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

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.

Restrictive housing, which includes solitary confinement, separates an incarcerated person from all forms of contact with others. For the increasing number of incarcerated people with a mental health or substance use disorder (MH/SUD), restrictive housing is deeply harmful and can lead to the deterioration of individuals’ conditions.[2] According to the Department of Justice (DOJ), 29 percent of incarcerated people in prisons and 22 percent in jails with symptoms of serious psychological distress have been subjected to restrictive housing.[3] There is also an increased risk of suicide or self-injury for incarcerated people placed in restrictive housing, regardless of whether the individual previously had an MH/SUD.[4] Spending time in restrictive housing is likely to result in anxiety, anger, sleep issues, and disorientation.[4] To mitigate increased risks, policies around restrictive housing need to be reevaluated and updated.[1]

The National Health Service Corps (NHSC) includes medical, dental, and mental health and substance use disorder (MH/SUD) providers who receive scholarships or loan repayment assistance in return for providing services within communities at eligible facilities in Health Professional Shortage Areas (HPSAs).[3][4][5] Currently, any clinic that provides care to Veterans or active military personnel is ineligible for NHSC support, even if the facilities are in a HPSA.[5] Over 456,000 active military and 5.2 million Veterans have experienced a mental MH/SUD).[6][7] Many face major barriers to care[8], including a shortage of health professionals at Veterans Health Administration (VHA) facilities and a lack of crisis intervention services.[9][10] To improve access to MH/SUD treatment for military personnel, VHA facilities and clinics should be included as a “medical facility” for the NHSC loan repayment programs.[1][2]

Formal, fully integrated partnerships between FQHCs and CCBHCs can empower both physical and MH/SUD providers to deliver a more comprehensive range of services and improve care delivery.[1][4] CCBHCs were first deployed by the Department of Health and Human Services (HHS) as a demonstration program in eight states to improve access to MH/SUD care at the community level, and have since been expanded to over 46 states and U.S. territories with over $120 million in funding made available.[5][6]

In 2016, HHS created a voluntary quality bonus payment for CCBHCs that meet certain state-determined performance requirements and federally required performance objectives.[8] However, these requirements do not reflect integration and do not apply to FQHCs, removing incentives for FQHCs to pursue integration.[1] Congress should encourage formal partnerships and increased integration between CCBHCs and FQHCs through a voluntary integration bonus program. Additionally, to further improve integration, FQHCs and CCBHCs should be allowed to bill for both physical and MH/SUD services on the same day, which is referred to as same-day billing.[7] Several explicit Medicaid policies prohibit billing for MH/SUD and physical health services on the same day.[7] Congress should amend rules to allow same-day billing for MH/SUD and physical health services to empower providers to increase care integration.