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

Self-funded employer plans (typically large employers) frequently hire third-party administrators (TPAs) to administer health plan benefits on their behalf. These TPAs are usually well-known insurance companies with recognizable brand names. Employers seeking to comply with the Mental Health Parity and Addiction Equity Act (MHPAEA) and other health coverage rules have reported that some TPAs refuse to provide information and data on the employers’ health plans, claiming that the information is proprietary. “[Employers] also say they often are unable to get the information they need from third parties—typically insurers—that administer their plans.”[1] Such refusals are unacceptable and inconsistent with employers’ and TPA’s obligations under the law. TPAs should be prohibited from imposing such indefensible barriers to compliance.

Health centers conduct more than 1.7 million substance use disorder (SUD) visits and over 15 million mental health visits.[4]  Unfortunately, despite providing indispensable integrated health care services for individuals enrolled in Medicaid and Medicare, a significant percentage of FQHCs have historically not provided core evidence-based treatments for SUDs, including opioid use disorder. One survey showed that, in 2019, 36 percent of community health centers did not offer MAT.[5] While the percentage of FQHCs providing MAT has improved over time, no FQHC should be permitted to not provide this life-saving treatment. Particularly now that Congress has eliminated the requirement that buprenorphine (a key MOUD) prescribers have a separate waiver (X-Waiver), there can be no excuse for an FQHC failing to provide MOUD and wraparound and counseling services.[1] FQHCs can be particularly important in increasing access to needed SUD treatment in rural communities.[6]

Additionally, there is a gap in coverage and treatment facilities across most states. More than 163 million people live in a mental health Health Professional Shortage Areas (HPSAs), meaning they do not have access to MH/SUD health professionals or treatment and support services.[7] Co-location of primary care and MH/SUD services has been shown to improve access to care and health outcomes.[8] This type of care entails providers using similar technologies, such as electronic health records, and being in the same physical location.[8]  By providing funding to states, they can develop the necessary infrastructure to provide MH/SUD care services at the same physical location.[2][3]

Currently, services that are indispensable treatments for common mental health and substance use disorders (MH/SUDs) are not covered by many public and private payers. For example, commercial plans largely fail to cover Coordinated Specialty Care, the evidence-based intervention for first episodes of psychosis, which often first appear in adolescence and early adulthood. The failure of commercial insurance to cover these services results in cost-shifts to Medicaid and contributes to approximately 75 percent of the 100,000 young people experiencing first psychosis each year not receiving this life-altering treatment. The federal government should not allow such evidence-based treatments to not be covered.[1][2]

MHPAEA, which was co-authored by former Congressman Patrick J. Kennedy, founder of The Kennedy Forum, requires most types of health insurance (including ERISA plans) to cover mental health and substance use disorders services no more restrictively than physical health services.[4][5] While the MHPAEA has significantly improved access to MH/SUD coverage for millions of Americans, the Department of Labor (DOL) and other state and federal regulators have uncovered numerous violations of the Parity Law.[6] For the law to be effective, however, health plans must be held accountable when they fail to comply with the law’s requirements.[7] The Parity Enforcement Act extends existing civil monetary penalty authority that DOL has to enforce the Genetic Information Nondiscrimination Act (GINA) to MHPAEA and includes safe harbor provisions for plans making good-faith efforts to comply with the law. The Parity Enforcement Act passed the House on two occasions in the 117th Congress. President Trump’s 2017 Opioid Commission, the Bipartisan Policy Center’s Task Force on Tackling America’s Mental Health and Addiction Crisis Through Primary Care Integration, and DOL itself have called for this authority.[2][3]

Currently, public and private payers across the country do not cover the full continuum of mental health and substance use disorder (MH/SUD) services, leaving large gaps in the service continuum. These gaps result in individuals not receiving the care they need and result in inappropriate level of care placement that is either too intensive or not intensive enough.

Congress should ensure that all health coverage covers the full continuum, as well as all FDA-approved medications for SMI. Specifically, Medicare should tie covered levels of care to The ASAM Criteria developed by the American Society of Addiction Medicine and the Level of Care Utilization System (LOCUS) family of criteria developed by the American Association of Clinical Psychiatrists and the American Academy of Child and Adolescent Psychiatrists to create a common language on the various levels of care. Medicaid programs should also cover all ASAM Crtieria levels of care and use the LOCUS/Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASSII) for mental health conditions. These criteria should be required to be used by providers, insurers - including private managed care plans particoipating in Medicare and Medicaid - to determine each individual’s most appropriate level of care at any given point in time. All medical necessity determinations under Medicare and Medicaid should be consistent with generally accepted standards of MH/SUD care.

Additionally, all payers – including Medicare and Medicaid – should be required to utilize the standardized definition of medical necessity endorsed by the American Medical Association[3] and the American Psychiatric Association[4] and require determinations to be consistent with generally accepted standards of MH/SUD care.[5] For any utilization review, including level of care determinations, all payers should be required to utilize exclusively criteria from nonprofit clinical professional associations. Such requirements have been implemented in numerous states, including recently in California[6], Illinois[7], and Oregon[8]. These nonprofit criteria are transparent, externally validated, and peer-reviewed by publicly identified reviewers who can be vetted for conflicts of interest. Criteria not publicly available, externally validated, nor peer-reviewed by publicly identified reviewers should be prohibited.

According to the U.S. Department of Labor (DOL), substance use disorders (SUDs) can lower worker productivity and increase absenteeism, health care costs, and legal liabilities for employers.[2] Best practices for preventing and treating SUDs in the workplace - including increased access to screening, early intervention, and treatment [3][4][5][6] - would reduce the impact of SUDs on both employers and employees.