Access to behavioral health care is improving, but more work is needed

“The landscape for access to mental health and substance use services has markedly improve in recent years” and “it is highly likely that these trends will continue,” according to the Final Report of the White House Mental Health and Substance Use Disorder Parity Task Force. President Obama created the Task Force with the goal of developing a set of tools, guidelines, and mechanism to ensure that mental health parity is actually enforced. The Task Force’s Final Report summarizes its work including reviewing progress to date, identifying and taking immediate steps as needed, and outlining recommendations.

Task Force participants and directives

The President directed the Task Force, which included the White House Domestic Council, the Departments of Treasury, Defense, Justice, Labor, HHS, and Veteran’s Affairs as well as the Offices of Personnel Management and National Drug Control Policy, to review parity implementation; increase awareness of the protections that parity provides; and improve understanding of the requirements of parity and its protections among key stakeholders, including consumers, providers, employers, insurance issuers, and state regulations. The task force also was directed to increase the transparency of the compliance process and the support, resources, and tools available to ensure that coverage is in compliance with party and improve the monitoring and enforcement process.

Gathering information

Among the information gathered from March through October 2016, the Task Force looked at barriers to implementation and enforcement, party compliance and documenting parity violations, identifying behavioral workforce issues, documenting treatment limitations, and clarifying the role of states and the federal government in bringing about parity.

The role of mental health laws

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) (P.L. 110-343) generally prohibits employment-based group health plans and health insurance issuers that provide group health coverage for mental health and substance use disorders from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. This includes restrictions related to financial requirements and quantitative treatment limitations, and nonquantitative treatment limitations. It also expands mental health parity requirements to substance use disorders, such imposing less favorable lifetime or annual dollar amount limits than the lifetime and annual dollar amount limits imposed on medical and surgical benefits.

The Patient Protection and Affordable Care Act (ACA) (P.L. 110-148) prohibits group health coverage and nongrandfathered individual market insurance from imposing lifetime and annual dollar limits on Essential Health Benefits (EHB), including mental health and substance use disorder services, and prohibits grandfathered individual markets from imposing lifetime dollar limits. The ACA increased access to mental health and substance abuse disorder coverage and parity by requiring coverage offered through Health Insurance Marketplaces and nongrandfathered health plans to cover EHBs including mental health and substance use disorder benefits. The ACA extended the application of the MHPAEA to the individual insurance market and qualified health plans and expanded Medicaid requirements to be in compliance with mental health parity.

Task Force actions

As directed by President Obama, the Task Force identified immediate actions that it could take in three main areas: education and awareness, clarification of parity requirements, and improving compliance, monitoring, and enforcement. In June 2016, the HHS and the Department of Labor jointly released a pamphlet for consumers that outlines the basic protections guaranteed by the MHPAEA and consumer rights to transparency and appeals, entitled, “Know Your Rights: Parity for Mental Health and Substance Use Disorder Benefits.” In March 2016, CMS published a Final rule to align the mental health and substance use disorder coverage benefits offered by managed care organizations, Medicaid, and the Children’s Health Insurance Program (CHIP) with parity protections required of the commercial market as well as releasing Frequently asked questions and hosting a webinar to explain the parity protections in the Final Rule.

In August of 2016, Substance Abuse and Mental Health Services Administration (SAMHSA) issued a report outlining promising best practices from state insurance commissioners related to implementing MHPAEA and monitoring and enforcement efforts to ensure compliance.

Recommendations

The Task Force recommendation fall into three main areas: supporting consumers, improving parity implementation, and enhancing parity compliance and enforcement. The Final Report identifies the specific recommendations for each area and provides details for developing and implementing the recommendations, and includes the initial steps it has taken. The recommendations include:

  • Supporting Consumers: Create a one-stop consumer web portal to help consumers navigate parity and provide simplified disclosure tools to provide consistent information for consumers, plans, and issuers.
  • Improving Parity Implementation: Update guidance to address the applicability of parity to opioid use disorder services, implement the Medicaid and CHIP parity final rule in a timely manner, conduct a thorough review of how parity principles apply in Medicare, and expand access to mental health and substance use disorder services in TRICARE.
  • Compliance and Enforcement: Provide federal support for state efforts to enforce parity through trainings, resources, and new implementation tools, increase federal agencies’ capacity to audit health plans for parity, allow the Department of Labor to assess civil money penalties for party violations, ensure parity compliance in state essential health benefit benchmark plans, and review substance use disorder benefits in the Federal Employees Health Benefits Program.

HHS marks Prescription Opioid and Heroin Epidemic Awareness week with $44.5M grant

The Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) will award more than $44.5 million in awards to training programs aimed at increasing the number of mental health providers and substance abuse counselors in the United States.  The funding includes 144 new and continuing grants through the Behavioral Health Workforce Education and Training (BHWET) program.

Behavioral Health Workforce Education and Training Program

 The BHWET program supports clinical internships and field placement programs for professional and paraprofessional behavioral health disciplines and occupations. The initiative serves children, adolescents, and transitional-age youth at risk for developing or who have a recognized behavioral health disorder by adding to the behavioral health workforce. Recipients of grants under this program are expected to expand the behavioral health workforce by participating in internships and field placements focusing on working with these at-risk individuals. Activities under the grant emphasize prevention and clinical intervention and treatment for those at risk of developing mental and substance abuse disorders and the involvement of families in preventing and treating behavioral health conditions.

Of the $44.5 million grant, more than $7.9 million will support a total of 34 new grantees, and the other $36.6 million will fund the program’s 110 existing grantees.

Prescription Opioid and Heroin Epidemic Awareness Week

President Barack Obama designated the week of September 18 – 23, 2016, Prescription Opioid and Heroin Epidemic Awareness Week. During this time, federal agencies focused on the work being done across government entities and announced new efforts to address the epidemic of prescription opioid and heroin abuse. In his announcement, Obama stated that he continues to “call on the Congress to provide $1.1 billion to expand access to treatment services for opioid use disorder.” The investments would build on the steps already taken to expand overdose prevention strategies and increase access to the overdose reversal drug naloxone.

Advocates say Medicaid can shelter the homeless in Pennsylvania

Pennsylvania could use Medicaid to address its homelessness problem, according to advocates that believe the state’s Medicaid program should include additional supportive housing services. Those individuals assert that additional supportive housing services can be included in Medicaid as a “wrap-around support service”—a type of service that CMS endorses and described in a Center for Medicare & CHIP Services Informational Bulletin last year.

Housing services

CMS expressly does not provide Federal Financial Participation (FFP) for room and board as part of additional support services. However, states are permitted to assist individuals through coverage of certain housing-related activities and services. Some of the housing-related services and activities that Medicaid can cover include: (1) services designed to support an individual’s ability to prepare for and transition to housing; (2) services aimed at supporting an individual’s ability to sustain tenancy; and (3) services dedicated to assisting a state in identifying and securing housing options for individuals. Specific examples of each of those services are covered in the Informational Bulletin. The Open Door is an example of an organization that provides housing support services.

Pennsylvania

In Pennsylvania, advocates like The Housing as Health Campaign are asserting that, for many Medicaid enrollees with substance abuse problems, additional support is needed to keep beneficiaries in their homes. Advocates argue that without a consistent funding stream, Medicaid beneficiaries wind up homeless. The Corporation for Supportive Housing (CSH) created a blueprint, or “Crosswalk,” to serve as a map to assist the Pennsylvania Department of Health and Human Services with aligning Medicaid-eligible services with supportive housing services.

Crosswalk

The Crosswalk was designed to guide the state of Pennsylvania, managed care entities, and service providers towards resources that can improve access to substance use treatment and mental health recovery, with a focus on housing. According to the report, individuals with unmet housing needs are often particularly vulnerable due to the high occurrence of low incomes, chronic health conditions, and behavioral health challenges among the population. The report proposes several methods to improve housing and care access for at-risk individuals. CSH started its analysis by considering the services that the state already provides through several Medicaid waivers. While Pennsylvania does have mechanisms to provide some housing support services for elderly individuals, beneficiaries with traumatic brain injuries, and individuals with a physical disability, CSH noted that additional individuals could benefit from supportive housing.

Alignment

The report identified potential opportunities for alignment, where services that are already covered under the state plan could be aligned to better address housing support service needs. For example, the report suggested that, because the Pennsylvania state Medicaid plan covers Individualized Service Plans (ISPs) for the treatment of individuals with severe mental illness, an individual could, possibly, identify housing goals as part of his or her treatment plan, thereby including housing support services through an ISP. The report lists several other types of services with potential for alignment to reduce or eliminate gaps in housing service coverage.

Rethinking Medicaid

Advocates are not directly asking for a change as to the kind of services covered by the Pennsylvania Medicaid program. Instead, the CSH report and other efforts are asserting that housing problems can be best improved through a better application of existing services under the Medicaid state plan. Advocates hope that such a rethinking of Medicaid will improve health by putting a roof over the head of more individuals.

The importance of parity and the problem of unenforcement

Federal law requires that mental health benefits are equivalent—in terms of restrictions and limitations—with medical health benefits. However, the specific provisions of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) that mandate the parity are, in many cases, going unenforced. The result is that individuals are having trouble accessing care—the very problem the parity was designed to remedy.

Why?

Although there many potential reasons why the parity rules aren’t being followed, one report suggests the failures are caused by the difficulty of implementing the ACA and the slow regulatory processes of the federal government. For example, the rules that govern parity for private insurers were not put into effect until 2014 and some rules—those pertaining to parity for Medicaid plans—have yet to take effect.

High stakes

The importance of parity is illustrated by the number of individuals with mental health and substance use disorders. According to the most recent survey by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), almost 44 million adults experienced some form of a mental illness. According to SAMHSA, fewer than half of those individuals receive mental health care. Additionally, 20.2 million adults had a substance abuse disorder in the past year. Also at issue is the nation’s heroin and painkiller epidemic, which claims 78 lives each day.

Task Force

Acknowledging that something is wrong with the state of parity enforcement, the White House issued a presidential memorandum creating an interagency Mental Health and Substance Use Disorder Parity Task Force designed to ensure better compliance with the parity rules.  Specifically, the task force was designed to:

  • identify and promote best practices for compliance and implementation;
  • identify and address gaps in guidance, particularly with regard to substance use disorder parity; and
  • implement actions during its tenure and at its conclusion to advance parity in mental health and substance use disorder treatment.

The memorandum also directs the task force to conduct outreach efforts to patients, consumer advocates, health care providers, specialists in mental health care and substance use disorder treatment, employers, insurers, state regulators, and other stakeholders.

Enforcement

Not all states have dropped the enforcement ball. For example, the California Department of Managed Health Care imposed a $4,000,000 administrative penalty on the Kaiser Foundation Health Plan, Inc. in 2013 for parity violations that resulted from mental health service wait times. However, continuing access problems and the creation of the task force suggest that enforcement is the exception rather than the rule.

Beyond parity

Part of the problem is that to meet behavioral health demands, stakeholders need to do more than obtain parity. Based upon that understanding, some lawmakers are pushing for more systemic changes with legislation like The Mental Health Reform Act of 2016, which would assist with enforcement of current requirements (including parity), ensure federal funding to help states provide mental health care services, promote best practices, and increase access. Whichever way is the next step forward, there is little doubt that some action is necessary to improve access to and the provision of behavioral health care.