OVERVIEW OF THE BEHAVIORAL HEALTH POLICY INVESTMENTS FOR OLDER AMERICANS IN THE 2023 OMNIBUS LEGISLATION
Joel E. Miller
Immediate Past Chair
National Coalition on Mental Health and Aging
In late December, Congress passed the OMNIBUS federal budget and new spending program legislation called the Consolidated Appropriations Act, 2023 (H.R. 2617), which was signed into law by President Biden on December 29.[i]
The legislation combines funding for all federal agencies through September 30, 2023, and several new programs and policies related to health care and mental health care, among other policy priorities.
The legislation includes several investments to address the needs of older Americans with mental health conditions that were supported by members of the National Coalition on Mental Health and Aging (NCMHA) in statements to the Senate Finance Committee and the House Ways and Means Committee in late 2021 and early 2022, respectively.
This blog summarizes the key mental health programs included in the OMNIBUS legislation, implications of those policies for older Americans, and what Congress is likely to consider in the way of mental health priorities in 2023.
Medicare Mental Health Care
Workforce Capacity Significantly Increased for Older Americans
- As of January 1, 2024, Medicare Part B will cover services provided by mental health counselors (MHCs) and marriage and family therapists (MFTs): MHCs and MFTs will be able to bill Medicare directly for covered services rendered to older adults and people with disabilities who are enrolled in Medicare. The omnibus legislation has addressed the workforce problem for older Americans with mental health conditions by substantially increasing the availability and accessibility of mental health providers. In a recent survey, nearly three quarters of mental health counselors (73 percent) indicated they would seek to become a Medicare-approved provider if they were recognized under the program.[ii]
Based on recent data released by the Health Resources and Services Administration (HRSA), there are 140,000 MHCs in the United States, and approximately 160,000 will be in practice in 2030. HRSA data also reveals that nearly 53,000 MFTs (some of whom are dually licensed as clinical social workers) are practicing in the United States, and about 75,000 will be in practice in 2030.[iii]
Moreover, MHCs and MFTs practice in rural and frontier areas, where the need for mental health services is growing. Similar to existing Medicare mental health providers (which includes psychiatrists, psychologists, clinical social workers, and clinical nurse specialists), MHCs and MFTs are trained not only to treat older adults with anxiety, depression, and post-traumatic stress disorder (PTSD), but also with substance use disorders (SUDs)—a growing problem among older adults in rural areas.
- Medicare Funded Residency Positions: The omnibus provides the distribution of 200 new Medicare-supported graduate medical education (GME) slots, 50 percent of which are allocated for psychiatry and psychiatry subspecialties.
- Loan Repayments: HRSA’s Substance Use Disorder Treatment and Recovery (STAR) Loan Repayment Program will receive $40 million for FY 2023.
Improvements in Delivery and Payment Program
- Telehealth: The omnibus continues Medicare’s expanded access to telehealth by extending COVID-19 telehealth flexibilities for an additional two years (through Dec. 31, 2024). The law also extends through calendar year 2024 the flexibility to exempt telehealth services from the deductible in high-deductible health plans that can be paired with a Health Savings Account.
- Intensive Outpatient Services: The omnibus revises Medicare’s partial hospitalization benefit to provide coverage of intensive outpatient services on January 1, 2024 to be provided at federally qualified health centers (FQHCs) or rural health clinics.
Currently under Medicare, there is a “partial hospitalization” mental health benefit for beneficiaries who require 20 hours a week of mental health services, provided in an outpatient setting. The new intensive outpatient benefit mirrors the partial hospitalization benefit, although it would apply for an individual who only needs 9 hours of services per week (compared to 20) to qualify.
- Payment for Crisis Psychotherapy Services: The law establishes a 50 percent payment increase in Medicare Physician Fee Schedule payment rates for crisis psychotherapy services when furnished by a mobile unit and additional settings on January 1, 2024.
- Payment Methodology Update for Inpatient and Psychiatric Facilities: The U.S. Department of Health and Human Services (HHS) Secretary is required to update the methodology for determining payment rates under the Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) beginning in 2025 based on new data collection for inpatient and psychiatric units.
- HHS Outreach for Behavioral Health Integration Services: The omnibus requires HHS to conduct outreach to physicians and other health care providers on the availability of behavioral health integration services as a covered benefit and report findings to Congress.
- GAO Study and Report Comparing Coverage of Mental Health and Substance Use Disorder Benefits and Non-Mental Health and Substance Use Disorder Benefits: The omnibus directs the Comptroller of the United States to conduct a study to compare the mental health and substance use disorder benefits offered by Medicare Advantage plans to traditional Medicare and to other benefits offered by Medicare Advantage plans.
Substance Abuse and Mental Health Services Administration (SAMHSA) Programs
Reauthorizations: The law reauthorizes the National Suicide Prevention Lifeline Program, the Community Mental Health Service Block Grants, and the renamed Substance Use and Prevention, Treatment, and Recovery Block Grants. SAMHSA received increases to several programs it administers (including the Minority Fellowship Program highlighted below.) The agency received:
- An increase of $970 million to invest in several mental health programs to expand access to services.
- $502 million, an increase of $390 million, to support the new 988 number and Behavioral Health Crisis Services.
- $20 million, an increase of $10 million to create mobile behavioral health crisis response teams.
- $2.8 billion, an increase of $707 million, for mental health, including $385 million for the Certified Community Behavioral Health Clinics (CCBHCs). (CCBHC grant funding opportunities in the omnibus come in addition to the funds allocated in the Bipartisan Safer Communities Act, which allows states to apply for planning grants to fund the development of a strategy for becoming a CCBHC Demonstration state. The CCBHC treatment model has proven its effectiveness in better meeting the needs of individuals with behavioral health or SUD conditions. An estimated 2.1 million clients are served collectively, by 450 CCBHCs and grantees nationwide as of August 2022. This estimated total represents an increase of 600,000 clients compared to the estimated total number of individuals served by CCBHCs in 2021).[iv]
Under SAMHSA programs, the omnibus law expands patient access to opioid addiction treatment by making it easier for health care providers to dispense buprenorphine (sometimes used in combination with naloxone) for opioid use disorder maintenance or detoxification treatment. The law also requires providers to complete training on identifying and treating patients with substance use disorders.
The Minority Fellowship Program received a $19.4 million allocation in the omnibus legislation, an increase of $1.3 million for 2023. This is a significant increase since the past two years the program has seen no funding increases. The law also reauthorizes the program through 2027, as it was set to expire after this year.
Medicaid Mental Health Provisions
- Improved Medicaid and Children’s Health Insurance Program (CHIP) Provider Directories: Starting July 1, 2025, state Medicaid and CHIP fee-for-service programs and managed care plans are required to publish searchable provider directories including information on whether the provider is accepting new patients, the provider’s cultural and linguistic capabilities, whether provider offers services via telehealth and other information. Often referred to as ghost or phantom networks, network directories with listings of providers who did not accept Medicaid enrollees have been linked to access barriers.
- Guidance and Technical Assistance Center on Continuum of Crisis Response Services: The law requires HHS to issue guidance to states and set up a technical assistance center by July 1, 2025, on the continuum of crisis services in Medicaid and CHIP, including how Medicaid and CHIP can support crisis call centers including the 988 crisis services hotline and best practices for the operation of a continuum of crisis response services under Medicaid and CHIP. The law provides $8 million in funding to the HHS Secretary to carry out the activities.
- Extension of the Money Follows the Person Rebalancing Demonstration through FY 2027: The law extends funding for the Medicaid Money Follows the Person Rebalancing Demonstration (MFP) for four additional years through fiscal year 2027 at current funding levels of $450 million per year. Initially created in 2005 under the Deficit Reduction Act, current funding for the program is was set to expire at the end of this fiscal year. With a four-year funding extension, states can leverage MFP to better support home and community-based services and supports for older Medicaid enrollees with behavioral health needs.
Veterans Administration Provisions
The following provisions were included in the omnibus to improve mental health care resources and suicide prevention efforts at VA. These provisions were included as part of $13.9 billion in mental health investments in the VA.
- Post-9/11 Veterans’ Mental Health Care Improvement Act of 2021—bipartisan legislation to strengthen VA’s mental health care workforce, expand care options, and support mental health research at the Department.
- Revising and Expediting Actions for the Crisis Hotline (REACH) for Veterans Act—bipartisan legislation to improve the Veterans Crisis Line’s staff training, management, and response to veteran callers at risk of suicide.
- American Indian and Alaska Native Veterans Mental Health Act—bipartisan legislation requiring VA medical centers to consult with local Tribes and deliver tailored outreach and culturally competent mental health care to Native veterans.
Other Key Mental Health Provisions
- REACHING Improved Mental Health Outcomes for Patients Act of 2022: This provision includes the previously proposed Reauthorizing Evidence-based and Crisis Help Initiatives Needed to Generate (REACHING) Improved Mental Health Outcomes for Patients Act of 2022 (H.R. 7237), which would replace Community Crisis Response Systems Grants with a Mental Health Crisis Response Partnership Pilot Program and authorize $10 million each year from FY 2023 through FY 2027.
- Peer Supported Mental Health Services: A key provision authorizes $65 million over 5 years in grants for consumer-run nonprofit organization, Tribes and Tribal organizations, Urban Indian organizations, or Tribal consortia to provide peer-supported mental health services, which would include virtual peer support.
The legislation also contains provisions from the PEERS Act to ensure that peer support specialist services are covered by Medicare and to help providers understand how to bill for those services.
The Virtual Peer Support Act is also part of the final omnibus bill to help boost the capacity of peer behavioral health support programs by providing grant funding to support their work, including transitioning to an on-line setting.
- Timely Treatment for Opioid Use Disorder: This package, includes the Timely Treatment for Opioid Use Disorder Act of 2022, which directs HHS to revise opioid treatment program (OTP) admission criteria to eliminate the requirement that patients must be addicted for at least one year prior to being admitted for treatment. This provision would also require SAMHSA’s Assistant Secretary to conduct a study and report within 180 days on the impact of treatment flexibilities allowed during the COVID-19 pandemic on the effectiveness and safety of the OTP.
This package also includes provisions related to efforts to improve the opioid crisis response. It would update sections of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act to require the development and dissemination of training materials for pharmacists who decline to fill a prescription, under certain circumstances, such as when pharmacists suspect the prescriptions are fraudulent, forged, or of doubtful, questionable, or suspicious origin. It would also allow the Centers for Disease Control and Prevention to prioritize jurisdictions with a high burden of drug overdoses when awarding grants to prevent overdoses of controlled substances. Additionally, HHS is required to conduct public education campaigns on synthetic opioids — fentanyl and its analogues — and other drug misuse issues, while disseminating other information about opioids to health care providers and providing training for first responders and individuals with high risk of exposure.
- The omnibus legislation incorporates features of the Behavioral Health Crisis Services Expansion Act to help incentivize and support crisis support services. Specifically, the omnibus will provide increased Medicare payment rates for mental health services delivered by mobile units and provide support for states designing and implementing crisis response services in Medicaid.
What Does 2023 Hold for Mental Health Policy for Older Americans?
The NCMHA will continue to report on proposals to improve mental health and SUD service delivery and payment initiatives that were included in legislative drafts developed in 2022 by the Senate Finance Committee and the House Ways and Means Committee. These proposals included applying mental health parity provisions to the Medicare program, addressing phantom provider networks, promoting the integration of mental health and primary care services for older Americans, and improving access to existing Medicare mental health providers.
The challenges surrounding substance use disorders will remain a significant priority for Congress in 2023, with a strong focus on fentanyl-related substances and their entry into the United States. Congress is expected to seek opportunities to implement policies intended to make a measurable impact on these problems.
In addition to Congress continuing to build on the mental health policy momentum embodied in the omnibus legislation, the White House will retain a substantial mental health policymaking role. This Administration will continue to use its authority to advance health and mental health policy, particularly to achieve mental health policy priorities where Congress may be unable to reach consensus, such as on mental health insurance parity issues.
Finally, health care and mental health policy in 2023 will begin to be influenced by the 2024 Presidential election cycle, which will begin in earnest early this year. Presidential candidates will develop their proposed policies on behavioral health issues that they would support if elected in 2024.
During 2023, NCMHA will keep members updated on policy activities related to improving the lives of older Americans with mental illness and substance use disorders. In addition, the NCMHA will strive to keep members informed about what they need to know and how they can be involved as provisions of the omnibus are implemented over the next several years.
[iii] HRSA Health Workforce Report. Behavioral Health Workforce Projections, 2017-2030.
[iv] QUALIFACTS 2023. Omnibus Appropriations Bill – Additional CCBHC Funding