GAO finds CMS should provide more substance use disorder coverage information

May 22, 2020

The Government Accountability Office (GAO) has recommended that Medicare include explicit information on covered services for beneficiaries with substance use disorders, according to new analysis. 

Medicare wants to expand access to substance use disorder treatment, but some beneficiaries may not know these services are covered. Medicare’s coverage of these treatments is not explicitly outlined in the Medicare & You publication—the most widely disseminated source of information on Medicare coverage for beneficiaries. 

GAO's analysis of Medicare claims data shows that in 2018 almost five million beneficiaries used behavioral health services—services for mental and substance use disorders. This represented about 14 percent of the more than 36 million fee-for-service (traditional) Medicare beneficiaries and reflects about $3.3 billion in spending. Additionally, about 96 percent of all behavioral health services accessed by Medicare beneficiaries in 2018, the latest data available, were for a primary diagnosis in one of five behavioral health disorder categories. Mood disorders, such as depression and bipolar disorders, accounted for 42 percent of services. SUD services accounted for about seven percent of all services accessed by beneficiaries. Further, two-thirds of behavioral health services were provided by psychiatrists, licensed clinical social workers, and psychologists in 2018. 

The Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services' (HHS) agency that administers Medicare, uses various approaches to disseminate information to Medicare beneficiaries about coverage for behavioral health services. As part of these efforts, CMS mails out Medicare & You —the most widely disseminated source of information on Medicare benefits—to all Medicare beneficiaries every year. 

GAO reviewed the fall 2019 and January 2020 editions of Medicare & You. While the January 2020 edition describes a new coverage benefit for beneficiaries with opioid use disorders, neither edition includes an explicit and broader description of the covered services available for substance use disorders. Both HHS and CMS have stated that addressing substance use disorders is a top priority. Given that coverage for substance use disorders is not explicitly outlined in Medicare's most widely disseminated communication, Medicare beneficiaries may be unaware of this coverage and may not seek needed treatment as a result. 

Behavioral health disorders often go untreated, potentially leading to negative health consequences. Behavioral health disorders include substance use or mental health disorders. Medicare provides coverage for behavioral health services. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act enacted in 2018 included a provision for GAO to examine Medicare behavioral health services and how beneficiaries are informed of coverage and treatment options. 

GAO has the report