Require coverage of the full continuum of MH/SUD care

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.