Medicare mental health proposals expand help for substance abuse

America’s 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 Medicare Physician Fee Schedule proposed rule for 2023 suggests changes to Medicare coverage for mental health and substance use disorder treatment when the final rule is published. It is expected next week.

Approximately 1.7 million Medicare beneficiaries suffered from a substance use disorder last year, according to a recent study. study Estimate. And while they were much more likely to have 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 “SUDs.”

It “effectively excludes coverage” for substance use disorder treatment in intensive outpatient programs, specialty addiction outpatient clinics and residential addiction programs, according to a recent study. study. Medicare also does not allow billing by the addiction specialists who dominate SUD’s treatment workforce: licensed counselors, certified addiction counselors, and peer counselors.

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

Attention of legislators, regulators

As opioid overdose and covid-19 deaths rise, regulators and lawmakers are paying more attention to the Medicare coverage gap for behavioral health services.

Last month, the House Ways and Means Committee marked six bills aimed at bolstering Medicare mental health coverage. And last week, Senator Richard Durbin and Rep. Lauren Underwood, both Democrats from Illinois, called Medicare act “quickly and thoroughly” to “explore ways to expand access to residential substance use disorder services provided by treatment programs that offer evidence-based care.”

The Biden administration is also looking into the issue. Buried in the 2,000-page Medicare proposed rule, the Centers for Medicare & Medicaid Services seeks comment on whether a “gap” in Medicare’s coding and payment mechanisms “may be limiting access to the levels of care necessary for the mental health or substance use disorder treatment. treatment, including and especially substance use disorders, for Medicare beneficiaries.

“We are particularly interested in the extent to which any potential gaps would be best addressed by creating new” billing codes or “revising particular billing rules for some types of care in specific settings,” the proposal said.

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

continuity of care

Intensive outpatient mental health services are part of a “continuing care” developed by the American Society for Addiction Medicine. Medicare now covers only the least intensive types of treatment on the continuum: early intervention and outpatient services, along with the most intensive type: inpatient hospital services, said Deborah Steinberg, a health policy attorney at the Legal Action Center, a policy organization and nonprofit laws. .

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

“It’s a little more intensive than someone who’s just getting weekly counseling, but not to the level where someone is in residential treatment. And that’s something we’re very confident CMS could do on its own without needing congressional approval,” Steinberg said.

CMS does not comment on proposals during the rulemaking process.

Individuals in intensive outpatient substance use disorder programs receive an individualized treatment plan, individual and group counseling, medication management, family therapy, and participate in occupational and recreational therapy and education groups.

Intensive outpatient services

On another front, Rep. Judy Chu (D-Calif.) has filed H.R. 8878that would create a Medicare benefit category for acute outpatient services.

At a recent House Ways and Means Committee hearing, Chu’s bill passed favorably by the committee. Chu, a psychologist, told the hearing that Medicare has 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 that are most appropriate for their condition and level of care,” Chu testified. “This is one of many glaring gaps in the Medicare program that prevents mental health coverage from keeping up with 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 at the facilities that best meet their needs,” he said at the hearing.

Rep. Adrian Smith (R-Neb.), a cosponsor of the bill, told the hearing that he “expects to see its eventual enactment into a larger bipartisan mental health care package before the end of the year.”

Savings may offset costs of changes

It would cost about $928 million a year to provide intensive outpatient coverage to the more than 116,000 beneficiaries with substance use disorder, according to research by RTI International, a nonprofit research institute, in association with the Legal Action Center.

Adding nearly 76,000 residential treatment stays would cost $935 million, and nearly 59,000 counseling sessions would cost another $66 million, the study estimates.

But those outlays would be nearly offset by savings of about $1.6 billion a year in expenses for drug-related ailments, hospitalizations and emergency room visits, the study estimates.

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

SUPPORT for Patients and Communities 2018 law Created a new benefit category that in 2020 allowed Medicare coverage of opioid treatment programs that provide methadone and other drugs to treat opioid use disorder.

But of the more than 1 million recipients with opioid use disorder in 2021, less than 20% received medication to treat it, the Department of Health and Human Services’ Office of Inspector General reported in September. “This low proportion may indicate that beneficiaries have difficulties accessing treatment,” the OIG data summary saying.