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

MA provides healthcare coverage through private managed care plans for hospital and physician services as an alternative to traditional Medicare FFS. Enrollment in MA has continued to grow over the years and now accounts for more than 50 percent of Medicare enrollees. As enrollment continues to increase in the MA program, it’s critical for policymakers and regulators to fully understand any key differences in ability to access care between MA and traditional Medicare FFS, including the ability to access care for MH/SUDs.

Unlike Medicare FFS, MA plans employ utilization management tools, such as cost-sharing and prior authorization requirements, that may impact how beneficiaries are able to access treatments and services. MA plans  may also provide additional services and benefits that are not covered by traditional Medicare FFS (e.g., dental and vision benefits).

Presently, the Mental Health Parity and Addiction Equity Act of 2008 does not apply to any part of Medicare. Thus, it is critical  to understand whether and how MA plans may be restricting access to MH/SUD care. While some information is known about the differences between the two programs [2], a clearer and more comprehensive assessment is needed. Congress should require the GAO to conduct a study that seeks to understand the differences in enrollee cost-sharing and utilization management with the goal of ensuring that MA plans are not restricting access to MH/SUD, particularly as compared to Medicare FFS.[1]

Healthcare practitioners are required to have a medical license for each state where they provide care. MH/SUD providers who prescribe medications for opioid use disorder (MOUD) are also required to have a DEA registration for every state they have a medical license.[2][3] This current policy has resulted in challenges for prescribers who face administrative burdens that may impact their willingness to seek DEA registrations, such as multiple fees and duplicative documentation requirements.[1][4] To alleviate administrative burdens and address workforce shortages related to MH/SUD providers, the DEA should have one registration that covers every state in which a prescriber has a medical license.[1]

Thirty-seven percent of Americans live in an area with a shortage of MH/SUD professionals, and two-thirds of those shortage areas are rural.[2] One quarter of rural residents receive health insurance through Medicaid and are more likely to report having poor mental health, making access to timely MH/SUD care vital for this population. However, many residents of rural communities often struggle to find care.[3] Pathways to workforce development and training grants currently exist, but more needs to be done to address provider shortages areas.[4] Congress should direct the Department of Health and Human Services (HHS) to issue guidance regarding workforce capacity in rural and other provider shortage areas, a step that was called for by a bipartisan group of Senate Finance Committee members.[1]

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.