Medicare Mental Health Proposals Expand Substance Abuse Aid

The American opioid crisis and the Covid pandemic have renewed calls from lawmakers and advocates to modernize and expand Medicare behavioral health coverage. And the Biden administration is listening.

The rule proposed by the Medicare medical tariff program for 2023 suggests that changes to Medicare coverage for the treatment of mental health disorders and substance use are coming when the final rule is released. It is scheduled for next week.

According to a recent study, approximately 1.7 million Medicare beneficiaries have had a substance use disorder in the past year. And while they were much more likely to have had severe psychological distress and suicidal thoughts, only 11% received treatment. The problem is not new.

Medicare does not cover the full range of services, providers and settings for the treatment of substance use disorders or “SUD”.

According to a recent study, it “effectively excludes coverage” for the treatment of substance use disorders in intensive outpatient programs, specialized addiction clinics, and residential addiction programs. Medicare also does not allow billing by addiction specialists who dominate the SUD treatment workforce: licensed counselors, certified addiction counselors, and au pair counselors.

And because the Mental Health Parity and Addiction Equity Act does not apply to Medicare, the program is not required to offer substance use disorders and mental health benefits at the same level as medical and surgical treatment benefits. This is in stark contrast to most private and work-based health insurance, and even Medicaid plans, which are covered by the law.

Attention from legislators, regulators

With Covid-19 and opioid overdose deaths rising, Medicare’s coverage gap for behavioral health services is receiving new attention from regulators and lawmakers.

Last month, the House Ways and Means Committee passed six bills aimed at strengthening Medicare mental health coverage. And last week, Senator Richard Durbin and Representative Lauren Underwood, both Democrats from Illinois, called on Medicare to act “swiftly and comprehensively” to “explore pathways to expand access to residential services for drug use disorders. substances provided by treatment programs that offer evidence-based care ”.

The Biden administration is also looking into the matter. Buried in Medicare’s proposed 2,000-page rule, the Centers for Medicare & Medicaid Services seek feedback that a “void” in Medicare coding and payment mechanisms “could limit access to the levels of care needed to treat mental health or substance use disorder treatment, including and in particular substance use disorders, for Medicare beneficiaries ”.

“We are particularly interested in the extent to which any potential gaps could best be addressed by creating new” billing codes or by “revising particular billing rules for certain types of assistance in specific contexts,” the proposal states.

The agency also asked if other coding adjustments are needed “to better reflect the relative costs of resources involved in providing intensive outpatient mental health services.”

Continuity of care

Intensive outpatient mental health services are part of a “continuum of care” developed by the American Society of Addiction Medicine. Medicare now covers only the less intense types of treatment on the continuum: early intervention and outpatient services, along with the more intensive type: hospital services, said Deborah Steinberg, a health policy attorney at the Legal Action Center, a legal and political organization. non-profit .

The addition of Medicare coverage of “intensive outpatient” services, which involves 9 to 19 hours of treatment services per week, would fill a large void in the program’s current coverage offerings, he said.

“It’s a little more intense than someone who only gets weekly counseling, but not at the level where someone is in residential treatment. And that’s something we are very confident CMS can do on its own without needing congressional approval, ”Steinberg said.

The CMS does not comment on proposals during the regulatory process.

People in intensive outpatient programs for substance use disorders receive an individualized treatment plan, individual and group counseling, drug management, family therapy, and participate in occupational and recreational therapy and education groups.

Intensive outpatient services

On another front, Representative Judy Chu (D-Calif.) Introduced HR 8878, which would create a Medicare benefit category for intensive outpatient services.

In a recent hearing of the House Ways and Means Commission, Chu’s bill was approved favorably out of commission. Chu, a psychologist, said at the hearing that Medicare applies significant restrictions, such as requiring beneficiaries to be eligible for hospital care, before covering intermediate treatment services for enrollees with substance use disorders.

“This has the unintended consequence of excluding many Medicare patients from the type of mental health services most appropriate for their condition and level of care,” Chu testified. “This is one of the many glaring gaps in the Medicare program that prevents mental health coverage from matching physical health.”

Chu’s legislation would allow outpatient hospitals, community mental health centers, rural health centers, and federally qualified health centers to provide intensive outpatient services so that “patients can access care in facilities that best meet their needs, “he said at the hearing.

Representative Adrian Smith (R-Neb.), A co-sponsor of the bill, said at the hearing that he “hopes to see its eventual enactment in a broader bipartisan mental health care package before the end of the year” .

The savings can offset the costs of changes

According to research by RTI International, a nonprofit research institute, in partnership with the Legal Action Center, would cost approximately $ 928 million annually to provide intensive outpatient coverage for the more than 116,000 beneficiaries with substance use disorder.

The addition of nearly 76,000 residential care stays would cost $ 935 million, and nearly 59,000 sessions with counselors would cost an additional $ 66 million, the study estimates.

But these expenses would be nearly offset by savings of about $ 1.6 billion annually in drug-related illnesses, hospitalizations and emergency room visits, the study estimates.

Of the 1.7 million beneficiaries with a SUD, about 77% struggled with alcohol use, 16% with prescription drugs, and 10% with a marijuana condition. 41% cited lack of motivation as a reason they did not seek treatment, 33% were concerned about what others might think, and 24% identified logistical barriers, such as transportation.

The SUPPORT for Patients and Communities Act of 2018 created a new category of benefits that enabled Medicare coverage of opioid treatment programs that provide methadone and other medications that treat opioid use disorder in 2020.

But of the more than 1 million beneficiaries with opioid use disorder in 2021, fewer than 20 percent received medication to treat it, the Department of Health and Human Services Inspector General’s Office reported in September. “This low percentage may indicate that beneficiaries are having difficulty accessing treatment,” says the OIG data document.

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