rates, focus on health equity, and use data-driven approaches to design effective payment policies.

Source

State-Level Variation in Supplemental Maternity Kick Payments in Medicaid Managed Care

35 States with Any Willing Provider laws

As a provider, if your request to join a payer network in the following markets has been denied, you might have some recourse for appeals.

As a provider, if your request to join a payer network in the following markets has been denied, you might have some recourse for appeals.

Any Willing Provider and Freedom of Choice laws restrict the ability of managed care
entities, including pharmacy benefit managers, to selectively contract with providers. The
managed care entities argue this limits their ability to generate cost savings, while proponents of
the laws suggest that such selective contracts limit competition, leading to an increase in
aggregate costs.

These laws generally require health insurance companies to allow any qualified healthcare provider who is willing to meet the terms and conditions of the insurer’s contract to participate in their networks.

States listed below have some form of Any Willing Provider laws:

Alabama:

Section 27-1-19: The agreement providing coverage to an insured may not exclude assignment of benefits to any provider at the same benefit paid to a contract provider.

Section 27-45-3: Plan Beneficiaries may choose the licensed pharmacist or pharmacy of their choice. Health insurance policies and employee benefit plans may not deny licensed pharmacies or pharmacists the right to participate.

Arkansas:

Sections 23-201, 23-202, 23-203, 23-204, 23-205, 23-206, 23-207, 23-208, 23-209 : Benefit differentials are prohibited. Insurers must give qualified health care providers the opportunity to participate if providers are willing to accept the plan’s terms and conditions.

Colorado:

Section 10-16-122: Any PBM/intermediary whose contract with a carrier includes an open network must allow all area pharmacy providers to participate if they agree to the terms and conditions of the contract. PBms/Intermediaries may contract with exclusive pharmacy networks if a 60-day notice is given before the termination or the effective date of such contract by publication in a newspaper of general circulation.

Connecticut:

Section 38a-471: A prescription program administrator shall allow a pharmacy to enroll in a program absent cause for excluding it.

Delaware:

Sections 18-7301, 18-7302, 18-7303: Beneficiaries may choose any pharmacy that has agreed to participate according to the terms.  Benefit differentials are prohibited.

Florida:

Section 110.12315: The state employees’ prescription drug program requires the Department of Management services to allow prescriptions to be filled by any licensed pharmacy pursuant to contractual claims processing provisions.

Section 440.13(3) (j): The worker’s compensation statute allows for a sick or injured employee to have free, full and absolute choice in the selection of the pharmacy.

Georgia:

Section 26-2-144(a)(9): That at least 30 days prior to the date a program becomes effective, the program contract therefor shall be offered to all pharmacies located within those counties wherein reside enrollees in that program, which pharmacies shall have at least 30 days from the time they receive the offer to accept that offer and become participating pharmacies.

Section 33-30-25: Insurers may impose “reasonable limits” on the number/classes of preferred providers that meet the insurers’ standards. Insurers must give all licensed and qualified providers within a defined service are the opportunity to become a preferred provider.

Section 33-30-4.3: Beneficiaries who do not use mail-order shall not be penalized if the provider used by the insured has agreed to the same terms and conditions applicable to mail-order and has agreed to accept payment or reimbursement at no more than the same amount that would be paid for the same mail-order services.

Hawai’i:

Section 451 R-1: It shall be a violation of this section for a prescription drug benefit plan, health benefits plan under chapter 87A, or pharmacy benefit manager to refuse to accept an otherwise qualified retail community pharmacy as part of a pharmacy benefit manager’s retail pharmacy network.

Idaho:

Sections 41-2872 & 41-3927: Any insurance company or health maintenance organization issuing benefits must be willing to contract with qualified providers who meet the terms of the organization. Organizations issuing benefits must be willing to contract with qualified providers who meet the terms of the organization

Illinois:

Section 215-5/370h: Insurers/administrators must be willing to enter into agreements with any non- institutional providers who meet the established terms and conditions. The terms and conditions may not discriminate unreasonably against or among non-institutional providers.

Section 215-134/72(a) : A plan may not refuse to contract with a pharmacy provider that meets the terms and conditions established by the plan.

Indiana:

Section 27-8-11-3 : Pharmacists who agree to comply with established terms and conditions

are entitled to enter into contracts with insurers. Terms and conditions established by insurers may not discriminate unreasonably against or among providers.

Iowa:

Section 514C.5: Policies or contracts providing for third-party payment may not require a beneficiary to order prescriptions by mail if the pharmacy chosen by the beneficiary agrees to comply with the same terms and conditions as the mail-order pharmacy.

Kentucky:

Section 304.17A-270: A health insurer shall not discriminate against any provider who is located within the geographic coverage area of the plan and who is willing to meet the terms and conditions for participation established by the plan, including the Kentucky State Medicaid program and Medicaid partnerships.

Section 304.17A-505: …if the provider meets the insurer’s enrollment criteria and is willing to meet the terms and conditions for

participation, the provider has the right to become a provider for the insurer.

Louisiana:

Section: 22:1964: Policies/plans must allow beneficiaries to select the pharmacy/pharmacist of their choice as long as the chosen pharmacy agrees to meet the terms and conditions of the plan.

Pharmacies that agree to meet the established terms and conditions have the right to participate as contract providers. Renamed from Section 22:1214(15).

Section 22:2181: The Louisiana State University Health Sciences Center Health Maintenance Organization shall enter into a contract with any willing provider licensed by the Louisiana State Board of Medical Examiners or the Louisiana State Board of Dental Examiners to provide primary care services delivered in an outpatient setting including medical and surgical services.

Maine:

24-A M.R.S.A. § 4317: insurance carriers offering health plans subject to the Maine Health Plan Improvement Act that provide prescription drug benefits through a network of participating pharmacies may not refuse to contract with a pharmacy that is willing to meet the terms and conditions for participation in the health plan’s pharmacy network. If the network is a tiered network, Maine pharmacies must be offered the opportunity to participate in each tier. A pharmacy benefits manager may not require a pharmacist or pharmacy to participate in one network in order to participate in another network. The pharmacy benefits manager may not exclude an otherwise qualified pharmacist or pharmacy from participation in one network solely because the pharmacist or pharmacy declined to participate in another network managed by the pharmacy benefits manager.

Massachusetts:

Section 176D(3B): Carriers who offer restricted pharmacy networks must follow certain requirements in contracting. Carriers must neither exclude nor favor individual pharmacies and must not impose greater restrictions on non-network pharmacies than those required on in-network pharmacies.

Mississippi:

Section 83-9-6: Beneficiaries may choose any pharmacy that has agreed to participate in the plan according to the insurer’s terms. Pharmacies that accept those terms are entitled to participate.

Benefit differentials are prohibited. Plans that restrict pharmacy participation shall give 60 days notice of offer to participate to all pharmacies in the geographic area.

Missouri:

Section 354.535: Every Health maintenance organization has to apply the same coinsurance, co- payment and deductible factors to all prescriptions filled by a pharmacy provider who participates in the network if the provider meets the contact’s product cost determination. Also HMOs may not set a limit on the quantity of drugs which an enrollee may obtain at any one time with a prescription unless such limit is applied uniformly to all pharmacy providers in the network.

Montana:

Section 33-22-1704: A preferred provider agreement must provide all providers with the opportunity to participate on the basis of a competitive bid.

Nebraska:

Section 44-513.02: Beneficiaries shall not be required to obtain pharmaceutical services from mail- order in order to obtain reimbursement.

Section 44-313(2) :…an insurer may contract with a licensed pharmacist for pharmacist professional

services. Nothing in this section shall prohibit an insurer from contracting with a licensed pharmacist who is not employed or associated with a pharmacy. Nothing in this section shall require a licensed pharmacist to contract with an insurer for pharmacist professional services.

New Hampshire:

Section 420-B:12(V): HMOs seeking bids from pharmacies for agreements to be preferred providers must admit and list all pharmacies that meet the bid.

New Jersey:

Sections 17:48-6j & 26:2J-4.7: An enrollee/subscriber shall be permitted to select a pharmacy/pharmacist provided the pharmacist or pharmacy is registered. Pharmacies/pharmacists shall have the right to participate as preferred providers if the agreement provides for coverage by preferred providers, so long as the pharmacy/pharmacist complies with the terms of the agreement. Benefit differentials shall not be imposed. Enrollees/subscribers shall not be required to use a mail- order pharmacy.

New Mexico:

Section16.19.6.7(f): “Point of care vendor” means an entity contracted with a prescriber to generate or transmit electronic prescriptions authorized by a practitioner directly to a pharmacy or to a “contracted” intermediary or “network vendor”, who will ultimately transmit the prescription order to a patient’s pharmacy of choice. Vendor must provide an unbiased listing of provider pharmacies and not use

pop-ups or other paid advertisements to influence the prescriber’s choice of therapy or to interfere with patient’s freedom of choice of pharmacy. Presentation of drug formulary information, including preferred and non-preferred drugs and co-pay information if available, is allowed.

North Carolina:

Section 58-51-37: Beneficiaries may choose any pharmacy that has agreed to participate according to the insurer’s terms. Pharmacies that accept such terms are entitled to participate and must participate if offered the opportunity. Benefit differentials are prohibited. Plans that limit pharmacy participation shall give 60 days notice of an offer to participate to all pharmacies in the geographic area.

North Dakota:

Section 26.1-36-12.2: Beneficiaries may choose any licensed pharmacy/pharmacist to provide services. Benefit differentials are prohibited. Licensed pharmacists who accept the terms may participate in the plan.

Oklahoma:

Section 36-3634.3 & 36-4511: Pharmacies must be provided the right to bid on a periodic basis on any pharmacy contract to provider pharmacy services. Employers may not require employees to obtain drugs from a mail-order pharmacy as a condition for reimbursement. Employers may not impose benefit differentials if they do not use mail-order.

Title 15 § 15-788(c): No third party prescription program administrator shall deny any pharmacy the opportunity to participate in any third party prescription program offered in this state in a manner which will restrain the right of a consumer to select a pharmacy.

Rhode Island:

Sections 27-18-33, 27-19-26, 27-20-23, 27-41-38: Insurers may not require covered persons to obtain prescriptions from a mail-order pharmacy as a condition of obtaining benefits.

RI Gen. Laws 27-29-1: Unfair competition and practices.

South Carolina:

Section 38-71-147: No individual or group accident and health or health insurance policy or HMO may prohibit a participant/beneficiary from selecting pharmacies/pharmacists that agreed to participate in the plan according to the terms of the insurer, or may deny pharmacies/pharmacists the right to participate as contract providers if they agree to insurer’s terms and conditions.

South Dakota:

Section 58-18-37: Group health insurance policies may not refuse to accept licensed pharmacies/pharmacists as participating providers if they agree to the same terms and conditions offered to other providers of pharmacy services under the policy.

Tennessee:

Section 56-7-117: Group medical benefit contracts covering prescriptions may not require a covered person to obtain prescriptions from mail-order, or to pay an additional fee, or be subjected to a penalty for declining to use a designated mail-order pharmacy.

Section 56-7-2359: Licensed pharmacies may not be denied right to participate on the same terms and conditions offered other participants; benefit differentials are prohibited.

Texas:

Section 21.52B 2(a) (2): A pharmacy/pharmacist may not be denied the right to participate as a contract provider under the plan if the pharmacy/pharmacist agrees to provide pharmaceutical services that meet all terms and requirements and to include the same administrative, financial, and professional conditions that apply to pharmacies/pharmacists that have been designated as providers under plan.

Utah:

Section 31A-22-617: Insurers must allow providers to apply for and be designated as preferred providers if they agree to meet established terms and conditions. “Reasonable limitations” may be placed on the number of designated preferred providers.

Virginia:

Section 38.2-3407: Insurers shall establish terms and conditions in order to receive payment as a preferred provider. The terms and conditions shall not discriminate unreasonably against or among such health care providers and cannot exclude any provider willing to meet the terms and conditions.

Section 38.2-3407.7: Insurers shall not prohibit any person receiving pharmacy benefits from selecting, without limitation, the pharmacy of his choice.

Section 38.2-4209: Providers who are willing to accept established terms and conditions may qualify for payment under preferred provider contracts.

Section 38.2-4209.1: Corporations must allow beneficiaries to select the pharmacy of their choice if pharmacies that are non-preferred providers have previously notified the corporation of their agreement to accept reimbursement at rates applicable to preferred providers.

Section 38.2-4312.1: No Health maintenance organization shall prohibit any person receiving pharmaceutical benefits from selecting, without limitation, the pharmacy of his choice. No monetary penalty which would affect or influence any person’s choice of pharmacy shall be imposed.

Wisconsin:

Section 628.36 (2m): An annual 30-day open enrollment period during which any pharmacist may elect to participate is required.

Wyoming:

Section 26-22-503: Any provider willing to meet the established requirements has the right to enter into contracts relating to health care services.

Section 26-34-134: Providers willing to meet an HMO’s established terms shall not be denied the right to contract. An HMO may not discriminate against a provider on the basis of the provider’s academic degree.

Please note that laws can change over time, so it’s always a good idea to verify the current status of AWP laws in specific states if you need the most up-to-date information.

Eligibility: Contract Language (Payer v Provider) and Sample to Use

Eligibility: Contract Language (Payer v Provider) and Sample to Use.

Payer contracting negotiations are a critical aspect of managing healthcare costs and ensuring access to care for patients. During contract negotiations, payers and providers work to establish agreements on reimbursement rates, covered services, and other important details. These negotiations can be complex and time-consuming, requiring careful attention to legal and financial considerations. Ultimately, successful negotiations can help to ensure that patients receive high-quality care at a reasonable cost, while providers are fairly compensated for their services. 

What language to negotiate from a provider v a payer’s perspective:

Favorable to physician:


Payor shall be responsible for identifying and verifying eligibility of Members. Payor shall provide each Member with an identification card. It is the Payor’s responsibility to update and maintain eligibility files and systems to ensure that eligibility verification is timely and accurate. Physician may rely on eligibility verifications obtained from a Payor or its designee and Payor shall reimburse Physician in accordance with this Agreement even if a Member is later determined to be ineligible on the date of service.


Favorable to payor:


Physician will verify a Member’s eligibility before providing a Covered Service unless the situation involves the provision of an Emergency Service in which case Physician will confirm eligibility in a manner that is consistent with Law on redeterminations of eligibility. Physician will not be reimbursed for any services furnished to a patient who was not an eligible Member on the date of service

Health Insurance Providers’ Actions Concerning Mental Health

  • AllWays Health Partners has teamed up with Lyra Health to offer a new solution to expand the availability of mental health support and counseling. Through Lyra, members will be able to seek clinically proven mental health support, find high-quality providers tailored to their individual needs, and book appointments quickly with a therapist or coach by video or in-person securely and confidentially. Lyra will be rolled out in phases beginning June 2022.
  • AmeriHealth Caritas posted 5 questions that patients can use to find culturally competent mental health professionals. The questions include:
    • Does the provider ask about your problems in the context of your social network, such as family or friends, others in your community?
    • Does the provider ask you what you think the causes of your problems are?
    • Does the provider ask about the most important aspects of your background or identity and whether they make a difference to your problem (i.e. discrimination)?
    • Does the provider ask about barriers that have prevented you from getting the help you need, including any stigmas or social determinants of health?
    • If there are differences in your backgrounds, does the provider ask about your concerns around these differences and what your expectations are?
  • A 3-year grant provided by the Anthem Blue Cross and Blue Shield Foundation to the Chris Atwood Foundation will allow more individuals to seamlessly progress from treatment for substance use disorder, incarceration, or other high-risk transition points into a safe and supportive recovery housing environment. For the past 9 years, the Foundation has worked to save lives from overdose and support recovery from substance use disorder. The $150,000 Anthem grant will support the organization’s Revive to Thrive program and allow them to offer housing and peer support to 300 more individuals.
  • The Anthem Foundation has committed $13 million in grants to promote equity in mental health, particularly for people with substance use disorders. Each program will focus on one of the following goals: prevention and early intervention of risk factors that lead to substance use disorders, improved access and quality of treatment to reduce morbidity and mortality of substance use disorders, and community support to promote lifelong recovery. These grants are part of up to $30 million the Foundation plans to invest over the next 3 years to make significant progress toward reducing substance use disorders and their health impacts.
  • Anthem Blue Cross and Blue Shield, through its Student Advantage health plans, has entered into an exclusive partnership with Christie Campus Health to help colleges and universities address escalating rates of anxiety and depression reported on campuses throughout the country. The 2 companies will provide a student-centered mental health platform that helps counseling centers meet the high demand for services. Christie Campus Health currently helps over 40 colleges and universities bring timely and accessible mental health and wellbeing support to more than 430,000 students. Christie Campus Health’s CONNECT@College product will allow Anthem Student Advantage to offer a comprehensive solution that focuses on both the physical and emotional wellbeing of today’s college student.
  • Anthem has launched a number of specific physical and mental health/substance use disorder (MH/SUD) health integrated care management and outreach programs utilizing predictive modeling related to comorbid conditions that include licensed clinicians and peer/wellness and recovery coaches. These programs include Cardiac Pain, Sleep Apnea, Predictive High Utilizing Alcohol and Opioid Users, and Suicide Prevention. Additionally, to meet the needs of members with complex conditions, Anthem created the High Outreach to Promote Engagement (HOPE) program. These populations have the highest rates of multiple chronic conditions and higher than average emergency room visits and inpatient admissions for both MH/SUD and physical health. Case managers in this program take a broad view of a patient’s whole health and assist consumers in a variety of ways, including providing transportation or coordinating doctor appointments. Anticipating and supporting member’s needs before and after they need medical care significantly improve member outcomes and lower healthcare costs. By anticipating and supporting members’ needs, Anthem has decreased major incidents such as ER visits and inpatient hospitalizations by 50%.
  • To respond to growing needs throughout its 72,000-square-mile footprint, Avera Health Plans opened a new four-story wing as part of its Avera Behavioral Health Hospital in Sioux Falls.The Helmsley Behavioral Health Center adds 60,000 more square feet of space for treating psychiatric needs among children, youth, and adults. This wing adds several new services including 24/7 Behavioral Health Urgent Care, observation care, youth addiction care services, and partial hospitalization for youth.The wing also will house Avera’s senior behavioral health unit, which is currently located on the Avera Prince of Peace campus. This will provide an opportunity to add to the continuity of mental health services while enhancing and expanding this program. In total, Avera Behavioral Health Hospital will have 146 inpatient behavioral health beds plus 8 addiction residential beds for adolescents – all private rooms.
  • Beacon Health Options has partnered with the Kennedy-Satcher Center for Mental Health Equity (KSCMHE) to address behavioral health equity ahead of the 988 suicide prevention lifeline launch in July. The partnership centers on 2 main components: a research and policy initiative that imagines equitable crisis response for the future of behavioral health service delivery, and a leadership summit to explore how to embed equity into crisis response. Some recommendations for embedding behavioral health equity into state and local 988 systems include:• Prioritizing visibility of groups that are historically excluded or inadequately reached by psychiatric emergency systems
    • Deploying law enforcement in psychiatric emergency response only as needed
    • Leveraging mobile crisis units staffed by culturally competent staffBeacon Health Options is a wholly-owned subsidiary of Anthem.
  • Blue Shield of California posted a back-to-school mental health Q&A with Dr. Nicole Stelter, Blue Shield’s Director of Behavioral Health. Dr. Stelter discussed the growing mental health crisis adolescents are facing, as well as steps students, parents, and teachers can take to support youth mental health.
  • Blue Shield of California is investing in 4 organizations that are working to support youth mental health in California. In total, Blue Shield of California is providing more than $1.1 million to the 4 organizations. Mental illness is the number one reason children in the state are hospitalized, and half of all lifetime cases of mental illness begin by the age of 14. The support is part of Blue Shield of California’s BlueSky Initiative, which provides resources and support for youth, families, educators, and caregivers to promote emotional well-being for youth. Over the last year, BlueSky and its programs almost doubled the number of educators it trained to spot warning signs of mental health concerns in youth, conducted more than 4,000 counseling sessions, and supported cultivating a pipeline of diverse youth to work in the mental health field. The new financial support will continue enhancing these mental health supports with a focus on reducing health disparities.
  • A recent Blue Shield of California post shared important points for seniors about behavioral health, mental health stigma, the pandemic’s effect on this health issue, and how treatment and self-care can help. Getting treatment sooner rather than later is important, and seniors should start by making an appointment to see a primary care doctor or a mental health care professional to discuss whether treatment might help, said Jennifer Christian Herman, vice president, Mindbody Medicine at Blue Shield of California.
  • Funding from Blue Shield of California’s BlueSky youth mental health initiative has let the National Alliance on Mental Health (NAMI) California expand its On Campus High School clubs throughout the state, increasing membership from 1,051 in 2020 to 1,271 participants in 80 clubs across 16 counties in 2022. The clubs provide peer-led support for students with mental health conditions, students whose family members have a condition, or students who are interested in the field or in advocacy – all focused on the goal of reducing mental health stigma among youth.
  • The Health Care Service Corporation is providing access to an online self-service platform to help fill a gap for some untreated members who have been reluctant to seek care or had difficulty finding it. The platform, provided by an independent company called Learn to Live, offers around-the-clock mental health assessments and online cognitive behavioral therapy (CBT) for mild to moderate depression, substance use, social anxiety, insomnia, and stress, worry, and anxiety. It is available at no added cost to 11 million members, starting at 13 years of age, in most group health plans across its communities in Illinois, Montana, New Mexico, Oklahoma, and Texas.
  • Blue Cross and Blue Shield of Montana awarded 4 nonprofits with a $70,000 Big Blue Sky Initiative major grant through the Healthy Kids, Healthy Families® program. All 4 grant recipients will use the funds to help improve pediatric behavioral health. In addition to the 4 grants, Blue Cross and Blue Shield of Montana also made a $15,000 grant to NAMI Montana to bolster the organization’s mission to support, educate, and advocate for Montanans with mental illnesses and their families.
  • Blue Cross and Blue Shield of Montana (BCBSMT) is providing access to an online self-service platform to help fill a gap for some untreated members who have been reluctant to seek care or had difficulty finding it. The platform, provided by an independent company called Learn to Live, offers around-the-clock mental health assessments and online cognitive behavioral therapy (CBT) for mild to moderate depression, substance use, social anxiety, insomnia, and stress, worry and anxiety. It will be available at no added cost to members at least 13 years old in most of group health plans.
  • Blue Cross and Blue Shield of Montana is becoming more strategic in coordinating access to life-saving behavioral health services for members throughout the state — particularly in its most isolated areas. BCBSMT launched Big Blue Sky Initiative in 2018 to help fight opioid abuse, rising suicide rates, and methamphetamine and heroin epidemics. The company also helped fund a new psychiatry residency to bring more mental health professionals to Montana, as well as other programs. To improve access, leaders are working with providers and policymakers to develop care models that will keep members closer to home and reduce obstacles to care, including expanded telehealth services. The effort is part of a larger initiative to create more medical and behavioral health access and better care management for BCBSMT members no matter where they live.
  • New Mexico Kids Matter received a $25,000 grant from Blue Cross and Blue Shield of New Mexico’s Healthy Kids, Healthy Families® initiative. The grant will support New Mexico Kids Matter’s Successful Transitions and Adulthood Readiness (STAR) Program, which works to prepare teen foster youth for their transition out of foster care and into healthy and safe adulthood and independent living situations. Studies have shown youth who spent their teenage years in foster care and/or aged out of the foster care system suffered significant challenges as adults in the areas of mental health, education, employment, and finances. Without intervention, these youth have a higher likelihood of violence, homelessness, incarceration, and poverty in their adult lives.
  • Jardin de los Niños has received a $25,000 grant from Blue Cross and Blue Shield of New Mexico’s Healthy Kids, Healthy Families® initiative. The grant supports Jardin de los Niños’ Flourishing Families Infant Mental Health and Wellness Program, which provides direct therapy services to homeless and near-homeless children and their families to address trauma. The grant also supports an anti-hunger component that provides healthy and nutritious meals to address food insecurity.
  • Blue Cross and Blue Shield of North Carolina is expanding its network of behavioral health providers through a collaboration with Headway, a mental health care company that works with insurers to deliver high-value mental health care. Together the 2 companies will make it easier for Blue Cross NC members to quickly access – as soon as 48 hours – in-network therapists and psychiatrists who meet their specific needs. The focus of the collaboration is on improving access to care for underserved communities, including rural and socially vulnerable counties, children and adolescents, and individuals across diverse racial and ethnic backgrounds.
  • Blue Cross and Blue Shield of North Carolina is investing more than $2 million to support 11 organizations across North Carolina to improve access to behavioral health care services in rural and marginalized communities and in HPSAs (Health Professional Shortage Areas). This funding initiative is part of Blue Cross NC’s statewide commitment aimed at addressing and eliminating racial, health, and geographical disparities in North Carolina and supports the company’s goal to improve access to behavioral health care in rural and underserved communities by 25% in 5 years.
  • Blue Cross and Blue Shield of North Carolina has announced a new collaboration with Mindoula to help address the complex health needs of members with serious mental illness and/or substance use disorder. The program leverages expertise from the tech-enabled behavioral health management company to expand access to behavioral health services and will launch on January 1, 2023. Blue Cross NC will work with Mindoula to directly address the mental health crisis and health care shortage in North Carolina by providing tech-enabled support that expands outpatient behavioral health care to members in the greater Triangle area, as well as eligible members outside of North Carolina.
  • Blue Cross and Blue Shield of Oklahoma has made a grant to the National Alliance on Mental Illness of Oklahoma to support mental health efforts focused on young children. The grant will support the “Meet Little Monster” coloring and mental health activity book created for young children to express and explore their feelings as well as to help foster dialogue between children and the safe adults in their lives. The book is available in English and Spanish for families, organizations, teachers, and young people across Oklahoma at no cost.
  • The CalOptima Board of Directors has authorized a grant agreement of up to $1 million to support the Be Well Orange Campus, a mental health and substance use treatment facility in Orange. The grant will enhance intake and admissions coordination services for CalOptima Medi-Cal members who need behavioral health services. The two-year grant will ensure CalOptima members have timely access to services, assessment and placement into care through an improved intake and coordination process at the Be Well Orange Campus. The cost of coordination includes staffing, training and development, administrative services, and a phone system upgrade.
  • The Cambia Health Foundation has invested more than $300,000 in non-profit organizations that are part of the National Suicide Prevention Lifeline system. The goal of the investments is to support, expand, diversify, and train the behavioral health workforce.
  • CareFirst BlueCross BlueShield is collaborating with Headway, a tech-enabled company that expands access to in-network mental health care by removing barriers faced by providers, payers, and the people they serve, to support CareFirst’s mental healthcare system. The collaboration will help eliminate obstacles to providing and accessing behavioral health while delivering quality, easy-to-access mental health care for all members. Headway’s secure online platform is available to CareFirst’s network of mental health providers at no cost and will enable efficient scheduling, billing and more. This allows providers to focus on quality care delivery, rather than administrative tasks.
  • CareOregon has provided Lutheran Community Services Northwest with a $79,867 grant to help make more culturally specific mental health resources available to newly arriving and already resettled Ukrainian refugees in the region. The funds from the grant will be used to hire 1 additional full-time peer support specialist and 1 Ukrainian speaking clinician that will support the increasing demand for care. The grant will also help fund additional support for the broader Ukrainian community. The peer support specialist will provide timely support to Ukrainian refugees to help address mental health and trauma and connect clients to the appropriate services and resources. Services include individualized psychological first aid such as mental health counseling, emotional support groups, workshops to aid in resettlement and referrals for any additional needs like wellness exams, immunizations, housing, employment and more.
  • CareOregon announced that it has awarded $210,000 in community giving grants to nine local nonprofit organizations that provide social support and improve access to medical care for seniors, communities of color and other underrepresented communities across the Portland metropolitan region. Among the grants awarded, CareOregon is investing $50,000 in Lines for Life’s Cultural Engagement Initiative, which prioritizes the mental health needs of communities of color. The funding will support Lines for Life’s effort to reach 1,500 community members who identify as Black, Indigenous, and from other communities of color with mental health support through direct outreach by community health workers and hosting community-wide events that aim to reduce stigma.
  • CareOregon and the Alliance for Culturally Specific Behavioral Health Providers have codesigned a payment model to improve health outcomes for Oregon’s communities of color. Numerous national studies have shown that these communities are disproportionately impacted by lack of access to mental health support. Over the past 2 years, the collaboration has hit several milestones, most recently resulting in expanded payments for culturally specific providers that leverages both traditional payment models by increasing rates and Health Related Service dollars to compensate providers for time invested in outreach and engagement activities. These changes will result in an increase of up to 20% in payment to culturally specific providers.
  • CareSource is collaborating with Clarigent Health to bring artificial intelligence to behavioral health providers in Ohio. Clairity, Clarigent Health’s software tool, analyzes speech with artificial intelligence trained to identify patients at risk of suicide. Behavioral health providers in the Ohio Children’s Alliance (OCA) and Ohio Behavioral Health Provider Network (OBHPN) can now be reimbursed through CareSource when using Clairity. Between the 2 networks, more than 265,000 families and youth will have access to the technology.
  • The CareSource Foundation has awarded Overdose Lifeline, Inc. a more than $178,000 grant to improve the prevention of and response to opioid overdoses in Indiana schools. These funds will provide school partners with the emergency, life-saving medication naloxone, develop a custom training course for school staff and connect schools to evidence-based prevention programs.
  • CareSource has announced a new option with the Montgomery County Board of Developmental Disabilities (MCBDDS) and I Am Boundless to provide respite care for parents and other caregivers of people with intellectual and developmental disabilities (I/DD) and behavioral health challenges. This new collaboration will provide respite services to those families with I/DD youth. Services such as after-school and day programming, and therapeutic supports will be embedded in each respite opportunity.
  • Centene has launched an all-employee training on Mental Health and Substance Use Disorder Parity to educate employees on parity law and outline Centene’s policies that ensure delivery of benefits that do not discriminate against individuals with mental health conditions or substance use disorders. Centene also maintains youth and adolescent programs focused on mental health, including the Choose Tomorrow™ Suicide Prevention Program, which uses evidence-based practices to screen for suicide risk, develop member-driven safety planning, provide connection to community resources, and monitor members’ treatment progress to prevent suicide.
  • Centene is a driving partner in solving the problem of social isolation in schools through No One Eats Alone® Day, created by the nonprofit Beyond Differences and sponsored by The Centene Charitable Foundation. Mental well-being is especially important now as youth continue to experience stressors from the COVID-19 pandemic. Centene health plans across the country helped raise awareness by hosting virtual and in-person events in February and March to encourage inclusion and teach children how to combat isolation. They worked with 108 schools across 10 states, engaging at least 48,500 students in educational and fun activities.
  • Centene recently released a white paper entitled, “Advocating for the Mental Health of Medicare Recipients.” The white paper notes the important role Medicare plays in the more than 63 million Americans who received Medicare benefits in 2021 and the unique challenges the Medicare population faces.The white paper also highlight’s Centene’s role in keeping people enrolled in Medicare healthy, stating: “While recent policy changes have improved access to mental health services for Medicare beneficiaries, there is still work to be done to ensure they can easily receive the care they need to live healthier, higher-quality lives. As an industry leader and one of the largest Managed Care Organizations in the country serving many of our nation’s most vulnerable citizens, Centene is committed to ensuring the mental wellbeing of Medicare beneficiaries through access to high-quality care, innovative programs, and a wide range of health solutions.”
  • The Cigna Foundation has made more than $3 million in grants to local nonprofits to help address childhood hunger and mental health concerns as schools return to session. Programs spanning communities in 16 states will receive critical financial support enabling them to positively impact thousands of children across the country. All grants are made available through Cigna Foundation’s Healthier Kids For Our Future® program, a 5-year, $25 million global initiative focused on improving the health and well-being of children. Since its inception in 2019, the program has awarded more than $18 million in grants.
  • Cigna Chairman and CEO David M. Cordani unveiled new findings about the growing mental health crisis among teenagers and the impact it is having on parents, both at home and work. Cigna and Evernorth, its health services business, commissioned the study from Economist Impact to examine the mental health effects of the COVID-19 pandemic on teenagers and their parents. The study was conducted in April 2022 and key findings include:
    • Approximately 80% of working parents reported some form of impact on the mental health of their teenage children as a result of the pandemic, including new or increased levels of anxiety, depression, behavioral issues, and problems with social interactions.
    • Nearly one in five working parents reported a negative impact on their work performance and productivity because of concerns about their child’s mental health.
  • Aetna, a CVS health company, and Psych Hub have launched an Adolescent Treatment Training Series to meet the urgent needs of youth and young adults. This joint effort arms the 283,000 behavioral health and employee assistance program providers in Aetna’s commercial network, Aetna’s internal clinicians, and CVS Health’s licensed counselors at MinuteClinics in select HealthHUB locations with access to a no-cost, evidence-based curriculum in the form of courses and resources to identify and treat adolescents and young adults along a full continuum of care, from prevention through intervention, for those at risk of suicide.
  • CVS Health is providing support to the National Association of Free and Charitable Clinics, the American Foundation for Suicide Prevention, and Mental Health America, in recognition of Mental Health Awareness Month. The support is focused on equitable, quality access to mental health care services and resources, particularly among the Black, Indigenous, and People of Color (BIPOC) community. A recent CVS Health/Morning Consult survey of Americans age 18+ also found that mental health concerns are continuing to rise among individuals of all backgrounds, especially Black, age 65+, young adult, and LGBTQIA+ respondents. The survey also found more Americans agree that the pandemic has made them more comfortable seeking support for mental health and using technology to address it.
  • Elevance Health is working to address the behavioral and mental health care needs of all members, at every age. Through the Sydney Health app, for example, a spectrum of care delivery options is available: digital, virtual, and in-person. Sydney Health can connect eligible members to a virtual text visit or a video visit with a behavioral or mental health provider such as a therapist or counselor. The app allows users to get important information about benefits and claims, track progress toward health goals, access a member ID card, and more. Elevance Health is also dedicated to advancing health equity through a “health equity by design” approach. This approach is personalized and intentional, ensuring that people can receive individualized care.
  • The Florida Blue Foundation is making a $3.8 million investment to enhance mental health for Florida’s children, families, and seniors. Twelve nonprofit organizations across the state share in the investment, which will support community-based programs that directly improve access to and quality of mental well-being services, particularly for the underserved and uninsured, including racial and ethnic minorities, and low-income populations. The investment will provide mental health counseling and education in schools for under/uninsured students and provide a safe environment for mental and emotional healing for members of the LGBTQ+ community, transgender individuals, victims of hate crimes, and LGBTQ+ seniors, in addition to supporting other mental health programs.
  • Highmark is encouraging members to focus on mental health in 2022 and is reminding them of resources that are available to better manage stress, anxiety, and depression. One new option for members is Meru Health, a 12-week evidence-based program to treat depression, anxiety, and burnout that mixes a clinical human touch with technology, self-care, and data via a discreet smartphone app. The 12-week treatment program includes consultation with a dedicated licensed therapist, evidence-based video lessons, guided mindfulness practices, habit-changing activities, and anonymous peer support groups, all done on a mobile device. Members will also have access to on-going support following the completion of the 12-week program.
  • Horizon Blue Cross Blue Shield of New Jersey members have access to Equip as an in-network option. Equip offers Family-Based Treatment for eating disorders through a 5-person virtual care team including a therapist, dietitian, medical provider, peer mentor, and family mentor. Equip is designed to replace the residential level of care and support families throughout their journey to really be the last treatment they will need.
  • Horizon Blue Cross and Blue Shield of New Jersey is offering eligible members access to MindRight Health, a mental health coaching service that leverages texting to provide coaching and emotional support to young adults ages 13 to 25. Once users sign up on their phones (no face-to-face meeting or phone call required), they can receive guidance from a team of coaches supervised by licensed mental health clinicians.
  • Independence Blue Cross released a video featuring Independence and community experts discussing how the COVID-19 pandemic has changed the ways in which people think about mental health and access behavioral health services. The video discussed changes in the workplace, the increased use of telemedicine, persistent disparities in health care, and how Independence can support young people who have suffered losses during this time.
  • Independent Health highlighted the mental and physical health benefits of yoga at the 2nd annual Yogathon for Suicide Awareness & Prevention, presented in conjunction with Power Yoga Buffalo. The Yogathon helped raise awareness of suicide prevention as well as funds to benefit mental health programs at Mental Health Advocates of WNY.
  • Independent Health has been awarded the 2022 platinum Bell Seal for Workplace Mental Health by Mental Health America (MHA). The Bell Seal is a workplace mental health certification that recognizes employers who strive to create mentally healthy workplaces for their employees. Independent Health is the only organization in Western New York to be certified by MHA. Independent Health’s status as a platinum-level Bell Seal-certified organization demonstrates the company’s ongoing commitment to employee mental health and well-being, which in turn is instilled in the company’s wellness and mental health programming for its employer groups and members.
  • Kaiser Permanente has awarded a 2-year, $125,000 grant to the Boulder Valley School District to bolster ongoing efforts to increase mental health among teachers, staff, students, and their families following the recent Marshall Fire. The grant will help the district expand an existing Kaiser Permanente initiative called Resilience in School Environments, or RISE. The program provides emotional support and trauma-informed training to staff members, who then help other staff members and students. The grant will extend support for staff members, students, and families who are experiencing traumatic stress following the Marshall Fire.
  • A mental health initiative developed by Kaiser Permanente and esports organization Cloud9 has been found to be an effective way of supporting the mental health of young adult esports players and fans, according to a new study from the NEJM Catalyst. Presence of Mind launched in May 2020 with the goal of reaching teens and young adults with positive mental health messages in places where they spend a lot of their time: online gaming and esports platforms. The initiative includes 2 seasons of live Twitch Stream series featuring prominent players; mental health experts and influencers; creator-led YouTube video content from some of esports’ favorite players sharing insights, positivity, and personal mental health messages; and a series of free, online interactive training sessions to help address critical mental health issues. As of May 2022, the training sessions have been accessed by more than 51,000 teens and young adult gamers who have learned how to better manage their mental health and support their friends when they need it most.
  • A telehealth program at Kaiser Permanente Northern California (KPNC) is expanding support for people with serious, persistent mental illness by adding psychiatric clinical pharmacists to their care teams. The care teams deliver a package of comprehensive care for a highly vulnerable patient population, who are more likely to have chronic conditions such as diabetes and hypertension and a lifespan shortened by 10 to 25 years. The program takes advantage of a growing workforce of clinical pharmacists with 2 years of postgraduate training in psychiatry. Working closely as a team with the patient’s psychiatrist and other clinicians, clinical pharmacists act as care navigators, establishing an ongoing partnership with patients through regular video and telephone appointments.
  • Kaiser Permanente adult members in Colorado now have access to a 90-day subscription to Ginger, an on-demand mental health care solutions provider. Ginger provides confidential emotional support through on-demand coaching via text-based chats and skills-building content. Eligible members can use their smartphone to connect with a highly trained emotional support coach 24/7 — at no cost and with no referral or appointment needed. The private, one-on-one texting sessions provide support in coping with common challenges such as managing stress or getting better sleep.
  • Kaiser Permanente in Hawaii has awarded a $500,000 grant to Mental Health America of Hawaii to support its youth resilience and wellness training and education program. The program will provide 1,300 youth and youth-serving adults with evidence-informed suicide prevention and bullying prevention training over 6 months and will enable Mental Health America of Hawaii to increase training to individuals in rural areas of Oahu, Hawaii Island, and Kauai.
  • Magellan Healthcare will hold a series of virtual events in support of Suicide Prevention Awareness Month and Recovery Month in September. Magellan will host events Sept. 14 and 22 focused on suicide prevention, and recovery from mental health and substance use conditions.
  • Magellan Health, Inc. has opened a complimentary 24-hour crisis line for individuals impacted by gun violence in Chicago and surrounding communities. Magellan confidential consultation services are offered at no charge to the communities to assist individuals as they work to cope with the feelings of fear, sadness, anger, or hopelessness related to these kinds of incidents. Crisis line callers may also seek information and guidance to other available resources, such as community-based support.
  • Magellan Health subsidiary Magellan Federal has launched a program that provides United States military families with personalized, digital mental health and well-being support by combining NeuroFlow’s technology with evidence-based resources and clinical support provided by Magellan Healthcare. The 18-month long first phase will be launched on three installations through the Military & Family Life Counseling (MFLC) program. NeuroFlow will supplement Magellan’s MFLC counseling services to provide service members and their spouses with personalized, self-directed mental health resources, tools, and support, all from a smartphone. Member usage of NeuroFlow will also produce de-identified, population-level data to highlight mental health trends at each installation without compromising an individual service member’s privacy.
  • Magellan Health has opened a complimentary 24-hour crisis line for individuals impacted by the elementary school shooting that occurred in Uvalde, Texas. The line is available to all Superior HealthPlan members and the local community. The toll-free number to access free, confidential consultation services is 1-800-327-7451. Magellan confidential consultation services are offered at no charge to the community to assist individuals as they work to cope with the feelings of fear, sadness, anger, or hopelessness related to these kinds of incidents.
  • Magellan Healthcare has launched a Digital Emotional Wellbeing program that helps members improve overall health and wellbeing, manage stress, and build resilience in a confidential manner. Participating Magellan members with emotional concerns who use the NeuroFlow app or website receive recommendations and have access to activities to help them improve their overall health. Activities include evidence-based videos, articles, and behavioral trackers, as well as Magellan’s digital cognitive behavioral therapy programs, FearFighter® for anxiety and MoodCalmer® for depression. These activities will provide members with personalized, self-directed behavioral health resources, tools, and support, all from the secure, anonymous convenience of NeuroFlow’s app and website.
  • Magellan Healthcare is offering resources to support the emotional wellness of first responders, health care workers, and the National Guard in Idaho who are serving on the front lines of the coronavirus pandemic. Magellan continues to make available a free, confidential 24-hour crisis line. This is available for all first responders, health care workers, and the Idaho National Guard citizen soldiers and airmen. Critical care workers coping with feelings of fear, sadness, anger and hopelessness can call the toll free 1-800-327-7451 (TTY 711) to speak directly with a licensed mental health clinician and receive information on community-based support.
  • Magellan Health launched eMbrace, an industry-first total wellbeing solution for employers with more than 500 employees, on April 1, 2022. The solution aims to help people move from suffering and struggling in their everyday life to thriving. eMbrace is built to address multiple areas of an individual’s life, proactively assessing if they are thriving, struggling, or suffering across six essential elements: career, social, financial, physical, community, and emotional. eMbrace also includes a special version of the Gallup® WellbeingFinder™ that offers employees a personalized wellbeing plan addressing all six elements. Employees are directed to services and resources that address their pressing needs first, from legal, financial, and identity theft services to digital cognitive behavioral therapy modules, coaching, and counseling.
  • Martin’s Point Health Care has released an update focused on helping men make mental health a priority. The update covers several steps men can take, including connecting with others, taking care of yourself, and talking to your doctor. Mental health struggles are linked to the increase in deaths related to alcohol and drugs, and 1 in 4 adults with mental health disorders also struggle with substance abuse.
  • Medica has introduced 2 new support programs to help simplify the mental health care experience and connect children and their families to the support they need. The Family Support Program provides clinical expertise and care navigation support to caregivers of children with complex mental health needs, while the Family Support Navigator is an interactive online tool that helps parents and caregivers find the right resources for children who may have autism or depression. Both programs are available to Medica members who have children with complex mental health needs.
  • MHS Indiana highlighted the mental health supports available to members, including access to MyStrength, a free resource that includes tools to hep reduce stress, anxiety, depression, and substance abuse. MHS also maintains a 24-hour crisis text line, where members can speak with trained crisis counselors, and offers members access to Teladoc for non-emergency issues.
  • Molina Healthcare of New Mexico has partnered with Pyx Health to expand access to behavioral health services for Molina’s Medicare members. Through a screening process, working with members and data, the Pyx Health platform gauges the emotional state of users. This data is then monitored by support staff that provides actionable recommendations for how to respond, such as calling a user to address their behavioral health needs or offering support during a rough time. By providing access to this platform, Molina will improve behavioral health outcomes for its members.
  • Molina Healthcare of California has partnered with WEconnect Health Management, giving Molina’s network providers access to the WEconnect Recovery mobile platform to support Molina members dealing with substance misuse and mental health challenges. The app provides a supportive environment to Molina’s Medi-Cal members engaged in the recovery process by delivering critical resources to their phones. WEconnect facilitates daily reminders, medical appointment alerts, and rewards milestones with incentives in the form of gift cards for CVS, Safeway, and Amazon, among others. Members also have access to mobile recovery meetings throughout the day and exclusive Molina-enabled peer recovery support services for on-demand, one-on-one support.
  • Molina Healthcare of California has partnered with BeMe Health, a digital behavioral health company, to provide Molina Medi-Cal members, ages 13 to 19, with access to digital tools, content, and support designed to tackle some of the most prevalent mental and social challenges facing today’s teens. The offering will provide young Molina members with activities, one-on-one coaching and more through an interactive mobile app designed to help teens feel acknowledged and empowered. The app features digital tools and interventions to teach teens coping skills, provide support for issues they may be facing, and offer engaging content that can help take the focus off daily struggles and challenges. In addition, teen members will have access to clinical services, with parental consent, and crisis support.
  • The MolinaCares Accord, in collaboration with Molina Healthcare of Washington, recently committed $400,000 to the University of Washington School of Nursing to help expand the behavioral health workforce in the state through the development and implementation of a blended family and psychiatric primary care curriculum for nurse practitioners.
  • The MolinaCares Accord, in collaboration with Molina Healthcare of Washington, has announced a $77,000 grant to SPARK, an organization dedicated to providing a career pathway for youth and students to become certified peer counselors in the state of Washington. The grant is just one component of MolinaCares’ Behavioral Health Initiative, an over $700,000 philanthropic effort to expand access to behavioral health care across Washington. The funds donated to SPARK will go toward the identification, outreach, training, and placement of youth peer supports in the state.
  • The Molina Healthcare Charitable Foundation, in conjunction with Molina Healthcare of Florida and in partnership with the Federation of Families of Central Florida, recently welcomed families to the MolinaCares Youth Festival. The event focused on supporting the growing number of young people and families affected by mental illness. This year, through a $15,000 grant from the Foundation, the Federation of Families of Central Florida is hosting monthly group meeting for teens and young adults centered on improving mental health. In those meetings, participants engage in activities and listen to speakers, while being encouraged to find creative outlets as part of the healing process.
  • The MolinaCares Accord, in collaboration with Molina Healthcare of Washington, has presented a $100,000 grant to support Compass Health’s Broadway Campus Redevelopment Project. The grant will help fund construction of a 72,000 square-foot facility that will expand community-based behavioral health care services and its workforce in northwest Washington. The grant is a part of The MolinaCares Behavioral Health Initiative to increase access to behavioral health across the state.
  • Eleanor Health, an outpatient addiction and mental health provider is collaborating with Point32Health on a program to support Tufts Health Plan MassHealth members with substance use disorders and other mental and physical health comorbidities. The value-based program uses a population health management model and provides patients with comprehensive care including access to medications for substance use disorder, psychiatry and mental health care, group and individual therapy, nurse care management and peer support.
  • Members of Regence Health Plans have access to a wide range of behavioral health care, from traditional in-person therapy to specialized virtual care. To improve access to care, Regence added more than 1,500 new behavioral health providers to its network in 2022. To support members in rural areas with little access to care, Regence has added virtual care providers available nationwide who specialize in everything from substance use disorder to individual therapy to child and family therapy, obsessive-compulsive disorder and more. Regence’s dedicated behavioral health team continually evaluates and contracts with virtual care providers that would add unique value to its array of resources for members seeking support. Regence is continuing an $11.5 million multi-year philanthropic initiative to increase access, improve quality of care, and reduce mental health stigma. Additionally, approximately $4 million of investments were made from its corporate foundation in 2021 to increase access to mental health support for people living in rural communities across Idaho, Oregon, Utah, and Washington.
  • Security Health Plan’s new partnership with Freespira, Inc., maker of the first FDA-cleared digital therapeutic treatment for panic attacks, panic disorder and post-traumatic stress disorder (PTSD), will provide many members with a clinical alternative to current treatments. Freespira works by addressing the underlying physiological factors behind panic attacks and post-traumatic stress disorder. As an adjunct to medications and counseling therapy, the treatment normalizes breathing irregularities developed in response to underlying carbon dioxide (CO2) hypersensitivity. The Freespira treatment provides users with real-time physiological feedback-based training to regulate their respiration rate and exhaled CO2 levels. Telehealth coaching guides patients throughout the 28-day care journey to deliver maximum benefits from the twice daily, 17-minute treatments.
  • Security Health Plan and Marshfield Medical Center-Rice Lake are investing in a mental health program from the Turtle Lake School District. School Pulse is an anonymous, interactive program that works to improve the mental health of students. The program provides social and emotional support to students through their cell phones and helps promote mental wellness and decrease suicide rates in young people. The School Pulse program uses texting to check in with students about their mental health 3 times a week, all year long. Students who wish to participate in the program will receive real-time help through open, anonymous communication through a platform that works just like texting.
  • Security Health Plan and Marshfield Clinic Health System are accepting applications from eligible school districts to implement b.e.s.t.® Universal Screening in the 2022-23 school year. b.e.s.t.® (Behavioral Emotional Social Traits) is an online screening tool designed to help education professionals build the emotional health of students and help identify students who may need additional positive behavioral support. The tool provides educators recommended actions to take with students based on their behaviors. Schools awarded a grant receive technical support, biannual screenings for students, and training consultation and support for teachers and staff.
  • Sharp Health Plan has released an update providing tips on finding the right mental health support. For example, there are many types of mental health professionals, including therapists and counselors, psychiatrists, and psychologists, all with distinct differences. Steps to take include thinking about your specific mental health needs, doing your research on what kind of mental health professional you’d like to see, and writing down question about things that are important to you before your appointment.
  • Sunflower Health Plan is partnering with the National Alliance on Mental Illness (NAMI) of Kansas to help increase access to educational resources for family members and supporters of those living with mental illness. Through the partnership, Sunflower will support NAMI’s Family-to-Family, a free, 8-session educational program for families, significant others, and friends of people with mental health conditions and Family Support Groups, peer-led support groups for adults with loved ones experiencing symptoms of a mental health condition. The groups allow family members to share their experiences and gain insight from the challenges and successes of others facing similar situations.
  • Sunshine Health recently sponsored the Volunteer Florida’s Healthy Minds Teen Summit, where roughly 75 Florida middle and high school student leaders gathered to talk about normalizing mental health as a critical self-care topic. Breaking the stigma was the number one topic for these teen leaders, who learned about strategies and resources to take back to their peers to help deal with everything from the stresses of everyday life, to dealing with severe trauma. Inspirational speakers helped motivate the teens and shared their stories about mental health. Former college basketball star turned business owner Iman MacFarland introduced three-time Olympic Gymnast Dominque Dawes.
  • Superior HealthPlan released a short video addressing mental illness and what Superior employees need to know about it. The video featured Dr. Sandy Vale, Superior’s lead behavioral health medical director, who talked about what mental illness is, warning signs, and potential treatments.
  • Sutter Health Plus members have premium access to Sanvello at no extra cost as part of their behavioral health care benefits through U.S. Behavioral Health Plan, California. Sanvello is an app that offers on-demand clinically proven techniques to manage symptoms of stress, anxiety, and depression as they happen. By answering a few questions in the Sanvello app throughout the week to assess mood and track activities like caffeine intake, sleep, and exercise, members can identify patterns in their behavior to make positive lifestyle changes. They can also create progress assessments using past mood and health ratings to discover new connections between their experiences and emotions.
  • Leaders at UCare and Kente Circle are seeking make it okay to discuss mental health issues with trusted barbers and stylists. The Confess Project – America’s First Mental Health Barbershop Movement – empowers frontline heroes to support their clients’ mental health and substance use disorder needs. The barbershop or hair salon is often a safe place for clients to discuss their concerns and needs. Armed with the Confess Project training, barbers and stylists will be able to say: “I am more than a pair of clippers. I am improving my community through the barber chair one client at a time.”
  • UCare and mental health providers Alluma and the Amherst H. Wilder Foundation have developed a pilot program to make it easier for prospective mental health professionals to join the field. Through the partnership, UCare will fund $100,000 in stipends for clinical interns as they complete the supervision necessary to graduate from and eventually be licensed in social work, clinical counseling, marriage and family therapy, and other mental health roles. Wilder and Alluma will provide thousands of hours of state mandated supervision at no cost. The pilot will focus on supporting clinical interns from cultural and ethnic minority groups, rural communities, and other underrepresented populations where the workforce needs are greatest.
  • UPMC Health Plan’s Special Needs Plan Severely Mentally Ill team provides community-based care management services to members with a serious mental illness diagnosis. The team services those with the highest needs of physical health and behavioral health indicators as identified by physical, behavioral and pharmacy claims utilization data in a rolling 12-month period. Goals of the program include: care integration for member physical health and behavioral health conditions, development of self-management skills and improved quality of life. Outcomes include improved HEDIS measures, as well as reductions in Emergency Department visits and inpatient admissions. UPMC’s Community Care Behavioral Health Organization, part of the UPMC Insurances Division, is also working with stylists and barbers to develop an innovative community engagement initiative known as Health Access Initiative for Recovery (Our HAIR). This initiative centers on partnering with barbers and stylists in Pittsburgh to build up black and brown communities through increasing familiarity with, comfort around and connection to resources related to behavioral health concerns seen within hair care settings. In the Our Hair initiative, hair stylists/barbers will have an opportunity to participate in a program that teaches them how to talk about and provide resources for mental health and drug/alcohol/substance use concerns within their communities. The goal is to increase engagement, education, and resource dissemination about behavioral health issues within historically underserved communities and to decrease the behavioral health care disparities between Black and White members.
  • UPMC Health Plan provides support to parents as they build resilience with their children to cope with the stresses of the pandemic and beyond. Teaching children the cognitive mental health techniques they need to excel will enhance their strength to overcome common psychological responses (such as insomnia or fear), health risk behaviors, and mental health conditions like depression and anxiety. UPMC providers continue to offer in-person and virtual appointments for members and UPMC Health Plan has several additional resources to assist in addressing children, youth, and parent/guardian behavioral health needs. RxWell, for example, is UPMC Health Plan’s evidence-based mobile app for ages 16 and older to help members become emotionally and physically healthy by building better lifestyle habits. The app combines health coaching support with provider-endorsed techniques, including self-guided exercises and other tools to help members manage stress, anxiety, and depression and reach their health-related goals. Currently there are 7 programs to choose from based on a member’s needs: Depression, Anxiety, Stress, Weight Management, Nutrition, Physical Activity, and Ready to Quit (tobacco cessation).
  • A team of investigators from UPMC Children’s Hospital of Pittsburgh found that a digital application may remove barriers to mental health care and is associated with reduced emotional distress when offered as part of routine pediatric care. The findings were published in Psychiatric Services. UPMC initially studied RxWell™, a digital application developed by UPMC Health Plan to support its members with management of depression and other health and wellness challenges and published positive outcomes in adult users.

NEW RULES:Bans on balance billing and out-of-network cost-sharing

Effective Jan. 1, 2022, Health Plan commercial members will be protected from balance billing after receiving emergency care and nonemergency care from certain out-of-network providers at in-network facilities. The No Surprises Act, which is included within the Consolidated Appropriations Act of 2021 (the CAA), provides the following:

Effective Jan. 1, 2022, Health Plan commercial members will be protected from balance billing after receiving emergency care and nonemergency care from certain out-of-network providers at in-network facilities. The No Surprises Act, which is included within the Consolidated Appropriations Act of 2021 (the CAA), provides the following:

Bans surprise billing for emergency services

If a member receives emergency services, they will be covered at the in-network rate, and the services do not require prior authorization from Health Plan. This is true even if the services are received at a facility or from a provider that does not participate in their network. Additionally, members will be protected from balance billing when receiving post-stabilization services at a nonparticipating facility.

Bans balance billing and out-of-network cost-sharing for emergency services as well as certain nonemergency services performed by a nonparticipating provider (or facility on behalf of the provider) at participating health care facilities including out-of-network ancillary providers such as pathologists, anesthesiologists, and radiologists at in-network facilities: 

In these situations, the member’s cost share cannot be higher than the cost share would have been if the services were provided by an in-network provider or an in-network facility. The member’s cost share must be based on the in-network rates.

Bans balance billing for out-of-network air ambulance service

Carenodes Behavioral Health Case Management

ETHOS AND PROGRAM DESIGN

The central premise of the Carenodes Behavioral Health Case Management (BHCM) Program is to promote collaboration between all treating providers, ensuring coordination between medical care and behavioral health care. Once members are identified, Behavioral Health Care Managers outreach / consult with our community partners in medical and behavioral health practice settings. Our program supports the treatment planning needs of providers with respect to behavioral health services and often provides consultation/ suggestions for modifications in current care. This coordination is performed through various avenues including

  • Notification letters to physicians informing them that their patients are engaged with the program,
  • Telephonic outreach calls,
  • Opportunity/option for physician peer-to-peer consultation when needed.

The essence of behavioral health management is ensuring that we direct our members to the right services at the right time.

Our triage and tracking processes include specialized support during service level transitions, such as a discharge from inpatient to outpatient follow-up treatment to ensure that members are attending follow up appointments with community providers within 7 days of hospital discharge. In addition, we utilize a readmission risk algorithm, which identifies members most at risk for readmission to inpatient hospital care. Specialty services are also offered to members diagnosed with eating disorders, maternal mental health issues, families of children and adolescents with a recent inpatient psychiatric stay, and members referred from community providers affiliated with Enhanced Personal Health Care. Also, consenting members engaged in medical care management programs with a positive PHQ2 depression screen or any other BH condition impeding the member’s ability to manage their medical condition are routed to BH for intervention.

Clinical Team/Patient/Family Engagement

Our clinicians work with the member and their family to:

  • Understand the options available for behavioral health treatment, utilize insurance benefits for the lowest possible out of pocket cost, and decrease unnecessary health care expenditures
  • Advocate for the coordination of all care, both medical and behavioral health
  • Educate on symptoms and condition management to prevent future inpatient hospitalization stays
  • Discuss and identify barriers to treatment compliance and offer resources and support to overcome them
  • Improve overall health outcomes for improved quality of life

1-Minute Pro Tip: How to Handle Claim Denials from Private Insurance Companies

Before challenging a claim, examine the reason for your denial. The reason for the payer’s denial can be found on the Explanation of Benefits or EOB. In some cases, the denial may have been caused by a clerical error such as an incorrect CPT code, a missing signature, or another simple oversight.

Before challenging a claim, examine the reason for your denial. The reason for the payer’s denial can be found on the Explanation of Benefits or EOB. In some cases, the denial may have been caused by a clerical error such as an incorrect CPT code, a missing signature, or another simple oversight.


A denial of coverage because a PA performed the service is usually phrased as “service only covered when provided by an M.D. or D.O.” or “physician assistants not considered authorized providers under the plan.” In some cases, first assisting at surgery claims are denied for incorrect use of modifier codes (Do not assume that all companies use the same code; some use -AS, some use -80, -81, or -82.) and in other cases, those claims are denied because of the use of a restricted code or for performing a surgery not necessarily requiring a first assistant.


You may need to contact the insurance company to find out what modifier should have been used and, in some cases, you may need documentation that a first assistant was medically necessary for the surgery. Insurance companies strive to (1) retain their subscribers, (2) maintain or increase their market share, and (3) keep a positive corporate image. If the insurance company made the coverage decision and you believe that the coverage decision was unfair, enlist the help of the patient and, if applicable, the business that pays the insurance plan’s premium. Their dissatisfaction is

Sample Letter: Enlisting Patients Assistance for Claims Payment

Enlisting patient assistance in health insurance claims payment issues.

Date

_____________
_____________
_____________
_____________

RE: Outstanding Health Insurance Payment  

Dear Patient:

I am writing you concerning an issue that has arisen between [ patient’s insurance carrier ] and our office concerning payment for the services provided to you on [ date of service ].”   We have made all reasonable attempts to collect from your insurance company and have not been successful.

PATIENT MESSAGING


[Explain the reason the plan has given for not paying you, or not paying you on time. Stick to the facts. Tell the patient you’re puzzled by the plan’s contention, and that you would appreciate their help in resolving any issues. If the plan’s policy is that the patient is ultimately responsible for the full cost of care, state that.]


We would appreciate your assistance in resolving this matter by:

  • Calling your insurance company directly and asking that the claim in question be paid immediately; and,
  • By asking your employer’s human resources staff to intervene.

Should you or your employer have any questions, please do not hesitate to contact our office at [practice contact and telephone number].

Thank you very much for your assistance and we appreciate your continued business.

Sincerely,

c: [ Name of Insurance Carrier ]

Updates to UnitedHealthcare Cost-Share Waivers

To ensure members are able to access the care they need as the COVID-19 pandemic continues, UnitedHealthcare is expanding cost share waivers for our Medicare Advantage and Individual and Group Market health plans for certain services. Here’s a high-level

The following provides healthcare providers and patients with information surrounding cost-share (copays, etc.) and applicable policies as enacted by United Healthcare (UHC).

Not ALL patients covered by UHC are implicated — please read the line of business (Medicare, type of commercial insurance, etc.) before making potentially detrimental changes in your cost-share collections.

PRIMARY CARE PROVIDERS WITH UHC PATIENTS, NEW POLICIES APPLY TO YOU

To ensure members are able to access the care they need as the COVID-19 pandemic continues, UnitedHealthcare is expanding cost-share waivers for our Medicare Advantage and Individual and Group Market health plans for certain services. Here’s a high-level summary of the changes.

New! Medicare Advantage Primary Care
Care Oct. 1, 2020 through Dec. 31, 2020, UnitedHealthcare is waiving cost share for Medicare

New! Medicare Advantage Primary Care
From Oct. 1, 2020 through Dec. 31, 2020, UnitedHealthcare is waiving cost share for Medicare Advantage plan members for primary care professional services. This applies to in-network and covered out-of-network COVID-19 and non-COVID-19 visits, whether they are conducted in-office or via telehealth.

Telehealth Originating Site Requirements (no changes since 9/28/20)

Telehealth Originating Site Requirements (no changes since 9/28/20)

The updates to originating site requirements that we announced on Sept. 28, 2020 have not changed.

  • Individual and fully insured Group Market health plans:
    • For Individual and fully insured Group Market health plans, there are changes related to COVID-19 and non-COVID-19 telehealth visits, as well as for in- and out-of-network providers. You’ll also find state-specific rules, regulations and emergency periods on the State Provision Exception page. These may vary from federal regulations. If no state-specific exceptions apply, UnitedHealthcare guidelines will apply.
      • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020.* This means health care professionals can temporarily provide telehealth services by a live interactive audio-video or audio-only communications system for members at home or another location. For more details on telehealth billing guidance and provider type eligibility, visit UHCprovider.com/covid19.
      • COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ends Oct. 22, 2020. As of Oct. 23, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.*
      • Non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ended July 24, 2020. As of July 25, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.

Medicare Advantage:

  • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020. Any originating site requirements that apply under Original Medicare are temporarily waived, so that telehealth services provided through live interactive audio-video can be billed for members at home or another location.
  • COVID-19 and non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access is extended through the national public health emergency period, currently scheduled to end Oct. 22, 2020.*
Medicare Advantage COVID-19 Treatment

Cost share waivers (copay, coinsurance and deductible) for COVID-19 testing and testing-related visits are extended through Dec. 31, 2020 for our Medicare Advantage health plans. This applies to in-network and covered out-of-network COVID-19 treatment.

COVID-19 Treatment

Individual and Group Market health plans:

Cost share waivers (copay, coinsurance and deductible) for in-network COVID-19 treatment are extended through Dec. 31, 2020. Out-of-network cost share waivers will end Oct. 22, 2020. Implementation for self-funded customers may vary.

Medicare Advantage:

Cost share waivers (copay, coinsurance and deductible) for COVID-19 treatment are extended through Dec. 31, 2020. This applies to in-network and covered out-of-network COVID-19 treatment.

COVID-19 and non-COVID-19 out-of-network telehealth visits:
  • Individual and fully insured Group Market health plans: For Individual and fully insured Group Market health plans, there are changes related to COVID-19 and non-COVID-19 telehealth visits, as well as for in- and out-of-network providers. You’ll also find state-specific rules, regulations and emergency periods on the State Provision Exception page. These may vary from federal regulations. If no state-specific exceptions apply, UnitedHealthcare guidelines will apply.
  • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020.* This means health care professionals can temporarily provide telehealth services by a live interactive audio-video or audio-only communications system for members at home or another location. For more details on telehealth billing guidance and provider type eligibility, visit UHCprovider.com/covid19.
  • COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ends Oct. 22, 2020. As of Oct. 23, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.*
  • Non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access for out-of-network providers ended July 24, 2020. As of July 25, 2020, out-of-network telehealth services are covered according to the member’s benefit plan and UnitedHealthcare’s telehealth reimbursement policy.

Medicare Advantage:

  • COVID-19 and non-COVID-19 in-network telehealth visits: The expansion of telehealth access is extended through Dec. 31, 2020. Any originating site requirements that apply under Original Medicare are temporarily waived, so that telehealth services provided through live interactive audio-video can be billed for members at home or another location.
  • COVID-19 and non-COVID-19 out-of-network telehealth visits: The expansion of telehealth access is extended through the national public health emergency period, currently scheduled to end Oct. 22, 2020.*