Omnibus Bill Will ‘Move the Ball Quite Substantially’ in Behavioral Health

The $1.66 trillion omnibus funding bill touches nearly every aspect of the behavioral health industry.

Advocates in the space weren’t shy about praising the bill even though it didn’t include some long-sought reforms. A quick tally of funding for the most germane items finds that the federal government is putting at least $10 billion into behavioral health in fiscal 2023.

The bill, which was signed by Pres. Joe Biden on Dec. 29, also includes tens of millions of additional dollars allocated to initiatives such as scientific research funding through organizations within the National Institutes of Health that won’t flow directly into the industry.

Some of the more direct initiatives include extending telehealth flexibilities for Medicare beneficiaries, deregulating buprenorphine and investing more money into workforce development programs. And that is a small sampling of the provisions that impact behavioral health.

“We’re trying to put together just a summary of all of the different provisions and I have to imagine that’s going to have to be a couple of pages long because there is just so so much in there,” Chuck Ingoglia, president and CEO of the National Council for Mental Wellbeing (NCMW), told Behavioral Health Business. “Unprecedented would be the word that I would use.”

NCMW is a behavioral health industry advocacy group that focuses on supporting certified community behavioral health clinics (CCBHCs).

The bill includes increased funding to continue the development of the CCBHC model across the U.S. Interest in this model has ballooned as the pandemic revealed and worsened the access problems in the behavioral health sector.

Even from a historic perspective, the omnibus bill shines even compared to the titular reforms that are keystones of behavioral health policy in the U.S. For example, previous reforms include the creation of the CCBHC model in the first place.

“I’ve been doing this now for NAATP for almost 20 years and this is by far the biggest advancement we’ve made in an omnibus, so I think it’s huge,” Mark Dunn, director of public policy for the National Association of Addiction Treatment Providers (NAATP) told BHB.

Founded in 1978, the NAATP is an advocacy and membership group for substance use disorder (SUD) treatment professionals.

A long time coming

The omnibus bill encompasses many of the proposals that lawmakers — especially those on the Senate Finance Committee — have championed all year.

A major reform is the elimination of the additional waiver physicians are required to get from the Drug Enforcement Administration (DEA) to prescribe buprenorphine. In effect, the bill nixes this waiver and requires all providers to get additional training on how to recognize and treat addiction.

The bill was championed during the year as the Mainstreaming Addiction Treatment (MAT) Act. It is hoped to eliminate administrative hurdles, stigma and access hurdles to the drug.

And even though 2023 will see the arrival of a divided government, with Republicans reclaiming a majority in the House of Representatives, Washington observers point out that behavioral health initiatives enjoy broad bipartisan support. One bill folded into the omnibus bill, the Restoring Hope for Mental Health and Well-Being Act of 2022 (H.R. 7666), passed the House on a strong bipartisan vote. This leaves the door open for additional action in 2023.

The passage of the omnibus bill portends well for those efforts.

In fact, the omnibus bill cleared the Senate on a 68-29 vote on Dec. 22, with 18 Republicans voting in favor of the bill. The next day, the House approved the bill, 225-201. All but one Democrat, New York Rep. Alexandria Ocasio-Cortez, voted for the bill while all but nine Republicans voted against it, according to GovTrack.us.

“I think this is more than the traditional haphazard, throw some dollars out there at the end of a congress and think you’ve done something,” Shawn Coughlin, president and CEO of the National Association for Behavioral Healthcare, told BHB. “I think this really does move the ball quite substantially.”

Parity efforts in the omnibus bill

The bill includes $50 million of funding spread across five years to help states enforce the federal parity provisions. The U.S. Department of Labor (DOL) oversees some parity regulations. States have primary parity enforcement authority for fully-insured individual and employer health plans.

It also removes a provision that allowed health plans offered by non-federal governmental entities — like states, municipalities, school districts and other public systems — to completely opt out of parity requirements.

The Kennedy Forum, an advocacy organization focused on health care and mental health reforms, estimates that over one million more children and families will gain improved mental health coverage through the elimination of the exemption. The Kennedy Forum pushed for the provision.

“As a former public servant who benefited from mental health and addiction treatment, I believe no public servant should be subject to discrimination that denies that treatment,” Patrick J. Kennedy, a former Rhode Island congressman and the founder of the Kennedy Forum, said in a statement. “Thankfully, we are finally seeing brain health as part of overall health.”

However, the bill did not address the DOL’s request to be able to levy fines for health plans that are out of compliance with parity regulations, Dunn noted.

“We would just say that probably the biggest advancement regarding access to care has been around parity,” Dunn said. “The fact that it really hasn’t been enforced vigorously in the last 15, 16 years has been a big disappointment. So anything that we can do to move the needle in that direction, we’re hugely in favor of.”

The bill does extend Medicare reimbursement to more behavioral health practitioners. However, it stops short of covering inpatient addiction treatment, a vital shortcoming in Medicare coverage according to some.

Major Medicare changes

The bill adds coverage for intensive outpatient mental health programs and care provided by marriage and family therapists and mental health counselors. This is seen as a meaningful expansion of access for Medicare beneficiaries.

It will also increase reimbursement provided via mobile crisis care units.

While not directly related to care, the bill will fund an additional 200 graduate medical education (GME) training positions, half of which must be reserved for psychiatry specialties. This is much less than the Senate Finance Committee proposed in its draft legislation on expanding the behavioral health workforce.

Psychiatrists are a shrinking population of the behavioral health workforce. They are also among the practitioners most likely not to take Medicare reimbursement. A previous review by the federal government found that the U.S. would likely have a shortage of about 12,500 adult psychiatrists to meet demand.

The bill also includes provisions for psychiatric facilities to include new data in reporting to the Centers for Medicare & Medicaid Services for reimbursement adjustments. These changes were proposed in a CMS rule announced in July.

Medicaid enrollment clarity

During the pandemic, the federal government offered states additional Medicaid funding if they made it easier for people to get on Medicaid and held off on making eligibility determinations during the public health emergency (PHE) for the COVID pandemic.

However, the transition period for states to begin operating Medicaid enrollment, as usual, has been separated from the undetermined termination of the PHE and set at April 1. Politico reports this move is meant to give states certainty in managing the transition back to Medicaid redeterminations. The bill also gives states funding and assistance in the transition.

It provides 12 months of coverage for children and new mothers previously eligible for Medicaid.

The bill requires Medicaid plans to create searchable, up-to-date directories of providers, including behavioral health providers, to combat the phenomenon of “phantom networks.”

Medicaid is the single-largest payer of mental health services in the nation. Medicaid enrollment has increased by about 26% over pre-pandemic levels to about 90 million adults and children. The health plan covers about 27% of the American population. Within Medicaid, about 29% of people have a mental illness or SUD, higher than U.S. averages.

CCBHC funding

While CCBHC funding increased to $385 million, Ingoglia said the funding is comparable to grand funding that is expiring in 2023.

“It’s not a huge increase but certainly, in this environment, it will keep steady with other programs,” Ingoglia said.

CCBHCs are largely supported by block grant funding. Some states are participating in a pilot program with the federal government that allows these one-stop-shop behavioral health clinics to be supported by prospective Medicaid payments and other federal funds. This program is limited to local government or nonprofit organizations.

Omnibus full of specific behavioral health efforts

The bill renews, funds or increases the funding for several discrete, issue- or group-specific behavioral health programs.

A few of the bigger dollar-amount programs include:

— $3 million for a maternal mental health hotline, $10 million for maternal depression screening and several grants for supporting maternal health

— $94 million for the National Child Traumatic Stress Initiative

— $13 million for pediatric mental health access

— $140 million for Project AWARE, a state-federal collaboration to raise mental health awareness among K-12 students, train staff and instructors to respond to mental health issues and facilitate connections to care

— $501.6 million in funding for the new 988 Suicide & Crisis Lifeline

— $1.58 billion for State Opioid Response Grants

— $4.4 billion in funding for the federal research entities the National Institute on Alcohol Abuse and Alcoholism, the National Institute of Mental Health and the National Institute on Drug Abuse

— Increasing the funding of the Substance Abuse and Mental Health Services Administration (SAMHSA) to $7.5 billion, an increase of $970 million