COMMONWEALTH OF MASSACHUSETTS
HEALTH POLICY COMMISSION
REPORT ON BEHAVIORAL
HEALTH MANAGERS
IN THE COMMONWEALTH
Report to the Massachusetts Legislature
NOVEMBER 2024
INTRODUCTION
Behavioral health managers, entities that contract with a fulfills some or all of the insurer’s functions of manag-
health plan to provide or arrange for behavioral health ing behavioral health services for health plan members,
services for plan members, are used for a significant number including duties required by statute or regulation of the
of Massachusetts residents with commercial health plans health plan related to their coverage of behavioral health
and the majority of residents with Medicaid coverage. care. 3 A health plan may choose to use a BHM for all
Chapter 177 of the Acts of 2022, An Act Addressing Bar- or substantially all of the functions regarding behavioral
riers to Care for Mental Health, directed the Health Policy health services or for select functions. BHMs are used by
Commission (HPC), in consultation with the Division of fully-insured health plans, subject to regulation by DOI as
Insurance (DOI), to conduct an analysis of the behavioral “carriers”; the state’s Medicaid program, MassHealth; and
health managers in the Commonwealth. Specifically, the commercial health plans contracting with MassHealth as
HPC was asked to analyze the services that behavioral Medicaid Managed Care Organizations (MCO) or Account-
health managers provide; the effect of behavioral health able Care Organizations (ACO). In addition, self-insured
managers on accessibility, quality and cost of behavioral plans offered by employers, which are not regulated by DOI,
health services, including an analysis of their impact on may contract with BHMs to manage behavioral health
patient outcomes; the oversight practices by other states services in addition to another third-party administrator
on behavioral health managers, and the effects of state for medical/surgical services.
licensure, regulation or registration on access to behavioral
health services; and any other issues pertaining to behavioral USE OF BEHAVIORAL HEALTH MANAGERS
health managers as deemed relevant by the HPC. IN MASSACHUSETTS
To conduct this study, the HPC reviewed laws and regula- MASSACHUSETTS LANDSCAPE
tions in Massachusetts and other states, reviewed research BHMs have been used by health plans in Massachusetts for
literature, and analyzed available data, including National many years and continue to be used across the Massachu-
Committee for Quality Assurance (NCQA) Health care setts health care landscape. Most commercial health plans in
Effectiveness Data and Information set (HEDIS®)1 measures. Massachusetts use a BHM for at least some services, and the
In addition, the HPC conducted interviews with payers, use of specific BHM vendors has remained relatively consis-
behavioral health managers, providers, and patient advocates. tent over time.4 Three national BHM companies operate in
In the following report, the HPC describes the use of behav- Massachusetts and serve the commercial and MassHealth
ioral health managers by commercial health plans and
Medicaid plans in the Commonwealth, summarizes the 2 Mass. Gen. Laws. Ch. 176O, § 1, defines “behavioral health manager”
as “a company, organized under the law of the commonwealth or
regulatory landscape in Massachusetts and other states,
organized under the laws of another state and qualified to do business
describes perspectives on the advantages and disadvantages in the commonwealth, that has entered into a contractual arrangement
of using behavioral health managers, and reviews compar- with a carrier to provide or arrange for the provision of behavioral,
ative health plan quality measures. The report concludes substance use disorder and mental health services to voluntarily
enrolled member of the carrier.” Behavioral Health Managers are
with recommendations about ways to improve the provision sometimes referred to as managed behavioral health organizations
of behavioral health care services when behavioral health (MBHOs), behavioral health vendors or behavioral health carve-outs.
managers are involved. 3 For purposes of this report, the HPC uses the term “behavioral health
services” or “behavioral health care” to encompass services for
individuals experiencing mental health, substance use and emotional
BACKGROUND disorders. Association for Behavioral Health care, Issue Brief, Kids
A behavioral health manager (BHM) is a company that con- Are Waiting, Children’s Behavioral Health Services Crisis and Col-
lapse, December 2023. https://www.abhmass.org/images/CBHI_Brief/
tracts with a public or commercial health plan to “provide ABH_Brief_Children_Are_Waiting_FINAL_121423_R.pdf.
for or arrange for the provision of behavioral, substance 4 See Examination of Health Care Cost Trends and Cost Drivers
use disorder, or mental health services” for health plan Pursuant to G.L. c. 6D §8, The Office of the Attorney General’s
members.2 Through this contractual relationship, the BHM 2015 report stated that MBHP, Optum, and Beacon (now Carelon)
provided behavioral health management services in the state at that
time as well. Optum served HPHC, Beacon served GIC’s Tufts Health
1 HEDIS® The Healthcare Effectiveness Data and Information Set Plan, GIC Unicare, Neighborhood Health Plan, BMC Health Net,
(HEDIS®) is a registered trademark of NCQA. and Fallon, and MBHP served MassHealth and HNE.
BEHAVIORAL HEALTH MANAGERS REPORT -1- HEALTH POLICY COMMISSION
managed care market: United Behavioral Health dba Optum Health and Life Insurance Company (Cigna) to manage all
(Optum), Carelon Behavioral Health Strategies, LLC (for- or substantially all of its behavioral health services.10
merly Beacon Health Options) (Carelon), and Evernorth
Tufts Associated Health Maintenance Organization, Inc. and
Behavioral Health, Inc. (Evernorth). Optum contracts with
Tufts Health Public Plans, Inc. (Tufts Health Plan), Harvard
ConnectiCare of Massachusetts, Inc. (ConnectiCare)5, Mass
Pilgrim Health Care, Inc. (HPHC)11, and Aetna Life Insur-
General Brigham Health Plan, Inc. (MGBHP)6, and United-
ance Company and Aetna Health, Inc. (Aetna) manage all
Healthcare Insurance Company (United)7 to manage all or
of their behavioral health services without the use of a BHM.
substantially all behavioral health services for those health
Blue Cross Blue Shield of Massachusetts12 and Health New
plans. Carelon contracts with Wellpoint Life and Health
England13 manage substantially all of their behavioral health
Insurance Company (formerly GIC Unicare) (Wellpoint),
services without the use of a BHM. The Massachusetts
Fallon Community Health Plan, Inc. (Fallon)8 and Boston
Medicaid program, MassHealth, and many MassHealth
Medical Center Health Plan, Inc. dba WellSense (WellSense)9
MCOs and ACOs use BHMs. The Massachusetts Behavioral
to manage all or substantially all the behavioral health ser-
Health Partnership (MBHP) serves as the BHM for most
vices for those health plans. Evernorth contracts with Cigna
Relationships between health plans and behavioral health managers in Massachusetts, 2024
MEDICAL PROVIDERS
MassHealth PCC plan
MassHealth Primary Care ACOs Cigna
Be Healthy Partnership Plan
HPHC BCBS MA Aetna Fallon Health Plan Connecticare
Wellpoint MGBHP
WellSense United
Tufts Health Health New
Plan England
Commercial
CARELON MBHP OPTUM EVERNORTH
BEHAVIORAL HEALTH PROVIDERS
Notes: This infographic is an updated version of an infographic displayed in the Examination of Health Care Cost Trends and Cost Drivers Pursuant to G.L. c.
6D §8, Office of the Attorney General, June 30, 2015.
10 Evernorth and Cigna are corporate affiliates. Evernorth also acts as a
behavioral health manager for health plans other than Cigna nationally.
11 Optum previously contracted with Harvard Pilgrim Health Care,
5 ConnectiCare has notified DOI that it is not renewing its Massachu-
Inc. to manage substantially all behavioral health services through
setts insured health plan as it prepares to exist the Massachusetts
October 31, 2023. The data in this report reflects calendar year
market.
2022. Since Harvard Pilgrim Health Care contracted with Optum
6 MGBHP operates one member-facing call center for all services, for the entirety of 2022 for behavioral health management, this
including behavioral health, and does not contract with Optum report categorizes Havard Pilgrim Health Care as using a behavioral
for its member-facing call center. health manager for enrollment and quality analysis.
7 Optum and United Health Care are corporate affiliates. 12 BCBSMA contracts with Carelon for its REACH program for adults
8 Fallon performs case management of behavioral health services and and children who have significant and persistent mental health
does not contract with Carelon for case management. difficulties or substance use disorders after discharge from a facility.
9 WellSense performs case management of behavioral health services 13 Health New England contracts with MBHP for its MassHealth
and does not contract with Carelon for case management. population.
BEHAVIORAL HEALTH MANAGERS REPORT -2- HEALTH POLICY COMMISSION
MassHealth members.14 MBHP is a division within Carelon to meet applicable network adequacy requirements
operating exclusively in Massachusetts. MBHP contracts through recruiting, credentialing, and contracting with
with MassHealth to provide behavioral health services for those providers as well as ongoing management of those
its Primary Care Clinician (PCC) plan and Primary Care provider relationships.
ACOs, Community Care Cooperative and Revere Health
• Quality of Care: reporting and working to improve
Choice. Health New England contracts with MBHP for its
performance on HEDIS quality measures and working
MassHealth population through its ACO, Be Healthy Part-
with providers to identify best practices.
nership Plan with Baystate Health Care Alliance.15
• Appeals and Grievances: facilitating appeals and griev-
Behavioral ances for members challenging denials or complaining
Estimated Members
Health Plans
Enrolled* about quality of care.
Manager
Connecticare, MGBHP, Commercial: 887,006 • Parity Compliance: assisting health plans in meeting
Optum
HPHC**, United MassHealth: 45,651
their responsibilities under state and federal parity
Carelon
Fallon, WellSense, Commercial: 171,904 requirements including preparing comparative analysis
WellPoint MassHealth: 388,219
of non-quantitative treatment limitations.16
MassHealth PCC plan; MassHealth FFS, PCC,
MassHealth Primary Care Primary Care ACOs
• Fraud, Waste, and Abuse Services: detecting and investi-
MBHP
ACOs: Community Care and HNE: 759,862 gating potential fraud, waste, and abuse, assisting with
Cooperative, Revere
Health Choice; Be Healthy
recovery when applicable, and performing analytics and
Partnership (HNE) compliance activities related to fraud, waste and abuse.
Evernorth Cigna Commercial: 217,726 • Claims: processing claims for behavioral health services,
which may include pricing, adjudication, and payment.
*Members enrolled estimated by CHIA Enrollment Data for December 15, 2022.
** HPHC contracted with Optum for the entirety of 2022 for behavioral health
• Reporting: performing a variety of reporting functions as
management.
required by the contract with the health plan, including
SERVICES PROVIDED BY BEHAVIORAL reporting to the health plan at the end of claim period,
HEALTH MANAGERS state and federal-mandated reporting, and analytics to
BHMs offer a wide range of services to health plans in support performance under value-based contracting.
Massachusetts. Health plans contract for a specific set of • Call centers: staffing and management of call centers
services, which may change over time based on the needs for both member-facing and provider-facing hotlines.17
of the health plan. For services that are not managed by
the BHM, the health plan manages and provides those CONTRACTS WITH BEHAVIORAL
services itself or “in-house.” BHMs may provide some or HEALTH MANAGERS
all of the following services: As noted above, many health plans in Massachusetts have
• Clinical Services: utilization management, including maintained long-term relationships with their chosen BHM
developing and using medical necessity criteria, and vendors. Health plans typically contract with BHMs for
case management, through communicating directly with multi-year terms. The contracts outline what services the
patients and providers, for either all or a specific subset BHM will provide and how the responsibilities for man-