LEGISLATIVE

In the United States, Mental Health (MH) and Substance Abuse Disorder (SUD) collectively pose a major health care crisis.

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In spite of the Mental Health Parity and Addiction Equity Act (MHPAEA} of 2008, issues related to Mental Health and Substance Abuse Disorders have continued to escalate in all our communities across the United States.  Here is some current data:

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• One person dies by completed suicide every 11 minutes and for children/adolescents suicidal/self-harm attempts have increased from 1,058 in 2010 to 5,606 in 2020 with death by completed suicidal among the top 5 causes of death among children/adolescents.

• Overdose deaths exceeded 100,000 in one year period in 2021 in the United States.

• First responders and health care providers continue to experience MH struggles. (KFF, 2022)

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Therefore, the need for mental health and substance abuse services has not only increased, as accessing health care has become increasingly difficult for all people.

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Access to care in the United States is impacted by health plans designed by commercial insurance companies.  Many currently available health plans do not provide treatment as required by the MHPAEA.

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A proposed Rule to improve the enforcement of the MHPAEA has been proposed by the current administration.  The “2023 Proposed Rule” would regulate the financial requirements and non-quantitative treatment limitations that Health Plans use when designing and administering Plan benefits.  This proposed Rule would provide needed increased enforcement and stricter penalties for noncompliance.

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We encourage all members of Congress to support the development of this Rule which will require insurers to develop non-quantitative treatment limitations for Mental Health /Substance Use Disorders (MH/SUD) that are equal to medical/surgical standards.  This would provide access to MH/SUD services by consumers and allow mental health care providers to deliver the services needed.  Along with the Mental Health Liaison Group, a coalition of over 80 MH/SUD groups, we strongly recommend that a version of the “generally accepted standard of care for MH/SUD” or use “Independent professional medical or clinical standards” be used to provide adequate treatment services.

The Clinical Social Work Association (CSWA) is concerned about consumers being limited in their access to mental health services provided by Licensed Clinical Social Workers (LCSWs), the largest group of mental health providers in the country (over 365,000).  Toward this goal, CSWA encourages all members of Congress to support pending legislation S.2173 and H.R.3712.

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Currently, access to mental health services is being restricted by Medicare and commercial insurers in the following manner:

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•  Even though LCSWs are the major providers of mental health services in the United States, patients are having difficulties accessing their services.  More and more LCSWs are choosing to not be a Medicare provider as the reimbursement rates are only 75% of what other Medicare providers receive for the delivery of the same mental health services. Thus, there are fewer providers for more patients.

• Many Medicare patients are in skilled nursing facilities (SNFs) under Medicare Part A. They  are currently unable to receive mental health services by an LCSW practicing independently. 

• Recent legislation passed in 2023 now allows Licensed Professional Counselors and Licensed Marriage and Family Therapists, who have similar training to LCSWs, to practice independently in skilled nursing facilities.  LCSWs had been Medicare providers under Medicare Part A to patients in SNFs since the implementation of Medicare in 1965; this ability was eliminated in 1997. The expansion of LPCs and LMFTs to practice independently in SNFs should include LCSWs.

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Medicare patients need access to mental health services provided by LCSWs.  It is past time to equalize reimbursement rates for LCSW services and allow LCSWs to work independently in Medicare Part A. LCSWs should be added back to the list of Medicare providers that can practice independently in skilled nursing facilities.  Passing pending legislation S.2173 and H.R.3712 would accomplish this goal.

Over half of Medicare beneficiaries are now enrolled in Medicare Advantage (MA) plans.   The MA plans are overseen by commercial insurers, who receive funding from the federal government to provide these plans and make significant profits from MA plans.  Over the past five years it has become clear that the MA plans, while less expensive than traditional Medicare and offering some benefits that Medicare does not, i.e., glasses, dentists, etc., these plans actually provide fewer health care services, including for mental health.  The ‘bait and switch’ tactics which have led to the major increase in MA plans need to be addressed by Congress to stop the ongoing ways that MA beneficiaries are tricked into believing that they will receive more robust benefits than they would by choosing traditional Medicare.

 

There is a philosophical debate going on about the way that health care should be defined. So believe that health care should be seen as a business which can be corporatized and provide profits to investors.  Others believe that health care should be a public service available to all citizens.  Still others believe there should be a range of options which can be available depending on cost and services offered.  In this context, traditional Medicare is in the middle ground, since all citizens over 65 are eligible for Medicare.

 

There is also a debate going on about the profits that should be made by commercial insurers, which have expanded exponentially since MA plans went into effect. Many of the millions of dollars that have been made by commercial insurers have gone to lobby members of Congress ($371,000 million in 2017). 

 

As for mental health and substance use disorders (MH/SUD), the following problems have been noted by CSWA members:

 

• Many MA plans restrict the number of psychotherapy sessions they will cover

 

• Many MA plans reimburse LCSWs working virtually at lower rates than for in person psychotherapy

 

• Many MA plans require prior authorization for psychotherapy, though this is at odds with mental health parity laws

 

• There are significant limits on the providers that will be covered by MA plans

 

At the very least, MA plans should have more oversight and limited profits from their current levels. CSWA calls on Congress to protect consumers from the way that they have been taken advantage of by many MA plans so that our citizens are able to get the MH/SUD services that are so necessary at this precarious time.

Telemental health, which was widely implemented in March, 2020, due to the pandemic, has been found by both therapists and patients to be an effective and efficient way of providing needed mental health care. Mental health conditions went up 20-40% in the past 4 years and show no signs of being lowered to pre-pandemic levels. Here are some reasons that Telemental Health treatment should be made permanent:

 

• The availability of mental health services through Telemental Health is as crucial to the well-being of our population as access to medical services. In 2021, suicides increased by 25% and deaths from drug overdoses were over 100,000.

 

• Many patients will be unable to continue treatment if they cannot continue using Telemental Health.

 

• As of 2025, LCSWs will be required to see every Medicare patient in person every six months.  This is unrealistic if patients are at a distance from the therapist and/or the therapist does not have an office.

 

• The 2022 MHPAEA Report to Congress from the Department of Labor (DOL), the Department of Health and Human Services (DHHS) and the Department of the Treasury recommends that “…Congress consider ways to permanently expand access to telehealth and remote care services.”

 

Because of the inconsistency in availability to telemental health psychotherapy services across the country, we urge Congress to create and pass a law that will rectify this inequity permanently by passing S. 3651/H.R. 3432. This bill would authorize the use of telemental health on a permanent basis, allow both video and audio only as acceptable procedures for telemental heath’s provision, and require parity in coverage and payment to in-person services.

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The ability of Licensed Clinical Social Workers (LCSWs) to work across state lines has been a problem ever since clinical social work licensure went into effect over 60 years ago.  The Clinical Social Work Association (CSWA) has been aware of the difficulties that this limitation creates for the over 365,000 LCSWs in the country. For this reason, CSWA strongly supports the creation of a Social Work Compact. As of this writing, Missouri, South Dakota, Utah, and Washington State have signed on to the Social Work Compact.

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During the pandemic, many laws requiring LCSWs to practice only in states where they had a specific license were relaxed.  The ability to work virtually was also relaxed.  Many LCSWs have been working virtually for the past four years and have patients who want to continue working with LCSWs who are in a different state from their own.  The Social Work Compact would offer patients a pathway to continue working with LCSWs in other states.

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The benefits of the Compact are as follows:

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• Eases mobility if patients and/or LCSWs move to a new jurisdiction

• Allows LCSWs to work in states that join the Compact

• Increased number of LCSWs to provide mental health treatment in Compact states

• Allows use of technology to work with patients in other states

• Preserves home state sovereignty for all LCSWs

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Nursing, psychologists, physicians and 10 other professional health care groups already have Compacts for 10-20 years and have had very few difficulties creating Commissions to oversee them.

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Feel free to contact CSWA for more information about how the Compact developed and how it can help your state.

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Contacts: Laura Groshong, LICSW, CSWA Dir. of Policy and Practice,  lwgroshong@clinicalsocialworkassociation.org

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Judy Gallant, LICSW, CSWA Deputy Director of Policy and Practice, judy.gallant@verizon.net