The spread of the COVID-19 pandemic represents a particular threat to individuals with mental health conditions and/or substance use disorders (SUD) who are particularly vulnerable to health complications if they were to contract the virus. People with “serious mental illness” have increased comorbidities with conditions associated with increased risk of complications with COVID-19, such as asthma and diabetes. Similarly, individuals with SUD may present decreased respiratory and lung function, which may exacerbate the impact of COVID-19.
Ensuring access to necessary and life-saving treatment during COVID-19
Because of their vulnerability, states must ensure that individuals with mental health conditions or SUD continue to have access to necessary, and in many cases life-saving, treatment, while protecting them from the heightened risks of contracting COVID-19. However, accessing mental health or SUD treatment at this time in states that have implemented stay-at-home orders may be difficult, particularly for low-income Medicaid beneficiaries. California, the first state to implement statewide movement restrictions, has taken early and important steps to guarantee access to behavioral health services for Medi-Cal beneficiaries.
DHCS issues guidance for specialty mental health services
For example, the Department of Health Care Services (DHCS) has issued guidance clarifying that mild-to-moderate mental health services provided by Medi-Cal managed care plans, specialty mental health services (SMHS) provided by county mental health plans, and Drug Medi-Cal Organized Delivery System (DMC-ODS) services are all reimbursable on equal terms when provided via telehealth or telephone. In fact, DHCS has encouraged counties to maximize the number of services provided through these mechanisms and asked counties that have not previously reimbursed for telehealth services to allow providers to bill for these services during the emergency.
Accessing specialty mental health services via telehealth
Regarding SMHS, DHCS’s guidance states that any service (including group services if the provider obtains consent from all participants) can be provided via telehealth or telephone and is reimbursable when provided in this manner. In addition, services that include an in-person component (such as residential treatment) may also include components that can be provided via telehealth or telephone. In these circumstances, providers may be reimbursed for and are encouraged to provide non-in-person components through virtual or telephonic communication.
Accessing SUD services during the COVID-19 emergency in DMC-ODS counties and non-DMC-ODS counties
Similarly, DHCS has clarified that most SUD services in counties participating in the DMC-ODS program (including group services if the provider obtains consent from all participants) may be provided via telehealth. This also includes an initial evaluation of individuals with SUD, which pursuant to recent federal guidelines, may be conducted via either telehealth or telephone for the duration of the COVID-19 emergency. For follow-up interventions, the guidance gives providers significant flexibility to determine which services are clinically appropriate for telehealth or telephonic delivery. Just like with SMHS, specific components of certain services may be provided remotely even if some other components require in-person interaction.
Importantly, while DHCS has said that reimbursement for telehealth is not available in non-DMC-ODS counties, guidance from the Centers for Medicare and Medicaid Services (CMS) explains that states may expand telehealth services without the need to submit a State Plan Amendment as long as there are no distinctions between reimbursement for services provided via telehealth and services provided through other ways. In addition, these counties may use non-Medi-Cal funding, such as Substance Abuse and Mental Health Services Administration (SAMHSA) grants, to encourage telehealth or telephonic services and limit patient exposure to COVID-19.
Accessing opioid use disorder treatment during the COVID-19 emergency
California has also taken steps to ensure that individuals who need it have continuous access to medications for opioid use disorders (MOUD) during the COVID-19 emergency. MOUD consists of treatment with the medications buprenorphine and methadone, and losing access to these medications will significantly increase the risk of relapse and overdose. However, all methadone treatment and most buprenorphine treatment in California is provided in Narcotic Treatment Programs (NTPs). Federal law imposes strict requirement on the delivery of medications at NTPs, including the amount of medications patients may take home.
In response to the federal government waiving some of these requirements, DHCS has released guidance encouraging NTPs in the State to submit blanket exception requests that would allow stable patients to receive 28 days of take-home doses and less stable patients to receive 14 days of take-home doses. In addition, DHCS has advised NTPs that they may provide medication delivery to patients at home or in a controlled treatment environment as long as the delivery is conducted by an authorized NTP staff member, law enforcement officer, or National Guard personnel. These necessary moves will extend access to life-saving medications while reducing exposure to the COVID-19 virus.
While significant gaps remain, all of these actions represent a step in the right direction to ensure access to medically necessary mental health and SUD services for the most vulnerable populations in California. The National Health Law Program will continue to monitor the State’s actions to protect Medi-Cal beneficiaries from the COVID-19 and from losses in medically necessary behavioral health care and encourages stakeholders in California and elsewhere to continue advocating for the rights of these individuals during these difficult times.