Federal and state health partners, behavioral health organizations and insurers are adapting their approaches to mental health and substance use treatments due to COVID-19, but additional struggles remain for patients.

Those looking for counseling, medication-assisted treatment, group therapy or other forms of care are turning to telehealth as state and federal officials and public health experts urge the public to stay at home and practice social distancing to curb the spread of COVID-19, the disease caused by the new coronavirus.

The Centers for Disease Control and Prevention recommends that individuals with preexisting mental health conditions continue their treatment during the pandemic and be aware of possibly worsening symptoms caused by increased stress and anxiety.

“We’re seeing a lot of states respond by proposing pretty radical changes to their telehealth reimbursement policies both by increasing types of services that can be delivered by telehealth, the types of professionals that can deliver those services, as well as thinking very broadly about the types of technologies that can be used,” said Chuck Ingoglia, CEO of the National Council for Behavioral Health.

People getting mental health or substance use disorder treatment face the additional struggle of finding appropriate care while isolated from things like in-person group meetings.

“We in the behavioral health community have been expecting that there is going to be an increased demand for our services during this time period because of the anxiety and all of the turmoil that might be out there and the isolation,” said Geoffrey Boyce, CEO of In-Sight Telepsychiatry + Regroup Telehealth. “We are having to be cognizant of some of the community access limitations that do exist.”

Some federal actions are being taken to make accessing certain medications easier.

Under a 2008 law pharmaceutical law known as the Ryan Haight Act, health care providers must conduct an initial exam in person before they can e-prescribe a controlled substance. Some medications, including those used for treating an opioid use disorder or some types of anxiety, are classified as controlled substances. On Wednesday, the Drug Enforcement Administration temporarily lifted that in-person requirement to allow for easier e-prescribing practices during the COVID-19 emergency.

The Substances Abuse and Mental Health Services Administration has also taken steps to make it easier to access medication-assisted treatment, an evidence-based treatment option for opioid use disorder. The agency released guidance on Monday expanding flexibility for opioid use disorder treatment.

States that declared an emergency can request an exception to allow stable patients in a treatment program to receive 28 days of medication for their opioid use disorder. The state can also request to allow a 14-day supply for patients who are less stable in their treatment.

If a state has not declared an emergency, a provider can request similar exemptions.

State actions

States like Indiana are also testing innovative approaches to getting opioid treatment to residents during the COVID-19 pandemic.

The state announced Monday it will use SAMHSA funding to provide opioid treatment programs with lockboxes and the opioid overdose reversal drug naloxone. The lockboxes will allow residents who are stable in their treatment to make fewer trips to get medication to receive their daily dose of methadone. Naloxone will be provided with lockboxes as a preventive measure.

“Urging Hoosiers to isolate themselves from each other is necessary, but for some it could bring unique health risks,” said Jennifer Sullivan, secretary of the Indiana Family and Social Services Administration. “For our fellow Hoosiers recovering from opioid use disorder, this innovative approach to delivering the medications they need daily will support them in their recovery while also helping contain the spread of COVID-19.”

Washington state applied for a Medicaid waiver this week that would increase flexibility and payment for telehealth.

The state’s Medicaid program, Apple Health, has already created new billing codes so that behavioral health services conducted by telehealth or telephone are covered and billed at the same rates as in-person appointments.

The waiver would waive any requirements for patients to see a provider in person for certain services during this time.

Telehealth coverage

More broadly, telehealth access has expanded in recent days.

On Tuesday, the Trump administration temporarily lifted regulations related to Medicare’s coverage of telehealth for various health services, but insurers are also taking steps aimed at behavioral health. Without changes, some insurance plans may not always cover telehealth for all services or may charge a different rate for a telehealth service than for an in-person visit.

Boyce says there can be some variation among plans.

“We do see examples with commercial insurers where we and the member think at a high level that it’s an eligible service, but when we run the enrollment checks we find this particular plan doesn’t have a home-based behavioral health telehealth benefit,” said Boyce. “There is some back and forth with some payers where the members have been having to advocate that it be a covered benefit within their plan.”

Aetna announced it would waive copays for telemedicine visits, including for mental health, until June 4. The insurer is also looking into ways to expand digital mental well-being methods. The Blue Cross Blue Shield Association said some of its plans, including Anthem, Florida Blue and Horizon, are making mental health available in their telehealth offerings. Cigna is operating a 24-hour hotline to connect customers with clinicians to ease anxiety.

“Anxiety is understandably high as we are learning more about the spread of this disease,” said Douglas Nemecek, Cigna’s chief medical officer for behavioral health, adding the company is expanding behavioral support and resources for the general public as well.

Limiting exposure

While some 12-step programs for addiction have been affected by mandated closures that vary by locality, the umbrella organizations for Alcoholics Anonymous and Narcotics Anonymous do not have a uniform policy on meetings due to COVID-19.

“Not only do you have the issue of how does the group work, but many times they were meeting in locations that are no longer open, like church basements,” said Ingoglia.

The General Service Office of Alcoholics Anonymous noted in a letter this week that some chapters have switched to meeting digitally, but some are still meeting in person.

“Our collected experience suggests that groups that are unable to meet at their usual meeting places have begun to meet digitally; doing so in a sensible and helpful manner to allow the group to continue keeping the focus on our common welfare and primary purpose,” the letter reads. “Regardless of group decisions, each individual is responsible for their own health decisions.”

Chapters that are still meeting in person have made changes like avoiding physical contact and suspending communal food. Some made contingency plans if in-person meetings must be discontinued.

Last week, Narcotics Anonymous posted similar guidance for its chapters.

“Some groups are discussing contingencies for the possibility that they will not be able to meet face to face for some period; ideas include hosting phone meetings or online meetings,” the group stated. “These are just a few thoughts; we honor each NA group’s responsibility to discuss and determine what is best for their meeting.”