NAMI and partners applaud CMS for making it easier to finance vital care for young people with early psychosis

Aug 24, 2023

Washington, D.C. – Every year, roughly 100,000 Americans experience the symptoms of early psychosis. Fortunately, a specialized model of care makes a significant difference in outcomes for young people, but these programs are only available to a small fraction of individuals who could benefit. The National Association of State Mental Health Program Directors (NASMHPD), Mental Health America (MHA), and the National Alliance on Mental Illness (NAMI) applaud the Centers for Medicare and Medicaid Services (CMS) for approving a team-based reimbursement for these evidence-based services, often referred to as Coordinated Specialty Care for Early Psychosis (CSC-EP). This new way to reimburse for these life-changing, and often lifesaving, services will help expand access to more individuals.

CMS has authorized two Healthcare Common Procedure Coding System (HCPCS) team-based billing codes, which will make it easier for private and public insurance programs to pay for these services and for community-based mental health programs to offer these critical services to those who need them.

Many more young people need access to these services, which include clinical care, peer support, case management, family education, and supports for working and attending college or technical training. Numerous studies have concluded that teams including clinicians, case managers, supported education and employment counselors, peer support specialists, and others are needed to support recovery. Studies of CSC-EP in particular show improved outcomes for young people experiencing psychosis, with more individuals connected to school, work, and their family and social networks.

David Shern, Ph.D., has led this multi-year effort by the Financing Work Group of the Psychosis Risk and Early Psychosis Program Network (PEPPNET). Shern, the senior public health advisor at NASMHPD, said, “CMS recognition of CSC-EP as an effective team-based approach for serving persons with early psychosis is a game changer. It will help ensure insurance coverage for this proven treatment and ultimately save both money and lives by avoiding the lifelong disability so often associated with these illnesses.”

Ken Duckworth, M.D., the Chief Medical Officer for NAMI, said, “CSC-EP is a wave that has swept the world. This public health model involves individuals’ strengths, their families, and their personal goals. The model is well established. It works—it is state-of-the-art care. The field has advanced beyond using medication and therapy services alone for this population and has recognized that supporting employment and education motivates young people to stay connected to treatment and improves outcomes, making this model simply better.”

Tom Insel, M.D., the former head of the National Institute of Mental Health (NIMH), currently Chairman of the Board of Vanna Health, and the author of “Healing: Our path from mental illness to mental health”, stated, “The evidence for CSC-EP is strong, but payment for it is a big impediment. It's hard to get the support that’s needed for all the different parts of the CSC model; a lot of things seem to be critical. The team-based rate can allow for the continuity of care that doesn’t exist for most people with early psychosis. The key is its flexibility: it gives the treatment team leader—the quarterback—the latitude to figure out who they want on the team, which licensed and non-licensed staff. That’s important because teams’ needs will differ.”

Martin Rosenzweig, M.D., the Chief Medical Officer of Optum Behavioral Health Solutions, one of the largest managed behavioral health insurers, stated, “We recognize that providing CSC-EP can greatly improve outcomes for young people diagnosed with schizophrenia and their families and would like to cover the important supportive services like case management, supported employment, and vocational counseling that we currently do not cover in a fee-for-service model.”

Mary Giliberti, J.D., the Chief Public Policy Officer at Mental Health America, said, “We are grateful to CMS for recognizing the importance of early psychosis programs and helping create codes for better financing of these team-based services. All young people who experience symptoms of psychosis should have access to these supports to aid in their recovery. Currently, many of these young people live in places where there are wait lists or no early psychosis programs and many programs lack the funds to conduct outreach and serve all who need them.  This is an important step forward to close those gaps.”

Contact: David Shern, Ph.D., 813-373-8873, [email protected]