The United States continues to face a behavioral health crisis that has worsened due to the COVID-19 pandemic. In 2021, nearly 40% of adults reported symptoms of depression or anxiety, an increase from 10% in 2019.i The behavioral health crisis is acutely impacting children; a 2020 national survey found that 71% of parents felt the pandemic had affected their child’s mental health.ii Limited access to behavioral health services for children was an issue prior to the pandemic; Centers for Disease Control and Prevention data from 2019 indicated that nearly 20% of children faced a mental, emotional, or behavioral disorder, yet only 1 in 5 of these children received treatment.iii Despite the clear need for increased access to behavioral health services for both adults and children, there is a persistent and severe shortage of behavioral health providers. The Health Resources and Services Administration estimates that by 2025 there will be a shortage of more than 250,000 behavioral health providers, including psychiatrists; clinical, counseling, and school psychologists; substance use and behavioral disorder counselors; mental health and substance use social workers; mental health counselors; and school counselors.iv
Telehealth has been an essential method of behavioral health care delivery during the pandemic. A recent report published by the Kaiser Family Foundation illustrates the critical role that telehealth has played in meeting the nation’s behavioral health needs during the pandemic. The report found that from March–August 2020, telehealth accounted for 40% of behavioral health visits. Rates of telehealth use have declined slightly since then, but use of telehealth for behavioral health still outpaces other outpatient visits; between March–August 2021, 36% of behavioral health visits were conducted via telehealth, compared to only 5% of other outpatient visits, and utilization remains high compared to pre-pandemic levels.v
Through our ongoing telehealth policy tracking, Manatt has identified that at both the federal and state levels, policymakers are designing their post-public-health-emergency (PHE) telehealth policies to ensure continued access to telebehavioral health going forward. At the federal level, the Centers for Medicare & Medicaid Services finalized several changes within the CY 2022 Medicare Physician Fee Schedule that enable permanent coverage of telebehavioral health services delivered to Medicare enrollees in their homes via both video and audio-only modalities.
States are utilizing a variety of policy levers to maintain access to telebehavioral health services. Commonly used levers include:
Creating Allowances for Out-of-State Behavioral Health Providers
Prior to the COVID-19 pandemic, states typically required all providers, including behavioral health providers, to be licensed in the state(s) where they were practicing. During the pandemic, many states allowed out-of-state providers to practice in state without a license if they were licensed and in good standing in another state. Now, multiple states have introduced or passed legislation that would create permanent allowances for out-of-state behavioral health providers to enable them to practice via telehealth across state lines.
- Virginia passed House Bill 537, which allows behavioral health providers, psychologists, and licensed social workers who are licensed in good standing in another state or territory to provide behavioral health services via telehealth to patients located in Virginia for no more than one year from the date on which the provider began providing such services to a patient.
- South Carolina recently introduced Senate Bill No. 1179, which would permit a broad range of behavioral health providers, including clinical social workers, addiction counselors, and marriage and family therapy counselors, among others, who hold licenses in other states or jurisdictions to provide services via telehealth to clients in South Carolina if the individuals follow specific-state board registration requirements. These include holding an active license issued by another state or territory that is substantially similar to a license issued by South Carolina and not being subject to disciplinary proceedings relating to a license in the last five years.
- Iowa recently introduced House File No. 2245, which would allow behavioral health providers who are physically located out of state to participate as a provider via telehealth, as long as the provider is licensed in state and is able to satisfy the same criteria as they would in person.
Enabling Coverage for Audio-Only Telebehavioral Health Services
Coverage for audio-only telehealth was limited prior to the pandemic, but nearly all states temporarily covered audio-only visits for at least some services during the pandemic to ensure access to care for low-income, rural, and other patients who lacked the technology, digital literacy, or resources to participate in a video visit. Many states recognize the importance of continuing coverage of audio-only visits, particularly for behavioral health services, and have taken action to permanently cover select behavioral health services delivered via audio only.
- North Carolina’s Medicaid program amended its clinical coverage policy for outpatient behavioral health services to cover select services when provided via audio only when a beneficiary’s physical or behavioral health status or access issues (e.g., transportation, telehealth technology) prevent them from participating in an in-person or video visit.
- New York’s Medicaid program issued new telehealth guidance for providers that includes coverage for a range of services delivered via audio only, including “assessment and patient management services” delivered by psychologists, social workers, and other practitioners to new or established patients.
Expanding Telehealth-Eligible Provider Types to Include a Broad Range of Behavioral Health Providers
Prior to the PHE, it was common for states to limit telehealth-eligible providers to a narrow list of provider types. In light of expanded use of telehealth during the PHE and increasing needs for a range of behavioral health services, some states have expanded their lists of telehealth-eligible providers to include a broader range of behavioral health providers such as addiction counselors, professional counselors, licensed clinical mental health counselors, and board-certified behavioral analysts, among others.
- Indiana passed Senate Bill No. 284, which includes occupational therapists, occupational therapy assistants, behavioral analysts (through 2025), and specific developmental therapists enrolled by the Bureau of Child Development Services in the list of Medicaid providers who can be reimbursed for medically necessary telehealth services.
- Louisiana introduced House Bill No. 826, which would enable addiction counselors, prevention professionals, and certified compulsive gambling counselors to provide telebehavioral health services if they meet specific licensing, certification, and registration guidelines.
Requiring Payment Parity for Telebehavioral Health Visits
Lower reimbursement for telehealth services relative to in-person care creates a major barrier to widespread adoption of telehealth among providers. According to Manatt’s ongoing tracking and analysis, prior to the pandemic, ten states had legislation requiring private payers to reimburse for telehealth services at parity with in-person care; now, two years after the onset of the pandemic, more than half of states have payment parity laws in place. While some states are hesitant to implement payment parity broadly for all services, some states have implemented or are considering implementing narrow payment parity for telebehavioral health services.
- Massachusetts passed Chapter 260, which requires all health plans to permanently reimburse for telebehavioral health services at parity with in-person care. Plans are also required to temporarily reimburse for primary and chronic care services delivered via telehealth at parity through the end of 2022.
- Iowa Insurance Code 514.34 requires health plans to reimburse health care providers and facilities for telehealth services delivered to a covered person for a mental health condition, illness, injury, or disease at the same rate that the plan would reimburse for the same services provided in person.
Manatt anticipates that states will remain focused on ensuring continued expanded access to telebehavioral health services as the PHE comes to an end. Each of the policy levers and examples listed above are options that other states may consider as they evolve their approach to telehealth policy going forward.
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i Kaiser Family Foundation. The Implications of COVID-19 for Mental Health and Substance Use. 2021. Available here.
ii Ann & Robert H. Lurie Children’s Hospital of Chicago. Children’s Mental Health During the COVID-19 Pandemic. 2021. Available here.
iii Centers for Disease Control and Prevention. Improving Access to Children’s Mental Health Care. 2022. Available here.
iv Health Resources and Services Administration/National Center for Health Workforce Analysis. Substance Abuse and Mental Health Services Administration/Office of Policy, Planning, and Innovation. 2015. National projections of supply and demand for behavioral health practitioners: 2013-2025. Available here.
v Kaiser Family Foundation. Telehealth Has Played an Outsized Role Meeting Mental Health Needs During the COVID-19 Pandemic. 2022. Available here.