Alignment for Progress: A National Strategy for Mental Health and Substance Use Disorders
It’s time for a meaningful national conversation about mental health and substance use care. We must remove the barriers to equitable and available coverage for these conditions so people can get the help they need.
Welcome To The National Strategy
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How Content Is Organized and How Best to Search/Sort the Recommendations
The National Strategy recommendations are organized by category, with impacted populations and topical areas providing additional nuance and the ability to narrow a search. We have also included the option to search recommendations by the relevant House and Senate committees of jurisdiction.
Recommendation Selection Methodologies and Criteria
After conducting a thorough review of the federal policy landscape, The Kennedy Forum team created this first-of-its-kind compilation of policy recommendations needed to transform our mental health and substance use systems. The recommendations have been sourced and vetted from numerous organizations, advocates, and experts across the country in order to capture a robust set of recommendations for lawmakers and federal agencies to act on.
All National Strategy Recommendations
These featured recommendations are highlighted based on their importance in beginning the national movement towards better care for everyone.
Make illegal denials of coverage subject to compensatory damages
Congress should amend the Employee Retirement Income Security Act (ERISA) to make illegal denials of coverage subject to compensatory damages.
ERISA governs private-sector employer-sponsored benefits for nearly 140 million Americans.[1] Under ERISA, individuals can only recover the value of the benefits due under their plan if a claim is wrongfully denied. They cannot receive compensation for any other harms suffered or for punitive damages, no matter how egregious the conduct. The failure of ERISA to hold health plans accountable for damages that illegal conduct has caused leaves individuals and their families without recourse for the harm they have experienced. When plans are only liable for the benefits that they have denied, there is a clear incentive to deny coverage, particularly when less than one percent of denials are ever appealed.[2] By allowing individuals to bring a civil action under ERISA to recover damages that are a result of bad-faith conduct or breaches of the health plan’s fiduciary duty, plans would be incentivized to proactively avoid violations of health coverage laws, including the Mental Health Parity and Addiction Equity Act.
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Create an ACO screening demonstration
The Centers for Medicare and Medicaid Services (CMS) should create a Medicare demonstration project with one or more accountable care organizations in which they screen for all common mental health and substance use disorders (MH/SUDs), including depression, anxiety disorders, psychoses, bipolar disorder, schizophrenia, and various addictions, and track outcomes for all of these conditions by using a quantifiable and standardized symptom rating scale.[1]
Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other healthcare providers who work together to coordinate the delivery of health care treatment and services on behalf of a patient. ACOs have been shown to be effective at reducing waste without compromising the quality of care, particularly for those with chronic conditions.[2][3] However, services for MH/SUDs have generally been left out of the ACO model despite the known cost and quality benefits of integrating MH/SUD care into primary care practices.[4][5] Screening for MH/SUD within ACOs continues to be primarily limited to depression and alcohol use disorder based on CMS’ preventive services guidelines.[6]
Medicare demonstration programs allow providers to test innovative approaches to care delivery while being sponsored by CMS, thus reducing risk to healthcare organizations. Given the known benefits of ACOs and the known benefits of MH/SUD care integration in other settings, a demonstration program that leverages ACOs to screen for all common MH/SUDs, including depression, anxiety disorders, psychoses, bipolar disorder, schizophrenia, and various addictions has significant opportunity for improving outcomes. The demonstrations should be evaluated on a standardized and quantifiable symptom rating scale to be monitored for efficacy.[1]
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Increase awareness of telehealth rights in Medicare
Congress should require original Medicare Fee-for-Service and Medicare Advantage plans to implement an awareness and education campaign regarding Medicare beneficiaries’ rights to receive telehealth services for mental health/substance use disorder (MH/SUD) treatment, as well as information on approximate cost-sharing obligations for telemental health services.[1]
While telehealth utilization has decreased slightly from COVID-19 pandemic peaks, demand has remained high for mental health and substance use disorder (MH/SUD) treatment.[2] Telehealth services for MH/SUD treatment can improve patient access, as providers can serve more geographically dispersed populations and help alleviate provider shortages in underserved areas. However, telehealth adoption for Medicare beneficiaries has consistently lagged behind adoption among those with private insurance.[3]
Although the Centers for Medicare and Medicaid Services (CMS) has made policy changes to facilitate access to telehealth services for Medicare beneficiaries during the Covid-19 Pandemic, beneficiaries may not have a clear understanding of what services are covered currently.[4][5] It is imperative this population have clear guidance on their rights to receive telehealth services for MH/SUD and related cost-sharing obligations so they are empowered to make informed decisions about their care.[1] The Department for Health and Human Services (HHS) has provided some guidance on how to inform patients about their options, but this is not sufficient as it relies heavily on individual providers and plans to act.[6] Congress should require CMS and any health plan serving Medicare beneficiaries to implement an awareness and education campaign about the telehealth services available to them, including MH/SUD treatment.
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Apply telehealth flexibilities to HBAI services
Congress should clarify that permanent Medicare telehealth flexibilities for mental health services under the Consolidated Appropriations Act 2021 also apply to health and behavior assessment and intervention (HBAI) services, which are provided to help individuals with chronic conditions deal with psychological obstacles to improved health and adherence to treatment regimes.[1]
Health and behavior assessment and intervention (HBAI) services are billable Current Procedural Terminology (CPT) codes to address psychological obstacles for those with primarily physical chronic health conditions.[2] Effective treatment of chronic physical health conditions can be impeded when psychological or emotional factors affect a patient’s ability to adhere to prescribed treatment, making HBAI an important part of comprehensive disease management. Psychologists are able to assess patients on the same day as receiving physical health services, and this is known to improve quality-of-life outcomes and medication adherence.[3]
Teletherapy utilization increased sharply during the initial months of the COVID-19 pandemic. While telehealth utilization has decreased slightly from pandemic peaks, it has remained strong for mental health and substance use disorder (MH/SUD) treatment.[4] Telehealth services for MH/SUD treatment can improve access as providers are able to serve more geographically dispersed populations, and can help alleviate provider shortages in underserved areas.
In 2021, the Consolidated Appropriations Act (CAA) made permanent flexibilities for the delivery of MH/SUD telehealth services.[5][6] Because HBAI services are designed to address the psychological and emotional needs of patients with physical health conditions, Congress should also clarify that recent changes in Medicare to facilitate the provision of telehealth services also applies to HBAI services.[1]
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CCIIO should enforce the federal parity law
The Center for Consumer Information and Insurance Oversight (CCIIO) should exercise its authority under 42 U.S.C.. § 300gg-22(a)(2) to enforce the Mental Health Parity and Addiction Equity Act (MHPAEA) in the individual market and for fully-insured, non-federal governmental plans when a “State has failed to substantially enforce” the law. Failure to “substantially enforce” should include solely relying on consumer complaints to determine if there is non-compliance, refusing to investigate all complaints involving mental health and substance use disorder (MH/SUD) denials of coverage for possible MHPAEA violations, and failing to conduct regular market conduct examinations to evaluate insurers’ MHPAEA compliance.[1]
MHPAEA requires equity in coverage between MH/SUD and medical/surgical benefits.[2][3] When passed in 2008, the MHPAEA applied only to group health plans and group health insurance.[2][3] However, in 2010, the Affordable Care Act (ACA) amended the law to include the individual health insurance market.[2][3] State enforcement of parity laws is critical. However, to date, only about 20 percent of states have ever penalized violations.[4] Everyone deserves equal coverage of mental health and addiction treatment services.[5] CCIIO has existing authority to enforce the Parity Law and has a responsibility to step in when a state is failing to do so.[1]
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Establish a consultation fee G-code
The Centers for Medicare and Medicaid Services (CMS) should establish a new G-code for a “consultation” fee. Such a code is critical to integrating mental health and substance use disorder (MH/SUD) care into primary care settings by supporting consultative relationships with a psychiatric professional, who would receive a supplemental G-code for providing decision supports.[1]
In 2017, the Centers for Medicare and Medicaid Services (CMS) began paying physicians and non-physician practitioners separately for supplying patients with Behavioral Health Integrated Services (BHI).[2] These services involve a closer partnership between treating physicians and mental or behavioral health professionals, which has proven beneficial to patients and has evolved into the Collaborative Care Model (CoCM). CMS uses G-codes to assess and address functional limitations in patients, including difficulty seeing, hearing, mobility, communication, cognition, and self-care.[3][4] These billing codes include approvals for reimbursement of services using CoCM approaches, but there is currently no appropriate billing code for physicians seeking a psychiatric professional for ad-hoc consultations.[1][5] CMS should establish a new G-code for a “consultation” fee that will empower physicians to more readily seek psychiatric consultations and foster more CoCM-centered care.[1] The CoCM has been demonstrated effective by more than 90 randomized-controlled trials and can help to more effectively utilize our limited MH/SUD provider capacity.[6]