The 2016 OPEN MINDS Update On Vertical Carve-Outs

In the past five years, payers have pushed for “integration” of care coordination – particularly for the super-utilizer group of high cost consumers with multiple chronic conditions and complex social support needs. This push for integrated care coordination has had a pronounced effect on the concept of the “behavioral health carve-out.” Traditional Medicaid carve-out markets in behavioral health have been “horizontal”– meaning that a specific type of service or benefit was managed separately from the rest of a consumer’s health care.

However, it has been difficult to manage care coordination within these horizontal carve-out models. As a result, we’re seeing the “traditional” horizontal carve-out replaced by a “vertical” carve-out model. Rather than having an entire class of benefits or services managed separately, payers are moving to models where the care for specific groups of consumers is managed separately. Vertical models typically include all health care services, including behavioral health; many include all pharmacy benefits as well. These are the new specialty health plans.

This market intelligence report provides a detailed analysis on specialty carve-out models in the Medicaid system and provides information on:

  • The differences between traditional behavioral health carve-outs and the new vertical specialty health plans
  • State Medicaid plans with traditional behavioral health carve-outs
  • States with specialty health plans and the number of consumers enrolled
  • The health insurers operating specialty health plans

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