Skip to main content
Robert Wood Johnson Foundation
  • Our Vision
    • Our Vision Overview
    • Why Health Equity
    • Focus Areas
    • Measuring RWJF Progress
  • Grants
    • Grants Overview
    • Active Funding Opportunities
    • Awarded Grants
    • Grantee Stories
    • Grant Process
    • Grantee Resources
  • Insights
    • Insights Overview
    • Blog
    • Our Research
    • Advocacy And Policy
  • About RWJF
    • About RWJF Overview
    • Our Guiding Principles
    • How We Work
    • Impact Investments
    • Staff And Trustees
    • Press Room
    • Careers
    • Contact Us
    • Accessibility Statement
Find A Grant
Global Search Dialog
    Robert Wood Johnson Foundation
    • Our Vision
      • Our Vision Overview
      • Why Health Equity
      • Focus Areas
      • Measuring RWJF Progress
    • Grants
      • Grants Overview
      • Active Funding Opportunities
      • Awarded Grants
      • Grantee Stories
      • Grant Process
      • Grantee Resources
    • Insights
      • Insights Overview
      • Blog
      • Our Research
      • Advocacy And Policy
    • About RWJF
      • About RWJF Overview
      • Our Guiding Principles
      • How We Work
      • Impact Investments
      • Staff And Trustees
      • Press Room
      • Careers
      • Contact Us
      • Accessibility Statement
    Find A Grant
    Global Search Dialog

      Marketplace Pulse: Differences in Cost-Sharing Create Barriers to Mental Healthcare in Medicare Advantage

      Brief Feb-01-2024 | Katherine Hempstead | 4-min read
      1. Insights
      2. Our Research
      3. Marketplace Pulse: Differences in Cost-Sharing Create Barriers to Mental Healthcare in Medicare Advantage
      RWJF Staff Profile
      Staff portrait of Katherine Hempstead

      Katherine Hempstead

      RWJF Senior Policy Adviser
      Learn more about Katherine

      The Marketplace Pulse series provides expert insights on timely policy topics related to the health insurance marketplaces. The series, authored by RWJF Senior Policy Adviser Katherine Hempstead, analyzes changes in the individual market; shifting carrier trends; nationwide insurance data; and more to help states, researchers, and policymakers better understand the pulse of the marketplace.

      With the growing popularity of Medicare Advantage (MA) plans has come increased criticism from policymakers and advocates. There has been a longstanding critique about whether insurers use the risk adjustment system to overpay themselves, reflected in a recent report from the Medicare Payment Advisory Commission (MedPAC), which projected that the combined effects of coding intensity and favorable selection will lead the government to spend $88 billion more on Medicare Advantage in 2024 than they would in traditional Medicare. The payment incentives that shape the growth and design of MA plans have important implications for racial equity among Medicare beneficiaries, since Black and Latino beneficiaries are disproportionately likely to enroll in Medicare Advantage, and have been shown to have less access to high-quality plans.

      Regulators are more actively scrutinizing communications with consumers, rejecting some advertisements for being misleading, and changing rules about how brokers are compensated. There has also been a rising chorus of concern about how MA plans manage utilization. Some of it has centered on prior authorization and denials. An explosive series of recent reporting focused on Optum's strict adherence to a model that dictated the length of time spent in post-acute care. Former employees reported that required compliance with an algorithm required them to make uncomfortable tradeoffs between patient care and their own performance ratings. Other investigations have found that many services are summarily denied, even if they would be approved in traditional Medicare. When patients appeal, they are likely to win. Provider networks in MA plans have also been criticized for being overly narrow and for containing non-existent providers.

      An important focus of complaints about Medicare Advantage concerns access to behavioral health services. This is part of a general concern throughout the healthcare system that access to mental healthcare is inadequate. Recently, the Biden Administration released a proposed rule to make it more difficult for plans to evade their responsibility under the Mental Health Parity and Addiction Equity Act of 2008. However, Medicare is not subject to the Parity Act, meaning that some of the constraints that bind Medicaid, employer insurance, and the individual market do not apply to Medicare Advantage plans.

      One issue is a shortage of behavioral health providers who are willing to see Medicare enrollees, leading to the recent change to allow marriage and family therapists and mental health counselors to participate in Medicare. This may have a disproportionate impact on communities of color, who are more likely to be enrolled in plans with lower quality ratings and potentially more narrow networks. For MA enrollees, this provider shortage can be compounded by narrow provider networks. A recent study found that psychiatrist networks in MA plans were narrower than in Medicaid and individual market plans. Congress and the Administration are considering additional measures to increase network adequacy.

      Policymakers seeking to increase access to mental health services may also wish to consider patient cost-sharing, which is another component of plan design that can impact access to care. Previously we have reported on cost-sharing in the individual market, where mental health visits often cost patients more than primary care visits. In fact, we found that nearly 20% of silver plans in 2024 had higher copays for a mental health visit.  

      In the case of Medicare Advantage, these differences in copays are far greater. Using data from Ideon, we analyzed nearly 6,000 MA plans on the market in 2024. Higher coinsurance for mental health visits in Medicare was eliminated in 2008, but nearly 90% of MA plans require copays for both mental health and primary care visits. In 80% of these plans, the copay for mental health visits is higher than the copay for a primary care visit. The differences are substantial. More than half of the time, the mental health copay is at least $25 more than the primary care copay, and in 20% of plans, the difference is $35 or more. 

      Low copays for mental health are a rarity in Medicare Advantage. While the copay for primary care visits was zero in 85% of plans, this is only true for mental health visits in 19% of plans. In three-quarters of plans, the copay for mental health services was $20 or more, which was the case for primary care visits in less than 1% of plans.

      This general pattern of differential cost-sharing is pervasive and shows relatively little geographical pattern, although the average difference between mental health and primary care copays varies somewhat among states.

      Scrutiny of MA plans has accelerated, and sustained attention from Congress and CMS should be expected. Additionally, the Office of the Inspector General will be continuing its oversight of managed care as outlined in their recently-released strategic plan. They may wish to include a consideration of differential cost-sharing as part of their analysis of plan benefit design.

      Table 1
      Chart

      Mental Health Support

      SAMHSA National Helpline

      If you are seeking support for mental health or substance abuse disorders, call the Substance Abuse and Mental Health Services Administration's (SAMHSA) National Helpline at 1-800-662-HELP (4357).

       

      988 Suicide and Crisis Lifeline

      If you or someone you know is in crisis, reach the 988 Suicide and Crisis Lifeline by calling or texting 988 or chat at 988lifeline.org.

      Related Content

      Library
      A nurse takes the blood pressure of a woman at a table.

      Marketplace Pulse

      The Marketplace Pulse series, authored by RWJF Senior Policy Advisor Katherine Hempstead, provides expert insights on timely policy topics related to the health insurance marketplaces.

      1-min read

      Brief
      A patient and doctor meeting in an office.

      Marketplace Pulse: The Challenge of Obtaining Mental Healthcare in the Marketplace

      A range of factors make mental healthcare difficult to access and afford.

      5-min read

      Healthcare Coverage and Access Policy and Law Mental Health
      Brief
      A teen boy looking out of a window.

      Marketplace Pulse: Differences in Cost-Sharing for Mental Health and Primary Care Services Persist

      Unmet demand for mental health services is a longstanding healthcare problem. There is an increasing awareness of insurance barriers such as inadequate provider networks and claims denials.

      4-min read

      Healthcare Coverage and Access Policy and Law Mental Health

      Subscribe to receive Funding Alerts & more

      Explore the latest in reflection and research from subject matter experts at RWJF and our wide network of partners.

      Email address already subscribed. Please check your inbox to manage your subscriptions.

      Subscribed!

      Thank you. You are now subscribed.

      Tell us what type of content you want to receive.

      Be informed with our twice a month newsletter updating you with relevant news and research around a Culture of Health, as well as the latest funding opportunities.

      Get funded by RWJF: Receive notifications when new funding opportunities are released.

      Receive monthly updates on RWJF-sponsored research that informs many robust health policy debates on Capitol Hill, covering topics like health equity, improving access to quality healthcare, equitable housing, and more.

      Shop talk for researchers. This monthly newsletter covers research news and opportunities from the Robert Wood Johnson Foundation.

      Communications expedite action. Get periodic research and expert insights on the best ways to communicate so we can spread what works.

      Sometimes we have news, announcements or opportunities that don't quite fit the subscription parameters above. If you're interested, we'll send you this information under "There's more...". *If you've indicated you are an EU resident, we will only send these communications if you intentionally check this box.

      Which profession or pursuit best describes you?

      Area(s) Of Interest

      Unsubscribe

      Stop receiving all emails from RWJF

      This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
      • CONTACT RWJF

        50 College Road East
        Princeton, NJ 08540-6614

         

        US Toll Free: (877) 843-7953

        International: +1 (609) 627-6000

      • MANAGE YOUR GRANTS

        MyRWJF Login

        • Facebook
        • LinkedIn
        • YouTube
        • Instagram

      • Our Vision
        • Our Vision Overview
        • Why Health Equity
        • Focus Areas
        • Measuring RWJF Progress
      • Grants
        • Grants Overview
        • Active Funding Opportunities
        • Awarded Grants
        • Grantee Stories
        • Grant Process
        • Grantee Resources
      • Insights
        • Insights Overview
        • Blog
        • Our Research
        • Advocacy And Policy
      • About RWJF
        • About RWJF Overview
        • Our Guiding Principles
        • How We Work
        • Impact Investments
        • Staff And Trustees
        • Press Room
        • Careers
        • Contact Us
        • Accessibility Statement

      ©2001- 

      Robert Wood Johnson Foundation. All Rights Reserved. 

       

      • Manage Email
      • Privacy Statement
      • Terms and Conditions