Recommendations on Coverage of Mental Health and Substance Use Disorder Services in the Essential

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Coalition for Whole Health

Recommendations on Coverage of Mental Health and Substance Use Disorder Services in the Essential

Health Benefit Package

In 2010, Congress enacted the Affordable Care Act (ACA), which will substantially expand health insurance

coverage for Americans, largely through state health insurance Exchanges for individuals and small businesses,

and through an expansion of Medicaid for low-income individuals and families. ACA requires the plans in the

Exchanges, as well as Medicaid expansion plans, to cover a set of “essential health benefits” that include

“mental health and substance use disorder [MH/SUD] services, including behavioral health treatment.” By

including MH/SUD as essential services, Congress recognized that substance use disorders and mental

illnesses are preventable, treatable health conditions, as accepted by the American Medical Association, all

other public health and medical standards, and decades of scientific research.

A well designed Essential Health Benefits package that includes sufficient coverage for mental health and

substance use disorders for children, youth and adults is central to efforts to ensure that health reform meets its

potential to allow individuals and families to recover from these diseases, improve health, and bend the cost

curve. The Coalition for Whole Health, a coalition of national organizations advocating for improved coverage

for and access to mental health and substance use disorder prevention, treatment, rehabilitation, and recovery

services, recommends full inclusion of mental health and substance use disorder services within the Essential

Health Benefits framework. This includes incorporating MH/SUD services in each of the Essential Health

Benefits categories, as appropriate, in addition to the mental health and substance use disorder services

category per se.

The ACA creates broad health care service categories that must be covered by certain health plans. The ACA

defines these Essential Health Benefits in ten general categories:

· mental health and substance use disorder services, including behavioral health treatment

· laboratory services

· emergency services

· hospitalization

· prescription drugs

· maternity and newborn care

· pediatric services

· rehabilitative and habilitative services and devices

· preventive and wellness services and chronic disease management

· ambulatory patient services

For an addiction and mental health system to be accessible, accountable, efficient, equitable and of high quality,i

the Coalition for Whole Health (“the Coalition”) believes that the Essential Health Benefits package covered by

both qualified health plans operating in state Exchanges and by Medicaid expansion plans must include, at a

minimum, the benefits detailed in this document. These recommendations are based on evidence based

practices to sustain addiction and mental health recovery – regardless of the setting. A list of Coalition for

Whole Health members who have endorsed this paper is attached.


Nearly one-third of adults and one-fifth of children had a diagnosable substance use or mental health problem in

the last year.ii Individuals with severe addiction and co-occurring mental illness, a significant percentage of

those with substance use or mental health problems, die prematurely–on average, 37 years sooner than

Americans without severe addiction and mental health problems.iii A recent study found that people with

serious mental illness die 25 years sooner than the general population from common medical conditions such as

cancer and heart disease.iv Individuals with severe mental health and severe substance use disorders not only

have greater mortality rates, but their health care costs throughout their lives are substantially higher, primarily

due to preventable emergency department visits and hospital admissions and readmissions. Appropriate

mental health and substance use disorder services will decrease costs in the medical system and lengthen the

lifespan of millions of Americans with these illnesses. In 2007, the Agency for Healthcare Research and Quality

found that nearly 13 percent, or one of every eight emergency department visits are related to a mental health or

substance use disorder.v Several states have found that providing adequate mental health/addiction treatment

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benefits stops the escalation in health care costs and reduces Medicaid spending. For example, Washington

State found that one year after providing a full addiction treatment benefit, $398 per member per month savings

were achieved in overall Medicaid However, in 2009, 23.5 million Americans needed treatment for

an illicit drug or alcohol problem, but only 4.3 million people received treatment – leaving a gap of 19.2 million

Americans who needed treatment for a substance use disorder but did not receive it.vii In addition, only 4.1

million of the 9.8 million Americans who needed treatment for a serious mental illness received it.viii

The costs associated with untreated mental health/addictive disorders also affect private payers. In 2006,

Robinson and Reiter estimated that more than two thirds of primary care visits are related to psycho-social

reasons.ix Even after controlling for a number of chronic co-morbid diseases, depressed patients covered by

private insurance had significantly higher costs than non-depressed patients across 11 chronic co-morbid

diseases. The costs associated with alcohol or drug-related hospitals stays are staggering – an estimated $12

billion in 2006 alone. In addition, it has been shown that the children of drug or alcohol addicted people have

higher medical expenses than children of non-addicted parents. Depression is one the of costliest health issues

for U.S employers, estimated to cost $44 billion annually. Untreated alcohol and drug problems are the number

one cause of disability claims and cause significant absenteeism and presenteeism. Total annual economic

costs for untreated alcohol and drug abuse total approximately $327 billion.x This does not include the increased

stress-related or trauma-caused medical costs for family members living with an active alcoholic or drug abusing


When substance use and mental health conditions are addressed and treated as the preventable, treatable

chronic diseases they are, systems reap substantial cost savings while dramatically improving health. Inclusion

of prevention, treatment and recovery of mental illness and substance use disorders through the ACA’s

Essential Health Benefits package will reduce health costs and ensure that millions of people lead healthier

lives, thereby strengthening individuals, families, communities, and our nation as a whole.

The Affordable Care Act, the Mental Health Parity and Addiction Equity Act, and Additional Provisions to

Ensure Good Access to Care

With passage in 2008 of the federal “Paul Wellstone and Pete Domenici Mental Health Parity and Addiction

Equity Act” (MHPAEA), Congress sought to end the long history of insurance discrimination against those with

MH/SUD that has prevented so many individuals from receiving the clinically appropriate type, level and amount

of care needed to get and stay well. MHPAEA precludes group health plans from providing MH/SUD benefits in

a more restrictive way than other medical and surgical benefits. The Affordable Care Act extends MHPAEA’s

requirements to qualified health plans in the state-based health insurance Exchanges and Medicaid benchmark

coverage offered under the Medicaid expansion. Plans may use cost containment techniques but must manage

MH/SUD benefits comparably with the way they manage other medical conditions. Final MHPAEA regulations

implementing parity in Medicaid managed care plans and clarifying what plans’ scope of services are, and what

their non-quantitative treatment limitations obligations are, must be fully implemented. To ensure that the

MH/SUD provisions of the ACA are implemented well, MHPAEA must first be fully implemented. A fully

operationalized MHPAEA must serve as the fundamental building block on which the MH/SUD essential health

benefit provisions in the Affordable Care Act are built. Without this non-discriminatory “floor,” meaningful access

to MH/SUD benefits will not be achieved.

As the Essential Health Benefits package is implemented, the Coalition also believes it must be affirmed that

State laws which provide better coverage, rights, methods of access to health care services and consumer

protections from the standpoint of the insured are not preempted by the Affordable Care Act. This is consistent

with Section 1321(d) in the ACA that makes clear that State laws will not be superseded by the new federal law.

We also support the other consumer protections in the law intended to ensure comprehensive access for

covered individuals to all essential services outlined in the Essential Health Benefits package. In particular, we

strongly support the requirement in the law that the Secretary shall “ensure that health benefits established as

essential not be subject to denial to individuals against their wishes on the basis of the individuals’ age or

expected length of life or of the individuals’ present or predicted disability, degree of medical dependency, or

quality of life.”xi These protections have very significant implications for individuals with mental health and/or

substance use disorders and health and mental health consequences for their family members, and we ask that

enforcement of these protections be included among the highest priorities for implementation and ongoing

administration of essential health coverage and other health plan requirements.

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Proposed Components of Comprehensive Coverage of MH/SUD in the Essential Health Benefits


The recommended MH/SUD benefits delineated below are based in part on a review of existing employer plans,

because the ACA requires the essential health package to reflect those covered in a “typical employer plan.” At

the same time, however, because final MHPAEA regulations have not been issued, and enforcement of existing

regulations has been limited, the parity-based services required under ACA are not yet reflected in the current

insurance market. Therefore, this list also draws on evidence-based and best practice approaches to

habilitative and rehabilitative services for individuals and families who have MH/SUD as well as employer

surveys done by the National Business Group on Health and the Kaiser Family Foundation.xii.xiii Like for other

chronic illnesses, the Coalition recommends an array of services to meet the needs of plan participants at all

stages of the continuum of their MH/SUDs, from mild to severe impairment. Clearly, some services will be

necessary for only the severely mentally ill and addicted, while other services will meet the needs of those with

mild to moderate MH/SUD.

Under the ACA, MH/SUD treatment must be sufficient to provide medically necessary care. Plans must be

required to provide transparent definitions of medical necessity for mental health, substance use disorder and

other medical conditions so that parity compliance can be measured. To date, the National Quality Forum has

developed the most comprehensive quality standards for treatment of SUD.xiv Based on these extensively

researched standards and others, the following represents the specific components of comprehensive MH/SUD

coverage, which can be delivered in a range of settings, that the Coalition for Whole Health recommends be

required as essential health benefits:

Mental Health and Substance Use Disorders, Including Behavioral Health Treatment

Assessment: For those assessed as needing MH/SUD services, individualized assessment tools must drive

the quality of care. Targeted MH/SUD services must be included in a distinct treatment plan and the beneficiary

must be involved in the treatment planning process. The Coalition for Whole Health supports provisions that

require the use of standardized assessment tools under the ACA. Standardized screening and assessment

tools, such as the Patient Health Questionnaire for one example, will allow clinicians to identify symptoms and

problems and determine the specific interventions that will best treat an individual’s presenting symptoms.

Standardized assessment tools should include:

· Assessment of health including a comprehensive bio-psychosocial assessment of related mental

health and substance use issues, and of needs and strengths that can be used to help individuals

attain their treatment, other service and support goals

· Ongoing mental health and substance use disorder assessments using evidence-based

assessment tools

· Specialized evaluations including psychological and neurological testing

· Diagnostic assessments of MH/SUD in general medical settings, including education and

counseling for mild MH/SUD

Patient Placement Criteria: Today, evidence-based patient placement criteria can help to effectively place

individuals into the optimal level of MH/SUD care for the amount of time that is deemed medically necessary.

For example, the Patient Placement Criteria for the Treatment of Substance-Related Disorders– Second

Edition, Revised (PPC-2R) of the American Society of Addiction Medicine (ASAM) is a widely used tool by which

practical and clinical determination of substance use levels of care can be measured; ASAM criteria are

currently used in some form in 30 states and have been adopted by a wide range of commercial payers and

providers.xv Similar mental health patient placement tools exist, such as Locus. In addition, the Substance

Abuse and Mental Health Services Administration is working with ASAM to develop the Recovery Support

Services Assessment Tool which will be a useful tool in assessing recovery support needs. More work is

needed to further develop these tools for operational use. Where available, patient placement criteria should be

used for the placement of patients in the appropriate level of care. As a result of MHPAEA and ACA, medically

necessary care cannot be subject to annual or lifetime benefit caps, nor can there be arbitrary limits on MH/SUD

that are not imposed on other medical conditions. The effects of MH/SUD treatment are optimized when

patients receive ongoing recovery supports and information on managing their own illness, and best outcomes

occur when individual patients are matched with appropriate levels of care.xvi

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Outpatient Treatment: As the parity provisions of the ACA require, outpatient treatment services are to be

provided as long as medically necessary with no limits on duration or frequency and patients must be allowed to

access treatment to manage relapses, as is the case with other chronic conditions. The totality of substantiated

interventions that offer promise for treatment resistant cases must also be covered in the essential health benefit

package. Outpatient treatment services should include evidence-based:

· Individual, group, and family therapies

· Devices and technology interventions for mental health and addictive disorders

· General and specialized outpatient medical services

· Consultation to caregivers and other involved collateral contacts, such as school teachers, in

accordance with confidentiality requirements

· Evidence-based complementary medicine services, comparable to complementary medicine

services covered for other health conditionsxvii

· Monitoring services, comparable to those provided to determine compliance with the treatment

regimens for other health conditions

Intensive Outpatient Services: Intensive outpatient and partial hospital programs are ambulatory time-limited

treatment programs which offer therapeutically intensive, coordinated, and structured group-oriented clinical

services as either a step down or alternative to inpatient acute services for both MH and SUD populations.

These services stabilize acute crises and clinical conditions, utilizing recovery principles to help return

individuals to less intensive outpatient, case management, peer support, and /or other recovery based services.

Coverage of these services is an integral part of most private MH/SUD benefit packages.

Intensive outpatient covered benefits should include:

· Substance use intensive outpatient treatment

· Mental health intensive outpatient treatment

· Partial hospitalization

· Dual-diagnosis partial hospitalization and intensive outpatient services for persons with co-occurring

MH and SUD conditions

· Intensive case management for MH/SUD

Residential Services: Residential MH/SUD services are a key component of an optimally-functioning service

delivery continuum and help offset the costs associated with emergency department visits, hospital admissions

and readmissions.xviii In 2008, approximately 2 million adults received inpatient or residential care for mental

health problems.xix According to SAMHSA’s 2009 National Survey of Substance Abuse Treatment Services (NSSATS),

as of 2009, 13,513 substance abuse treatment facilities provided medication, counseling, behavioral

therapy, case management, and other types of services to persons with substance use disorders. Of these

13,513 facilities, 4,317 provided inpatient services. Of the 4,317 facilities providing inpatient services, 3,520 or

81.5% were non-hospital residential treatment facilities, and merely 797 or 18.5% were hospital-based treatment

providers. The National Survey shows that during 2009, of the 117,515 individuals who obtained inpatient

substance abuse treatment, 103,174 or 87.8% received inpatient treatment in a residential, non-hospital facility,

and merely 14,341 or 12.2% received inpatient treatment in a hospital setting.xx

Coverage of medical residential services is also common in most heath plans. Milliman, Inc found that most

health plans have analogous levels of care with MH/SUD residential services including orthopedic, stroke and

cardiac rehabilitative services in non-hospital settings.xxi

Placement in a residential or inpatient setting—as with placement at all levels of MH and SUD care across the

continuum—should be based on the individual needs of the patient. Patients should be regularly assessed to

ensure that they are at all times placed within the appropriate treatment setting for the appropriate duration,

receiving the appropriate level of care befitting their needs and the severity of their illness. To the greatest

extent possible the use of uniform patient placement criteria should drive placement decisions.

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Residential treatment is an essential part of this treatment continuum. ASAM and other professional

organizations define residential treatment as occurring 24 hours a day, in a live-in setting that is either housed in

or affiliated with a permanent facility. While there are several types of residential programs of varying intensity, a

defining characteristic of all residential programs is that they serve “individuals who require safe and stable living

environments in order to develop their recovery skills.” The services provided are organized and staffed by

addiction and mental health personnel who provide a planned regimen of care, and generally include medical

and social services needed by the patient population. Analogous residential treatment modalities for other

medical conditions include stroke rehabilitation, spinal cord injury rehabilitation, traumatic brain injury

rehabilitation, and orthopedic rehabilitation.xxii Covered benefits should include:

· Residential crisis stabilization

· Detoxification in clinically-managed non-hospital residential treatment facilities for SUD care,

including the use of medication-assisted withdrawal management services

· Mental health residential for adults and youth

· Substance use disorder residential, including the use of medication-assisted treatment, for adults

and youthxxiii

· Dual-diagnosis residential services for adults and youth with co-occurring MH and SUD conditions

· Clinically managed 24-hour care

· Clinically managed medium intensity care

· Inpatient psychiatric hospital

· Inpatient mental health and substance use disorder care

· Inpatient hospital dual-diagnosis care for youth and adults with co-occurring MH and SUD


Laboratory Services

While the use of laboratory tests at all levels of care (hospital, residential, outpatient) is clearly indicated to

identify potentially co-occurring general medical conditions, or general medical complications of treatments for

MH/SUD conditions, evidence-based medical care for persons with MH/SUD conditions requires the ability to

offer integrated general medical and MH/SUD care. The Essential Health Benefit should include coverage for

laboratory tests whether offered by MH/SUD specialists, general medical professionals such as primary care

providers, or persons in non-behavioral, non-primary care medical/surgical specialties.

· Laboratory services, including drug testing

Emergency Services

· Crisis services in both MH/SUD and medical settings, including 24 hour crisis stabilization and

mobile crisis services, including those provided by peers

· 24/7 crisis warm and hotline services

· Hospital-based detoxification services

Prescription Drugs

Pharmacotherapy and Medication-Assisted Treatment: Medications approved for mental illness, alcohol,

drug and tobacco treatment are proven to be effective and must be a covered essential health benefit. All FDA

approved medications should be covered for SUDs and matched to the assessed individuals’ clinical need and

personal preference. The full continuum of FDA approved medications for MH/SUD must be covered and parity

in access to medications prescribed for the treatment of mental health and substance use disorders must be

enforced. Coverage should be continued as long as medically necessary with no limits. Medication services

should include:

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· Medication management

· Medication administration

· Pharmacotherapy (including medication-assisted treatment)

· Home-based, mobile device or internet-based medication adherence services

· Assessment for medication side effects

· Appropriate wellness regimens for consumers who are experiencing metabolic effects as a result of

their medication

Rehabilitative and Habilitative Services and Devices

The history of insurance discrimination in MH/SUD benefits has been a major barrier for individuals to access

the type and amount of care they need. Individuals with histories of untreated chronic conditions, including

MH/SUD, may have complex and varied health problems that will need to be addressed to help them to get and

stay well.

Case management has been identified by both medical and behavioral health authorities as an effective service

for improving health outcomes among people with chronic medical, mental health and substance use disorder

conditions.xxiv Comprehensive case management secures access to and retention in services, promoting

compliance with recommended treatment protocols throughout an episode of care. For patients with severe

substance use and mental health conditions, multiple co-morbidities and for patients who are resistant to

medically necessary treatment, case management services are necessary to promote participation in treatment

of sufficient intensity and duration to address underlying illness. Case management also supports successful

transitions between more structured care (i.e., residential, partial hospitalization, detoxification services) and

less structured care (i.e., outpatient) and addresses practical barriers to participation that impede clinical

progress. These effective strategies to improve health outcomes through care management and coordination

are consistent with those in the ACA that seek to reduce costs and improve chronic disease care.

Rehabilitative Services: The following rehabilitative services should be covered:

· Psychiatric rehabilitation services

· Behavioral management

· Comprehensive case management in physical health or MH/SUD settings which should include

individualized service planning with periodic review to address changing needs, treatment matching,

navigation between all needed services, communication between all service providers, enrollment in

Medicaid/insurance, and support to maintain continued eligibility

· Assertive Community Treatment (ACT) Teams

· Peer provided telephonic and internet based recovery support services, including those delivered by

recovery community centers

· Recovery supports, including those delivered by peer run mental health organizations

· Skills development including supported employment services

Recovery supports: Twenty-three states provide Medicaid reimbursement for peer-delivered mental health

and/or addiction recovery support services.xxv Ongoing recovery supports for at least one year following an

active phase of treatment have treatment has been shown to improve and sustain treatment and health

outcomes for individuals with substance use disorders.xxvi Recovery supports have also been shown to be an

effective engagement tool prior to and during treatment. A June 2008 study of Texas drug court participants

who received recovery support services found that “among the specific types of recovery support services,

those that were most closely related to the process of recovery such as individual recovery coaching, recovery

support group, relapse prevention group and spiritual support group, were more strongly associated with

successful outcomes.”xxvii

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For other individuals, recovery supports are their preferred method of self-managing addiction and mental health

issues. Recovery support coaching (both clinical and non-clinical) serves as a strengths-based method for

individuals to achieve health and wellness goals. Telephonic recovery support services (provided through

recovery support centers) have been shown to improve health outcomes and sustain recovery one year

following treatment.xxviii Certain interactive communication technology devices should be covered if the

interactive device aids in sustaining a beneficiary’s recovery. Recovery support services should include:

· Peer provided recovery support services for addiction and mental health conditions

· Recovery and wellness coaching

· Recovery community support center services

· Support services for self-directed care

· Community Support Programs and other continuing care for mental health and substance use


Habilitative Services should include:

· Personal care services

· Respite care services for caregivers

· Transportation to health services

· Education and counseling on the use of interactive communication technology devices

Preventive and Wellness Services and Chronic Disease Management

According to National Institute of Mental Health research, 50 percent of all lifetime mental health and substance

use disorders start by age 14. Yet, because the early signs of a mental health disorder or substance use

disorder often are missed, diagnosis regularly occurs 10 years or more after the onset of symptoms and the

disease is then allowed to progress. In addition, children who first smoke marijuana under the age of 14 are

more than five times as likely to abuse drugs as adults than those who first use marijuana at age 18.3.xxix

Furthermore, adolescents who begin drinking before the age of 15 are four times more likely to develop alcohol

dependence, whereas each additional year of delayed drinking onset reduces the probability of alcohol

dependence by It is therefore critical that health-related school, community wide and workplace health

promotion initiatives include a specific and discrete emphasis on substance use/abuse prevention and mental

health promotion.

The ACA places a mandatory requirement on all group health plans and health insurance issuers offering group

or individual health insurance to offer, without cost-sharing, a minimum level of preventive health services,

including services that have a rating of A or B by the United States Preventive Services Task Force (USPSTF).

These mandatory USPSTF recommendations include depression screening for adults and youth age 12 to 18,

alcohol screening and counseling and tobacco screening and cessation interventions for adults. These and

other preventive services, such as drug screening and counseling, are a critical component of prevention and

should be included in the preventive and wellness services and chronic disease management Essential Health

Benefit because approximately four million Americans have both a serious mental illness and a substance use

disorder.xxxi Health promotion is also a significant part of comprehensive prevention and wellness plans and

should be included in the preventive and wellness services and chronic disease management Essential Health

Benefit. Services identified in the Preventive, Wellness and Chronic Disease Management Essential Health

Benefits category should include:

· Screening (including screening for depression, alcohol, drugs, and tobacco), brief interventions

(including motivational interviewing) and facilitated referrals to treatment

· General health screenings, tests and immunizations

· Appropriate MH/SUD related educational programs for consumers, families and caretakers,

including programs related to tobacco cessation, the impact of alcohol and drug problems,

depression and anxiety symptoms and management, and stress management and reduction, and

referral for counseling or support as needed

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· Caretaker education and support services, including non-clinical peer-based services, that engage,

educate and offer support to individuals, their family members, and caregivers to gain access to

needed services and navigate the system

· Health coaching, including peer specialist services, provided in person or through telehealth, e-mail,

telephonic, or other appropriate communication methods

· Health promotion, including substance use prevention and services that impact well-being and

health-related quality of life

· Wellness programming for youth, including student assistance programming

· Services for children, including therapeutic foster care

· Interventions aimed at facilitating compliance with treatment and improving management of physical

health conditions

· Care coordination (including linkages to other systems, recovery check-ups, linkages to peer

specialists, recovery coaches, or support services based on self-directed care)

· Relapse prevention, including non-clinical peer-based services, to prevent future symptoms of and

promote recovery strategies for mental and substance use disorders.

For these preventive services to have the greatest impact on community health and health care cost

efficiencies, beneficiaries should receive substance use and mental health screenings free of cost sharing; even

if they visit a health professional for another service. Under interim final ACA regulations, beneficiaries must

make an appointment specifically for preventive care in order for the screenings to be free of cost sharing.

However, with SUD and MH screenings in particular, it is critically important that no-cost screenings be allowed

during visits for other primary care services, since individuals most in need of mental health and addiction

screenings are unlikely to seek them out on their own.

Screening, Brief Intervention, and Referral to Treatment, or SBIRT, is a preventive intervention that has been

shown to be very effective in hospitals, health clinics and primary care settings in reducing MH/SUD prevalence

and future emergency room visits.xxxii SBIRT targets people who are just beginning to be symptomatic with

mental health or substance use disorders (including tobacco). Medical benefits must support and encourage

SBIRT through full reimbursement in emergency rooms and primary care settings. Laws and policies that

create barriers to screening, including state Uniform Policy Provision Laws (UPPL) that permit insurers to deny

reimbursement for any injury that occurs while a patient is under the influence of alcohol or other drugs, must be

repealed or preempted.xxxiii

Coverage for Youth

While most services mentioned above apply to youth, there are additional MH and SUD services that are only

appropriate for youth and families. These services are listed below in the appropriate corresponding Essential

Health Benefits categories.

The Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit should serve as a

model for coverage for children and youth up to age 21 who are insured through the state Exchanges and

Medicaid expansion plans.xxxiv These comprehensive benefits are essential to ensure the early identification,

treatment and recovery of youth diagnosed with a mental illness or substance use disorder. Specific attention

should also be paid to ensure that the needs of transition age youth are well met.

Maternal and Newborn Services

· Pre-natal and peri-natal screening and brief interventions for maternal depression and substance

use disorders and referral to treatment

· Health education

· Targeted case management

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· Maternal, infant, and early childhood home visiting programs

Pediatric Services

· Screening for substance use, suicide, and other mental health problems using tools such as the

CAGE questions, the Alcohol Use Disorders Identification Test (AUDIT) instrument and other rapid

identification toolsxxxv,xxxvi

· Early intervention services

· Service planning

· Caretaker coaching on children’s social/emotional development and support

· Therapeutic mentoring

· Skill building

· Intensive home-based treatment

· Targeted case management


The Affordable Care Act holds tremendous promise for the millions of Americans with, at risk for, or in recovery

from mental health and substance use disorders. Providing the full range of MH and SUD prevention,

treatment, recovery and rehabilitation across the lifespan will save lives, improve health, and reduce health

costs. We appreciate your consideration of the above recommendations and ask that you use us as a

resource moving forward.

i Substance Abuse and Mental Health Services Administration. Draft Description of Good and Modern Addictions and Mental Health Service

System. (2011) Retrieved from:

ii Garfield, RL. Mental health financing in the United States: A primer. Kaiser Commission on Medicaid and the Uninsured. May 2011.

iii Oregon Department of Human Services Addiction and Mental Health Division. Measuring premature mortality among Oregonians. June


iv Parks J, Svendsen D, Singer P, Foti ME. Morbidity and Mortality in People with Serious Mental Illness. Alexandria: National Association

of State Mental Health Program Directors, 2006

v Owens, PL, Mutter, R, Stocks, C. (2010) Mental health and substance-abuse related emergency department visits among adults, 2007.

Agency for Healthcare Quality and Research. Retrieved from:

vi Stark K. & Mancuso D. (2007) Using cost offsets to fund chemical dependency treatment: The Washington State Experience. Testimony

before Senate Health Finance Committee, Spokane WA. July 23, 2007.

vii Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on Drug Use and Health:

Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4856Findings).

Rockville, MD.

viii Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey on Drug Use and Health:

National Findings (Office f Applied Studies, NSDUH Series H-36, HHS Publication No. 09-4434). Rockville, MD.

ix Robinson, P. J. & Reiter, & J. T. (2007) Behavioral Consultation and Primary Care: A Guide to Integrating Services, Springer

x Harwood, HJ. 2000. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States. National Institute on Alcohol Abuse

and Alcoholism. Available from the World Wide Web:

xi Patient Protection and Affordable Care Act, Section 1302(b)(4)(D).

xii National Business Group on Health. EMPAQ Annual Summary Research Report

xiii Claxton, G et al. Employer health benefits 2010 annual survey. Kaiser Family Foundation & Health Research and Educational Trust.

Retrieved from:

xiv National Quality Forum. National voluntary consensus standards for the treatment of substance use conditions: evidence-based treatment

practices. 2007.

xv Gastfriend DR: Addiction Treatment Matching: Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria.

Binghamton NY: Haworth Medical Press, 2004, pp. 170. Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Griffith JH, eds. ASAM

Patient Placement Criteria for the Treatment of Substance-Related Disorders, 2nd edition, revised. Chevy Chase, MD: American Society of

Addiction Medicine; 2001. Mee-Lee D, Shulman GD. The ASAM Placement Criteria and matching patients to treatment. In: Ries RK, Fiellin

DA, eds. Principles of Addiction Medicine, 4th edition. Chevy Chase, MD: American Society of Addiction Medicine; 2009:387-399

xvi Sheedy C. K., and Whitter M. (2009). Guiding Principles and Elements of Recovery-Oriented Systems of Care: What Do We Know From

the Research? HHS Publication No. (SMA) 09-4439. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental

Health Services Administration.

xvii Arns, M., de Ridder, S., Strehl, U., Breteler, M., & Coenen, A. (2009). Efficacy of neurofeedback treatment in ADHD:

The effects on inattention, impulsivity and hyperactivity: A meta-analysis. Clinical EEG and Neuroscience : Official

Page 10 of 10

Journal of the EEG and Clinical Neuroscience Society (ENCS), 40(3), 180-9.

xviii Butler, M., Kane, R. L., McAlpine, D., Kathol, R. G., Fu, S. S., Hagedorn, H. & Wilt, T. J. (2008). Integration of mental health/substance

abuse and primary care no. 173. AHRQ Publication No. 09-E003. Rockville, MD: Agency for Healthcare Research and Quality, U.S.

Department of Health and Human Services. Retrieved from

Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009

National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of

Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 10-4586Findings).

Rockville, MD.

xx Substance Abuse and Mental Health Services Administration, Office of Applied Studies. National Survey of Substance Abuse Treatment

Services (N-SSATS): 2009. Data on Substance Abuse Treatment Facilities, DASIS Series: S-54, HHS Publication No. (SMA) 10-4579,

Rockville, MD, 2010.

xxi Melek, S. MHPAEA Scope of Services Research. Prepared by Milliman, Inc for the Parity Implementation Coalition. December 2010.

xxii Reif, S. et al. Adult residential treatment for substance use disorders: summary of the evidence. Institute for Behavioral Health, Heller

School for Social Policy and Management, Brandeis University. November 2010.

xxiii Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment

Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services

Administration, 2004.

xxiv CDC Task Force on Preventive Services, Recommendations on Diabetes Case Management, Accessed Online on 8/11/10 at ; Agency for Healthcare Research and Quality, U.S. Department of

Health and Human Services, Rockville, MD Designing and Implementing Medicaid Disease and Care Management Programs: A User’s

Guide Prepared by The Lewin Group, Falls Church, VA, March 2008; Mejta, C.L., Bokos, P., Mickenberg, J., Maslar, M.E., Senay, E. (1997)

“Improving Substance Abuse Treatment Access and Retention Using a Case Management Approach,” Journal of Drug Issues, Vol. 27(2):


McLellan, T., Weinstein, R.L., Shen, Q., Kendig, B.A., Levine, M. (2005). “Improving Continuity of Care in a Public Addiction Treatment

System with Clinical Case Management,” The American Journal on Addictions, 14:426-440, 2005. American Academy of Addiction

Psychiatry; Siegal, H.A., Li, L. Rapp, R.C. (2002). “Case Management as a Therapeutic Enhancement: Impact on Post-Treatment

Criminality”, Journal of Addictive Diseases, Vol. 21(4): 37-46.

22 Daniels, A., Grant, E., Filson, B., Powell, I., Fricks, L., Goodale, L.

(Ed), Pillars of Peer Support: Transforming Mental Health Systems of Care

Through Peer Support Services,; January, 2010.

23McKay, J.R. (2005). Is there a case for extended interventions for alcohol and drug use disorders? Addiction, 100 (11), 1594-1610.

xxvii Gulf Coast ATTC. Interim evaluation report: creating access to recovery through drug courts. Texas Department of State Health

Services Community Mental Health and Substance Abuse Services Section. February 2007.

Texas Department of State Health Services Community Mental Health and Substance Abuse Services Section. February 2007.

25McKay, J.R., Lynch K., Shephard D., Pettinati H. (2005). The Effectiveness of Telephone Based Continuing Care for Alcohol and Cocaine

Dependence: 24 Month Outcomes. Archives of General Psychiatry. 62 (199-207).

xxix The National Household Survey on Drug Abuse (NHSDA) report. August 23, 2002. Available:

xxx National Institute on Alcohol Abuse and Alcoholism. (2006). Underage Drinking A Growing Healthcare Concern. Available:

xxxi Epstein J., Barker, P., Vorburger, M., & Murtha, C. (2004). Serious mental illness and its co-occurrence with substance use disorders,

2002 (DHHS Publication No. SMA 04–3905, Analytic Series A-24). Rockville, MD: Substance Abuse and Mental Health Services

Administration, Office of Applied Studies.

xxxii Fleming, MF et al. (2002). Brief physician advice for problem drinkers: long term efficacy and benefit-cost analysis. Alcoholism: Clinical

and Experimental Research, 26(1), 36 – 43.

xxxiii Ensuring Solutions to Alcohol Problems. Retrieved from:

xxxiv Section 1905 of the Social Security Act provides that coverage for youth up to age 21 shall include regularly scheduled, comprehensive

preventive health screenings sufficient to “determine the existence of certain physical or mental illnesses or conditions” and “such other

necessary health care, diagnostic services, treatment, and other measures described in section 1905(a) to correct or ameliorate defects and

physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the

State plan.” Section 1905(a) also states that “no service (including counseling) shall be excluded from the definition of ‘medical assistance’

solely because it is provided as a treatment service for alcoholism or drug dependency.” The benefits provided for under Section 1905(a)

are comprehensive and include services such as “other diagnostic, screening, preventive and rehabilitative services, including any medical

or remedial services (provided in a facility, a home or other setting) recommended by a physician or other licensed practitioner of the healing

arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an

individual to the best possible functional level.”

xxxv Ewing, John A. “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: 1905-1907, 1984 PMID 6471323

xxxvi AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care, second edition, by Thomas F. Babor, John C.

Higgins-Biddle, John B. Saunders, and Maristela G. Monteiro. Retrieved June 24, 2006.


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