The Centers for Medicare & Medicaid Services (CMS) issued new guidance to clarify that state Medicaid and CHIP programs will be able to pay specialists directly when a beneficiary’s primary healthcare provider asks for advice. The aim is to help improve access to specialty care, particularly mental health care services. Citing FORHP-supported research, CMS notes that, “Rural areas face the most significant provider shortage challenges; more than 60 percent of nonmetropolitan counties do not have a psychiatrist and almost half of the nonmetropolitan counties do not have a psychologist.” Up to now, providers referring a patient to specialty care were required to coordinate payment through separate agreements with the treating practitioner. The new policy gives state-level Medicaid and CHIP agencies the flexibility to reimburse consulting practitioners directly. Importantly, these consultations can occur when the beneficiary is not physically present. To be covered under Medicaid or CHIP, both the treating practitioner and the consulting practitioner must be enrolled in Medicaid or CHIP. For consultations that cross state lines, consulting practitioners must be enrolled in Medicaid or CHIP providers in the state in which the beneficiary resides. For more information, see the State Health Official Letter available on Medicaid.gov.
