States play an essential role in providing and overseeing behavioral health care, and many states have longstanding strategies to increase access to high quality, behavioral health interventions. State innovations in Medicaid (now the largest public payer of behavioral health care) along with strategic deployment of federal grants have provided a foundation for the behavioral health safety net. But the system remains fragmented and strained under the twin crises of mental illness and escalating overdose deaths. Additionally, the alarming rise in mental health challenges among children and youth underscores the need to integrate prevention and early intervention approaches across our child-serving systems. To be successful, reforms rely also on commitment at the federal and local levels to align policies and investments aimed at high quality interventions where and when people need it.
As federal partners pursue a comprehensive policy agenda to address mental health and substance misuse crises, the following considerations are offered to foster alignment of federal and state efforts to improve behavioral health outcomes.
As part of an 18-month state technical assistance project supported by the Commonwealth Fund, NASHP has gathered insights from state health and behavioral health policy leaders who are actively working to improve state behavioral health systems. These insights were gleaned through convenings of state policymakers and key informant interviews to exchange best practices and gather insights on federal legislative or administrative approaches that support state approaches.
The following is a non-exhaustive list of considerations shared as priorities among state health policymakers. Considerations are grouped categorically according to some of the most pressing priorities for states and are not intended to be in order of priority. Categories include:
Federal Inter-agency Alignment in Support of State and Local Needs and Priorities Alleviates Administrative Burden
Modern approaches to building an effective behavioral health system with access to best practice, evidence-based, and culturally informed interventions require sophisticated cross-agency collaboration, braided funding approaches, and alignment of administrative, reporting and accountability processes. State leaders routinely note that cross-agency alignment of resources, guidance, and reporting requirements at the federal level is necessary to effectively modernize their behavioral health systems.
Below are a few considerations for federal inter-agency alignment and coordination that would facilitate behavioral health transformation efforts at the state level:
- Federal grant programs could include more flexible requirements that allow for strategic braided funding approaches to address common and interrelated issues, greater alignment, and extended spending timelines to support state cross-agency efforts — including across U.S. Health and Human Services (HHS) agencies and offices (such as the Substance Abuse and Mental Health Services Administration (SAMHSA), Centers for Disease Control and Prevention, the Administration for Children and Families (ACF), and others).
- Federal partners could intentionally align these grant programs with opportunities/guidance/demonstrations from the Centers for Medicare & Medicaid Services (CMS) and other federal partners that have a goal of increasing the use of evidence-based interventions, such as the U.S. Department of Housing and Urban Development (HUD) for health and housing interventions and the U.S. Department of Justice (DOJ) for justice-involved initiatives.
- Federal agencies (such as CMS, SAMHSA, the U.S. Department of Education (ED), the Assistant Secretary for Planning and Evaluation (ASPE) and ACF) could align and collaborate on policy, funding, and reporting requirements to better support and streamline state efforts for youth behavioral health. This includes ED and HHS leveraging their inter-agency working group to increase access to and provide funding for evidence-based culturally appropriate mental health services in schools (including addressing suspension and juvenile justice involvement).
Behavioral Health in Children and Youth
During the COVID-19 pandemic, children and youth across the United States have faced a dramatic increase in behavioral health challenges. Fortunately, there is widespread momentum from policymakers, schools, and communities to support children and youth with mental health concerns. Stemming the acute increased need for services through prevention, early identification, and improved timely access to high quality care are top priorities for state policymakers across the country.
To help states invest in children and youth behavioral health, state policymakers observe that Congress may consider the following actions:
- Increase the Medicaid federal medical assistance percentage (FMAP) for pediatric behavioral and physical health integration.
- Incentivize expanded home and community-based care options as opposed to residential/hospital-based services through enhanced FMAP including evidence-based interventions such as Assertive Community Treatment, supportive housing, supported employment, intensive in-home therapy models for children, and wraparound care coordination.
- Provide timely guidance and technical support to states regarding uptake and implementation of maternal mental health-related provisions in the Consolidated Appropriations Act, 2023 (P.L. 117-328) (CAA), which made permanent the state option to provide Medicaid postpartum coverage to 12 months via a state plan amendment, and provided for a task force to coordinate federal activities around maternal mental health and a national maternal mental health hotline.
Collectively, these provisions may improve the likelihood of children’s coverage and access to care.
To advance federal and state collaboration in addressing child and youth behavioral health, HHS and other federal agencies may consider the following actions:
- Update Medicaid guidance regarding reimbursement of mental health services in schools to clarify allowable payments and identify strategies to reduce administrative burden.
- Elevate best practices and work across relevant federal agencies to align and enhance funding for behavioral health prevention and resiliency programs (with a trauma-informed and health-related social needs lens).
- Provide guidance defining integrated care for pediatric populations and data sharing approaches to guide and evaluate integrated care models.
- Develop waivers to fund innovative children’s behavioral health services with a focus on trauma-informed care and social determinants of health — building on early insights from the Integrated Care for Kids (InCK) model (which is operating in only six locations) and support additional opportunities for states to build and test related models.
- Revisit (with input from state policymakers) and elevate guidance on best practices in care coordination to address children’s mental health (such as Medicaid health home options) and guidance and technical support around improving systems of care for children and youth with co-occurring intellectual and developmental disabilities and/or behavioral health conditions and other complex challenges.
- Designate Health Professional Shortage Areas based on children’s behavioral health resources and provide incentives for providers to practice in youth-focused behavioral health care.
- Provide updated guidance and support on best practices in data sharing across child-serving systems (e.g., child welfare, Medicaid, etc.) while protecting privacy.
- Provide additional flexibility to (and correct misinformation about) requirements that children have a behavioral health diagnosis to access care in a timely manner — to reduce delays in care and address concerns about stigma.
Integrated Care and Community-Based Services
Integration of physical and behavioral health care and supports (at multiple access points in the care continuum) is considered a pillar of modernized behavioral health systems. Many states view this approach to care as an opportunity to de-silo behavioral health (expanding access to screening and treatment options), align systems toward whole person care, and create cost-effective solutions to meet the complex needs of their residents. Some integration approaches are backed by strong evidence, and state officials note the need to expedite payment and delivery reforms along with quality strategies to incentivize those approaches and disincentive ineffective interventions. For example, the Collaborative Care model — a team-based approach to integrating behavioral health into primary care — is among the most studied models of effective and cost-effective care.
Evidence for other interventions is emerging and states are working to align systems to provide and study those approaches — such as integrated care approaches for children and for people with more complex behavioral health and social support needs. At least 31 states have moved to carve-in most behavioral health services into their Medicaid managed care plans to encourage integration in service delivery, and many are experimenting with models such as InCK and the Certified Community Behavioral Health Clinics model (or derivatives thereof), which requires incorporating evidence-based interventions and quality monitoring into the service array. Uniformly, states agree on the critical need to address underlying workforce and provider capacity limitations to build and sustain access to integrated care.
To help states prioritize integrated care, community-based services, and upstream prevention, Congress may consider the following actions:
- Make permanent the American Rescue Plan Act’s enhanced 10% FMAP for home and community-based services (HCBS) to support state approaches in increasing access to behavioral health care and address HCBS workforce shortages.
- Incentivize integrated care by providing additional Health Information Technology for Economic and Clinical Health (HITECH) like funding to behavioral health providers to adopt interoperable and integrated systems with electronic health records and engage in health information exchange with primary care providers.
To collaborate with states to advance integrated care, community-based services, and upstream prevention, HHS and other federal agencies may consider the following actions:
- Ensure timely access to federally funded grants and technical assistance for adoption of the Collaborative Care model and other evidence based integrated care approaches provided for in the CAA and address regulatory barriers to implementation, and/or offer planning grants and enhanced FMAP to states through CMS to cover the model.
- Provide guidance, clear pathways, and technical assistance to state Medicaid programs to support integrated care for both children and adults within primary care, including through consultation, co-location, and chronic/complex care models.
- Provide guidance (and myth-busting) to health, behavioral health, and health-related social needs providers on allowable data sharing under the Health Insurance Portability and Accountability Act (HIPAA) and other federal laws (e.g., 42 CFR Part 2 — confidentiality of substance use disorder patient records and Family Educational Rights and Privacy Act (FERPA)). In addition to guidance on financing approaches for cross-sector data sharing (e.g., breadth and appropriate use of Medicaid 90/10 authority).
Parity Enforcement in States
In recent years, state policymakers have actively sought to address barriers to mental health parity enforcement and increase access to high quality care. While much can be achieved at the state level, continued federal action and clear guidance are sought.
Innovators in Action: Two State Examples
Washington state enacted legislation in 2022 that aligns coverage of the full range of behavioral health emergency and urgent care services with coverage of the full range of medical emergency and urgent care services and protects consumers of behavioral health crisis services from out-of-network charges, thereby aligning state law with the federal No Surprises Act and Mental Health Parity and Addiction Equity Act. This law advances consumer protections and access to behavioral health crisis services in facilities and appears to apply across payers; however, clear federal guidance on the latter would benefit all states.
As part of sweeping mental health legislation enacted in Massachusetts, the state has bolstered parity implementation and enforcement tools, including quicker resolution of parity complaints, greater reporting and oversight of carrier’s policies and processes, and establishment of reasonable penalties and other remedies to address noncompliance.
(Please refer to the Appendix for a more in-depth overview of state activity around behavioral health parity legislation.)
To support state parity enforcement, state policymakers suggest that Congress consider the following actions:
- Amend the No Surprises Act (NSA) to include behavioral health emergency services providers (mobile crisis response, crisis stabilization, acute medical detox, evaluation, and treatment facilities (72-hour holds)). We appreciate the recent Department of Labor (DOL) recent frequently asked questions, which allows states to bring behavioral health crisis facilities into the NSA via licensure of these facilities. Amendments to the NSA itself would apply this policy across 50 states and bring mobile crisis response teams into the law.
To support state parity enforcement and increase access to care, HHS and other federal agencies could consider the following actions:
- Provide additional resources (technical assistance, toolkits, and funding) to states for enforcement of parity and develop a center of excellence for parity between Self-Compliance Tool for the Mental Health Parity and Addiction Equity Act (MHPAEA).
- Convene an inter-state collaborative on increasing access to care and advancing parity across relevant agencies, including state insurance regulators, Medicaid agencies, DOL and other public payers. The National Association of Insurance Commissioners’ Working Group on Mental Health Parity has brought states, CMS, and DOL together for productive discussion, but Medicaid agencies could benefit from inclusion in comparable discussions at the federal level.
- Identify gaps that require federal action for coverage issues outside of state oversight.
- Reduce or standardize requirements for behavioral health treatment planning to align with that of physical health.
- Allow standardized behavioral health assessments as a means of prior authorization.
Behavioral Health Workforce and the Role of Telehealth
Workforce shortages remain a significant barrier to addressing the nation’s behavioral health crisis. The longstanding behavioral health workforce challenges have been exacerbated by reductions in the workforce and the major uptick in demand for behavioral health services. During the pandemic, increased partnership with the community-based workforce and people with lived experience along with telehealth flexibilities encouraged greater access to behavioral health care. Today, states are seeking to maintain some of these gains while continuing to address chronic workforce shortages. Federal support in describing the behavioral health workforce needed to increase access to evidence-based, culturally relevant interventions is key.
States are also eager to identify the right balance between increased access to behavioral health services via telehealth and ensuring quality and preserving choice. In addition, there has been a proliferation of consultative models (e.g., Pediatric Mental Health Care Access programs and Project ECHOs) that maximize access to licensed behavioral health professionals and link to support services on the ground. To ensure the continued success of these models, sustainable funding approaches are needed.
Overall, states indicate that workforce development and innovative use of technology are among their top priorities for improving behavioral health care. To help states address these gaps, states suggest that Congress consider the following actions:
- Expand broadband and telehealth access options with an emphasis on rural, frontier, and other underserved areas; facilitate Medicaid payment for phones, tablets, and related expenses for Medicaid enrollees to ensure connectivity; and support research on best practices for behavioral health care through telehealth.
- Study the optimal use of telehealth in increasing access to high quality, person-centered delivery of behavioral health interventions during the extension of flexibilities under the CAA to inform policies and investments through the HHS Office for the Advancement of Telehealth and other HHS efforts.
- Expand funding and eligibility for grants, scholarships, and federal student loan forgiveness and loan repayment program opportunities for behavioral health providers at all levels of training (including, where eligible, paraprofessionals such as peer recovery specialists/peer support providers and community health workers) in these programs.
- Permit a federal Medicaid match for workforce training programs, including programs focused on developing career paths for peers and community health workers.
- Consider developing a Medicaid workforce capacity planning grant and demonstration.
To collaborate with states in addressing workforce gaps, HHS could consider collecting, analyzing, and sharing data with states on behavioral health workforce needs and strategies based on modern, team-based care approaches (with a special focus on rural areas and diversity).
A Robust and Responsive Continuum of Care
In the past year, there has been growing interest in behavioral health crisis care as a result of the 988 Suicide & Crisis Lifeline, as well as Medicaid reimbursement for mobile crisis teams. Due to increased public attention, states are prioritizing enhancements to their behavioral health crisis continuum, increasing access to care for justice-involved populations with behavioral health conditions, and supporting veterans’ mental health and recovery from substance use disorders.
To help states with building a robust and responsive continuum of care, state policymakers suggest that Congress consider the following actions:
- Provide additional funding for the 988 Lifeline and Veterans Crisis Line, both through appropriations and in reauthorizing grants for related services such as crisis intervention teams and mental health courts.
- Invest in training emergency services dispatchers and crisis call center personnel to competently respond to behavioral health crises and provide these workers with mental health support to reduce burnout and turnover.
- Work with states to understand and address challenges around the 24/7 requirement in the American Rescue Plan’s mobile crisis option, invest in systems and supports to enhance rural behavioral health crisis systems, support states in developing multi-payer funding mechanisms for crisis response, and extend the 90-10 Medicaid match for mobile crisis teams beyond four years.
- Recognizing different needs for adults and children, youth, and families, provide guidance on designing and implementing child and family crisis interventions and ensure sustainable funding for children’s mobile crisis interventions.
- Build on recent federal policy to improve care coordination and transitions of care for people leaving institutional settings (such as Section 5121 of the Consolidated Appropriations Act of 2023 authorization of Medicaid and CHIP coverage of certain services for youth in public institutions 30 days before release and CMS’s approval of California’s 1115 demonstration waiver to provide Medicaid coverage of certain services 90 days before release).
- Provide planning and implementation grants to help state health and human services programs (including Medicaid) build data exchanges and shared processes with jails, prisons, and other related partners.
- Allow states to provide Medicaid coverage for justice-involved people (including eligible youth and adults) who have not yet been sentenced or for up to the first 90 days of a pre-trial stay in jail.
- Establish Medicaid state plan requirements that include behavioral health screening and referral services for youth in the juvenile justice system.
To support states in building a robust and responsive continuum of care, federal agency partners could consider the following action:
- Build on federal grant programs and Medicare investments in the crisis services by developing mechanisms to encourage commercial payers to contribute adequately to operating costs for 988 call centers across the United States and use existing federal statutory authority (e.g., the No Surprises Act and MHPAEA) to increase commercial health plan coverage of behavioral health crisis services.
The Opioid and Drug Overdose Epidemic
Before the COVID-19 pandemic, opioid and drug overdoses were increasing at an alarming rate. Unfortunately, in the aftermath of the pandemic, overdoses from opioids and other drugs have skyrocketed, and the increased presence of fentanyl, methamphetamine, and polysubstance abuse present additional layers of complexity for state strategies. States have few tools at their disposal to mitigate the opioid and drug overdose epidemic, especially in the context of the other pressing behavioral health challenges that they must address.
To help states mitigate the opioid and drug overdose epidemic, state policymakers have noted that Congress may consider the following actions:
- Repeal (i.e., make permanent the changes from the public health emergency to) the Ryan Haight Act provisions that inhibit use of telehealth for medications for opioid use disorders (MOUD).
- Bolster access to affordable, evidence-based opioid use disorder /substance use disorder (SUD) treatment for pregnant and parenting people through dedicated grant funding — building off lessons learned from the Center for Medicare and Medicaid Innovation (CMMI) Maternal Opioid Misuse model
Working across appropriate federal partners, federal agencies may consider the following actions to mitigate the substance use and overdose epidemic:
- Make permanent HHS and Drug Enforcement Administration flexibilities around buprenorphine and methadone to increase access to MOUD.
- Leverage SAMHSA’s existing regulatory authority to examine and eliminate non-evidence-based restrictions on the prescribing and dispensing of methadone under 42 CFR Part 8. SAMHSA, CMS, DOJ, and other agencies can also work with states to provide incentives for implementing models designed to expand methadone access and address barriers to access posed by network adequacy and restrictive regulatory and zoning restrictions at a state level.
- Establish an CMMI demonstration(s) around value-based purchasing strategies that incentivize treatment retention, use of evidence-based practices, and addressing racial and ethnic disparities in treatment of SUDs. One demonstration could be focused on pregnant and parenting people broadly focused on SUD (building on lessons from the Maternal Opioid Use Model demonstration).
- Expand collaboration between SAMHSA, CMS, and HRSA to provide guidance and technical assistance to states to expand access to SUD treatment for parents, highlighting best practices to reduce disruptions for the child, minimize increases in child welfare placements/costs, and maintain family continuity.
Conclusion
Building a sustainable, responsive, high quality behavioral health system requires federal, state, and local alignment. The imperative to do so in a coordinated and effectively resourced manner has been brought into sharp focus during the pandemic. As they create the conditions for long-needed, system transformation, federal policymakers can benefit from key insights from state officials who are seeking to create sustainable behavioral health safety nets in their states and strengthen connections with other public and private partners to address the full continuum of behavioral health needs for all their residents.
Appendix: How States Are Prioritizing Behavioral Health Parity
| State | Investment in Parity |
|---|---|
| CA | California has adopted the Jim Ramstad Model State Legislation to Advance Mental Health and Addiction Equity by Requiring Compliance with Generally Accepted Standards of Care via statute. This model legislation requires every insurance policy to provide coverage for medically necessary mental health and substance use disorder services in the same way that it covers hospital, medical, or surgical coverage. A key aspect of this legislation is that carriers cannot limit benefits or coverage for chronic mental health/SUD to short-term or acute settings. Also, medical necessity determinations must follow generally accepted standards of mental health/SUD care from clinical experts/peer-reviewed studies, and denials and appeals must be made by a professional with the same level of education as the provider requesting the authorization. Lastly, there are civil penalties for violations. |
| MA | In its sweeping Act Addressing Barriers to Care for Mental Health, Massachusetts has required its insurance commissioner to perform behavioral health parity market conduct examinations of each carrier every four years. The act also requires parity enforcement for commercial, state-contracted, and student health insurance plans; greater reporting and oversight of insurance carriers’ mental health care coverage processes and policies; and reasonable financial penalties and alternative remedies for when an insurance company does not comply with the law. |
| WA | The Washington state legislature passed E2SHB 1688 in its 2022 legislative session. The legislation protects consumers from charges for out-of-network health care services by addressing coverage of emergency services and aligning the Washington state Balance Billing Protection Act and the federal No Surprises Act (NSA). The legislation clarifies the role of behavioral health crisis services providers in meeting the needs of individuals enrolled in fully insured individual and group health plans when they experience a behavioral health emergency. Ultimately, the new legislation brings provisions related to emergency behavioral health services and providers into alignment with NSA and MHPAEA. |
| AZ, CT, CO, DC, DE, IN, KY, MA, MD, ME, MT, NJ, NV, NY OK, PA, TN, WV | Seventeen states and DC have adopted the “Six-Step” Parity Compliance Guide for Non-Quantitative Treatment Limitation (NQTL) Requirements via statute. This guide operationalizes guidance from DOL, HHS, and the U.S. Treasury and is a tool for regulators, health plans, and issuers to perform comparative analyses to determine if a plan or issuer follows the NQTL requirements (e.g., prior authorization and provider credentialing) specified in the MHPAEA. The guide requires a final, detailed summary that the processes and standards used to impose NQTL on mental health/SUD benefits are comparable to those of medical/surgical benefits. |
| LA, RI, TX | Three states have adopted the “Six-Step” Parity Compliance Guide for NQTL Requirements via regulation/administrative action. |
| IL, GA, OR | The most comprehensive behavioral health parity legislation has been enacted in Oregon, Georgia, and Illinois. These states have adopted both the Jim Ramstad Model State Legislation and the “Six-Step” Parity Compliance Guide for NQTL Requirements via statute. |
Further information about parity progress in states can be found on The Kennedy Forum’s website.
