News
Congress Must Close Medicare’s Coverage Gaps for Substance Use Disorder Care
FOR IMMEDIATE RELEASE
February 15, 2024
Rockville, MD - Today, leading organizations dedicated to improving affordability and accessibility to high-quality, substance use disorder (SUD) and mental health care called on Congress to address alarming coverage gaps in Medicare and to establish federal protections to ensure mental health and addiction parity for Medicare beneficiaries. Notably, Medicare lags behind other payers by not covering non-hospital-based residential addiction treatment programs or outpatient treatment in most community-based SUD treatment facilities. In addition, Medicare does not cover services from the full range of providers that make up a significant part of the SUD and mental health workforces and tends to undervalue SUD and mental health services.
The call for reforms came during a congressional briefing on Capitol Hill, sponsored by the Coalition for Whole Health and the Mental Health Liaison Group, in coordination with the U.S. House Addiction, Treatment and Recovery Caucus. Leaders from the American Society of Addiction Medicine (ASAM), the Legal Action Center, the National Association of Social Workers, the Illinois Association for Behavioral Health, and the National Council for Mental Wellbeing all emphasized that older adults and individuals with chronic disabilities deserve robust health insurance coverage of SUD care.
“Older adults and people with disabilities deserve equitable access to substance use disorder treatment, and yet the failure to apply the Mental Health Parity and Addiction Equity Act in Medicare means that millions of individuals face unnecessary barriers to care” said Paul Samuels, JD, Director/President of the Legal Action Center. “We are grateful for the substantial progress Congress and CMS have made over the past few years to expand Medicare coverage, and we look forward to continuing to work together to close the remaining gaps that prevent people from getting the treatment they need. With over 52,000 overdoses among Medicare beneficiaries in a year, we must end the discrimination that persists in health insurance.”
“Too few people realize that the nation’s addiction crisis impacts nearly 2 million seniors and Americans with disabilities covered by Medicare. Even fewer understand that Medicare does not fully extend coverage across the addiction care continuum to this incredibly vulnerable population,” said R. Corey Waller, MD, MS, Editor-in-Chief of The ASAM Criteria by ASAM. “We look forward to working with Congress to champion bipartisan legislation to close gaps in evidence-based residential addiction treatment programs under Medicare. We will work tirelessly to help Medicare beneficiaries get the evidence-based care they need and deserve.”
“Certified Community Behavioral Health Clinics in Missouri have increased access to Medication Assisted Treatment (MAT) by 268%, serving a total of 11,500 people with opioid use and/or alcohol use disorders,” said Natalie Cook, MS, Vice President, CLIVE Solutions, Missouri Behavioral Health Council. “These MAT services are often available on the same day or within 24 to 48 hours. Medicare only patients, including seniors, compose a substantial portion of our total patient caseload. Older adults have unique needs that require targeted services and supports. Establishing CCBHCs as a provider type in Medicare—with a payment model comparable to that they receive in Medicaid—would be a game-changer for our clinics’ abilities to expand their efforts to serve this population.”
“Nationwide clinical social workers are one of the largest providers of mental and behavioral health services yet face significant barriers in providing mental health and substance use disorder services and continuity of care to Medicare beneficiaries. This is because the scope of practice for clinical social workers is limited in Medicare and reimbursement in Medicare is far too low. Sadly, for the first time in my career I’ve been forced to turn away new Medicare beneficiaries because I simply cannot afford to see them. Medicare rates are already lower than private insurance and self-pay, but on top of that, social workers only get paid 75% of the physician fee schedule. We ask Congress to please pass the Improving Access to Mental Health Act and the Integrating Social Workers Across Health Care Settings Act to help improve access to clinical social worker services in Medicare,” said Cathy Lawder, LCSW, clinical social worker and member of the National Association of Social Workers.
Representative Paul Tonko, co-chair of the U.S. House Addiction, Treatment and Recovery Caucus, gave remarks during the briefing, highlighting the severity of this issue and underscoring the urgency for lawmakers to act. Stakeholders also discussed advocating for the introduction of federal legislation that would create a new Medicare Part A benefit for residential addiction treatment programs that meet nationally recognized standards outlined in The ASAM Criteria. The legislation would also establish a new prospective payment system for covered residential addiction treatment services.
"As a leading provider of residential treatment services, it's disheartening to see Medicare beneficiaries unable to access the comprehensive care they desperately need for a substance use disorder, said Kelly Epperson, JD, General Counsel, Rosecrance Residential Treatment Centers. “Our facilities and expert staff are prepared to deliver evidence-based treatment that offers the best opportunity for lasting recovery, but the current Medicare coverage gaps prevent us from extending our services to this vulnerable population. It's imperative that Congress takes swift action to close these disparities in coverage, ensuring that Medicare beneficiaries have access to the full continuum of care necessary for their recovery and well-being."
There is an urgent need for reform. Opioid use disorder among Medicare beneficiaries has skyrocketed over the years and drug overdose death rates have risen higher among seniors than any other age group. A report from the Legal Action Center demonstrates that a modest federal investment would provide life-saving Medicare coverage for an estimated 75,637 residential treatment episodes per year under Medicare - averting unnecessary hospitalizations, supporting more opportunities for recovery, saving more lives, and reducing costs to the Medicare program.
“A 2023 UCLA Health study found that drug overdose fatalities among people aged 65 and older quadrupled between 2002 and 2021,” said Illinois Association for Behavioral Health CEO Jud DeLoss. “Expanding SUD treatment options for Medicare beneficiaries can help curb this explosive growth of overdose deaths among older adults.”
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About the Legal Action Center
The Legal Action Center (LAC) is a non-profit law and policy organization that fights discrimination, builds health equity, and restores opportunities for people with substance use disorders, arrest and conviction records, and HIV/AIDS. For over 50 years, LAC has worked to expand access to substance use disorder and mental health care, including through enforcement of the Mental Health Parity and Addiction Equity Act (Parity Act) in public and private insurance, and reduce barriers to treatment and support. LAC’s Medicare Addiction Parity Project seeks to improve access to comprehensive and equitable substance use disorder services in Medicare. For more information, visit www.lac.org.
About the American Society of Addiction Medicine
The American Society of Addiction Medicine (ASAM), founded in 1954, is a professional medical society representing over 7,000 physicians, clinicians, and associated professionals in the field of addiction medicine. ASAM is dedicated to increasing access and improving the quality of addiction treatment, educating physicians and the public, supporting research and prevention and promoting the appropriate role of physicians in the care of patients with addiction. For more information, visit www.ASAM.org.
About the National Council for Mental Wellbeing
The National Council for Mental Wellbeing is a membership organization that drives policy and social change on behalf of more than 3,400 mental health and substance use treatment organizations and the more than 10 million children, adults and families they serve. We advocate for policies to ensure equitable access to high-quality services. We build the capacity of mental health and substance use treatment organizations. And we promote greater understanding of mental wellbeing as a core component of comprehensive health and health care. Through our Mental Health First Aid (MHFA) program, we have trained more than 3 million people in the U.S. to identify, understand and respond to signs and symptoms of mental health and substance use challenges. For more information, visit https://www.thenationalcouncil.org/.
About the National Association of Social Workers
The National Association of Social Workers (NASW) is the largest membership organization of professional social workers in the world. NASW works to enhance the professional growth and development of its members, to create and maintain professional standards for social workers, and to advance sound social policies. For more information, visit www.socialworkers.org.
About the Illinois Association for Behavioral Health
Established in 1967, the Illinois Association for Behavioral Health is a statewide organization representing addiction and mental illness prevention, treatment and recovery services agencies, staff, consumers, affiliated organizations, and corporations. For more information, visit https://ilabh.org/.