Strengthening Behavioral Healthcare To Meet The Needs Of Our Nation

Over the past several years, mental health and substance use challenges among Americans have increased in prevalence and severity. Rates were already on the rise before the pandemic, but the toll of COVID-19 on youth and adults has been significant.  As physician leaders across the Centers for Medicare & Medicaid Services (CMS) — the federal agency that administers Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Affordable Care Act (ACA) health insurance Marketplaces, programs through which more than 150 million Americans obtain health coverage – we are focused on supporting President Joe Biden’s Strategy to Address Our National Mental Health Crisis by ensuring our beneficiaries have access to equitable, high-quality health care services.

In his 2022 State of the Union Address, as his part of his Unity Agenda’s focus on tackling our nation’s mental health crisis, President Biden called on federal agencies to prioritize policies to expand access to and increase the quality of our mental health and substance use disorder (SUD) services. Secretary Becerra and the Department of Health and Human Services (HHS) have heeded that call with a National Tour to Strengthen Mental Health. In addition, CMS is developing a comprehensive vision that includes improving access to high-quality, integrated preventive and treatment services for mental health and substance use disorders (collectively known as behavioral health disorders).

The CMS Behavioral Health Strategy underscores the importance of access, equity, quality, and effective data integration in preventing and treating mental health, substance use disorders and acute and chronic pain.  Across CMS, we are committed to 1) expanding access to behavioral health care; 2) focusing on the behavioral health needs of children and youth; 3) integrating behavioral health and primary care through delivery system transformation; 4) bolstering the behavioral health workforce; and 5)  improving the quality of behavioral health care. Overlaying all these efforts, CMS is working to advance equity in behavioral health care, treatment, and recovery services, in collaboration with other agencies across HHS and the entire federal government.

Improving Access To Behavioral Health Care

During the COVID-19 crisis, the number of adults reporting adverse behavioral health conditions has increased sharply, with higher rates of depression, substance use, and self-reported suicidal thoughts. Communities of color, children, and older adults have all experienced disproportionate harm, and many have also forgone needed behavioral health care. It is critical that we improve access to behavioral health care, and CMS is taking action to ensure that people with Medicaid and CHIP, Medicare, and Marketplace coverage can get the care they need, when they need it.  

For example, the CMS Center for Medicaid & CHIP Services (CMCS) has been working with state Medicaid agencies to ensure enrollees have access to services across the continuum of care: prevention, diagnosis, treatment, crisis, and recovery services; and across settings of care, from outpatient to intermediate and acute care settings. Our goal is to work with state partners to ensure adequate reimbursement rates for behavioral health services, which have overall lagged investments in physical health—especially for high-quality behavioral health providers who are able to provide comprehensive, integrated care; offer 24/7 open access and urgent care; and improve care coordination—and to ensure coverage decisions are based on generally accepted standards of care.  

In Medicare, following Congressional action, CMS in the final 2022 Physician Fee Schedule permanently extended access to telehealth—originally a flexibility made available during the pandemic—by allowing people to access telehealth services for the diagnosis, evaluation, and treatment of behavioral health conditions. This includes telehealth via audio-video communications, as well as audio-only telephone calls when the patient is not able to use, or does not consent to using, video technology. Audio-only calls are an important way to support equitable access to care for people who may live in rural or underserved areas with poor broadband infrastructure or those who cannot use audio-video communication devices. CMS has also created a State Medicaid & CHIP Telehealth Toolkit to assist states in expanding the use of telehealth.

In addition, CMS is working with other operating divisions in HHS such as the Substance Abuse and Mental Health Services Administration (SAMHSA), as well as the Departments of Labor and the Treasury (collectively, the Departments), to advance mental health and substance use disorder treatment parity with physical care through implementation and enforcement of the Mental Health Parity and Addiction Equity Act of 2008. MHPAEA prohibits health plans from imposing stricter constraints on coverage for behavioral health treatments than for other, physical health services.

In January 2022, the Departments issued the 2022 Report to Congress, outlining the Departments’ efforts to enforce MHPAEA, including the amendments made to MHPAEA in the Consolidated Appropriations Act, 2021 (CAA); they also collaborated on parity resources for policymakers, families and caregivers, group health plans, and health insurers. The CAA amendments to MHPAEA require insurers and health plans to demonstrate that they are not applying non-quantitative treatment limitations in a manner that discriminates against behavioral health treatment, thus providing the Departments with an important new enforcement tool as well as additional funding to implement it. Looking ahead, the Departments will be working together to issue a new proposed rule under MHPAEA to further ensure health plans and issuers are providing parity in the coverage they offer, and that Americans have access to the mental health and substance use disorder care they need.

Finally, CMS is encouraging states to advance coverage of behavioral health care as part of the Affordable Care Act’s (ACA) Essential Health Benefits (EHBs). The ACA requires most health plans in the individual and small group markets to provide coverage in ten categories of EHBs, including mental health and substance use disorder treatment. While CMS regulations allow states to define the specific services covered by plans among these ten broad EHB categories offered in each state, CMS has worked with six states—Illinois, South Dakota, Michigan, New Mexico, Oregon, and Colorado—to add additional behavioral health services to their state “benchmark” plan since 2019.

Integrating Behavioral Health And Primary Care Through Delivery System Transformation

CMS is working to strengthen the integration of behavioral health with primary care, which can further improve access for many of the people we serve. Our goal is to utilize investments and policies to make routine the provision of behavioral health care in the primary care setting (including pediatric primary care), building on the Collaborative Care Model and general behavioral health integration payment codes.

CMS is further exploring opportunities to better integrate behavioral health through Medicare fee-for-service payment policy. The CMS Innovation Center has tested multiple models and demonstrations that have included a focus on behavioral health, with particular emphasis on integration of physical and behavioral health care services; a notable example is the Comprehensive Primary Care Plus (CPC+) Initiative, a primary care model that has required behavioral health integration. Going forward, the Innovation Center is exploring options for new models, including payment models that support the delivery of whole-person care through behavioral health integration. We will continue to identify opportunities to incorporate behavioral health care into other models under development as well.

Outside of specific care models, in Medicaid and CHIP CMS is encouraging states to take up existing flexibilities and promising practices to promote better integration. These include: the elimination of prohibitions on billing for both primary care and behavioral health treatments that occur on the same day, allowing patients to seamlessly move from one treat to the other without the need for multiple visits]; reimbursement parity for the same billing codes across primary care and behavioral health clinicians; reimbursement for interprofessional consultations between primary care providers and specialists, including those in behavioral health; reimbursement of behavioral health integration activities such as care management and inter-specialty care (currently reimbursed in Medicare); reimbursement of non-specific codes to allow provision of behavioral services in primary care and pediatric settings to individuals without established behavioral health diagnoses; and implementation of health homes to coordinate whole-person care for beneficiaries with chronic conditions, including those with serious and persistent mental health conditions.

CMS also has made efforts to educate consumers about their behavioral health benefits.

Finally, CMS is making behavioral health care a key component of delivery system transformation writ large. Accountable care relationships (such as within Accountable Care Organizations) mean that doctors and other health care providers work with each other and their patients to manage each patient’s overall health, including behavioral health; this is intended to lead to coordination of behavioral health treatment with their entire care team. CMS has set ambitious goals so that all Medicare beneficiaries and the vast majority of Medicaid beneficiaries will be in an accountable care relationship by 2030. This means that more people will see providers who will be more likely to better communicate with one another and more people will have access to programs like the Medicare Shared Savings Program, which has demonstrated higher performance in managing patient depression compared to physician group practices reporting through the Merit-based Incentive Payment System.

Bolstering The Behavioral Health Care Workforce

Behavioral health care that meets our nation’s health needs is not possible without a strong behavioral health workforce. A recent internal review of critical lessons learned from CMS Innovation Center models found that the behavioral health workforce has too few providers given the scale of need. Further, many primary care providers lack sufficient training needed to feel comfortable treating behavioral health needs.

CMS, along with other agencies such as SAMHSA and the Health Resources and Services Administration, is examining ways to bolster the nation’s behavioral health care workforce. In Medicaid and CHIP, CMS is working with states to promote ways to expand behavioral health provider networks. To improve our oversight of Medicare Advantage (MA) plans’ ability to deliver care to enrollees, including behavioral health care, CMS also strengthened application requirements for MA organizations to evaluate network adequacy, and we solicited comment on how to further strengthen behavioral health network adequacy going forward.

Current Medicaid authorities can be used to undertake innovative care models that include supporting providers across a full spectrum of community-based services and supports. Recent legislative changes also provide avenues to expand behavioral health access and system capacity. For example, the American Rescue Plan authorizes a state option to provide qualifying community-based mobile crisis intervention services for up to five years and offers enhanced funding to strengthen home and community-based services (HCBS), including provider recruitment, reimbursement increases, and telehealth expansions for behavioral health.   

In Medicaid and CHIP, CMS also encourages states to expand behavioral health provider networks, authorize providers across a broad spectrum of licensure and qualifications (including peer support providers), maintain coverage of telehealth, and provide reimbursement of care in subacute settings that enable greater access to crisis, diversionary, and intermediate levels of care. 

Improving Access To Substance Use Disorder Services

Overdose deaths resulting from substance use disorders have spiked during the pandemic to the highest level on record, and CMS is committed to further expanding access to substance use disorder treatment as part of a larger HHS effort to address the crisis. CMS continues to encourage state uptake of the section 1115 SUD demonstration opportunity, which aims to increase identification, initiation, and retention in treatment; reduce overdose deaths; improve access across the continuum of care; and promote delivery of services that treat co-occurring mental health and substance use disorders.  Substance use disorder screening has been added to the Medicare Annual Wellness Visit to identify people who may need additional help and support. Going forward, CMS is exploring ways to expand access to opioid use disorder treatment through implementation of the SUPPORT Act, which established the Medicare Part B benefit for Opioid Treatment Programs.

In addition, the CMS Innovation Center has launched two efforts to address the nation’s overdose crisis: the Maternal Opioid Misuse (MOM) Model and the Value in Opioid Use Disorder Treatment (Value in Treatment) Demonstration Program.  The MOM Model addresses fragmentation of care for pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD) by coordinating physical, behavioral, and social services. The Value in Treatment Program is designed to address barriers to high quality care that includes medication-based treatment for opioid use disorder.

Focusing On The Behavioral Health Needs Of Children And Youth  

As noted above, the pandemic has accelerated the mental health crisis among children and youth. During 2020, the proportion of mental health-related emergency department visits among teenagers (ages 12 – 17) increased by nearly one third compared with the year prior.

While many of the previously cited actions and recommendations effect children and youth, we are committed to doing more. Building on prior guidance, we are prioritizing maximizing school settings as a location for behavioral health service provision in Medicaid, including via telehealth. HHS Secretary Becerra and the U.S. Department of Education Secretary Miguel Cardona recently announced a joint effort to develop and share resources, such as guidance on Medicaid administrative claims, to improve access to school-based health services.

Furthermore, the Connecting Kids to Coverage National Campaign promotes enrollment in Medicaid and CHIP and reminds families of available coverage.  Specifically, Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit provides comprehensive and preventive health services for children under age 21 enrolled in Medicaid, including screenings, assessments, and treatments for behavioral health conditions. CMS is also committed to ensuring sufficient access to behavioral health treatment and pediatric providers, as well as more intensive specialized supports such as health homes for children with medical complexity, inclusive of mental health conditions, authorized by the ACE Kids Act. And the CMS Innovation Center is testing the Integrated Care for Kids (InCK) Model, which is designed to improve child health through early identification and treatment of children with health needs across different care settings.

Improving Quality Of Behavioral Health Care

Quality measurement and improvement are effective strategic tools that are increasingly integrated into the operations of health care systems. CMS is promoting quality measurement through inclusion of behavioral health measures in programs (e.g., Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence) to enable person-centered care across payers and care settings, from home and community-based settings to hospitals, post-acute care and nursing homes.

Of note, some hospitals and clinicians already use electronic clinical quality measures to provide feedback on their care systems and to inform quality improvement initiatives. These quality measures may also be considered for integration into value-based arrangements for health care facilities, and alternative payment models and arrangements for clinicians and practices, including integration into payment and service delivery models tested by the CMS Innovation Center. We want to emphasize that outcome measures of behavioral health care are still needed.

Summing Up

Our overarching goal is to make equitable, high-quality, affordable, data-informed care for mental health and substance use challenges available to the people we serve, building on the system’s evolution towards value-focused care.  We intend for these actions, taken collectively, to enable a better care experience that is seamless, supportive, and effective throughout the journey from detection and diagnosis to management and recovery. 

As we advance our work in behavioral health, we take this opportunity to thank those who, despite the challenges of the pandemic, have remained committed to serving people who are covered by Medicare, Medicaid, CHIP, and private health insurance plans, in addition to those without insurance. We now ask that each of you envision your part in helping us make aligned improvements across the care continuum. We ask you to commit yourselves to actions that support the people we serve together so that we may best meet the behavioral health needs of our nation.