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President Biden’s 2023 Budget Seeks to Transform U.S. Behavioral Healthcare Delivery

President Biden is proposing new, mandatory investments totaling $51.7 billion over 10 years to enhance behavioral healthcare in America in the fiscal year (FY) 2023 budget proposal he released Monday.

Among the budget blueprint’s most notable behavioral health provisions is the president’s request of $697 million for the Substance Abuse and Mental Health Services Administration (SAMHSA) to ensure that 100% of contacts are answered for the new 988 behavioral health crisis hotline that will begin to operate in July. This is an increase of $590 million from what was enacted for fiscal year 2022.

Another significant provision is the president’s proposal for a new, $7.5 billion Mental Health System Transformation Fund through Medicaid to increase access to mental health services through workforce development and service expansion, including the development of non-traditional health delivery sites, the integration of quality mental health and substance use care into primary care settings, and the dissemination of evidence-based practices.

President Biden’s budget also provides an investment of $397 million for the Health Resources and Services Administration’s (HRSA) Behavioral Health Workforce Development Programs, which is $235 million above FY 2022 enacted level. This funding is intended to increase training of new behavioral healthcare providers, including a track for health support workers such as peers and community health workers. The program also places an emphasis on team-based care.

This investment is meant to promote inclusive and equitable behavioral healthcare for youth and focus on the knowledge and understanding of children, adolescents, and youth at risk for a mental health disorder, serious emotional disturbance, or substance use disorder (SUD). The budget also includes increases in primary care training and enhancement and nurse education, practice, and retention to expand behavioral health services into primary care.

The FY 2023 budget provides $4.6 billion for SAMHSA’s mental health activities, an increase of $2.5 billion above the FY 2022 enacted level. These investments would provide a historic investment in the Behavior Health Crisis Services; expand access to crisis services; ensure access to early intervention and prevention services to the nation’s vulnerable populations; and invest in children’s mental health.

NABH is pleased to see President Biden’s budget calls for improving compliance with behavioral health parity standards by requiring plans and issuers to use medical necessity criteria for behavioral health services that are consistent with the criteria developed by not-for-profit medical specialty associations. The proposal would also place limits on the consideration of profit in determinations of medical necessity.

The budget would authorize the secretaries of the U.S. Health and Human Services, Labor, and Treasury Departments to regulate behavioral health network adequacy, and to issue regulations on a standard for parity in reimbursement rates based on the results of comparative analyses submitted by plans and issuers at a cost of $720 million over 10 years.

The budget proposes requiring all plans and issuers to cover three behavioral health visits and three primary care visits each year without charging a copayment, co-insurance or deductible-related fee.  And it would provide $125 million in mandatory funding over five years for grants to states to enforce mental health and SUD parity requirements.  Any funds not expended by states at the end of five fiscal years would remain available to the HHS secretary to make additional mental health parity grants.

It also proposes to eliminate the ability of self-insured non-federal governmental plans to opt out of parity, affording state and municipal employees the same consumer protections that apply to other employees with private health insurance.

In Medicare, the president’s budget would eliminate the 190-day lifetime limit and would require Medicare to cover up to three behavioral health visits per year without cost-sharing.

Also related to the Medicare program, current law requires the Centers for Medicare & Medicaid Services (CMS) to terminate psychiatric hospital participation in Medicare after six months of non-compliance with conditions of participation, even if the deficiency does not jeopardize patient health and wellbeing.  This provision does not apply to any other provider category. The president’s proposal would give CMS flexibility to allow a psychiatric hospital to continue receiving Medicare payments when deficiencies are not considered to immediately jeopardize the health and safety of its patients and where the facility is actively working to correct the deficiencies identified in an approved Plan of Correction.  This provision is considered budget-neutral and would not have cost implications.

Among other provisions, the White House budget proposal would also establish a Medicare benefit category for licensed professional counselors and marriage and family therapists that authorizes direct billing and payment under Medicare for these practitioners; remove limits on the scope of services for which Medicare can pay clinical social workers, licensed professional counselors, and marriage and family therapists; and allow these practitioners to bill Medicare directly for their mental health services for covered Part A qualifying Skilled Nursing Facility stays.

And the proposal would ensure that mental health and SUD benefits under Medicare do not face greater limitations on reimbursement or access to care relative to medical and surgical benefits.  The Medicare Payment Advisory Commission (MedPAC) would be required to issue a report to identify existing gaps in mental health and substance use disorder benefits to be addressed in the Medicare statute.

Specifically for SUD, President Biden has proposed $519 million, more than double the 2022 enacted level, for the Family Violence Prevention and Services program. This is the primary federal funding stream dedicated to the support of emergency shelter and related assistance for victims of domestic violence and their children.

The funding represents an increase of $292 million over FY 2022 enacted for the base program’s shelters and supportive services. This funding provides services to an estimated 1.3 million children and families to prevent family violence, domestic violence, and dating violence. This includes $250 million in cash assistance for domestic violence survivors and $30 million for the Safe Recovery Together demonstration grants. The demonstration grants will support families affected by domestic violence at the intersection of substance-use coercion, housing instability, and child welfare involvement.

President Biden’s FY 2023 budget also proposes:

  • $413 million to SAMHSA in FY 2023, and $4.1 billion over 10 years, for community health centers
  • A $238 million increase above the FY 2022 enacted level in funding for Certified Community Behavioral Health Center Expansion Grants
  • An increase in the amount of Mental Health Block Grant funds reserved for crisis intervention services to 10% from 5%
  • An investment of $11.4 billion, including $10.8 billion in discretionary funding, in programs addressing opioids and overdose-related activities across HHS.

After President Biden kicked off the federal budget process on Monday with his budget proposal, Office of Management and Budget Director Shalanda Young testified Tuesday before the House Budget Committee. Director Young will take more questions from the Senate Budget Committee on Wednesday.

Meanwhile, congressional appropriators will begin their work soon, starting with a House Appropriations Committee hearing this Thursday that will feature U.S. Health and Human Services Department (HHS) Secretary Xavier Becerra.