Medicare: CMS Should Provide Beneficiaries More Information about Substance Use Disorder Coverage
Released: 2020-05-21T00:00:00

Letter

Background

Medicare beneficiaries with behavioral health conditions have a diverse range of conditions, of different severity, requiring different types of care. Beneficiaries with mild behavioral health conditions—such as mild depression—may require less complex care than beneficiaries with serious behavioral health conditions—such as schizophrenia—or with multiple interacting behavioral or physical health conditions. Subpopulations of Medicare beneficiaries also may face different behavioral health challenges. For example, dual-eligible beneficiaries— individuals eligible for both Medicare and Medicaid—are three times more likely to have been diagnosed with a major psychiatric disorder than non- dual beneficiaries.

Medicare Services and Providers

Medicare covers services for the diagnosis and treatment of behavioral health conditions, which includes the inpatient care covered by Part A and the physician services and outpatient care covered by Part B. Key behavioral health services in Medicare Part B include visits with a physician or other covered provider, partial hospitalization program services, annual depression screening, alcohol misuse screening and counseling, psychotherapy, screening, brief intervention, and referral to treatment services, and behavioral health integration services.

Dual-eligible beneficiaries may be able to access additional behavioral health services through Medicaid that are not available through Medicare.

Medicare covers behavioral health services delivered by a range of providers, including psychiatrists and physicians, clinical psychologists, licensed clinical social workers (LCSW), nurse practitioners, physician assistants, and clinical nurse specialists.

In order to bill for services provided to Medicare beneficiaries, providers must enroll with CMS. Providers who do not want to enroll in the Medicare program may “opt out” of Medicare. Behavioral health providers have among the highest opt-out rates, with over 7,000 psychiatrists, psychologists, and LCSWs opting out of Medicare, representing nearly one-third of all providers who opted out of Medicare in 2017. Beneficiaries may still see these providers but must enter into a private contract with them. Medicare will not pay for any services furnished by providers who have opted out, so in these cases, beneficiaries must pay the provider’s entire charge out of pocket. According to researchers, psychiatrists have low participation rates across all forms of insurance, including Medicare, which may be explained, in part, by the reimbursement rates for time intensive treatments, low supply and high demand for psychiatry services, and high administrative burdens for solo practitioners to participate in insurance programs.

Provision of Information to Medicare Beneficiaries

CMS is required by law to provide information annually to Medicare beneficiaries about their coverage, including benefits and limitations on payment. Various factors affect how beneficiaries receive and process information about behavioral health conditions and their coverage options for behavioral health services. According to HHS, low health literacy is a key barrier that impacts individuals’ ability to comprehend health-related information. Moreover, researchers have found that low health literacy is associated with poor physical and mental health. More specific challenges facing individuals with behavioral health conditions include the stigma surrounding behavioral health conditions that may discourage individuals from seeking help or treatment. According to advocates for Medicare beneficiaries and individuals with behavioral health conditions, some individuals may have caregivers or other support for finding information and engaging in decision-making about their behavioral health care.

Medicare Advantage Plans

According to CMS, one-third (36 percent) of Medicare beneficiaries in 2019 were enrolled in MA plans, which CMS pays on a monthly capitated basis to deliver all covered services needed by an enrollee. MA plans contract with provider networks to deliver care to Medicare beneficiaries and must meet CMS’s network adequacy standards. MA plans may employ care management and utilization management strategies. Care management may include case managers or care coordinators who work with enrollees and providers to manage the care of complex or high-risk enrollees, including those with behavioral health conditions. According to the MA plan officials we interviewed, prior authorization—a utilization management strategy—may be employed for high-cost treatments. Officials from all five MA plans told us that they may have difficultly recruiting behavioral health providers to participate in their network. One study found access to psychiatrists to be more limited than any other physician specialty in MA plan networks, with 23 percent of psychiatrists in a county included in network on average, compared to 46 percent of physicians in a county across all physician specialties in 2015.

Nearly One in Seven Medicare Beneficiaries Used Behavioral Health Services in 2018; Most Services Were Provided by Psychiatrists, Social Workers, and Psychologists

Fourteen Percent of Medicare Beneficiaries Used Behavioral Health Services in 2018, Totaling More than $3 Billion in Spending

Our analysis of Medicare claims data shows that in 2018 approximately 5 million beneficiaries used behavioral health services through Medicare Part B. This represented about 14 percent of the more than 36 million fee- for-service (traditional) Medicare beneficiaries, and CMS paid providers about $3.3 billion for approximately 39.3 million behavioral health services in 2018. (See fig. 1.)

Our analysis of claims data also shows that among Medicare beneficiaries who used behavioral health services in 2018, utilization of the services varied significantly. (See fig. 2.)

The average number of services used by Medicare beneficiaries who used behavioral health services in 2018 was eight, while the median was three.

Nearly half of all such beneficiaries used between two and seven behavioral health services during the year.

Nearly one-third (30 percent) of beneficiaries using behavioral health services used one behavioral health service during the year.

The 11 percent of beneficiaries who were the highest behavioral health service users used 19 or more behavioral health services (the 90th percentile) during 2018, and accounted for about half of all Medicare expenditures on behavioral health services.

Our analysis also found that the services beneficiaries received largely fell into two broad categories in 2018: general patient consultations (53 percent of services) and psychiatry services, including psychotherapy (43 percent of services). Other services, such as central nervous system assessments and drugs administered by providers, accounted for about 5 percent of services.

Beneficiaries receiving behavioral health care were largely diagnosed with a condition in at least one of five diagnostic behavioral health conditions categories, each of which contain multiple specific diagnoses. In 2018, 96 percent of all behavioral health services were for a primary diagnosis within one of these five categories. For example, the mood disorder category, which includes diagnoses such as depression and bipolar disorder, accounted for 42 percent of services provided. (See fig. 3.)

Medicare claims data for 2018 show that some Medicare beneficiaries used behavioral health services to obtain treatment for SUDs. Seven percent of the behavioral health services in 2018 were for SUDs. Moreover, Medicare beneficiaries with SUDs represented 11 percent of beneficiaries using behavioral health services. On average, Medicare beneficiaries with SUDs used five behavioral health services in 2018, which is less than the number of behavioral health services used on average by all beneficiaries with a behavioral health diagnosis.

Overall, beneficiaries under age 65 and dual-eligible beneficiaries were disproportionately represented among users of behavioral health services compared to the Medicare population. (See fig. 4.) In 2018, while beneficiaries under age 65 constituted 16 percent of all Medicare beneficiaries, they represented 34 percent of the Medicare beneficiaries who used behavioral health services and accounted for 42 percent of all behavioral health services paid for by Medicare that year. Similarly, while dual-eligible beneficiaries, many of whom are under age 65, constituted 20 percent of all Medicare beneficiaries, they represented 39 percent of the Medicare beneficiaries who used behavioral health services in 2018 and accounted for 45 percent of all behavioral health services paid for by Medicare. Finally, women constituted about 55 percent of all Medicare beneficiaries in 2018 and represented 62 percent of the beneficiaries who used behavioral health services that year.

Two-Thirds of Behavioral Health Services Were Provided by Psychiatrists, Licensed Clinical Social Workers, and Psychologists in 2018

Our analysis of Medicare Part B claims shows that in 2018 two-thirds of behavioral health services (67 percent) were delivered to Medicare beneficiaries by behavioral health specialists: psychiatrists, psychologists, and licensed clinical social workers (LCSW). (See fig. 5.) Psychiatrists provided the most behavioral health services (31 percent), followed by LCSWs (19 percent), and psychologists (17 percent). A range of other providers delivered the remaining one-third of behavioral health services, including advanced practice providers (16 percent), primary care physicians (11 percent), other physicians (5 percent), and other providers (1 percent).

As figure 5 shows, beneficiaries who were relatively high users of behavioral health services received a greater share of services from behavioral health specialists compared to all Medicare beneficiaries who used behavioral health services. Approximately three-quarters of services (78 percent) provided to the highest service users (those in the 90th percentile with 19 or more services per year) were delivered by behavioral health specialists: psychiatrists (31 percent), LCSWs (25 percent), and psychologists (22 percent). However, this pattern did not hold for Medicare beneficiaries with SUDs. Our analysis showed that beneficiaries with SUDs received 20 percent of their behavioral health services from a behavioral health specialist, and the other 80 percent of services were delivered by providers who did not specialize in behavioral health.

See appendix I for additional information on Medicare behavioral health utilization.

CMS Uses Various Approaches to Provide Coverage Information to Beneficiaries, but Annual Mailing Does Not Include Explicit Information on SUD Treatment Coverage

CMS Uses Various Communication Approaches to Provide Information to Medicare Beneficiaries on Coverage for Behavioral Health Services

According to CMS officials, the agency’s overall strategy for providing information to beneficiaries about coverage of behavioral health services involves a variety of communication and outreach approaches. For example, CMS disseminates information to beneficiaries through written and online publications, Medicare.gov, scripted answers to questions through 1-800-MEDICARE, and social media.

CMS is required by law to provide information to beneficiaries about coverage under Medicare. CMS annually mails out the Medicare & You handbook to all beneficiaries, and according to CMS officials, it mailed the handbook to 42.6 million households in 2018. The information provided in the publication includes descriptions of benefits and services, a summary of cost sharing, and the types of providers Medicare covers. According to CMS officials, Medicare.gov also includes information about covered benefits and a provider directory, although some may not be accepting new Medicare patients. According to CMS officials, the most comprehensive source of information on coverage for behavioral health services is contained in the publication Medicare & Your Mental Health Benefits, which is also available at Medicare.gov.

We obtained statistics from CMS officials on the frequency with which Medicare beneficiaries requested copies of Medicare & You or the agency’s other publications or accessed the agency’s web-based tools to obtain information on Medicare coverage, including coverage for behavioral health services. The most frequently accessed in 2018 were Medicare & You, Medicare.gov, and the “What’s Covered?” smartphone application. (See table 1.) These sources of information cover Medicare more broadly and provide information about Medicare benefits in general, rather than those dealing specifically with behavioral health.

Like CMS, MA plans use different approaches to provide information to the beneficiaries enrolled in MA plans, including publications, phone calls, and websites. According to officials from the five MA plans in our review, MA plans use multiple modes of communication to meet the preferences of their enrolled populations. MA plans are required to provide information to each enrollee at the time of enrollment and annually thereafter; for example, MA plans must share information about providers reasonably available to enrollees. MA plans are also required to provide marketing materials to CMS for review to ensure the adequacy and accuracy of the information in the materials. Two of the MA plans in our review offer digital health tools to their enrollees. One plan offers a tool that allows enrollees to communicate with case managers, and another plan provides enrollees access to test results, the ability to refill prescriptions and schedule appointments, as well as resources for patient education.

According to CMS officials, the agency also uses other strategies for providing information to beneficiaries about coverage of behavioral health benefits. CMS officials stated that it partners with stakeholders to assist beneficiaries and caregivers seeking help with behavioral health conditions. For example, CMS officials described webinars and workshops it conducts to educate partners and stakeholders who educate and counsel Medicare beneficiaries. According to agency officials, the webinars cover a range of topics related to Medicare benefits and coverage, including behavioral health. The officials also told us that CMS partners with state health insurance programs to provide information about Medicare, including information to help Medicare beneficiaries understand their coverage. CMS officials also stated that the agency conducts public awareness and outreach campaigns to provide information to beneficiaries.

CMS’s Annual Mailing to Beneficiaries Does Not Include Explicit Information on Medicare Coverage for SUD Treatment

Medicare & You—the most widely disseminated source of information on Medicare benefits and coverage—does not provide explicit information about coverage of services for beneficiaries with SUDs, although HHS and CMS have identified addressing SUDs as a top priority. We reviewed the fall 2019 edition of the Medicare & You publication and found that, while it does provide information on Medicare coverage for behavioral health services, it does not contain an explicit description of the services that may be covered for treatment of SUDs. CMS officials noted that printing the almost 43 million hard copies of the fall 2019 edition of Medicare & You started in July 2019, several months before the rule implementing expanded OUD coverage under Medicare was finalized. In December 2019, CMS officials updated the 2020 edition of Medicare & You to include information on the expanded OUD treatment authorized by the SUPPORT Act, which were finalized in November 2019, and became effective in January 2020. According to CMS officials, as of December 2019, this updated version was available on Medicare.gov, and CMS officials told us it will be sent to all individuals who become eligible for Medicare throughout calendar year 2020. We reviewed the updated 2020 web version of Medicare & You and found that a reference to opioid treatment was included; however, explicit information about Medicare’s coverage for other SUDs was not added.

Although information on Medicare’s coverage for treating OUD is important, OUD represents only a subset of the SUDs for which Medicare beneficiaries may need treatment. Further, several of the advocates we interviewed noted that Medicare beneficiaries would benefit from clearer and more specific information about SUD coverage. According to data from SAMSHA, about one in 10 SUD cases is related to an OUD, while the rest are related to non-opioid substances.

We asked CMS officials why the additions to Medicare & You relate only to OUDs, and they explained that it is the only distinct Medicare benefit category for substance abuse treatment. Officials also stated that while there is no category in Medicare & You for other SUDs specifically, the publication does note some related benefits, such as for counseling and services for behavioral issues, alcohol misuse screening, and behavioral health integrative services. However, the alcohol misuse screening benefit is specifically for beneficiaries who do not meet the criteria for alcohol dependency and covers brief counseling in a primary care setting. The description of behavioral health does not specify that SUDs are a behavioral health condition.

The absence of information on Medicare’s coverage for SUDs in Medicare & You is inconsistent with HHS and CMS strategic priorities related to treatment for SUDs. The Department of Health and Human Services’ Fiscal Year 2018-2022 Strategic Plan includes among its strategic objectives reducing the impact of SUDs through treatment. Additionally, CMS has made addressing SUDs a top priority and has a stated commitment to treat SUDs, including OUDs. Beneficiaries lacking information on coverage of SUDs may be less likely to seek treatment.

Conclusions

HHS and CMS have made addressing SUDs a priority. However, in its most widely disseminated publication on Medicare coverage and benefits, CMS does not provide explicit information about the program’s coverage for SUD treatment services. As a result, beneficiaries with SUDs may not be aware of this coverage and may not seek needed treatment.

Recommendation for Executive Action

We are making the following recommendation to CMS: The Administrator of CMS should ensure that the Medicare & You publication includes explicit information on the services covered by the Medicare program for beneficiaries with a SUD. (Recommendation 1)

Agency Comments and our Evaluation

We provided a draft of this report to HHS for review. HHS concurred with our recommendation, and provided written comments that are reproduced in app. II, and technical comments, which we have incorporated as appropriate. In its written comments, HHS stated it would explore opportunities to modify the Medicare & You handbook to ensure beneficiaries with substance use disorders are aware of the services covered by Medicare. HHS also reiterated some of the situations under which substance use disorder may be covered under Medicare, as well as its communication strategies and tools to ensure that beneficiaries and providers are aware of all of the services available under Medicare.

We are sending copies of this report to the appropriate congressional committees, the Secretary of Health and Human Services, the Administrator of CMS, and other interested parties. In addition, the report will be available at no charge on GAO’s website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at CosgroveJ@gao.gov. Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix III.

Appendix I: Additional Tables on Behavioral Health Utilization among Medicare Beneficiaries, 2018

To produce the tables below describing the utilization of behavioral health services by Medicare beneficiaries and the providers furnishing these services, we analyzed the 2018 Medicare Part B claims file, the most recent data available at the time of analysis. Our analysis only includes Medicare beneficiaries in fee-for-service Medicare because similar reliable information was not available for beneficiaries enrolled in Medicare Advantage.

Appendix II: Comments from the Department of Health and Human Services

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact

Acknowledgments

In addition to the contact named above, Lori Achman (Assistant Director), N. Rotimi Adebonojo (Analyst in Charge), Todd Anderson, Sauravi Chakrabarty, Kelly Krinn, Rich Lipinski, Drew Long, Diona Martyn, Vikki Porter, and Caitlin Scoville made key contributions to this report.