Mental Health & Substance Use

CMS finalized their ruling on mental health and substance use for Medicaid and CHIP on March 29, 2016. The goal for CMS was to strengthen access to mental health and substance use services to ultimately align themselves to that of private/commercial insurance companies. The overall goal of the program was to make the services for mental health and substance use similar to those of medical and surgical services offered to their beneficiaries.

The Affordable Care Act was instrumental in increasing access for patients so that more people could get the help that they need with regards to the challenges they are experiencing in their lives. The final rule allows services to be enhanced for approximately 23 million people enrolled in Medicaid Managed Care Programs, Medicaid Alternative Benefit Plans, and CHIP. The final ruling keeps the flexibility for the states to manage this process, and at the same time, guaranteeing that Medicaid enrollees are able to access these important services.  

Through this final rule, insurance plans must disclose information on mental health and substance use disorder benefits upon request. These requests will include the criteria that is used to determine medical necessity. In addition, the states are required to disclose the reason for any denial of payment for these services for their Medicaid beneficiaries. CMS introduced several initiatives to help states transform their existing programs to be better capable of meeting the needs of their beneficiaries. 

They are as follows as listed in the final rule:

·         In 2014, CMS launched the Innovation Accelerator Program, a new strategic and technical support platform designed to improve delivery systems for beneficiaries that are high need and high cost.

·         CMS issued guidance to states on a new section 1115 demonstration opportunity to develop a full continuum of care for beneficiaries with a substance use disorder, including coverage for short-term residential treatment services not otherwise covered by Medicaid.

·         In response to the growing prescription opioid abuse epidemic, CMS recently released information on effective safeguards and options to help address over-prescribing of opioid pain medications.

·         CMS disseminated important information regarding screening and early intervention services for children and youth who have or may have a mental illness or substance use disorder, including best practice information for the delivery of medication-assisted treatment as well as services and supports that can address first psychiatric episodes to reduce the likelihood of ongoing hospitalizations, involvement with police and courts, and increase the chances of keeping families intact.  

As we can see, the epidemic that society and our healthcare system are facing is not going unnoticed. However, continued enhancement to behavioral health and substance use disorders needs to take place, not only at the federal level, but at the private/commercial level as well. Most importantly, a clear and easily understandable set of rules and guidelines, along with ease of communication between payer and patient, would be helpful for all parties involved.

Submitted by Kevin Harrington, Full-Time Faculty, Saint Joseph's College