2024 Grassroots Fly-in: Advancing Health Equity Across the Lifespan

Sample Thank You Note to Send After Your Visits

Fly-In Resources

Continuing Education

Virtual Palm Card

Legislative Request 1: Cosponsor the Telemental Health Care Access Act (H.R. 3432/S. 3651) (factsheet)

Background:

Seeking to ensure continuity of care during the COVID-19 public health emergency (PHE), Congress temporarily expanded the ability of Medicare beneficiaries to access health care treatment via telehealth. This included allowing patients to receive telehealth services from their own homes. While Congress permanently allowed patients to receive “mental health” services from their own homes, it did not do so for the broader array of “behavioral health” services and required patients receiving mental health services via telehealth to have at least one visit in-person every six (6) months. This in-person visit requirement is set to go into effect after December 31, 2024; several other Medicare coverage flexibilities are set to expire on the same date.

The Telemental Health Care Access Act would repeal the in-person service requirement. The House version of the bill would also allow Medicare beneficiaries to access behavioral health treatment via telehealth from their own homes.

Sample Talking Points:

• Congress must act promptly to ensure that a “telehealth access cliff” does not occur after the end of this year.
• Telehealth is an effective treatment mode for mental and behavioral health services. Some patients are, in fact, better able to engage in treatment when they do so from the familiarity and comfort of their own homes, rather than an office setting.
• Telehealth also overcomes a number of social and practical barriers to treatment that have long impeded access to quality mental and behavioral health care. These include but are not limited to social stigma, lack of access to transportation, and difficulty finding a local provider.
• The decision to provide and receive services via telehealth is based on a careful determination of various patient-specific factors. Therefore, the decision to utilize telehealth is best left to the shared decision between patient and provider.
• The six-month in-person service requirement is an unnecessary barrier to treatment. I am concerned that once it goes into effect, many of my patients affected by it will simply choose to discontinue treatment. Particularly those who live in rural communities and previously struggled to access treatment.
• The differences between “behavioral health” and “mental health” services are subtle and indeed these two categories of treatment often overlap. But some “behavioral health” services are classified as such because the patient does not have a primary “mental health” diagnosis.
  1. A classic example of this is health behavior assessment and intervention services, where a behavioral health specialist is brought in to help a patient with a chronic medical condition like diabetes or obesity understand why they are not complying with a prescribed medical regimen and devise a strategy for coming into compliance.
  2. Behavioral health services and mental health services may be provided together on a patient’s plan of care, so allowing one category of services to be furnished via telehealth but not another invites further confusion and higher costs.

Telehealth Frequently Asked Questions:

Telehealth is a bipartisan issue in Congress, and there are several bills seeking to continue coverage of telehealth services after the end of the year. What makes this bill unique?

As a psychologist, I can only speak to the evidence for and impact of telehealth access for mental and behavioral health services. So while I understand there are a number of bills that enable access to telehealth services in a broader health care context, I can’t tell you how this would impact treatment in, say, cardiology or oncology. The legislation we are discussing today has a positive and specific impact on tele-mental and tele-behavioral health services, but if your office has any other ideas, I would be happy to work through them with you in coordination with APA Services.

Do you think this bill will impose a heavy cost on the Medicare program?

According to a recent APA analysis, despite the expansion of telehealth in recent years, overall claims for two key sets of services—diagnostic interviews and psychotherapy—continue to decline, with telehealth claims occupying a robust share of the total number of claims.

Telehealth also allows patients to access mental and behavioral health services at an earlier phase of treatment, allowing the provider to treat minor symptoms of a mental or behavioral health disorder before it escalates to a point of crisis. In addition to averting worse outcomes for the patient, telehealth also saves costs from minimizing the risk of a crisis.

Are you concerned that the lack of an in-person requirement will enable considerable fraud, waste, and abuse in the Medicare program?

I am not aware of any evidence that a uniform in-person requirement deters or lowers fraud, waste, or abuse. Instead, I am concerned that such a requirement will deter or disadvantage legitimate claims for mental health treatment.

I also note that this provision uniquely applies to mental health treatment, which I fear perpetuates a bias against coverage of mental health services in other health insurance programs.

I would be happy to work with your office in conjunction with APA Services to craft equitable and effective mechanisms for deterring fraud, waste, and abuse.

Given the differences between the House and Senate versions of the bill, do you have a preference for either the House or Senate version?

Both versions of the bill repeal the in-person service requirement, so for that reason alone I strongly support them. However, given a choice between two options, I would hope the sponsors of the Senate bill would consider a friendly amendment that would match the House version of the bill. 

How will this affect patients who are not Medicare beneficiaries?

Medicare coverage policy has a considerable influence on coverage through other health insurance programs. State Medicaid and CHIP programs, as well as private health insurance plans, often look to Medicare coverage policies as a benchmark in crafting their own versions of these policies. 

Who is already a co-sponsor for this legislation?

House: Reps. Doris Matsui (D-CA), Troy Balderson (R-OH), Grace Napolitano (D-CA), Jim Costa (D-CA), Melanie Ann Stansbury (D-NM), Paul Tonko (D-NY), Rep. Mark Takano (D-CA), Debbie Lesko (R-AZ), Kathy Manning (D-NC), Yvette Clarke (D-NY), Tony Cardenas (D-CA), Don Bacon (R-NE), Susan Wild (D-PA), Alma Adams (D-NC), Betty McCollum (D-MN), David Trone (D-MD), Marcus Molinaro (R-NY), Madeleine Dean (D-PA), Dutch Ruppersberger (D-MD), Shri Thanedar (D-MI), Ed Case (D-HI), Zoe Lofgren (D-CA), Gus Bilirakis (R-FL), Debbie Dingell (D-MI), Steve Cohen (D-TN), and Del. Eleanor Holmes Norton (D-DC).

Senate: Sens. Bill Cassidy (R-LA), Tina Smith (D-MN), John Thune (R-SD), Ben Cardin (D-MD), and Mike Braun (R-IN).

Where can I see the text for this bill?

View the text of the House version of this bill (H.R. 3432) at the following link.

View the text of the Senate version of this bill (S. 3651) at the following link.

Legislative Request 2: Cosponsor the Increasing Mental Health Options Act (S.669/HR.8458) (factsheet)

Background:

Psychologists are the most highly trained behavioral health service specialists, and serve a critical role in providing mental and behavioral health services. In addition to independently providing these services directly to patients, psychologists also lead treatment teams and use psychological science to help patients manage chronic medical conditions. Yet in a few critical care settings, Medicare still requires psychologists to receive approval from the patient’s physician before providing services.

All state psychologist licensure laws allow psychologists to practice independently in all treatment settings.  Despite this, Medicare requires physician authorization and sign-off of psychological services provided by psychologists in skilled nursing facilities, comprehensive outpatient rehabilitation facilities, partial hospitalization programs, inpatient psychiatric facilities, and home health agencies.  No other insurer requires physician approval of psychologists’ services like this.

Patients in these treatment settings are more likely to need behavioral healthcare than older Americans living in the community, and frequently are only treated using psychotropic medications.  In addition, the workforce of psychologists is limited in rural and underserved areas, with research showing Medicare beneficiaries in these areas are far less likely to see behavioral health specialists than those living in urban areas.

The Increasing Mental Health Options (IMHO) Act would address both issues by: (a) allowing psychologists participating in Medicare to independently provide services in all Medicare treatment settings; and (b) making psychologists eligible for Medicare bonus payments for services provided in areas that are designated as Mental Health Professional Shortage Areas (MHPSAs). These MHPSA bonus payments are currently provided only for psychiatrists.

Sample Talking Points:

• The physician oversight requirements for psychologists’ services in Medicare only serve to delay and disrupt treatment, and do not serve a legitimate function in improving quality of care or patient outcomes.
• In many cases, psychologists must obtain the approval of clinicians who have little to no training in mental health before services can be provided. Consent must also be obtained from a clinician with whom the patient has no prior relationship, and even if the psychologist has already been treating the patient prior to entering the facility.
• These unnecessary delays in treatment have resulted in severe harm for patients seeking mental health treatment, including escalation of their symptoms.

IMHO Frequently Asked Questions:

In which settings does Medicare require physician sign-off before care can be provided by a psychologist?

Psychologists in Medicare can independently practice in traditional office settings, but physician sign-off is required for care provided in the following key settings:

• Skilled nursing facilities
• Partial hospitalization programs
• Comprehensive outpatient rehabilitation facilities
• Inpatient psychiatric hospitals
• Home health agency services

Do other health insurance programs have these physician sign-off requirements for services provided by psychologists?

No. Medicaid/CHIP, private sector health insurance plans, TRICARE, and the VA all allow psychologists to practice independently in all settings.

Would this bill change the kinds of treatments that psychologists can provide to patients?

Absolutely not. This bill would have no effect on psychologists’ scope of practice, which is defined under state law, and would have no effect on the range of services that Medicare reimburses psychologists for providing.

The IMHO Act also retains Medicare’s requirements that psychologists must consult with the patient’s physician in accordance with professional ethical standards.

Who is already a co-sponsor for this legislation?

House: Reps. Nicole Malliotakis (R-NY) lead sponsor, Judy Chu (D-CA), August Pfluger (R-TX), and Jan Schakowsky (D-IL)

Senate: Sens. Sherrod Brown (D-OH) lead sponsor, Susan Collins (R-ME), Markwayne Mullin (R-OK), and Martin Heinrich (D-CO).

Where can I see the text for this bill?

View the text of the Senate version of this bill (S. 669) at the following link.

Legislative Request 3: Cosponsor the COMPLETE Care Act (H.R. 5819/S. 1378) (factsheet)

Background:

Integrated care is an evidence-based approach to combining primary care and mental and behavioral health clinicians together as a team to provide whole person care for patients and their families. Despite its benefits, implementing integrated primary and behavioral health models of care can be difficult, as it requires more substantial changes to primary care provider practices than simply co-locating behavioral health staff. 

The COMPLETE Care Act would: 

• Temporarily increase Medicare reimbursement rates for behavioral health integration (BHI) services to help cover the costs of adoption and implementation
• Require the Centers for Medicare and Medicaid Services (CMS) to provide technical assistance on integrated care to primary care practices
• Require CMS to establish quality measurement reporting requirements on behavioral health integration for physicians and other providers participating in alternative payment models within Medicare.

Sample Talking Points:

• Integrating mental and behavioral health specialists into team-based primary care systems can improve access to behavioral health treatment, especially rural and underserved communities where primary care is the default health system. 
• Individuals’ behavioral and physical health and well-being are deeply interconnected, and epidemiologic studies suggest that socioeconomic and behavioral factors influence health outcomes more than health care or genetics do.  Integrated “whole person” care that addresses behavioral factors can improve treatment outcomes for physical and chronic conditions.
• Rather than simply co-locating behavioral health and primary care providers, evidence-based integrated care involves adopting a coordinated, team-based approach to ongoing patient care, and seamless transitions between behavioral health and primary care services.
• The COMPLETE Care Act adopts a “model-neutral” approach to assisting practitioners with adoption of integrated care, allowing the patient and provider to select whatever model of behavioral health integration works best for the primary care provider and their community.
• There is ample evidence that integrated care can result in cost savings across the health care system, including through reductions in emergency department visits and unnecessary hospitalizations for physical and chronic health conditions.
• Despite its promise, there are many obstacles to adoption of integrated care, including up-front costs for adding clinical or administrative staff, modifications to physical offices, upgrades to health IT systems, and changes in practice and billing patterns. Practitioners frequently need assistance in navigating the practice changes involved in adopting integrated care.

COMPLETE Care Frequently Asked Questions:

Are there different methods of providing integrated care? Is there a “one size fits all” solution?

The two leading models of integrated primary and behavioral healthcare are the Primary Care Behavioral Health (PCBH) and Collaborative Care (CoCM) models, but primary care practices also implement hybrid or combined versions of these models. These can vary depending on the practice’s patient population and the available behavioral health provider workforce.

Although there are a spectrum of behavioral health integration approaches and interventions, in the most effective programs care is directed by a primary care team using structured care management, regular assessments of patients’ clinical status,  frequent primary care-behavioral health consultations and “warm hand-offs” to provide whole-person care, and treatment modifications as needed.

The COMPLETE Care Act would provide support for both the CoCM and PCBH models, and other models identified by the Secretary.

Would this affect patients who are not Medicare beneficiaries?

By providing stronger Medicare support for adoption of integrated care, the COMPLETE Care Act will make it easier for primary care practices to provide integrated behavioral health services for patients with other forms of insurance. Additionally, Medicare coverage and reimbursement policies heavily influence state Medicaid and CHIP programs and private insurance policies. 

Aren’t there already reimbursement codes to cover provision of these services?

CMS established reimbursement codes for behavioral health integration consultations between providers back in 2017.  However, these codes are not widely used, in part because their reimbursement rates do not adequately compensate for the initial and ongoing costs of adopting integrated care.

Who is already a co-sponsor for this legislation?

• House: Reps. Michelle Steel (R-CA) lead sponsor, Nanette Diaz Barragan (D-CA), Tony Cardenas (D-CA), Josh Harder (D-CA), Jay Obernolte (R-CA)

Yadira Caraveo (D-CO), Brittany Pettersen (D-CO), Gus Bilirakis (R-FL), Daniel Kildee (D-MI), Don Davis (D-NC), Deborah K. Ross (D-NC), Don Bacon (R-NE), Jefferson Van Drew (R-NJ), Melanie Ann Stansbury (D-NM),Susie Lee (D-NV), Daniel Goldman (D-NY), Paul Tonko (D-NY), Nicole Malliotakis (R-NY), Marcus Molinaro (R-NY), Andrea Salinas (D-OR), Brian Fitzpatrick (R-PA), John Joyce (R-PA), Seth Magaziner (D-RI), Lizzie Fletcher (D-TX), August Pfluger (R-TX)

• Senate: Sens. Catherine Cortez Masto (D-NV) lead sponsor, and John Cornyn (R-TX).

Where can I see the text for this bill?

View the text of the House version of this bill (H.R. 5819) at the following link.

View the text of the Senate version of this bill (S. 1378) at the following link.

General Frequently Asked Questions

How can I prepare for the Fly-In?

All information for the Fly-In, including our legislative requests, fact sheets, agenda, and participant list can be found on this action center. If you are not seeing the information you are looking for, please check back later - this page will be updated as we receive more information. 

If you are new to advocacy or would like a refresher, please watch APA’s Federal Advocacy for Psychology video.

Do I have to schedule my Hill visits for June 11?

No. Our partner, Soapbox Consulting, is handling all scheduling for legislative hill visits for June 11.

When will I get by schedule from Soapbox?

All Hill meeting schedules will be emailed to you by Soapbox prior to the Hill Day on June 11. On the “Meeting Roster” button next to each meeting, you can find the names and email addresses of your fellow advocates for each meeting so you can reach out in advance to introduce yourselves.

What if I can no longer make the June 11 Hill visits?

Please contact us at advocacy@apa.org as soon as possible so we may remove you from the congressional meeting schedule.

What is the program for the Fly-In?

The program for the Fly-In will be available soon.