Behavioral health providers are starting 2023 invigorated with the winds of change at their back. Thanks to the Biden Administration, the Centers for Medicare and Medicaid Services (“CMS”) and Congress, behavioral health providers will be able to bolster their workforce, expand services and extend telehealth flexibilities afforded by the COVID-19 Public Health Emergency (“PHE”).
The pandemic revealed what was well known for years in the behavioral health community, that behavioral health services have been understaffed, underfunded, inaccessible, and undervalued. Complete parity with medical service benefits has yet to be achieved.
The impact of the pandemic contributed to an increase in the demand for behavioral health services. Based on two surveys done in 2020 and 2021, the American Psychological Association (“APA") reported a 62 percent increase in patient referrals. Psychologists also reported increases in treating anxiety disorders (84 percent, up from 74 percent), depression (72 percent up from 60 percent) and trauma and stress related disorders (62 percent up from 50 percent).[1]
In its Calendar Year (CY) 2023 Physician Fee Schedule (“PFS”) final rule, CMS accordingly acknowledges, “We understand that circumstances related to the PHE for COVID-19 have likely contributed to an increase in the demand for behavioral health services while also exacerbating existing barriers to beneficiaries’ access to needed behavioral health services.”
Here are the highlights of the encouraging news.
Workforce Boost
On December 23, 2022, the Mental Health Access Improvement Act (S. 828/H.R. 432) was passed by Congress and enshrined as part of the 1.7 trillion massive omnibus appropriations bill that was signed on December 29, 2022, by President Biden.
This legislation amends title XVII of the Social Security Act and effective January 1, 2024, under Part B of the Medicare Program, payment will be made for the services of Licensed Marriage and Family Therapists (“LMFTs”) and Licensed Professional Counselors (“LPCs”). For years, professional organizations have tirelessly been lobbying for this change which will permit Medicare beneficiaries access to 54,800 LMFTs (as of May 2021[2]) and to what is estimated to be 160,000 LPCs[3].
Between now and the start of 2024, behavioral health providers can take advantage of an important change per the CY 2023 PFS Final Rule, where CMS now allows for the services of LCSWs and LPCs to be rendered under general versus direct supervision when billing incident to a physician’s services. This certainly gives some relief to organizations where circumstances or geography make the requirement to have a psychiatrist or non-physician practitioner (“NPP”) on site to provide direct supervision an ongoing challenge and at times impossible. Now there is more flexibility.
Attention to behavioral health provider shortages was announced in March 2022 by President Biden with the roll out of a robust and multi-pronged strategy to address the country’s mental health crisis.[4] Central to this plan is the acknowledgement of the severe shortage of behavioral health providers with specific plans and monies budgeted to expand the pipeline of behavioral health providers and improve their distribution to areas of greatest shortage and populations consistently underserved. This strategy includes the following:
Investing in proven programs that bring providers into behavioral health.
Piloting innovative approaches to train a diverse group of paraprofessionals.
Building a national certification program for peer specialists.
Promoting the mental well-being of the frontline health workforce.
Expansion of and Access to Services
Behavioral Health Integration
Themes of the integration of mental health and substance use treatment in primary care settings are found in both President Biden’s and CMS’ behavioral health strategy plans. This integration contributes to the larger goal of increasing access to both mental health and substance use services.
A growing body of research has demonstrated that integrated care helps patients with chronic conditions who are more likely to have behavioral health concerns. Patients referred to other places for behavioral health treatment do not follow-up but feel less stigmatized with the “one stop shopping” of integrated care. Treatment-seeking behaviors vary across races and ethnicities, as members of many culturally and linguistically diverse communities are unlikely to receive or seek behavioral health services. Integrated behavioral health may allow clinicians to provide services to populations that otherwise would go underserved.[5]
In the 2023 PFS final rule, a new Behavioral Health Integration (“BHI”) HCPCS code, G0323, will allow Clinical Psychologists (“CPs”) and Licensed Clinical Social Workers (“LCSWs”) to bill for monthly care integration (under general supervision rather than direct) when the mental health services they furnish in a primary care setting serve as the focal point of care integration. To bill G0323, a CP or LCSW must spend at least 20 minutes per calendar month providing services and meet all the following required elements:
Initial assessment or follow-up monitoring, including the use of applicable validated rating scales.
Behavioral healthcare planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes.
Facilitating and coordinating treatment such as psychotherapy, coordination with and/or referral to physicians and practitioners whom Medicare authorizes to prescribe medications and furnish evaluation and management (E/M) services, counseling and/or psychiatric consultation.
Continuity of care with a designated member of the care team.
All BHI services, including G0323, require an initiating visit for a new patient or a beneficiary not seen within a year of commencement of BHI services to establish the beneficiary’s relationship with the billing practitioner, ensure that the billing practitioner assesses the beneficiary before initiating care management processes, and provide an opportunity to obtain beneficiary consent.
CMS recognized that existing initiating visit codes are not entirely within the scope of practice of a CP or LCSW, so it finalized CPT 90791 (psychiatric diagnostic evaluation) to serve as the initiating visit for G3023. CPs and LCSWs can bill this code.
Opioid Use Disorder Treatment
Starting January 1, 2020, under the CY 2020 PFS Final Rule, the CMS started paying bundled payments for opioid use disorder (“OUD”) treatment services in an episode of care provided to individuals with Medicare Part B. Only Opioid Treatment Programs (“OTPs”) fully certified through the Substance Abuse and Mental Health Services Administration (“SAMHSA”) and enrolled in Medicare are eligible for this payment.
CMS continued its support of the OTPs with the following changes reflected in the CY 2023 PFS final rule as follows:
Revised pricing methodology for drug component of methadone weekly bundle and the add-on code for take-home methadone supplies.
Modified payment rate for individual therapy in non-drug component of the bundled payments for episodes of care.
Allows OTP intake add-on code to initiate treatment with buprenorphine provided via two-way audio-video communications technology or audio-only technology when audio-video technology is not available, and all requirements are met.
Extended the flexibility through the end of CY 2023 to provide periodic assessments via audio-only when video is not available.
Clarified that OTPs can bill for medically reasonable and necessary services provided via mobile units increasing access to care for hard-to-reach individuals such as those who are homeless or living in rural areas.
Telehealth Flexibilities
The recent passage of the omnibus appropriations bill provided a two-year extension, through the end of 2024, for many Medicare telehealth flexibilities allowed under the COVID-19 PHE. Those relevant to behavioral health providers include:
Expanding originating and geographic site to include anywhere the patient is located, including the patient’s home.
Extending the ability for federally qualified health centers (“FQHCs”) and rural health clinics (“RHCs”) to furnish telehealth services.
Delaying the in-person requirement for mental health services furnished through telehealth, including the in-person requirements for FQHCs and RHCs.
Extending coverage and payment for audio-only telehealth services.
Unfortunately, it has taken an unprecedented nationwide mental health crisis to generate more aggressive action to support behavioral health providers and thousands of Americans needing mental health and substance use treatment. While the aforementioned changes may seem modest relative to the extent of the needs, they signal a critical shift in the understanding of behavioral health and its contribution to the overall health of our nation.
SunStone offers services specifically geared to assisting behavioral health organizations or organizations providing behavioral health services manage the ever-changing professional regulatory environment. If you have any questions, please contact Georgia Rackley, Senior Clinical Specialist at georgiarackley@sunstoneconsulting.com or Joli Fitzgibbons, Director at jolifitzgibbons@sunstoneconsulting.com.
[1] https://www.apa.org/pubs/reports/practitioner/covid-19-2021
[2] https://www.bls.gov/oes/current/oes211013.htm
[3] https://www.counseling.org/docs/default-source/government-affairs/a-survey-of-licensed-professional-mental-health-counselors.pdf?sfvrsn=49d22e2c_4
[4] https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/01/fact-sheet-president-biden-to-announce-strategy-to-address-our-national-mental-health-crisis-as-part-of-unity-agenda-in-his-first-state-of-the-union/
[5] https://integrationacademy.ahrq.gov/about/integrated-behavioral-health/patients