In a presentation to the Medical Assistance Advisory Committee today, Office of Mental Health and Substance Abuse Services (OMHSAS) Deputy Secretary Jen Smith shared data that shows a significant increase over the past three years in behavioral health managed care organization (BH-MCO) decisions to deny services to their members or contracted providers.

In addition to denial data for calendar years 2022 through 2024, the report also provides data on grievances and complaints and defines what each of those is. Notably, the 2024 data does not include the fourth quarter of the year.

The most egregious service type denials are seen in two categories: 1) non-hospital residential withdrawal management, rehabilitation and halfway-house services for drug/alcohol abuse or substance use disorders; and 2) IBHS for children and adolescents with mental health or substance use disorders. Although the IBHS denials appear down slightly in 2024, when the fourth quarter data is added, the number is likely to increase. On the SUD side, even without fourth quarter data, denials for the non-hospital residential substance use disorder treatment services are up 45 percent over 2023.

The presentation breaks down the number of denials per year per BH-MCO since 2022.

The increases in denials in 2024 occurred at the same time OMHSAS acknowledged a significant miscalculation of capitation rates, resulting in underfunding of the behavioral health system, including primary contractors and BH-MCOs, by hundreds of millions of dollars.

Deputy Secretary Smith cautioned that there are multiple factors to consider when reviewing the data and increase in denials, including Pennsylvania’s SUD treatment system’s ongoing alignment with ASAM Criteria and the increased BH-MCO scrutiny on providers and individual BH-MCO interpretation of ASAM Criteria.

The full presentation is available here.