The opioid crisis in the United States 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 proposed rule for Medicare’s 2023 Physician Fee Schedule suggests changes will be made to Medicare’s coverage for treatment of mental health and substance abuse disorders when the final rule is released. It’s scheduled for next week.
About 1.7 million Medicare beneficiaries have had a substance use disorder in the past year, according to a recent study. And although they were much more likely to have had severe psychological distress and suicidal thoughts, only 11% received treatment. It’s not a new problem.
Medicare does not cover the full range of services, providers, and facilities for the treatment of substance use disorders, or “SUDs.”
According to a recent study, it “effectively excludes coverage” of treatment for substance use disorders in intensive outpatient programs, outpatient addiction clinics, and residential addiction programs. Medicare also does not allow billing by the addiction specialists who dominate the SUD treatment workforce: licensed counselors, certified addiction counselors, and peer counselors.
And because the Mental Health Parity and Addiction Equity Act does not apply to Medicare, the program is not required to provide benefits for substance use disorders and mental health on the same level as medical and surgical care benefits. This is in stark contrast to most private and employment-based health insurance — and even Medicaid plans — that are covered by law.
Attention of legislators, regulators
As Covid-19 and opioid overdose deaths rise, the Medicare coverage gap for behavioral health services is attracting new attention from regulators and lawmakers.
Last month, the House Ways and Means Committee drafted six bills aimed at bolstering Medicare mental health coverage. And last week, Sen. Richard Durbin and Rep. Lauren Underwood, both Democrats from Illinois, called on Medicare to act “swiftly and comprehensively” to “explore avenues to expand access to residential services.” treatment for substance use disorders provided by treatment programs that offer evidence”. care-based.
The Biden administration is also looking into the matter. Buried in Medicare’s proposed 2,000-page rule, the Centers for Medicare & Medicaid Services is seeking comment on whether a “loophole” in Medicare’s coding and payment mechanisms “may limit access to levels care necessary for the treatment of mental health or substance use disorders treatment, including and especially substance use disorders, for Medicare beneficiaries.
“We are particularly interested in the extent to which any potential gaps would be better addressed by the creation of new ‘billing codes’, or the ‘revision of particular billing rules for certain types of care in specific contexts,’ the proposal states.
The agency also asked if further coding adjustments were needed “to better reflect the relative resource costs involved in providing intensive outpatient mental health services.”
Continuum 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 least intensive types of treatment on the continuum: early intervention and outpatient services, as well as the most intensive type: inpatient services, said Deborah Steinberg, health policy attorney at the Legal Action Center. , a non-profit organization. .
Adding Medicare coverage of “intensive outpatient” services, which involve nine to 19 hours of treatment services per week, would fill a big void in the program’s current coverage offerings, she said.
“It’s a bit more intensive than someone just getting weekly counseling, but not to the level where someone is in residential treatment. And that’s something that 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.
People participating in intensive outpatient programs for substance use disorders receive an individualized treatment plan, individual and group counseling, medication management, family therapy, and participate in education groups and counseling. occupational therapy and recreation.
Intensive outpatient services
On another front, Rep. Judy Chu (D-California) introduced HR 8878, which would create a category of Medicare benefits for intensive outpatient services.
At a recent House Ways and Means Committee hearing, Chu’s bill passed the committee favorably. Chu, a psychologist, told the hearing that Medicare applies significant restrictions — like requiring beneficiaries to be eligible for hospital care — before covering interim treatment services for enrollees with substance use disorders. substances.
“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 said. “This is one of the many glaring flaws in the Medicare program that keeps mental health coverage from being on par with physical health.”
Chu’s legislation would allow outpatient hospitals, community mental health centers, rural health centers and federally licensed health centers to provide intensive outpatient services so that “patients can access care at facilities that best meet their needs,” she said during the hearing.
Rep. Adrian Smith (R-Neb.), a co-sponsor of the bill, told the hearing that he “hopes to see its eventual enactment into a broader bipartisan package of mental health care before the end of the year”.
Savings can offset change costs
It would cost about $928 million a year to provide intensive outpatient coverage for more than 116,000 beneficiaries with substance use disorders, according to a study by RTI International, a nonprofit research institute, in partnership with the Legal Action Center.
Adding nearly 76,000 residential treatment stays would cost $935 million, and nearly 59,000 sessions with counselors would cost an additional $66 million, the study estimates.
But those expenses would be nearly offset by savings of about $1.6 billion a year in spending on drug-related conditions, hospitalizations and emergency room visits, the study estimates.
Of the 1.7 million recipients with SUD, an estimated 77% had alcohol use problems, 16% with prescription drugs, and 10% with a marijuana use condition. Forty-one percent cited lack of motivation as the 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, in 2020, enabled Medicare coverage for opioid treatment programs that provide methadone and other drugs that treat disorders related to the use of opioids.
But of more than one million beneficiaries with opioid use disorder in 2021, less than 20% received medication to treat it, the Department of Health and Health’s Office of Inspector General reported. of Social Services in September. “This low proportion may indicate that recipients are having difficulty accessing treatment,” the OIG data note states.
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