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

The Department of Health and Human Services should assist in elevating the standards of MH/SUD care that are generally accepted by MH/SUD clinicians by examining peer-reviewed scientific studies and medical literature, recommendations from nonprofit clinical specialty associations, recommendations from federal agencies, and drug labeling approved by the U.S. Food and Drug Administration.This database of generally accepted standards of care could be utilized by federal and state insurance regulators in their enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA) and other health coverage requirements. The Department of Health and Human Services should further identify guidelines and criteria that are consistent with generally accepted standards of MH/SUD care to help improve the quality of MH/SUD service delivery and coverage. The Department could consult with the New York State Office of Mental Health, which has put out “Guiding Principles” for clinical review criteria for mental health services and a “Best Practices Manual for Utilization Review for Adult and Child Mental Health Services. In its reviews, OMH found that no health plans’ submitted criteria met these Guiding Principles.[1][2]

Currently, the lack of such a definition weakens MHPAEA’s protections, especially for autism spectrum disorders. Federal regulators have made clear that health plans must define MH/SUDs consistent with generally recognized independent standards of current medical practice, such as the DSM or International Classifications of Disease (ICD), unless state law defines otherwise. This generally results in individuals with autism being protected under MHPAEA, given that autism is defined as a mental health condition in the DSM and ICD. However, at least one state – North Carolina – defines autism as a physical health condition, not a mental health condition, and MHPAEA’s protections do not apply to fully-insured plans in the state. In their 2022 report to Congress, the Departments of Labor, Health and Human Services, and Treasury have requested that Congress define MH/SUD[1], and the Promoting Clarity in Mental Health and Substance Use Disorder Treatment Act was introduced later that year, which would tie the definition of MH/SUD to the DSM and ICD[2].

Congress established the CCBHC model as a Medicaid demonstration under Section 223 of the Protecting Access to Medicare Act of 2014. The original 10 CCBHC demonstration states will be graduating from the demonstration over the next few years and will need to seek a state plan amendment or an 1115 waiver to maintain their already-implemented CCBHC models. Additionally, other states that seek to establish the CCBHC model outside of the demonstration will also need to apply through a state plan amendment or waiver. The lack of a federal CCBHC definition creates a risk that states and their CCBHCs may not have consistent models, affecting both outcome data and the quality of care provided.

The Bipartisan Safer Communities Act of 2022 allows for 10 new states to join the CCBHC Medicaid demonstration every two years. Having a standard federal CCBHC definition gives states the ability to continue their existing CCBHC models and will expedite efforts for states implementing the CCBHC model by having clear guidance for state plan amendments and 1115 waiver. This will also support fidelity to the CCBHC model that Congress established and continues to support.[1]

Older adults and individuals with disabilities may require long-term care.[2] An estimated 11 million Americans qualify for long-term services and supports (LTSS).[3] Those who qualify for LTSS may have a range of physical or mental health or substance use disorder (MH/SUD) needs which require intensive caregiving. Qualified individuals face two paths to long-term care: institutional care in a facility or care provided through HCBS.[2] HCBS provide significant support to those who require long-term care, including home health aides, case management, adult day care, and more, while allowing patients to remain at home.[4]

While most states currently offer HCBS waivers, many who qualify for LTSS find themselves on long waiting lists for a waiver, and when care is needed immediately, eventually turn to institutional care despite preferring to remain at home.[2] Individuals with a MH/SUD that requires long-term care should not feel forced into institutional facilities when they would prefer to remain at home and can do so with better outcomes.[5] Congress should pass the HCBS Access Act, which would require Medicaid to allow all eligible adults to choose between receiving care at home or another facility.

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA or Parity Law) requires equity in coverage between mental health and substance use disorder (MH/SUD) and medical/surgical benefits.[4][5] When passed in 2008, the MHPAEA applied only to group health plans and group health insurance.[4][5] However, in 2010, the Affordable Care Act (ACA) amended the law to include the individual health insurance market.[4][5] While the MHPAEA has significantly improved access to MH/SUD coverage for millions of Americans, several gaps persist. Tens of millions of Americans who receive health coverage through Medicare, fee-for-service Medicaid, TRICARE, and the Indian Health Service (IHS) are not covered by the Parity Law, leaving individuals with health insurance through these programs open to discrimination.[5][6][7] Parity protections shouldn’t apply only to a subset of Americans based on the type of insurance they have. Everyone deserves to receive equal coverage of mental health and addiction treatment services.[6]

In addition to expanding the MHPAEA’s applicability, the existing regulatory rules need to be updated and strengthened. In July 2023, the Departments of Health, Treasury and Labor issued a proposed rule that would require health plans to act when there are disparities in consumers' ability to access care, require data reporting to evaluate plans' compliance, and would create new rules regarding "network composition" to address whether individuals can access care within plan networks.[8] The administration should work quickly to finalize the proposed regulation and implement these new protections.

Congress should amend the Public Health Service Act to include the following additional insurance protections that increase access to MOUD and MAUD, which have been proven to save lives.[1] Specifically, Congress should ensure the following protections are codified:

• Health plans and issuers may not exclude coverage of any Food and Drug Administration (FDA) approved medication for the treatment of substance use disorders (SUDs) if such medication is medically necessary according to the most recent National Practice Guideline on the Use of Medications for the Treatment of Addiction Involving Opioid Use established by American Society of Addiction Medicine (ASAM).[1]
• All FDA-approved medications for the treatment of SUDs should be placed on the lowest tier of a health plan or issuer’s prescription drug formulary.[1]
• Health plans and issuers may not impose step therapy requirements on MOUD/MAUD before coverage is approved.[1]
• Health plans and issuers may not exclude coverage for any prescription medication approved by the FDA to treat SUDs and any associated counseling or wraparound services because such medications and services were court-ordered.[1]

While the  Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)  improved access to MH/SUD treatment and services, patients still encounter obstacles in accessing care, including MOUD/MAUD.[2] Many barriers may impact the availability of these medications including stigma, the availability of prescribers, and insurance benefit designs.[2] MOUD/MAUD have been proven to be an effective treatment for MH/SUDs, but it can be costly for people who are uninsured or underinsured.[3] Having quality health insurance coverage can make treatment more affordable and accessible.[4] Given the recent increases in overdose deaths and alcohol use, Congress should ensure health insurance coverage provides access to critical SUD medications.