Alignment for Progress: 
A National Strategy for Mental Health and Substance Use Disorders

Ongoing provider shortages affect youth access to mental health and substance use disorder (MH/SUD) services disproportionately. An estimated 10.8 million children and adolescents report experiencing a mental health or substance use disorder (MH/SUD). However, there are not enough providers who are trained to address the unique needs of younger patients, especially in rural areas.[2][3] State Medicaid programs experiencing provider shortages can opt to allow out-of-state providers to enroll as licensed telehealth providers, but since the end of the COVID-19 public health emergency, states have adopted a patchwork of out-of-state licensing policies creating confusing conditions for patients and providers.[4] The process to become an out-of-state provider is highly variable by state, which de-incentivizes providers from expanding their coverage area.[5] Providers wishing to support young patients in nearby states should not have to overcome administrative hurdles to provide care, and patients should have timely access to MH/SUD treatment. Congress should require all states to adopt a uniform and streamlined process for enrolling out-of-state providers in their Medicaid programs in order to adequately meet the MH/SUD needs of their under-21 population.[1]

Risk adjustment is a method used by CMS to ensure private Medicare Advantage plans are compensated for beneficiaries who have significant health care needs. Health plans participating in Medicare Advantage who provide coverage to these high-risk beneficiaries receive extra payments to help defray the cost of the care provided.[2] Hierarchical Condition Categories are used as a risk-adjustment tool by CMS to estimate the future cost of care for patient populations based on a range of physical health factors and some pertaining to MH/SUDs for Medicare Advantage (MA) plans.[3]

Congress directed CMS to evaluate whether additional MH/SUD factors should be included in risk adjustment, but screening for some common conditions such as anxiety, and factors related to social determinants of health (SDOH) remain unaddressed.[1] Nearly 30 percent of Americans are affected by anxiety at some point in their lives.[4] SDOH impacts the likelihood of a person to require MH/SUD treatment and their likelihood of accessing treatment.[5][6] Congress and CMS should work together to determine what additional MH/SUD and SDOH factors should be included in Hierarchical Condition Categories to effectively estimate risk adjustment payments, which may improve access to MH/SUD care for beneficiaries enrolled in Medicare Advantage plans.[1]

During the COVID-19 Public Health Emergency, federal and state policymakers put in place a variety of “flexibilities” that suspended various rules that affected individuals with MH/SUDs’ ability to receive services via telehealth. Such flexibilities allowed usage to skyrocket, with nearly one-third of all MH/SUD visits occurring via telehealth in the second quarter of 2022 – a 45-fold increase.[1] Unfortunately, Congress did not make all the beneficial changes made during the Public Health Emergency permanent prior to the Emergency’s expiration, though it did delay their expiration for two years. To ensure permanent access to MH/SUD services via telehealth, Congress must act.

The most comprehensive bill, the CONNECT for Health Act, has broad bipartisan support and would make all COVID-19 telehealth flexibilities in Medicare permanent and further expand access to telehealth services.[2] Critical provisions include permanently removing all geographic restrictions, allowing telehealth visits to originate from homes and other sites, and eliminating the requirement that Medicare beneficiaries receiving mental health services via telehealth have an in-person visit every six months. The in-person requirement does not exist for substance use disorder services and creates a barrier to access, particularly for individuals without easy access to in-person telehealth services. Other key bipartisan legislation includes the Telemental Health Care Access Act[3], which would also eliminate the Medicare mental health services in-person requirement, and the Telehealth Expansion Act[4], which would extend provisions that allow employers to provide pre-deductible coverage of telehealth services for individuals with high-deductible health plans linked to health savings accounts.

The external review process is key to ensuring that individuals denied coverage can have an external reviewer (i.e., not someone employed or contracted by the health plan) evaluate if denied services were medically necessary. In individual and group health plans, the Affordable Care Act guarantees the right to external reviews of denials (otherwise known as “adverse benefit determinations”). Unfortunately, in practice, this right to external review is often undermined. There are three categories of external review systems for individual and group health plans. First, there is a state-administered system that is created by state law and where states must contract with so-called Independent Review Organizations (IROs). Second, there is a federal external review process, in which federal law sets requirements under which plans must operate, but plans administer the process by contracting with IROs of their choice. Third, there is a federally-administered external review process, which the federal government administers.[1] For fully-insured individual and group plans that are subject to state law, states can administer their own external review system and, if they do not, can use either the federal external review process or the federally-administered external review process. Self-funded group plans (which are not subject to state law) are subject to the federal external review process.

Unfortunately, insurers and claims administrators often also have contracts with the same IROs that conduct external reviews to conduct internal reviews. IROs often view insurers and administrators as their clients, and IROs have said that “client preference” is a leading determinant of the basis for review. Under the federal external review process, claims administrators assign external reviews to IROs and frequently instruct them to limit the scope of reviews, despite regulations requiring IROs to evaluate non-quantitative treatment limitations (i.e., medical management techniques). Additionally, many states and the federal external review process (though not the federally-administered external review process) effectively are subject to no oversight, with no transparency as to whether external review timeframes and notice requirements are complied with. This is critical, because under the federal external review process, IROs are permitted to terminate external reviews and automatically reverse adverse benefit determinations when insurers/administrators fail to provide timely and complete information. Finally, the identity of external reviewers is concealed from consumers, making it impossible to validate their training and experience, credentials or conflicts.

To ensure proper external reviews, Congress should, for self-funded group plans, require use of the federally-administered external review process, which is more transparent and lacks such conflicts. For state-regulated fully-insured individual and group health plans, Congress should require that states only contract with IROs that do not accept direct business from health insurers or administrators in any market segment and require external reviewers’ identities to be made available to consumers. (California utilizes an external review vendor that does not accept private contracts from insurers/claims administrators.)[2] If a state does not administer its own system, Congress should require the state to use the federally-administered external review process.

Insufficient reimbursement has led to in-network provider shortages for Medicaid beneficiaries seeking mental health and substance use disorder (MH/SUD) treatment.[3][4] Medicaid is the single largest payer of MH/SUD services. However, 35 percent of beneficiaries report not being able to access treatment.[5] Congress should mandate that evidence-based MH/SUD treatments are reimbursed at their true cost to incentivize providers to accept Medicaid.[1] To facilitate increased access to treatment, the Medicaid Bump Act would increase the Federal Medical Assistance Percentage (FMAP) to provide states with additional financial resources to improve access to MH/SUD providers.[6] It would also require the Department of Health and Human Services to report on how the increased FMAP impacts access to MH/SUD services.[6] Congress should pass this important legislation.[2]

Immigrants and refugees need support in navigating the healthcare system and finding appropriate and culturally responsive care. Immigrant communities also encounter many challenges such as discrimination, isolation, stigma, and a sense of separation. These challenges often compound the trauma that they faced before and after migrating. Some of the most significant health and well-being service gaps are often language barriers, stigma, and lack of diversity amongst service providers. Providing resources and information about available services and providing culturally competent outreach and care are vital to ensuring that they access the services they need.[2]

The CLAS standards aim to ensure cultural competency of social workers, healthcare, and mental health care workers, so that they can better serve diverse communities, including immigrants. HHS should require, rather than simply making available, adoption of their Culturally and Linguistically Appropriate Services (CLAS) standards in health and health care settings by organizations receiving federal funding.[2] Title VI of the Civil Rights Act of 1964 requires organizations receiving federal funds to take “reasonable steps to provide meaningful access to their programs for individuals with limited English proficiency.” The Departments of Justice and Labor should prioritize handling language access discrimination cases in healthcare and other service settings.[3]

Many critical programs that serve people with low incomes are federally funded but state and locally administered. States and localities vary greatly in the resources they devote to language access and in the number of languages they translate important materials such as health care and mental health care materials. Federal agencies, such as HHS and OMH, should provide more translated materials that can be adapted by state and local agencies (adding specific program names, websites, phone numbers) and should enforce legal requirements to provide qualified translation and interpretation services. The National Virtual Translation Center assists in identifying the language of and ensuring quality of pre-translated materials for federal agencies; it can assist in ensuring information on health care access is appropriately translated across all relevant federal agencies. The Limited English Proficiency Federal Interagency Website provides links to documents that provide guidance on language access service and hosts actual translated documents; the website should host specific guides on culturally competent language access services in health and health care settings and actual translated documents on the topic for health care agencies to use. [3]