Behavioral health providers nationwide are navigating major shifts. Recent Medicaid policy updates, including new work requirements and tighter funding caps, are changing how care is delivered and financed. These shifts can generate confusion, raise administrative burdens, and threaten continuity of care for vulnerable individuals.
As a pharmacy specializing in behavioral health conditions, intellectual and development disabilities, and substance use disorders, we understand these issues and stand ready to support. By working alongside providers, we help reduce administrative strain, improve outcomes, and ensure access to essential medications and services in an evolving landscape.
In this post, we’ll summarize the Medicaid changes, explore their impacts on your work, and highlight practical ways our pharmacy can help your team through this transition.
Understanding the Medicaid Changes Affecting Behavioral Health
Medicaid covers many adults with serious mental illness or substance use disorders. But recent legislation introduces several significant reforms:
New Cost-Sharing Rules
Beginning October 1, 2028, states must impose cost-sharing of no more than $35 per service or 5% of family income for Medicaid expansion adults earning 100–138% of the poverty level. Critically, mental health and substance use services and those delivered at FQHCs, rural health clinics, and community behavioral health clinics are fully exempt from this charge.
Medicaid Work Requirements
Starting as early as December 31, 2026, able-bodied adults aged 19–64 in the expansion population must complete 80 hours of work or community service per month, or qualify for exemptions (e.g., due to serious health conditions or caregiving responsibilities). Failure to comply may result in loss of coverage.
Provider Tax and Payment Caps
The law prohibits new state provider taxes and requires expansion states to phase down their existing provider tax safe harbor from 6% to 3.5% by 2031. States cannot reimburse providers more than 100–110% of Medicare rates, limiting flexibility in Medicaid payments.
HCBS Expansion Funding
From July 1, 2028, states may expand Home and Community-Based Services (HCBS) eligibility to those needing support but not nursing home care. The act provides $50 million in FY 2026 and $100 million in FY 2027 to support implementation.
How These Changes Impact Behavioral Health Providers
- Higher administrative burden: Providers must navigate new cost-sharing exceptions, work requirements, and more frequent eligibility verification, which adds to administrative workloads.
- Coverage risk for individuals: Noncompliance with work rules may result in loss of Medicaid coverage. Gaps in benefits can disrupt access to medications and therapy, increasing relapse and hospitalization risk.
- Funding uncertainty: Caps on provider taxes and reimbursement may limit resources, potentially reducing services, shrinking clinic staff, or curtailing expansion.
- Demand for expanded community services: Providers will see more need for HCBS support and coordinated transitions from institutional to community care, even as waitlists grow.
How Our Pharmacy Supports You Through These Changes
We offer services designed to lighten your administrative load and sustain high-quality care:
- Prior authorization support: We handle paperwork and follow-up to accelerate medication access and reduce delays.
- Adherence tracking and refill reminders: Using outreach tools, we track refill needs and send reminders to reduce workload and support continuity.
- Long-acting injectable (LAI) coordination: We assist with scheduling, outreach, and follow-ups to ensure consistent treatment management.
Why Partner with Altruix?
Our specialized expertise means we understand your challenges and regulatory environment. Working together with us means:
- Less administrative burden so your team can focus on clinical work
- Better medication adherence and continuity of care
- Greater stability during policy shifts
- A true collaboration grounded in your operational goals
Final Thoughts
These Medicaid reforms bring challenges and opportunities. With thoughtful partnerships and proactive planning, providers and pharmacies can support stronger, more resilient behavioral health care systems. Together, we can help ensure individuals continue to receive the medications and services they need to thrive in changing times.
Partner with Altruix to support the individuals you serve through Medicaid shifts.
