OCA proposes payer‑specific, phased benchmark to increase in‑network outpatient behavioral health spending

The Office of Health Care Affordability (OCA) presented preliminary analyses of commercial claims showing increases in behavioral health spending and proposed a two‑phase, payer‑specific benchmark to push additional investment into in‑network outpatient and community‑based behavioral health services.

OCA staff told the OCA investment and payment work group that the draft approach would use each payer’s 2025 spending as a baseline and require annual increases in per‑member‑per‑month (PMPM) spending for 2025–2029, then reassess and reset longer‑term goals for 2030–2034 based on the first phase’s experience. “OCA’s recommending that its benchmark focus on in‑network outpatient and community based services,” said Debbie Lindes, OCA’s healthcare delivery system group manager.

The proposal follows OCA’s review of Health Care Payments Data Program (HPD) analyses, and parallel work by Covered California and CalPERS, using a Milbank Memorial Fund–recommended code set to identify behavioral health spending in claims. OCA staff summarized that HPD commercial claims show behavioral health growing from roughly 6.6% of total medical expense in 2018 to about 8.2% in 2023, and that in‑network outpatient/community behavioral health PMPM rose at an average annual rate near the mid‑teens across 2018–2023. OCA used an illustrative average PMPM value from HPD (about $20.23) to model how 10%, 15% or 20%…