Lawmakers pressing CMS to expand substance abuse disorder coverage and close key gaps in care

Several lawmakers are pressing the Centers for Medicare & Medicaid Services (CMS) to expand Medicare’s coverage of substance abuse disorder to address key gaps exacerbating the addiction crisis.

Rep. Lauren Underwood, D-Illinois, and Sen. Dick Durbin, D-Illinois, wrote a letter to CMS Administrator Chiquita Brooks-LaSure (PDF) earlier this week calling out CMS to use new funding and existing authority to expand Medicare coverage. The letter comes amid rising rates of addiction deaths exacerbated in part by the pandemic.

“It is essential that CMS acts swiftly and comprehensively to ensure older adults in our communities have access to the substance use disorder treatments they need and deserve,” the letter said. 

While Medicare does cover low-intensive levels of substance use disorder like therapy and high levels of care such as inpatient treatment, experts and advocates worry that CMS does not cover the full continuum of care for beneficiaries. 

“By forcing people to wait until their conditions become acute enough to need inpatient hospital care, we are doing them a disservice,” Deborah Steinberg, a health policy attorney with the Legal Action Center, told Fierce Healthcare. “We are forcing them to wait until things get worse when they shouldn’t have to.”

Durbin and Underwood called on CMS to expand Medicare coverage of residential substance use treatment services.

“These programs offer high-quality substance use disorder treatments that are appropriately matched to a patient’s individual needs,” the letter said. 

The lawmakers pointed to a study released earlier this year that found 1.7 million Medicare beneficiaries had a substance use disorder in the past year. 

That study found that of those beneficiaries, only 11% of them got treatment via Medicare. The most common reason was a lack of motivation (44%) followed by financial barriers at 33%. 

Nearly a quarter of respondents (24%) cited logistical barriers such as a dearth of transportation options.

Addiction deaths have also spiked since the start of the COVID-19 pandemic. The Centers for Disease Control and Prevention reported that a record-breaking 92,000 people died in 2020 due to a drug overdose.

Experts say another key issue is the reimbursement rates and licensure barriers for substance abuse treatment providers.

“There are a fair number of restrictions on who can deliver that treatment,” said Shawn Ryan, chair of legislative advocacy for the American Society of Addiction Medicine, told Fierce Healthcare. “We don’t have nearly enough folks who have the right licensure.”

A funding package passed earlier this year gave the Substance Abuse and Mental Health Services Administration (SAMHSA) $6.5 billion to address the issue. The funding included $50 million to CMS to combat “emerging health challenges,” the letter said.

“We urge you to use your existing authorities and the funding you have received from Congress to strengthen initiatives that will help people prevent and treat substance use disorders among Medicare beneficiaries,” the lawmakers added.

However, experts say the $50 million and block grants from SAMHSA can help, but more permanent fixes are needed. 

“We are not going to be able to truly integrate care if we don’t ensure it is truly being sustainably funded through insurance rather than these block grants,” said Steinberg. 

CMS told Fierce Healthcare that it is working to address the substance use disorder issue. The agency said it has developed a new behavioral health strategy. 

The Department of Health and Human Services also recently announced a new funding effort to expand the number of behavioral health clinics.