New law advances integrated care by including psychologists as behavioral health clinicians in patient-centered primary care homes and behavioral health homes.

A recent Oregon law provides for psychologists’ role in integrated behavioral health in primary care and behavioral health homes and allows interns and residents in these settings to bill for services for Medicaid patients. On July 28, 2015, Oregon Governor Kate Brown signed Senate Bill 832 into law. This bill sponsored by the Oregon Psychological Association is an achievement for behavioral health integration in general, and the field of psychology in particular. 

This bill is a model for legislation promoting one of the stated goals of the Affordable Care Act (ACA): integrating behavioral and mental health into primary care. It defines “behavioral health clinicians” as a broad base of providers who can provide care in these primary care and behavioral health homes, including licensed psychologists, professional counselors and others who are able to treat mental illness within their scope of practice. 

This bill will allow behavioral health clinicians to work within Oregon’s coordinated care organizations (CCO), which generally administer Medicaid services for the State of Oregon. The legislation elevates the role of psychology in these integrated settings. 

Robin Henderson, PhD, a psychologist and chief of behavioral health officer and vice president of strategic integration for St. Charles Health System, was a major supporter who helped draft this legislation and worked to push it through the Oregon legislature. Henderson has been instrumental in working with the APA Practice Directorate and Practice Organization’s Office of Legal and Regulatory Affairs on a variety of issues, including integrated care, hospital practice and Medicaid expansion.

Medicaid advocacy

APA and the APA Practice Organization’s (APAPO) Legal and Regulatory Affairs Office (LRA) and APA’s Education Directorate have made it a priority to remove barriers for psychologists’ and interns’ full participation in the Medicaid system — thereby enhancing care for the underserved Medicaid population. 

Because Medicaid is a state-based program, LRA has supported several state-level initiatives by providing resources and APA Practice Organization grants. APAPO grants and staff attorneys have supported states such as Minnesota, Missouri, Wyoming, Kentucky and Mississippi in their pursuit of psychologist inclusion in Medicaid expansion, the reimbursement of health and behavior (H&B) codes and issues involving reimbursement rates. 

Additionally, LRA and the Education Directorate have joined forces in order to work with state associations to attain the full inclusion of psychologists and doctoral psychological interns in state Medicaid programs. Both directorates provided support to the Arkansas Psychological Association in achieving reimbursement for the services provided by doctoral psychology interns in Medicaid in the state.

The Practice and Education Directorates created a Policy and Advocacy fellowship in order to work to remove these barriers to psychological services in Medicaid and help correct the internship imbalance by increasing the financial sustainability of internships through Medicaid reimbursement for interns. In coordination with LRA attorneys and Education staff, the fellow will work with representatives of state psychological associations and with the education community (for example, internship directors) to develop and implement strategies to increase the sustainability of internship programs. 

This will include advocating for reimbursement from Medicaid for psychological services provided by doctoral psychology interns supervised by licensed psychologists. The fellow is also exploring avenues to create reimbursement for independently practicing licensed psychologists and their ability to bill using health and behavior (H&B) codes. 

These three provisions are closely linked. Expansion of independent practice for psychologists in Medicaid can increase available internship sites, and utilization of H&B codes helps achieve the integration of psychology into the primary care setting to help meet the mental health needs of the growing Medicaid population expanded under the Affordable Care Act. As of Sept. 11, 2015, 30 states plus the District of Columbia have adopted Medicaid expansion under the Affordable Care Act. One state is still debating the matter, and 19 have elected not to expand Medicaid.

Since the fellowship began, LRA has worked to identify a series of key states with which to work to remove the barriers to the independent practice of psychology, utilization of H&B codes, and intern reimbursement. Currently, there are six state psychological associations with which APA will be working on these important Medicaid issues as they relate to psychologists and patient access to psychological services.  

As part of this initiative between Education and LRA, the fellow and LRA attorneys are working in collaboration with the District of Columbia Psychological Association and the D.C. Behavioral Health Association (an association for D.C. community mental health centers) to develop advocacy strategies that will improve mental health access for D.C. Medicaid beneficiaries in the district. Issues include: reimbursement of psychologists in independent private practice for the provision of psychological services; increasing the provision of psychological services under the existing system; payment for the utilization of H&B codes; and reimbursement for Medicaid services provided by psychological interns under supervision.