Skip to main content

You’re not alone. Call 988 to connect to the National Suicide and Crisis Lifeline.

Join Us    |    Contact

Medicaid Policy Proposals May Disrupt Behavioral Healthcare Access

Written by Meghan Barrett on . Posted in Analysis, News & Insights.

Background

Behavioral health conditions such as major depressive disorder, schizophrenia, and opioid use disorder are highly prevalent among Medicaid beneficiaries; in 2020, almost 40% of nonelderly adult beneficiaries had a mental or substance use disorder.[1] These individuals depend on the wide range of behavioral health benefits in Medicaid programs, including clinical services across the continuum of care, prescription drugs, and recovery support services. Medicaid is also the single largest payer for behavioral healthcare services in the United States and is an essential revenue source for behavioral healthcare organizations such as outpatient clinics, inpatient and residential facilities, and Opioid Treatment Programs (OTPs).[2]

Several policy proposals have been made to lower federal financial participation (FFP) in Medicaid, such as changing the current formula for Federal Medical Assistance Percentages, instituting caps to FFP at the state- or enrollee-levels (such as by transitioning Medicaid to a block grant), or limiting the existing safe harbor preventing a portion of state taxes on providers’ net patient revenue from being considered when calculating FFP.[3] Additionally, proposals have been made to institute work requirements for Medicaid beneficiaries.[4]

Medicaid Financing Proposals Could Exacerbate Existing Challenges

Reductions in FFP could prompt states to make harmful changes to their Medicaid programs to offset reduced revenue, such as:

  • Decreasing provider payments.
  • Restricting benefits, particularly optional benefits such as prescription drugs and home- and community-based services.
  • Limiting eligibility, such as for the Medicaid expansion population.

These changes could make it much more difficult for people with behavioral health conditions to access needed care. Despite Medicaid being the nation’s largest payer of behavioral healthcare services, there is still significant unmet need for care[5]; each year, millions of people with behavioral health conditions do not receive any treatment.[6] This gap in treatment is largely attributable to a pervasive misalignment between payment for and coverage of behavioral healthcare services, and the positive impact these services have on people and communities.

Existing insurance payment rates for behavioral healthcare services are inadequate, and reductions would worsen this problem. Substantial disparities exist between behavioral healthcare providers and the rest of the healthcare system: an analysis found that, compared with psychiatrists and psychologists, benchmarked commercial insurance reimbursement for office visits with specialist medical/surgical physicians was 25% and 29% higher, respectively.[7]

Meanwhile, Medicaid payment is typically much lower than other insurance programs, with average Medicaid reimbursement for physician office visits being 38% less than employer-sponsored insurance and 26% less than Medicare.[8] Another study found that psychiatrists were reimbursed by Medicaid fee-for-service 19% less on average than by Medicare.[9] Further, Medicaid rates do not necessarily cover provider costs; in 2018, Medicaid payments for community hospital services amounted to only 89% of the cost to deliver those services.[10]

Therefore, reduced payment may further disincentivize behavioral healthcare providers’ participation in Medicaid, exacerbating current issues with inadequate insurance networks of behavioral healthcare providers. For example, a secret shopper survey in New York found that only 14% of calls made to mental healthcare providers listed as in-network by health plans led to an appointment being offered.[11] Another analysis found that over half of mental healthcare providers in Oregon Medicaid managed care plan directories did not see Medicaid beneficiaries in 2018.[12] This reflects the current state of low in-network use of behavioral healthcare services. In 2021, commercially insured patients had out-of-network office visits with psychiatrists 8.9 times more and with psychologists 10.6 times more than with medical/surgical specialists.7

Restricting benefits may also lead to greater out-of-network use, as many important behavioral healthcare services are not mandatory benefits in Medicaid, including residential and inpatient behavioral healthcare, most psychiatric medications, targeted case management, and various other clinical services.[13]

Accordingly, each of the Medicaid policy changes could result in individuals incurring greater out-of-pocket expenses, which, according to the Congressional Budget Office (CBO), could “possibly [lead] to a significant increase in medical debt and bankruptcies.”[14] Otherwise, more individuals could delay or forgo care due to unaffordability, which could result in worsened symptoms that necessitate more intensive care than if treated earlier.

These risks are magnified for Medicaid beneficiaries who lose coverage, as a portion of them may be unable to enroll in other plans (e.g., employer-sponsored, Marketplace). If FFP caps are implemented, CBO and Joint Committee on Taxation staff estimate that about 65% of people who lose Medicaid coverage would become uninsured.[15]

Work Requirements Must Include Behavioral Health Exceptions

Beyond financing, other proposals have been made to implement work requirements for Medicaid beneficiaries (also called “community engagement requirements”), whereby adults’ Medicaid eligibility is conditioned on continued participation in work or other qualifying activities (e.g., educational activities, volunteer programs).4 If pursued, work requirements must incorporate sufficient exceptions to ensure that individuals whose mental or substance use disorders prevent them from satisfying the requirements remain eligible for Medicaid enrollment and are not terminated.

These exceptions should reflect the enormous challenges that people with behavioral health conditions face, many of whom need treatment but cannot access it. Therefore, exceptions should not be limited to people actively enrolled in treatment. Additionally, while some people with behavioral health conditions may qualify for a disability exception, these determinations are often complex and do not capture everyone with significant impairment, so relying on disability exceptions alone risks people who cannot work because of their condition losing coverage. Further, some people with behavioral health conditions experience diminished mental capacity that interferes with their ability to complete administrative processes such as verifying exception eligibility or work requirement compliance, so processes must be designed to accommodate these circumstances. Finally, some people who are not working due to their behavioral health condition may be able to obtain employment if they receive appropriate treatment and recovery supports, so continued Medicaid coverage could actually help facilitate people getting employed.

Importance of Medicaid for the Behavioral Healthcare System

With Medicaid beneficiaries having a disproportionately high prevalence of behavioral health conditions,[16] Medicaid is critical to the delivery of services that people with mental and substance use disorders rely upon to treat their conditions. Therefore, the proposed Medicaid policy changes pose significant risks to behavioral healthcare organizations, which already are stretched thin by low reimbursement and uncompensated care amounting to billions of dollars per year.[17] These changes could necessitate cuts to service availability, leading to decreased access for patients amidst unprecedented need for services.

For OTPs, Medicaid funding enables them to be at the front line of the national response to the overdose crisis. OTPs deliver evidence-based treatment that promotes long-term recovery from opioid use disorder and prevents overdose deaths, and their efforts have transformed the lives of countless Medicaid beneficiaries, especially considering that Medicaid beneficiaries have an overdose death rate that is twice as high as the overall rate in the United States.[18] With 86% percent of OTPs accepting Medicaid in 2023[19] – more than any other insurance type – less funding from Medicaid could threaten the sustainability of OTPs and undermine the recent progress made to reduce overdose deaths.

Beyond the essential care that behavioral healthcare organizations provide, these facilities also have tremendous positive impacts on the economy. For example, one study found that the national economic impact of inpatient psychiatric facilities is nearly three times higher than expenditures, and these facilities alone create almost half a million jobs.[20] If Medicaid expenditures are reduced, we could expect even greater decreases in economic output attributable to behavioral healthcare facilities.

Recommended Actions

The 119th Congress and Trump administration have several major opportunities to reduce burden on behavioral healthcare organizations and better support them as they work to combat the nation’s behavioral health crisis. With respect to Medicaid, NABH recommends the following immediate actions to expand access to treatment:

  • Eliminate the Institution for Mental Diseases exclusion, which blocks access to treatment for millions of Americans with severe mental and substance use disorders.
  • Align mental health parity requirements for Medicaid managed care plans with the recent final rule for commercial markets, which was a major step forward in expanding access to care.
  • Promote adequate Medicaid reimbursement of behavioral healthcare services to match the cost of delivering those services and the value they provide to patients.

Conclusion

For too long, payment and coverage inadequacy has inhibited the availability of behavioral healthcare services. Proposed changes to Medicaid financing and eligibility could have devastating impacts on Medicaid beneficiaries’ access to behavioral healthcare and the organizations that deliver these services. Congress and the Trump administration should undertake policy efforts that promote access to care for the millions of Americans with mental and substance use disorders.

References

[1] Guth M, Saunders H, Corallo B, Moreno S. Medicaid coverage of behavioral health services in 2022: findings from a survey of state Medicaid programs [Internet]. Kaiser Family Foundation; 2023 Mar 17 [cited 2025 Jan 17]. Available from: https://www.kff.org/mental-health/issue-brief/medicaid-coverage-of-behavioral-health-services-in-2022-findings-from-a-survey-of-state-medicaid-programs

[2] Medicaid and CHIP Payment and Access Commission. Behavioral health [Internet]. Medicaid and CHIP Payment and Access Commission; [cited 2025 Jan 17]. Available from: https://www.macpac.gov/topic/behavioral-health

[3] Congressional Budget Office. Options for reducing the deficit: 2025 to 2034 [Internet]. Congressional Budget Office; 2024 Dec [cited 2025 Jan 17]. Available from: https://www.cbo.gov/system/files/2024-12/60557-budget-options.pdf

[4] Limit, Save, Grow Act of 2023, H.R. 2811, 118th Cong., 1st Sess. (2023). Available from: https://www.congress.gov/bill/118th-congress/house-bill/2811

[5] Meiselbach MK, Ettman CK, Shen K, Castrucci BC, Galea S. Unmet need for mental health care is common across insurance market segments in the United States. Health Aff Sch. 2024 Mar 8;2(3):qxae032. doi: 10.1093/haschl/qxae032. PMID: 38756925; PMCID: PMC10986235. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10986235

[6] Substance Abuse and Mental Health Services Administration. 2023 NSDUH Detailed Tables [Internet]. Substance Abuse and Mental Health Services Administration; 2024 Jul 30 [cited 2025 Jan 17]. Available from: https://www.samhsa.gov/data/report/2023-nsduh-detailed-tables

[7] Mark TL, Parrish W. Behavioral health parity – pervasive disparities in access to in-network care continue [Internet]. RTI International; 2024 Apr 17 [cited 2025 Jan 17]. Available from: https://dpjh8al9zd3a4.cloudfront.net/publication/behavioral-health-parity-pervasive-disparities-access-network-care-continue/fulltext.pdf

[8] Biener AI, Selden TM. Public and private payments for physician office visits. Health Aff. 2017 Dec;36(12):2160-2164. doi: 10.1377/hlthaff.2017.0749. PMID: 29200346. Available from: https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0749

[9] Zhu JM, Renfro S, Watson K, Deshmukh A, McConnell KJ. Medicaid reimbursement for psychiatric services: comparisons across states and with Medicare. Health Aff. 2023 Apr;42(4):556-565. doi: 10.1377/hlthaff.2022.00805. PMID: 37011308; PMCID: PMC10125036. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10125036

[10] Appendix 1: supplementary data tables. Trends in the overall health care market [Internet]. American Hospital Association; [cited 2025 Jan 17]. Available from: https://www.aha.org/system/files/media/file/2020/10/TrendwatchChartbook-2020-Appendix.pdf

[11] Office of the New York State Attorney General. Inaccurate and inadequate: health plans’ mental health provider network directories [Internet]. Office of the New York State Attorney General; 2023 Dec 7 [cited 2025 Jan 17]. Available from: https://ag.ny.gov/sites/default/files/reports/mental-health-report_0.pdf

[12] Zhu JM, Charlesworth CJ, Polsky D, McConnell KJ. Phantom networks: discrepancies between reported and realized mental health care access in Oregon Medicaid. Health Aff. 2022 Jul;41(7):1013-1022. doi: 10.1377/hlthaff.2022.00052. PMID: 35787079; PMCID: PMC9876384. Available from: https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.00052

[13] Medicaid and CHIP Payment and Access Commission. Behavioral health services covered under state plan authority [Internet]. Medicaid and CHIP Payment and Access Commission; 2021 Jan 11 [cited 2025 Jan 17]. Available from: https://www.macpac.gov/subtopic/behavioral-health-services-covered-under-state-plan-authority

[14] Congressional Budget Office. Options for reducing the deficit: 2023 to 2032 [Internet]. Congressional Budget Office; 2022 Dec [cited 2025 Jan 17]. Available from: https://www.cbo.gov/system/files/2022-12/58164-budget-options-large-effects.pdf

[15] Congressional Budget Office. Establish caps on federal spending for Medicaid [Internet]. Congressional Budget Office; 2022 Dec 7 [cited 2025 Jan 17]. Available from: https://www.cbo.gov/budget-options/58622

[16] Saunders S, Rudowitz R. Demographics and health insurance coverage of nonelderly adults with mental illness and substance use disorders in 2020 [Internet]. Kaiser Family Foundation; 2022 Jun 6 [cited 2025 Jan 17]. Available from: https://www.kff.org/mental-health/issue-brief/demographics-and-health-insurance-coverage-of-nonelderly-adults-with-mental-illness-and-substance-use-disorders-in-2020

[17] Government Accountability Office. States’ use and distribution of supplemental payments to hospitals [Internet]. Government Accountability Office; 2019 Jul [cited 2025 Jan 17]. Available from: https://www.gao.gov/assets/gao-19-603.pdf

[18] Mark TL, Huber BD. Drug Overdose Deaths Among Medicaid Beneficiaries. JAMA Health Forum. 2024 Dec 6;5(12):e244365. doi: 10.1001/jamahealthforum.2024.4365. PMID: 39641942; PMCID: PMC11624576. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11624576/

[19] Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. National Substance Use and Mental Health Services Survey (N-SUMHSS), 2023: annual detailed tables [Internet]. Substance Abuse and Mental Health Services Administration; 2024 [cited 2025 Jan 17]. Available from: https://www.samhsa.gov/data/sites/default/files/reports/rpt53013/NSUMHSS-Annual-Detailed-Tables-23.pdf

[20] Dobson A, DaVanzo JE, Heath S, Berger G, El-Gamil A. The economic impact of inpatient psychiatric facilities: a national and state-level analysis. National Association for Behavioral Healthcare; 2010 Feb 19 [cited 2025 Jan 17]. Available from: https://www.nabh.org/wp-content/uploads/2018/06/NAPHS-Final-Report-2-19-10.2.pdf

Decorative News Icon

President Biden’s 2023 Budget Seeks to Transform U.S. Behavioral Healthcare Delivery

Written by Emily Wilkins (NABH) on . Posted in Analysis.

[vc_row][vc_column][vc_column_text]President Biden is proposing new, mandatory investments totaling $51.7 billion over 10 years to enhance behavioral healthcare in America in the fiscal year (FY) 2023 budget proposal he released Monday. Among the budget blueprint’s most notable behavioral health provisions is the president’s request of $697 million for the Substance Abuse and Mental Health Services Administration (SAMHSA) to ensure that 100% of contacts are answered for the new 988 behavioral health crisis hotline that will begin to operate in July. This is an increase of $590 million from what was enacted for fiscal year 2022. Another significant provision is the president’s proposal for a new, $7.5 billion Mental Health System Transformation Fund through Medicaid to increase access to mental health services through workforce development and service expansion, including the development of non-traditional health delivery sites, the integration of quality mental health and substance use care into primary care settings, and the dissemination of evidence-based practices. President Biden’s budget also provides an investment of $397 million for the Health Resources and Services Administration’s (HRSA) Behavioral Health Workforce Development Programs, which is $235 million above FY 2022 enacted level. This funding is intended to increase training of new behavioral healthcare providers, including a track for health support workers such as peers and community health workers. The program also places an emphasis on team-based care. This investment is meant to promote inclusive and equitable behavioral healthcare for youth and focus on the knowledge and understanding of children, adolescents, and youth at risk for a mental health disorder, serious emotional disturbance, or substance use disorder (SUD). The budget also includes increases in primary care training and enhancement and nurse education, practice, and retention to expand behavioral health services into primary care. The FY 2023 budget provides $4.6 billion for SAMHSA’s mental health activities, an increase of $2.5 billion above the FY 2022 enacted level. These investments would provide a historic investment in the Behavior Health Crisis Services; expand access to crisis services; ensure access to early intervention and prevention services to the nation’s vulnerable populations; and invest in children’s mental health. NABH is pleased to see President Biden’s budget calls for improving compliance with behavioral health parity standards by requiring plans and issuers to use medical necessity criteria for behavioral health services that are consistent with the criteria developed by not-for-profit medical specialty associations. The proposal would also place limits on the consideration of profit in determinations of medical necessity. The budget would authorize the secretaries of the U.S. Health and Human Services, Labor, and Treasury Departments to regulate behavioral health network adequacy, and to issue regulations on a standard for parity in reimbursement rates based on the results of comparative analyses submitted by plans and issuers at a cost of $720 million over 10 years. The budget proposes requiring all plans and issuers to cover three behavioral health visits and three primary care visits each year without charging a copayment, co-insurance or deductible-related fee.  And it would provide $125 million in mandatory funding over five years for grants to states to enforce mental health and SUD parity requirements.  Any funds not expended by states at the end of five fiscal years would remain available to the HHS secretary to make additional mental health parity grants. It also proposes to eliminate the ability of self-insured non-federal governmental plans to opt out of parity, affording state and municipal employees the same consumer protections that apply to other employees with private health insurance. In Medicare, the president’s budget would eliminate the 190-day lifetime limit and would require Medicare to cover up to three behavioral health visits per year without cost-sharing. Also related to the Medicare program, current law requires the Centers for Medicare & Medicaid Services (CMS) to terminate psychiatric hospital participation in Medicare after six months of non-compliance with conditions of participation, even if the deficiency does not jeopardize patient health and wellbeing.  This provision does not apply to any other provider category. The president’s proposal would give CMS flexibility to allow a psychiatric hospital to continue receiving Medicare payments when deficiencies are not considered to immediately jeopardize the health and safety of its patients and where the facility is actively working to correct the deficiencies identified in an approved Plan of Correction.  This provision is considered budget-neutral and would not have cost implications. Among other provisions, the White House budget proposal would also establish a Medicare benefit category for licensed professional counselors and marriage and family therapists that authorizes direct billing and payment under Medicare for these practitioners; remove limits on the scope of services for which Medicare can pay clinical social workers, licensed professional counselors, and marriage and family therapists; and allow these practitioners to bill Medicare directly for their mental health services for covered Part A qualifying Skilled Nursing Facility stays. And the proposal would ensure that mental health and SUD benefits under Medicare do not face greater limitations on reimbursement or access to care relative to medical and surgical benefits.  The Medicare Payment Advisory Commission (MedPAC) would be required to issue a report to identify existing gaps in mental health and substance use disorder benefits to be addressed in the Medicare statute. Specifically for SUD, President Biden has proposed $519 million, more than double the 2022 enacted level, for the Family Violence Prevention and Services program. This is the primary federal funding stream dedicated to the support of emergency shelter and related assistance for victims of domestic violence and their children. The funding represents an increase of $292 million over FY 2022 enacted for the base program’s shelters and supportive services. This funding provides services to an estimated 1.3 million children and families to prevent family violence, domestic violence, and dating violence. This includes $250 million in cash assistance for domestic violence survivors and $30 million for the Safe Recovery Together demonstration grants. The demonstration grants will support families affected by domestic violence at the intersection of substance-use coercion, housing instability, and child welfare involvement. President Biden’s FY 2023 budget also proposes:
  • $413 million to SAMHSA in FY 2023, and $4.1 billion over 10 years, for community health centers
  • A $238 million increase above the FY 2022 enacted level in funding for Certified Community Behavioral Health Center Expansion Grants
  • An increase in the amount of Mental Health Block Grant funds reserved for crisis intervention services to 10% from 5%
  • An investment of $11.4 billion, including $10.8 billion in discretionary funding, in programs addressing opioids and overdose-related activities across HHS.
After President Biden kicked off the federal budget process on Monday with his budget proposal, Office of Management and Budget Director Shalanda Young testified Tuesday before the House Budget Committee. Director Young will take more questions from the Senate Budget Committee on Wednesday. Meanwhile, congressional appropriators will begin their work soon, starting with a House Appropriations Committee hearing this Thursday that will feature U.S. Health and Human Services Department (HHS) Secretary Xavier Becerra.[/vc_column_text][/vc_column][/vc_row]
Decorative News Icon

NABH Analysis: CMS Proposes Expanding Medicare Telehealth Benefits and Scope of Practice Changes Beyond Pandemic

Written by Emily Wilkins (NABH) on . Posted in Analysis.

CMS Proposes Expanding Medicare Telehealth Benefits and Scope of Practice Changes Beyond Pandemic The Centers for Medicare & Medicaid Services (CMS) is proposing to maintain—either permanently or temporarily— many of the Medicare telehealth benefits and workforce flexibilities authorized during the Covid-19 pandemic, according to the fiscal year 2021 Medicare physician fee schedule proposed rule the agency released Monday. In issuing these proposed changes, CMS referred to President Trump’s Aug. 3 Executive Order on “Improving Rural Health and Telehealth Access” that directs the Health and Human Services secretary to propose regulations to extend flexibilities provided during the Covid-19 public health emergency (PHE) as appropriate. Proposed Extensions of Medicare Coverage of Telehealth On a permanent basis, CMS proposes to continue Medicare coverage for these telehealth services authorized during the PHE:
Home visits for the evaluation and management of an established patient: less complex and last typically 25 minutes,
Certain types of visits for patients with cognitive impairments,
Group psychotherapy,
Neurobehavioral status exams,
Care planning for patients with cognitive impairment,
Less complex domiciliary, rest home, or custodial care services, and
Prolonged evaluation and management (E/M) services.
CMS has requested public feedback on other services to add to this list of permanent Medicare-covered, telehealth services. CMS is also proposing to extend Medicare coverage on a temporary basis for telehealth delivery of the following services until the end of the calendar year when the PHE ends:
Psychological and neuropsychological testing,
Emergency department visits,
Home visits to address moderate to severe issues, typically lasting 60 minutes,
More complex domiciliary, rest home, or custodial care services, and
Nursing facilities discharge day management.
CMS has also requested comments on this list of telehealth services that the agency proposes to cover temporarily in Medicare. CMS said it intends these temporary extensions of coverage to allow time for the agency to consider whether these services should be extended permanently. In the proposed rule, CMS clarified that licensed clinical social workers, clinical psychologists, (as well as physical therapists, occupational therapists, and speech-language pathologists) can furnish the brief online assessment and management services via telehealth as well as virtual check-ins and remote evaluation services. In addition, CMS has clarified that telehealth rules do not apply when the beneficiary and the practitioner are in the same location even if audio/video technology assists in providing a service. CMS has not proposed to continue separate payments for audio-only evaluation and management services beyond the end of the PHE. Instead, the agency has requested comment on whether to develop coding and payment for a service similar to virtual check-in but for a longer unit of time with a higher value. CMS is seeking feedback on duration of services and resources required to furnish this service and also whether Medicare coverage of this audio-only service should be extended temporarily or permanently. Meanwhile, CMS is proposing to allow direct supervision to be provided using real-time, interactive audio and video technology (excluding telephone that does not also include video) through Dec. 31, 2021. The agency is requesting comments on this proposal, including guardrails that should be in place and risks to patient safety and concerns about waste, fraud, and abuse. CMS also included a number of clarifications about Medicare coverage for remote physiologic monitoring codes and new payment rates for immunization administration.

Updates to Evaluation and Management Codes

In this proposed rule, CMS has proposed revaluing a number of code sets that rely on or are analogous to E/M visits including psychiatric diagnostic evaluations and psychotherapy services. CMS has also proposed simplified coding and billing requirements for E/M visits to take effect in January 2021.

Proposed Changes to Scope of Practice Rules and Related Issues

CMS has also proposed changes to allow healthcare professionals to practice up to the top of their professional training and to continue some of the workforce flexibilities allowed during the PHE, including:
Allowing nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives (instead of only physicians) to supervise others performing diagnostic tests consistent with state law and licensure, providing that they maintain the required relationships with supervising/collaborating physicians as required by state law,
Clarifying that physicians and nonphysician practitioners, including therapists, can review and verify documentation entered into the medical record by members of the medical team for their own services that are paid under the Medicare physician fee schedule,
  • Accordingly, in the inpatient psychiatric facility prospective payment system final rule issued July 31, CMS also confirmed as final, changes to the special conditions of participation rules for psychiatric facilities allowing non-physician practitioners, or advanced practice providers (including physicians assistants, nurse practitioners, psychologists, and clinical nurse specialists) to document progress notes in accordance with state laws and scope-of-practice requirements.
Clarifying that therapy students, and students of other disciplines, working under a physician or practitioner who furnishes and bills directly for their professional services to the Medicare program, may document in the record so long as it is reviewed and verified (signed and dated) by the billing physician, practitioner, or therapist, and
Requesting comment on whether to continue temporarily or permanently Medicare coverage for services of residents that are provided outside of the scope of their approved GME programs and furnished to inpatients of a hospital in which they have their training program as separately billable physicians’ services.
Proposed Changes to Opioid Treatment Program Benefit CMS has proposed making several changes to claiming rules and payment codes for the new Medicare Part B benefit for opioid use disorder services, including medications and services furnished by opioid treatment programs. Of note, add-on codes for nasal naloxone and auto-injector naloxone are proposed along with clarification on periodic assessment add-on code requirements. SUD Screening in Medicare Initial and Wellness Visits CMS is implementing a new requirement that the Medicare Initial Preventive Physical Examination and Annual Wellness Visit include screening of beneficiaries for potential substance use disorders, including a review of any current opioid prescriptions, as well as referral for specialty treatment, as appropriate. This new requirement was enacted in the SUPPORT Act. Electronic Prescribing of Controlled Substances CMS said it is implementing another SUPPORT Act provision that requires prescriptions of Schedule II, III, IV, or V controlled substances for Medicare Part D beneficiaries to be electronic. CMS issued a request for information on July 30 requesting feedback on whether to include exceptions to this requirement and whether CMS should impose penalties. Public comments on this proposed rule are due by Monday, Oct. 5.

NABH Analysis: OTP Provisions in 2020 Physician Fee Schedule

Written by Emily Wilkins (NABH) on . Posted in Analysis.

OTP Provisions in 2020 Physician Fee Schedule

CMS finalized provisions for the nation’s opioid treatment programs (OTPs) in the 2020 Physician Fee Schedule regulation that the agency released on Nov. 1. This NABH Analysis provides a summary of those provisions, which provide for the treatment of opioid use disorders (OUDs) with new bundled service codes for OTPs, and for telehealth and opioid use treatment services in office-based settings. The final rule will be published in the Federal Register on Nov. 15. The regulations implement requirements that were included in last year’s Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patient and Communities (SUPPORT) Act. NABH is pleased that the final rule addressed the following issues that NABH mentioned in its comment letter on Sept. 28:
  • CMS raised the non-drug bundle to 161.71, which aligns with NABH’s valuation. We used a building block methodology to demonstrate that the proposed non-drug bundle, based on the CMS PFS rates, was undervalued by 31-48 percent.
  • We also identified a range of indirect and direct services routinely performed by OTPs that CMS included in the final bundle.
  • NABH advocated for the elimination of the partial bundle and recommended a more gradual overall implementation of elements of the proposed rule. In the final rule, CMS temporarily eliminated the partial episode of care with the intent to engage in future rulemaking to more gradually phase in their bundled approach.
  • Comments and data were provided to CMS reflecting potential destabilization of the workforce relevant to the proposed service requirements. CMS addressed these issues through deference to state laws and scopes of service provisions, and a reduction of the number of services needed to bill the bundle.
  • In explanatory text, CMS made note of the NABH recommendation for a rural add-on rate of 17 percent and indicated it may be considered in future rulemaking to incentivize rural care.
  • NABH recommended consideration to permanently set a zero co-pay, and CMS indicated the intent to address the issue in future rulemaking.
  • We advocated to remove OTPs from the high-risk category. CMS finalized a compromise proposal that moves OTPs that have been fully and continuously certified by SAMSA since October 23, 2018 to moderate risk, while maintaining those without full and continuous certification in the high-level risk category, as they are newly-recognized Medicare providers.
  • NABH-supported telehealth codes were finalized.
  Final Rule Highlights: Opioid Treatment Programs
  • Definition of OUD Treatment Services
    • FDA-approved opioid agonist and antagonist treatment medications
    • Dispensing and administering of such medications (if applicable)
    • Substance use counseling
    • Individual and group therapy
    • Toxicology testing (both presumptive and definitive testing)
    • Intake activities
    • Periodic assessments
  • Bundled Rates/Episode of Care
    • Bundles reflect a weekly episode of care with no time limits.
    • Rates are a combination of a drug and non-drug component.
    • Full and partial episode construction was finalized to eliminate of partial episodes of care. Utilization will be monitored, intent is to create a partial bundle in the future.
    • One service must be furnished within a week to bill a weekly drug or non-drug bundle.
  • Drug component reflects drug dispensing/administration services; rates vary according to the specific drug (methadone-oral, buprenorphine-oral, buprenorphine-injection, buprenorphine-implant, naltrexone injection), and includes buprenorphine-only products.
    • Maintenance dosage and calculation for oral buprenorphine was increased from 10 mg to 16 mg daily.
    • Created an NOS code for new medications.
  • Non-drug component includes counseling, psychotherapy, toxicology testing and tracks with SAMHSA certification.
    • Does not require counseling and psychotherapy but defers to medical need and state laws relevant to scopes of practice.
    • Case/care management is not included as a bundled or add-on code. Intent to collaborate with OTPs to better understand services, with potential future rulemaking.
    • Rates were increased using building block methodology that values the services based on established Medicare PFS (non-facility) rates for similar services; the Medicare Clinical Laboratory Fee Schedule (CLFS); and state Medicaid programs.
    • Bundles include payment for presumptive and definitive drug testing, with no separate billing under CLFS. There is no add-on code in order to avoid incentive to test more frequently than needed.
  • Add-ons
    • Intake activities for new patients, including a physical examination
    • Periodic assessments during an episode of care, such as for pregnant or postpartum patients
    • Take homes for methadone/buprenorphine for up to 7 days of medication
    • Counseling 30-minutes when counseling or therapy substantially exceed the amount in the individual treatment plan
PFS Bundles for Office-based Services/Telehealth
  • Bundled Rates/Episode of Care
    • Codes for three new (monthly) OUD treatment bundles have been added to the telehealth list on a Category 1 basis for care coordination, individual and group therapy, and counseling through two-way interactive audio-video communication technology.
      • G2086, 70-minute psychotherapy, first month. Includes treatment planning, care coordination, individual and group psychotherapy and counseling
      • G2087, 60-minute psychotherapy, subsequent months. Includes care coordination individual and group psychotherapy and counseling
      • G2088, for each additional 30-minute service required beyond 120 minutes. Includes care coordination, individual and group psychotherapy, and counseling
    • To bill G2086 and G2087, one psychotherapy services must be furnished.
    • If no therapy is provided, the bundle may not be billed. Instead, existing CPT codes for care management 99484, 99492, 99493, 99494 and E/M codes may be used.
    • Psychotherapy codes 90832, 90834, 90837, 90853 may not be used by the same practitioner for the same beneficiary in same month that episode bundles are billed.
    • Rates do not include medications, as they are reimbursed under Medicare Part B or D or toxicology testing that is billed under CLFS.
    • Provider must be licensed in the jurisdiction/location of the patient.
    • The codes are not restricted to use by addiction specialists.
    • Additional telehealth services may be requested before February 10, 2020 for consideration for the following calendar year.
    • The rule notes the prior removal of geographic limitations for telehealth services for SUD or co-occurring mental health disorders.
    • The SUPPORT ACT permits services to be furnished at any originating site, including the patient’s home, and requires that no originating site facility fee is permitted when the individual’s home is the originating site.
    • OTP services are not considered physician/practitioner services, and as such may not bill these codes. Instead, services are covered through OTP bundled rates.
NABH will closely monitor and work with CMS and other stakeholders in the implementation of this benefit and provide updates to NABH members as necessary. If you have questions, please contact Sarah Wattenberg, NABH’s director of quality and addiction services.