Guest article by Deb Steinberg, Senior Health Policy Attorney, Legal Action Center
On November 2, 2023, the Centers for Medicare & Medicaid Services (CMS) released its Physician Fee Schedule (PFS) and Outpatient Prospective Payment System (OPPS) final rules for Calendar Year (CY) 2024. These rules include new coverage options for substance use disorder treatment for beneficiaries that will close some of the longstanding gaps in Medicare. Here are some of the highlights of the new rules, as well as future opportunities to continue to improve coverage.
Treatment and Billing by Mental Health Counselors & Marriage and Family Therapists
With the publication of the new rules, mental health counselors and marriage and family therapists can officially enroll in Medicare and begin to treat beneficiaries with substance use disorders and mental health conditions as of January 1, 2024. The term “mental health counselor” is defined broadly to include licensed and certified professional counselors, addiction counselors, and alcohol and drug counselors – or other practitioner titles used by states – who (1) have a master’s or doctorate degree in counseling, (2) are licensed or certified by the state in which they furnish services, and (3) have performed at least 2 years or 3000 hours of supervised clinical experience after obtaining their degree. Like clinical social workers, these new practitioners will be reimbursed at 80% of the lesser of the actual charge or 75% of the PFS rate for psychologists, and they may not separately bill for services in skilled nursing facilities. The American Counseling Association estimates that approximately 200,000 new counselors will be able to enroll in Medicare as a result of this final rule.
While the new coverage of these practitioners will greatly expand beneficiary access to counselors, the discriminatorily low reimbursement rate (75% of the PFS, compared to the 85% that non-physician medical practitioners receive) may prevent this change from achieving its full potential. Additionally, not all states have master’s level addiction or alcohol and drug counselors, further contributing to disparate access to substance use disorder counseling across the country. We will continue to work with Congress to establish equitable reimbursement rates for all mental health and substance use disorder counselors, and identify other avenues to ensure that all those who are licensed and certified to provide substance use disorder counseling can treat Medicare beneficiaries.
Peers & Community Health Workers Addressing Social Determinants of Health
While CMS does not have the statutory authority to allow peer support specialists and community health workers to bill Medicare, federal regulators took the initiative to develop new service codes – community health integration (CHI) and principal illness navigation (PIN) – that will allow these individuals to address the social determinants of health (SDOH) needs of Medicare beneficiaries while working under the supervision of certain Medicare providers. Billing practitioners can partner with community-based organizations that employ peers and community health workers to help meet their patients’ needs, as supervision for these services does not need to be on site.
One of the limitations of these new services is that only providers who can bill Evaluation and Management (E/M) codes along with psychologists can initiate and bill for these new SDOH services. As a result, clinical social workers, mental health counselors, and marriage and family therapists are excluded. Another limitation is that the billing provider must initiate these services, while, in practice, peers and community health workers are often the point of entry for individuals with mental health conditions and substance use disorders to get the care they need. We will continue to work with CMS as Medicare rolls out these new services and advocate that they be expanded to ensure more meaningful access by beneficiaries.
Coverage of Intensive Outpatient Treatment
Congress and CMS have closed a significant gap in the continuum of substance use disorder treatment by covering intensive outpatient (IOP) services in certain settings, beginning January 1, 2024. The definition of IOP is consistent with and builds on the existing partial hospitalization (PHP) benefit. PHP is a structured outpatient program for patients who need a minimum of 20 hours of therapy and other mental health and substance use disorder services in a week for beneficiaries who would otherwise require inpatient hospitalization. IOP is for patients who need a minimum of 9 hours, but no more than 20, and does not require the beneficiary to otherwise need to be hospitalized. The IOP benefit will be reimbursable in hospital outpatient departments, community mental health centers, federally qualified health centers, rural health clinics, and opioid treatment programs (OTPs), while PHP can only be delivered in hospital outpatient departments and community mental health centers. In the final rule, CMS clarified that both IOP and PHP are available for Medicare beneficiaries with a mental health or a substance use disorder diagnosis, and that services may be delivered by mental health or substance use disorder professionals.
An outstanding concern is that freestanding substance use disorder treatment facilities are still not covered in Medicare, which is the setting in which most individuals with substance use disorders get IOP and PHP services. IOP coverage in OTPs is an important first step, but this coverage is limited to individuals with opioid use disorders. Beneficiaries with other substance use disorders, including the most prevalent condition – alcohol use disorder – will not have access to this essential level of care. We will continue to work with CMS to ensure this new coverage is available for individuals with all substance use disorders.
Reimbursement Rate Increases
CMS has also increased the reimbursement rates for a number of substance use disorder and mental health services, including psychotherapy codes, behavioral health integration codes, and the bundled office-based substance use disorder codes (G2086-G2088). These changes reflect CMS’s concern that the reimbursement rates for mental health and substance use disorder services do not accurately value the amount of work that goes into delivering these services and contributes to a workforce shortage, amidst the ongoing mental health crisis and opioid public health emergency. While CMS appropriately recognizes the need to address the low reimbursement rates, much greater rate increases and structural reform are necessary to meet the demand for mental health and substance use disorder services and close the discriminatory reimbursement gap between these and medical services. We will continue to work with federal regulators to ensure providers can deliver evidence-based care to their patients, and beneficiaries have sufficient access to the providers and services they need.
Read more about these and other changes to Medicare’s coverage of substance use disorder treatment at the Legal Action Center’s website.
November 28, 2023 – D. Steinberg