The One Year Anniversary of 988: A Roadmap for States Seeking to Expand Access to Behavioral Health Crisis Services

JoAnn Volk and Sabrina Corlette, Georgetown University’s Center on Health Insurance Reforms

One year ago, the United States transitioned to a new, three-digit nationwide number for suicide prevention and mental health crisis response services. The new hotline is intended to offer an alternative to calling 911 for a behavioral health crisis. A recent survey found that about 1 in 4 adults said that calling 911 for a mental health crisis would result in more “harm” than “help.” This is especially true for 3 in 10 Black adults and 4 in 10 LGBTQ+ adults.

Still, many communities rely on law enforcement response teams to assist those experiencing a behavioral health crisis. A report from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) has found that in many cases, this means that individuals experiencing a mental health crisis are not able to connect with appropriate services in real time and are often brought by first responders to the hospital or the local jail. The result is crowded emergency departments, higher rates of referral to more expensive inpatient care, and high rates of incarceration for individuals with mental health conditions.

Mobile crisis services are a core element of a comprehensive continuum of care for people experiencing a behavioral health crisis and help to ensure people obtain the right services in the appropriate location. Counselors who take 988 calls and texts can dispatch a mobile crisis team to provide emergency services, including screening, assessment, de-escalation, peer support, coordination with medical and behavioral health services, and crisis planning and follow-up care. SAMHSA has developed best practices for mobile crisis services that call for two-person teams that include a licensed and/or credentialed clinician and a peer counselor.

In the year since the launch of 988, the hotline has fielded more than 4 million calls, texts and chats from people seeking help. Experts expect most people who call or text 988 will be helped by counseling provided by the hotline. For those needing additional services, the hotline connects people experiencing a crisis to a continuum of services, including behavioral health crisis facilities and, where available, mobile crisis services. As new federal funding helps states bolster their capacity to field calls and texts, states have an important role to play in strengthening the continuum of services available to people calling 988 by making sure it includes robust care options and protects patients from balance billing for emergency behavioral healthcare.

Spotlight on Washington: A Comprehensive Approach to Covering Behavioral Crisis Services

Washington has taken a comprehensive approach to expanding access to services and protections for people who experience a behavioral health crisis. In 2022, Washington amended their state Balance Billing Protection Act (E2SHB 1688) to align with the No Surprises Act (NSA). In that legislation, Washington ensured the broad spectrum of services would be available to people experiencing a behavioral health crisis and that they would be protected from balance billing.

The new law broadly defines “behavioral health emergency services providers” to include facilities or providers licensed to provide behavioral health crisis services, such as evaluation and treatment facilities, crisis triage facilities, medical withdrawal management services facilities, and mobile rapid response crisis teams. Because the facilities included in this definition are licensed to provide emergency services and they are geographically separate and distinct from a hospital, they are in scope for the NSA. Mobile rapid response crisis teams are not considered “facilities” under the NSA. However, the 2022 law prohibits behavioral health emergency services providers, which includes mobile rapid response crisis teams, from balance billing an enrollee for emergency services.

The Washington Office of the Insurance Commissioner issued a memo following enactment of E2SHB 1688, noting that the expansive definition of behavioral health emergency services providers are “equivalent to the full range of emergency and crisis services for medical and surgical conditions including hospital emergency rooms, ambulance (mobile outreach), and urgent care centers.” This clarification, it notes, brings state law into alignment with provisions of the federal Mental Health Parity and Addiction Equity Act (MHPAEA), particularly those requiring that benefits for mental health and substance-use disorders be classified according to the same standards that apply to medical and surgical benefits; those that prohibit any separate treatment limits that are applicable only to behavioral health benefits; and those that limit the scope of coverage of behavioral health services based on “facility-type.”

Policy Options for States Seeking to Ensure Access to Behavioral Health Crisis Services

Requiring Coverage of Mobile Crisis Services

States have two primary pathways to requiring insurers to cover mobile crisis services. One way is to update their Essential Health Benefits (EHB) benchmark plan; the other is to leverage the MHPAEA.

Updating an EHB Benchmark Plan: States can ensure that consumers in private individual and small-group market plans have mobile crisis benefits by incorporating them into their EHB benchmark plan under the Affordable Care Act (ACA). Under the ACA, insurers that sell health plans to individuals and small employers must cover a minimum set of 10 EHBs, including emergency, mental health and substance-use disorder (SUD) services. If a state requires insurers to cover a benefit that is in addition to the benefits covered by a state’s EHB benchmark plan, the state must defray any additional premium cost associated with that benefit mandate. However, states wishing to add mobile crisis services to their EHB benchmark plan can avoid incurring an additional cost through one of two pathways:

• Leveraging the “generosity” test included in federal parameters for states to update or change the EHB benchmark plan: States that wish to make changes to their EHB benchmark plan must demonstrate that: (1) The scope of benefits is equivalent to those in a “typical” employer plan and (2) the new benchmark plan does not “exceed the generosity” of either the benchmark plan in place in 2017 or any of the 10 benchmark plan options the state had available for 2017. Five states have added benefits to their EHB benchmark plan in recent years using an actuarial analysis demonstrating that their new benchmark plan was not more generous than the most generous of the 10 benchmark plan options in their state. States can leverage a similar strategy to add mobile crisis services to the EHB benchmark plan, as long as doing so would not violate the generosity test. In order to use this option, a state will need to first determine if their current EHB benchmark plan is already the most generous option of the 10 plans from which the state can choose.
• Adding benefits to comply with the MHPAEA: States can also update their EHB benchmark without triggering the ACA’s defrayal requirement if they are doing so to comply with federal law. Under this safe harbor, a state may revise the definition of emergency services to include mobile crisis services in order to ensure that insurers comply with MHPAEA, which is cited in federal regulations as being integral to the “provision of EHB.”  If a state were to do this, they might redefine emergency services to, for example, include crisis services needed to respond to and stabilize a patient in an acute or with an emergent behavioral health condition, and require that they be covered in the same manner in which other medical services are covered for an acute or emergent medical condition.

To update an EHB benchmark plan, states must allow for public comment on the proposed changes; and notify the federal government of their intent to select a new benchmark plan about one and a half years before the new benchmark would take effect.

MHPAEA: Some insurers may limit coverage of behavioral health emergency services in ways that could violate MHPAEA. States can leverage their authority to enforce MHPAEA to assess whether state-regulated insurers are applying any coverage limits more stringently to behavioral health emergency services than to other medical benefits. For example, if insurers impose restrictions on coverage of behavioral health emergency services based on geographic location, facility type, or provider specialty that they do not impose for medical emergency services, they could be in violation of MHPAEA’s parity requirements. Thus, if an insurer covers mobile medical services (i.e., an ambulance) to respond to an emergency, they should also be covering mobile behavioral health services to respond to emergencies.

States that take this path may choose to provide guidance to health plans and providers on the emergency services definitions and interpretation to support this, as Washington did, and to review insurer offerings (in form review) and coverage of claims (as with a market conduct exam) to confirm insurers are complying.

Ensuring Access to Mobile Crisis Service Providers

Access to behavioral health providers has historically been a problem. People are more likely to go out-of-network for behavioral healthcare or avoid getting care due to cost. This trend is likely to apply to behavioral health crisis care, as well. Many mobile crisis teams may not have contracts with a patient’s health plan. If mobile crisis services are a covered benefit, a state could require insurers to include mobile crisis teams within their contracted network in order to meet the network adequacy standard.

Even where states require health plan networks include mobile crisis teams, individuals may be balance billed if they are treated by an out-of-network provider dispatched in an emergency situation. To prevent that from happening, states can include mobile crisis services among the “emergency services” protected from balance billing under state surprise medical billing protections. The NSA defers to state surprise billing laws that are more protective than the federal standard.

States can also prohibit balance billing for care received at a behavioral health crisis services facility. The NSA prohibits balance billing for emergency services to treat an emergency medical condition that are furnished as part of a visit to a hospital emergency department or an independent freestanding emergency department. The law defines an emergency medical condition to include a mental health condition or substance-use disorder. Federal rules implementing the NSA define an “independent freestanding emergency department” to include any healthcare facility that is geographically separate and distinct from a hospital and is licensed by a state to provide emergency services.

Federal officials further clarified that the NSA protections apply to a behavioral health crisis facility as long as it meets the definition of an independent freestanding emergency department. States can therefore expand access to services along the behavioral health crisis services continuum and protect individuals from balance billing by licensing certain facilities to provide behavioral health emergency services.

Conclusion

A recent survey found about half of all adults say they or a family member have experienced a severe mental health crisis. For these individuals and their families, 988 offers a lifeline to behavioral health crisis services, including potentially life-saving care. However, for the hotline to connect people to appropriate care, states will have to ensure a robust set of services be available in the communities where people need them. Mobile crisis teams, in particular, meet people where they are and offer a range of services, including on-site care, referrals and follow-up care. States can leverage state and federal laws to require those services be covered under state-regulated plans and that people experiencing a behavioral health crisis are protected from balance billing as they would be for any other emergency.