When Conrad Kalcich lost his property management job at the beginning of the pandemic, he switched to Medicaid insurance. But there was a problem: his online therapist of four years couldn’t get credentialed to accept it.
He knew it would be difficult to find another therapist who was transgender-affirming and met his other treatment needs. So for months, he paid $80 per session out of pocket.
“Finding a new therapist is crazy town and overwhelming,” said Kalcich.
Lizzie Anderson, a therapist in Polish Hill, applied to be able to accept Medicaid five times since 2016 through UPMC’s Community Care Behavioral Health organization [CCBH]. She has a few clients who switched to Medicaid when they lost their jobs. “I said, ‘Look, I’m already seeing three clients who receive Medicaid for free, out of my own ethic,’” she recalled telling CCBH, which decides which therapists can accept Medicaid in Allegheny County. She was denied four times. She continued to see those clients at her own expense until she was finally credentialed in May.
Medicaid provides coverage for low-income people and people with disabilities. The entities that oversee Medicaid services in Allegheny County maintain that there are enough credentialed mental health providers to meet the need, including more than 600 therapists in private practice as well as those at community mental health centers.
Yet PublicSource spoke to more than a dozen residents who rely on Medicaid and two dozen therapists who described a dearth of therapists authorized to accept Medicaid, especially those specializing in care for Black, LGBTQ, neurodiverse, disabled and other underserved communities.
And many therapists in private practice who want to accept Medicaid insurance can’t, facing repeated denials and a slow-moving credentialing process.
“There are more than enough clients out there with commercial insurances that we will not be hurt by not taking Medicaid," therapist Mike Elliot wrote in an email to PublicSource. "But we want to take it, so that we can help people regardless of their financial situation.”
While he was able to get credentialed, the other five therapists at his Squirrel Hill practice were turned away.
When therapist Jonathan Simmen moved from a community mental health center to private practice, his application to get credentialed was denied in late 2020, so his clients from the center couldn’t continue working with him. “It just creates a revolving door of having to start over with someone because of circumstances that could have otherwise been fixed,” he said.
Eight therapists told PublicSource they applied in recent years and were denied. Of those, Simmen was credentialed in April, after appealing his denial three times. Anderson and another therapist, who'd been trying for more than five years, were both approved in the past month during the course of reporting this story.
Allegheny County contracts with CCBH to manage the Medicaid mental health network. When deciding whether to credential a provider, CCBH considers factors such as need, quality and location, spokesperson Denise Hughes wrote in a March email to PublicSource. Hughes declined an interview request for this story.
In a June response to additional questions, Hughes provided a statement from UPMC saying more than 90% of providers who applied in 2020 were credentialed. UPMC did not respond to questions seeking additional information.
In denying credentials, CCBH’s letters often note that the county already has enough providers.
That “could not be further from the truth,” said Sharise Nance, a therapist with a private practice Downtown. After applying roughly half a dozen times over three years, she got the green light in 2016. Now, about 80% of her clients have Medicaid insurance. “We still have a waiting list,” she said, “and we’re not the only practice that has a waiting list.”
The pandemic has brought about an unprecedented need for mental health services. Now, roughly 4 in 10 adults in the United States have reported symptoms of anxiety or depression, four times as many as in 2019, according to a poll by the Census Bureau and the National Center for Health Statistics.
A rising number of Pennsylvanians are also relying on Medicaid for their health care. Between February 2020 and February 2021, statewide enrollment in the program rose by 13.7%, Spotlight PA found. Enrollment in Allegheny County rose by the same margin, bringing the number of beneficiaries in the county to just over 268,000.
Pittsburgh-area residents with Medicaid can face months-long waiting lists for approved therapists, or face a choice to pay out of pocket for services despite having limited incomes.
When a person can't find a therapist in private practice, their only option is a community mental health center like Pittsburgh Mercy Behavioral Health or UPMC Western Psychiatric Hospital. The care might be good, but individuals can face waitlists and turnover of therapists over time.
Brandi Phillips, CEO of Allegheny HealthChoices Inc., said complaints about lack of access have been few and far between. Allegheny HealthChoices is a county-formed nonprofit that oversees CCBH.
Some locations may have longer wait times than others, Philips said, but most have availability. “It might just not be with exactly who you want, exactly where you want it, today,” she said.
CCBH publishes a list of credentialed providers for members on its website, but several people seeking services told PublicSource the list is inaccurate and out of date. The list can be filtered to only show providers who are accepting new patients, but the website says the information may only be updated every three years.
Leaders of Pittsburgh Mercy and Western Psych said many therapists have been leaving for private practice since the pandemic began. “The therapists who are left are taking on the caseload of the therapist who moved on, which also has an impact, obviously, on wait times for new patients,” said Deborah Brodine, president of Western Psych.
While CCBH is the decision-maker on credentialing, four entities have jurisdiction over Allegheny County’s Medicaid mental health services. Besides CCBH and Allegheny HealthChoices, Pennsylvania’s Department of Human Services determines the requirements for Medicaid mental health care in the state, and Allegheny County’s Department of Human Services [DHS] controls how services are delivered.
There is no magic number of Medicaid-approved clinicians the county needs, said Denise Macerelli, deputy director of the DHS Office of Behavioral Health. But there are reasons to limit the number of providers, she said, including licensing requirements and quality metrics like the number of patient complaints against a provider.
CCBH did not respond to questions about why it does not credential more providers and would not tell PublicSource how many providers it authorized or denied to accept Medicaid in 2020. Allegheny HealthChoices did not provide the numbers, and the state and county human services departments said they didn’t have them.
One medical biller said in the past two years, she’s helped numerous therapists apply to accept Medicaid through CCBH. Only a fraction have been accepted. “It’s next to impossible, to be honest,” said the biller, who asked to remain anonymous because of ties to UPMC. “Unless you’ve got some glaring specialization that hardly anybody else has, they’re gonna turn you down.”
Robert Lawrence II, a therapist in Squirrel Hill, expressed frustration with the credentialing process. While he is credentialed, he regularly has to turn people away because he is at capacity. “Then you have people who willingly want to extend their services,” he said, “and the door is slammed in their face.”
Several therapists also pointed out what they believe is a conflict of interest with UPMC managing an essential public service that it also profits from. The healthcare giant has its own Medicaid insurance plan and mental health providers, and UPMC’s Western Psychiatric Hospital is one of the county’s largest mental health providers. “You can see the agenda there. They don’t want to credential private practice because we’re literally taking money out of their pocket,” said Downtown-based therapist Jodie Hnatkovich. “Because my money doesn’t go back into UPMC.”
In response, UPMC noted that the majority of providers approved in 2020 were outside its organization, and both Phillips of Allegheny HealthChoices and Macerelli of DHS pushed back against claims of a conflict of interest.
“The network is very diverse, it’s open, and even though there are some practitioners that have not gotten into the network in the past year, there are many more practitioners who have,” Macerelli said, adding that if providers have concerns, they should report them to the county.
The need for options
After two months of hunting for a therapist who could accept Medicaid, Nina Riley almost gave up.
During the pandemic, the mother of two from McKeesport began prioritizing her mental health. She hoped to find a therapist who was a Black woman, like her, and could accept Medicaid. But of the four practices she reached out to, few of the therapists accepted Medicaid, and the ones who did were completely booked. “The people that I want to serve me, they just can’t serve me,” Riley said.
The search was time-consuming and draining. After a few dead ends, she stopped looking.
“Pretty much with Medicaid — not just with mental health but just in general — it’s like a Catch-22,” Riley said. “We provide you with this, but good luck trying to find someone to accept it.”
Through a friend, Riley eventually connected with a therapist who takes Medicaid and has been seeing her since October. Still, she feels the process was exhausting, especially since she was already experiencing mental burnout.
Some providers and clients say the solution is simple: approve more therapists to take Medicaid.
“Why not any willing and qualified provider when there’s demand?” asked Laval Miller-Wilson, executive director of the Pennsylvania Health Law Project, which advocates for people with Medicaid. He said he was “alarmed” to hear Medicaid members are paying out of pocket for treatment. “They shouldn’t have to do that,” he said.
More therapists would not only solve the scarcity issue — but it would also allow clients to access better quality care.
Many people noted the importance of having a therapeutic bond with one’s therapist, on top of important factors like the availability of trauma- or disability-competent care and a shared cultural background. “The history of medical racism, sexism — those are the things that push people away,” said Lawrence, the therapist in Squirrel Hill.
Approval barriers can result in broken relationships between client and therapist.
When therapist Rachel Marchetti moved from a licensed outpatient center to private practice in 2019, she had seven Medicaid clients who wanted to continue treatment with her. Some she’d helped through addiction or suicide attempts. But when she applied to accept Medicaid, she was told the network was full.
One of Marchetti’s clients wrote a letter to CCBH in August, pleading for it to allow Marchetti to accept her Medicaid insurance. It didn’t work.
The client, who asked to remain anonymous for privacy concerns, now pays $35 for each session. Because of the price, she can only afford to see Marchetti once a month, and Marchetti makes less than half of what she would if Medicaid reimbursed her.
Her client said starting over with someone else would only make her mental health worse. “Where do you start, you know? They’re not going to read like, four years’ worth of notes to catch up to where I’m at in my life."
This story was fact-checked by Matt Maielli.
Mental health reporting has been made possible with funding by the Staunton Farm Foundation, but news decisions are made independently by PublicSource and not on the basis of donor support.