Medicaid Unwind

Medicaid Unwind Should Not Be the Undoing of the Community Mental Health System

By Jay Couture

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For the ten community mental health centers (CMHCs) in New Hampshire, Medicaid is the primary source of revenue and has been for many years. Unlike hospitals and other health care providers, which receive less than 20% of their revenue from Medicaid, the non-profit CMHCs receive between 80% and 90% of their funding from this source. This means that changes in the state’s Medicaid program are felt most acutely by the community mental health system, and changes in revenue that the CMHCs receive can be devastating.

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When the Public Health Emergency (PHE) was declared at the start of the COVID pandemic in January 2020, one safeguard offered was to protect individuals on Medicaid from losing coverage, to ensure continuity in access to care.? This provided a level of health care security that was critically important to covered individuals, particularly those with mental illness served by the CMHCs.? But when the PHE ended in March 2023, that safeguard ended as well.? This happened just as NH was seeing both a skyrocketing increase in the demand for mental health services and a workforce shortage at CMHCs and other mental health and health care facilities.

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While a process called “unwinding” was planned by the State with the intention of having the smoothest redetermination process possible, thousands of individuals in New Hampshire have lost Medicaid coverage during the past year. Some are still eligible but have not made it through the approval process, for any number of reasons. At Seacoast Mental Health Center, 898 patients have been disenrolled or ultimately closed; this represents almost 35% of our Medicaid population. This also represents a very significant loss of Medicaid revenue for Seacoast - a decline of $1.1 million through 01/31/2024 compared to FY23.

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Recently, Patricia Carty, President and CEO of the Mental Health Center of Greater Manchester, reported similar numbers to the State’s Medical Care Advisory Committee (MCAC). Since the unwind began, through 12/31/2023, Manchester’s CMHC has seen 1,506 patients disenrolled or ultimately closed, and the Center’s Medicaid revenue decline compared to FY23 is $2,946,167.

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As state-designated community mental health centers, we are not able to just close out these cases. These individuals were already in treatment when they lost their coverage. Individuals are deemed eligible based on diagnosis and functional impairment as defined in administrative rules and State law requires that the CMHCs provide services without regard to ability to pay.

The effect is that New Hampshire’s non-profit community mental health centers are now caring for thousands of individuals whose care is not being paid for, creating an unsustainable financial situation. Although there was a significant investment made last year in a Medicaid rate increase for the CMHCs, those funds cannot be used to care for these non-Medicaid patients.

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In addition, some individuals served by CMHCs are on Conditional Discharges from an involuntary admission that require them to continue treatment or be readmitted to a designated receiving facility such as New Hampshire Hospital.? In reality, given the shortage of beds for psychiatric crises, discontinuing outpatient treatment would mean a trip to the emergency department to await admission when a bed becomes available. Some individuals would be at increased risk of suicide without the treatment and supports they need for a successful treatment journey.

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Also, individuals with a Medicaid spend down - a deductible each month before Medicaid becomes active - no longer have that waived, which has only increased the burden on CMHCs who provide services with little to no compensation until the spend down is met. Staff vacancies and turnover rates continue to be high, with five of the ten CMHCs reporting 12-month turnover rates greater than 20%, as of January 2024.? Staff surveys reflect a post-COVID workforce that wants a different work/life balance, lower productivity expectations, and higher compensation to keep up with inflation.?

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The State needs to take immediate action to respond to this dire situation and develop a plan to address the very significant financial impacts of the Medicaid unwind on the ten CMHCs. There have been many unforeseen consequences of the COVID pandemic. Let’s not let one be the undoing of the NH community mental health system.

Jay Couture is President and CEO of Seacoast Mental Health Center in Portsmouth. She lives in Rye.