Nevada Medicaid is pausing enrollment for two types of behavioral health-care providers beginning Saturday while the agency develops new rules aimed at curbing fraud and abuse within the state-run insurance program.

For the next six months, Medicaid will not enroll any new lower-level mental health providers, known in Nevada as Qualified Mental Health Associates and Qualified Behavioral Health Aides, as it seeks input on what additional qualifications or oversight should be imposed on them. The moratorium comes amid Medicaid’s ongoing effort to respond to an executive audit earlier this year that identified inappropriate billing practices for behavioral health-care services and in the wake of intense backlash against state efforts to limit certain therapy services.

Medicaid Acting Administrator Cody Phinney said that under the existing rules, mental health associates and aides may not have the experience or training needed to carry the responsibilities of their positions. She said that the moratorium will give the state some “breathing room” as it rethinks how it certifies the lower tiers of mental health providers.

“It’s not that people are malicious, but if they don’t have adequate training, they may be doing something that they think is helpful that isn’t helpful,” Phinney said.

Phinney said Medicaid decided to examine possible changes to the two provider types after a series of focus groups this summer highlighted issues with the less-than-stringent requirements on certain mental health professionals. The focus groups were a direct response to outcry over a short-lived proposal to require psychologists, therapists and other mental health professionals to provide extensive documentation to the state in order to offer more than three therapy sessions with a patient.

“This was part of the information that was reflected to us from providers in the community, that what we really needed were some stronger, more specific requirements for people as they come into the field,” Phinney said.

As of Nov. 1, there were about 1,600 Qualified Mental Health Associates and 1,200 Qualified Behavioral Health Aides certified with Medicaid, according to data provided by the state. The moratorium will not affect already enrolled providers so long as they re-enroll on time, Phinney said.

Under the current model, Qualified Mental Health Associates function as “extenders” for therapists, Phinney said. They are responsible for identifying issues with patients, participating and developing treatment plans, and even providing parenting skills training, and are required to be licensed as a registered nurse or hold a bachelor’s or associate’s degree in a related field with some additional requirements.

On a lower tier are the Qualified Behavioral Aides, who are only required to complete 16 hours of training and hold a high-school degree to be certified. Phinney said the aides are supposed to provide direct assistance to patients under the supervision of a higher-level professional, but that Medicaid has found that its policy wasn’t specific enough in outlining the qualifications for those individuals.

“It has been interpreted more loosely,” Phinney said. “We need to make sure we are clear about what it is we need and expect and that we have enough capacity to oversee things so that it’s not wasteful and everybody is safe. Our big concern is that everybody is safe and everybody is getting services that really accomplish the goal.”

Phinney said that “everything is on the table” as it relates to potential changes to the two provider positions, though she highlighted Washington as a state Nevada could possibly model itself after. Washington requires workers who fall into two provider categories similar to Nevada’s to pass state-approved exams and complete extensive training, and also limits the scope of practice for each type of worker.

“We’re very sensitive to the fact that we want feedback from the community about how to do this right for Nevada … This is one path,” Phinney said. “But we really want to come up with what works best for Nevada.”

She said that Medicaid will have additional public meetings to craft a proposal, but that it is also planning to lean on the Bureau of Health Care Quality and Compliance and the state’s various licensing boards for guidance. Phinney expects that the process will take Medicaid the full six months of the moratorium, though she said it’s possible Medicaid could reach a solution sooner.

Until the moratorium is lifted, no new providers will be able to enroll with the state, something Phinney said is designed to prevent providers from enrolling with either provider type only to be disqualified a few days later but also to give the state time to design an appropriate fix.

She said the state also has mechanisms in place that would allow it to consider provider applications on a case-by-case basis as to not create a problem with access to services. Over the last year, Nevada enrolled an average of about 20 Qualified Mental Health Assistants and about 21 Qualified Behavioral Aides a month, according to state data.

In addition to the moratorium, Phinney said Medicaid is working through other changes recommended by the focus groups, including revisions to enrollment for certain kinds of therapy services and clarifying policies with providers.

“We’re seeing a lot of good outcomes from that, as far as things becoming more clear and more consistent,” Phinney said. “We certainly want to hear from anybody who is having challenges, and we are available to help them work through any challenges.”

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Medicaid to pause mental health associate, aide enrollment as new requirements considered – Elko Daily Free Press