NAMI believes innovation is vital to reduce disparities.
We’re fighting for:
- Integration of mental health and primary care to provide holistic treatment
- Telehealth services that increase access
- Research that improves our knowledge base
- Financing models that sustain effective, patient-centered care
NAMI believes improving mental health care is critical to achieve better outcomes.
We’re fighting for:
- Coordinated Specialty Care for First Episode Psychosis so that young people can experience recovery
- Expanded coverage with patient protections and parity in Medicaid, Medicare and commercial health insurance
- Mental health care for veterans so our service members get the help they need and deserve
- Increased use of mental health outcome measures to hold providers accountable
NAMI believes supporting recovery is fundamental to reduce injustices.
We’re fighting for:
- Supported housing that helps people get back on their feet and engaged in treatment
- Peer support services that help people know that recovery is possible
- Crisis response models that provide help, not handcuffs
Medicare, unlike Medicaid, is entirely funded by the federal government. It provides health coverage to older Americans and to adults with disabilities. Many older adults on Medicare have mental health conditions. In addition, there are millions of younger adults who are on Medicare because they have a psychiatric disability.
Medicare is made up of “parts” that cover different benefits:
- Part A: Hospital care, short-term skilled nursing, home health services, hospice
- Part B: Health care professionals, outpatient and preventive care, some medical equipment and supplies
- Part C: Medicare Advantage—an alternative coverage option that covers both part A and B benefits, and often includes part D prescription benefits
- Part D: Prescription drugs
What are the “6 protected classes” in Medicare Part D?
Medicare Part D provides drug coverage for 43 million seniors and adults with disabilities. Today, Part D plans must cover “all or substantially all” drugs in six classes, including:
- Anticonvulsants (often prescribed for epilepsy)
- Antineoplastics (prescribed for cancer)
- Antiretrovirals (prescribed for HIV/AIDS)
- Immunosuppressants (prescribed for transplants)
These six protected classes were created to ensure people with conditions treated by these medications are not discriminated against, as well as to ensure access to a range of options that meet individual needs.
What is CMS proposing to change?
CMS is proposing a number of changes to how Medicare pays for drugs. Of these proposals, NAMI is concerned that the following will negatively affect people with mental illness:
Medicare Advantage (Part C) changes
- Step therapy for Part B drugs
NAMI has a long-standing policy of opposing step therapy for mental health medications. The proposed rule would put into regulation what CMS already allowed in an Aug. 7, 2018 memo—allowing Medicare Advantage plans to implement step therapy for drugs covered under Part B.
What drugs are covered under Part B? Part B covers drugs that have to be administered intravenously, such as chemotherapy. One long-acting injectable (LAI) antipsychotic is also covered by Part B, while newer LAIs are covered under Part D.
Part D changes
- Prior authorization and step therapy in the six protected classes
CMS is proposing changes that would allow plans to use prior authorization and step therapy more widely in the six protected classes, even for people who are stable on their current medication. NAMI opposes this rule change, which would cause dangerous disruptions in treatment for millions of Medicare enrollees with mental illness.
- Restrictions on new formulations of drugs
The new rule would allow Part D plans to not cover new formulations of existing drugs, such as the long-acting injectable form of an antipsychotic or a new extended release formula. NAMI opposes this rule change, which would limit important innovations that make medications easier to take, better tolerated, or better tailored to a specific condition.
- Price increases above inflation
The new rule would allow plans, starting in January 2020, to exclude coverage of drugs, including “protected class” antipsychotics and antidepressants, if their wholesale acquisition cost (WAC) rose more quickly than general, not medical, inflation. General inflation generally rises more slowly than inflation for medical goods or services. This change could result in people not having access to needed medications and experience harmful disruption in their treatment.
Earlier this week, NAMI released a report, Mental Health Parity at Risk, that highlights how badly health insurance plans treated people with mental illness before the ACA. Join us on Wednesday, June 20 at 4 PM EDT to hear from Georgetown University researchers about what they learned in researching the report—and how recent Administration actions may jeopardize mental health coverage in your state.
The report reviewed barriers and gaps in insurance coverage for mental health and substance use services prior to the Affordable Care Act (ACA). The report found that, prior to the ACA:
- 28 states had no requirement that individual market health insurance plans cover or even offer mental health services;
- Health plans avoided enrolling individuals with mental health or substance use conditions by screening applicants;
- Even when individual market insurance was accessible, insurers effectively fined people with a history of mental health or substance use conditions by applying a 20–50% increase in premiums while also excluding needed mental health and substance use services; and
- Plans often used lifetime caps, limits on outpatient visits, limits on inpatient days covered, restricted access to mental health medications and high cost-sharing for mental health services.
While the Affordable Care Act (ACA) made mental health and substance use services an essential health benefit (EHB), there are new threats that would weaken protections in insurance coverage and hurt people with mental illness.
NAMI released a report, Mental Health Parity at Risk. The report, written by researchers at Georgetown University, highlights how badly health insurance plans treated people with mental illness before the Affordable Care Act (ACA). For the first time, comprehensive data has been gathered showing barriers and gaps in mental health and substance use coverage in the individual insurance market prior to the ACA. It highlights just how horrible things were for people with mental illness, and emphasizes the dangers of turning back the clock. You can learn more and read the report at nami.org/parityatrisk.
To discuss this report as well as other challenges we are facing, NAMI participated in a live event at Washington Post this morning. The event, Mental Health and Well-being in America, featured policymakers including Sens. Schatz and Tillis, health care experts including Dr. Josh Gordon, and others. To view this event, you can access it at https://www.facebook.com/washingtonpost/videos/10157823570822293/
Congress has been busy this month advancing several priority items before it adjourns for the November elections. Below is an update on the opioid package and the fiscal year (FY) 2019 budget, and the impact of both pieces of legislation on mental health.
Last week, the Senate passed opioid legislation with overwhelming bipartisan support. The Senate’s bill had several key differences from the version the House passed in June. The House and Senate have reconciled their respective versions of the bill, and, earlier today, the House voted to pass the new version of H.R. 6, the SUPPORT for Patients and Communities Act. We expect the Senate to vote on this bill next week and that the President will sign it into law.
Even though the House voted by an overwhelming bipartisan margin of 357-57 to modernize 42 CFR Part 2, which treats substance use information differently than other health information, this provision is not included in the final bill. NAMI believes that Congress cannot adequately address the opioid problem unless it aligns this outdated federal regulation with HIPAA, which protects health information for all other medical conditions.
By eliminating this provision, we continue a history of unequal treatment of substance use information that can result in tragic consequences for individuals in recovery. While we are disappointed, our work on this issue will not end. NAMI will continue to advocate in the future to make sure all health information is treated equally.
Fortunately, there are many provisions important to people with mental illness and co-occurring substance use conditions that are included in the bill, such as:
- Requiring state Medicaid programs to suspend—not terminate—a juvenile’s Medicaid eligibility while incarcerated;
- Expanding the use of telehealth services for substance use and co-occurring mental health conditions in Medicare;
- Requiring state Medicaid programs to report on behavioral health quality measures;
- Promoting incentives to help spur the use of electronic health records for behavioral health providers;
- Mandating loan repayment for substance use treatment professionals in mental health professional shortage areas; and
- Authorizing a pilot program to provide stable, temporary housing for individuals in recovery.
The bill also includes several changes to the IMD exclusion that are focused solely on the treatment of substance use disorders. NAMI will continue to advocate for changes that include people with mental health conditions.
FY 2019 Budget
Earlier this week, the House passed an $855.1 billion FY 2019 appropriations bill to avert an October government shutdown. The bill, already passed by the Senate, will fund the Departments of Defense, Labor, Health & Human Services (HHS) and Education for the fiscal year beginning October 1. It also includes a continuing resolution (CR) to extend current funding for agencies not included in the bill through December 7. The bill is now with the President, who has promised to sign it.
A smaller appropriations package was signed by the President on September 21 to fund several other agencies, including Veterans Affairs (VA).
Below is a summary of key provisions that impact people with mental illness and their families (increases noted below reflect additional funding over FY 2018 numbers):
Department of Health & Human Services (HHS)
National Institutes of Health (NIH)
NIH will receive $39.1B, a $2B increase, which includes:
- National Institute of Mental Health (NIMH): $1.812B, a $101M increase
- The BRAIN Initiative: $429.4M, a $29M increase
The BRAIN Initiative is a collaboration between 10 institutes at NIH, including NIMH.
- All of Us—the Precision Medicine Initiative: $376M, an $86M increase
Substance Abuse and Mental Health Services Administration (SAMHSA)
SAMHSA will receive $5.7B, a $584M increase, which includes:
- Community Mental Health Block Grant (MHBG): $722.6M (flat funding)
The MHBG includes a 10% set-aside to support evidence-based programs that provide treatment for first episode psychosis (FEP).
- Certified Community Behavioral Health Centers (CCBHCs): $150M, a $50M increase
This funding is for states that received previous CCBHC planning grants and brought their CMHCs up to the CCBHC standards but are not the 8 states in the Excellence in Mental Health Act Demo.
- Children’s Mental Health: $125M (flat funding)
- Primary Behavioral Health Integration: $49.9M (flat funding)
- Suicide Lifeline: $12M, a $4.8M increase
Department of Veterans Affairs (VA)
VA funding for mental health and suicide prevention programs includes:
- VA Mental Health and Suicide Prevention Programs: $8.6B, a $220M increase
- VA Medical and Prosthetic Research: $779M, a $57M increase
- Veterans Choice Program for FY 2019: $1.25B
The Veterans Choice Program allows veterans to receive treatment, including mental health services, in community provider settings. This program will need an additional $18.2B in funding for FY 2020 and FY 2021.
Funding for the Department of Housing and Urban Development and the Department of Justice is included in the continuing resolution.
We support efforts to make mental health treatments and services available to all Floridians, including supportive housing and employment. We also strongly encourage the Legislature to invest in efforts that increase public awareness around the signs and symptoms of mental illness and ways that Floridians can find help.