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.
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]
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Expand National Health Service Corps eligibility
The Health Services and Resources Administration (HRSA), within the Department of Health and Human Services, should educate mental health and substance use disorder (MH/SUD) professionals about Public Service Loan Forgiveness for work in the criminal legal system.[1] Congress should expand National Health Service Corps (NHSC) eligibility to local and county corrections and a wide range of SUD treatment and recovery support professionals and make permanent the Fiscal Year (FY) 2018 NHSC expansion of eligible participating sites to include SUD treatment facilities.[1]
An increasing number of individuals with mental health and substance use disorders (MH/SUDs) are involved with the criminal legal system, where there is a scarcity of health professionals who can provide MH/SUD care.[1][2] An estimated 44 percent of individuals in jail and 37 percent in prison have a mental health condition and 63 percent and 58 percent, respectively, have an SUD. Sixty-three percent of these individuals don’t receive the treatment they need in prisons and less than half receive treatment in jails.[3][4] One way to incentivize MH/SUD professionals to work in the criminal legal system is by expanding loan forgiveness and repayment programs.[1]
Licensed clinical social workers and professional counselors; health service psychologists; marriage and family therapists; psychiatric nurse specialists; physicians with a specialty in psychiatry, including child and adolescent psychiatrists; nurse practitioners; and physician assistants who specialize in mental health and psychiatry who work in the criminal legal system are eligible for Public Service Loan Forgiveness.[5][6] In Fiscal Year (FY) 2018, Congress expanded National Health Service Corps (NHSC) eligibility to include SUD treatment facilities and additional MH/SUD health professionals.[1][7] However, this expansion is not permanent and does not include eligibility for local and county corrections and MH/SUD treatment and recovery support professionals.[1][7][8] Education and permanent expansion of loan repayment and forgiveness programs is necessary to increase the number of MH/SUD health professionals in the criminal legal system.[1]
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Eliminate out-of-state licensure requirements
To address the continued need for provider flexibility and remove federal barriers to meeting workforce demands, Congress should permanently eliminate the out-of-state licensure requirements under Medicare and Medicaid. Congress should also direct the Department of Health and Human Services (HHS) to convene a working group representing state health profession licensure boards to identify barriers to participation in state licensure compacts and develop a framework or model application for reciprocity to facilitate provider approval to practice across state lines.[1]
In response to the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) temporarily waived requirements that out-of-state Medicare practitioners be licensed in the state where they are providing services.[2] CMS also released guidance stating that state Medicaid agencies could use Section 1135 waiver authority to permit providers located out of state to provide care to another state’s Medicaid enrollee impacted by the COVID-19 emergency.[2] These changes were particularly helpful in enabling mental health and substance use disorder (MH/SUD) providers to meet increasing demand for services around the country throughout the pandemic. While the public health emergency has officially ended, the need for increased flexibility to maintain the capacity of providers has not. Congress should amend the Social Security Act to allow licensed providers participating in Medicare, Medicaid, and CHIP to provide services across state lines.
In May 2023, the Health Resources and Services Administration (HRSA) Office for the Advancement of Telehealth released new resources on interstate licensure.[3] These resources include the latest guidance on how to practice telehealth across state lines legally while encouraging the uptake of licensure models that increase access to health care. As part of this ongoing work, HHS and HRSA should convene stakeholders to identify remaining barriers to participating in interstate compacts and develop a framework for overcoming those obstacles.
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Require CMMI to advance behavioral health integration
Congress should require the Center for Medicare and Medicaid Innovation (CMMI) to advance behavioral health integration by adding support for adopting behavioral health integration as one of the types of opportunities the CMMI must consider when developing new demonstration models or revising existing models. [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 primary care and MH/SUD providers, which has proven beneficial to patients and has evolved into the Collaborative Care Model (CoCM). The CoCM has been demonstrated effective by more than 90 randomized-controlled trials and can help to more effectively utilize limited MH/SUD provider capacity.[3] CMMI is responsible for testing alternative payment models. Given the demonstrated success of BHI/CoCM payment models at improving care and improving delivery efficiency, CMMI should be required to consider these models when developing new demonstration models or revising existing ones.[1][4] In 2022, the Senate Finance Committee’s bipartisan Mental Health Care Integration workgroup recommended such a requirement.[1]