Section 1. Short Title
This Act may be cited as the “TREAT for All Act,” the Tele-Mental Health Reimbursement Equity and Access to Treatment for All Act.
Section 2. Congressional Findings
Congress finds that:
-
Mental health care is essential health care.
-
Outpatient mental health care, including psychiatry, mental health therapy, counseling, psychotherapy, behavioral health treatment, substance use disorder counseling, crisis prevention, safety planning, and medication management, is a core component of the Nation’s health care system.
-
Most outpatient mental health care does not require hands-on physical procedures.
-
The principal exceptions to telehealth-appropriate outpatient mental health care include electroconvulsive therapy, inpatient psychiatric hospitalization, residential treatment requiring physical presence, crisis stabilization requiring physical supervision, physical examination when medically necessary, laboratory testing, toxicology testing, and services that cannot meet the applicable standard of care unless delivered in person.
-
Requiring in-person attendance as a condition of receiving outpatient mental health care creates barriers for rural patients, disabled patients, working patients, parents, caregivers, students, older adults, patients without reliable transportation, patients with limited broadband access, patients with limited income, and patients whose mental health symptoms make travel difficult.
-
Unnecessary in-person requirements reduce access to mental health care, delay treatment, increase missed appointments, worsen workforce shortages, and increase the public costs of untreated and undertreated mental health conditions.
-
Telehealth, including audio-video and audio-only care when clinically appropriate, is an essential access pathway for outpatient mental health care.
-
Payment reductions for telehealth mental health services discourage providers from offering telehealth, narrow provider networks, and create financial incentives that restrict access to care.
-
It is in the national interest to encourage every State to make telehealth the default mode of access for outpatient mental health care and to require reimbursement for covered tele-mental health services at rates equal to comparable in-person services.
Section 3. Purpose
The purposes of this Act are to:
-
encourage all States to enact and enforce a State-level Tele-Mental Health Reimbursement Equity and Access to Treatment Act, known as the TREAT Act;
-
make telehealth the default access pathway for outpatient mental health care nationwide;
-
prohibit unnecessary in-person requirements for outpatient mental health care;
-
protect audio-only telehealth when clinically appropriate or necessary for access;
-
require payment parity for covered outpatient mental health services delivered by telehealth;
-
preserve patient choice and individualized clinical judgment;
-
protect patients and providers from reduced access caused by state inaction; and
-
condition a portion of covered federal mental health payments on State adoption and enforcement of TREAT-compliant laws.
Section 4. Definitions
For purposes of this Act:
A. “Audio-only telehealth”
“Audio-only telehealth” means the delivery of health care services through real-time, two-way voice communication without video when the treating provider determines that the service can be delivered consistent with the applicable standard of care.
B. “Covered federal mental health payment”
“Covered federal mental health payment” means any federal payment, allotment, grant, cooperative agreement, or federal financial participation paid to or administered by a State for outpatient mental health services, behavioral health services, or substance use disorder services.
The term includes, to the extent permitted by federal law:
-
Community Mental Health Services Block Grant funds;
-
federal block grant funds used for outpatient mental health or substance use disorder treatment;
-
federal grants to a State mental health authority or behavioral health authority for outpatient mental health access;
-
federal Medicaid payments to a State attributable to outpatient mental health, behavioral health, or substance use disorder services;
-
federal Children’s Health Insurance Program payments to a State attributable to outpatient mental health, behavioral health, or substance use disorder services;
-
federal administrative payments to a State for mental health access, behavioral health access, Medicaid mental health administration, or telehealth implementation; and
-
any other state-administered federal funds designated by the Secretary as covered federal mental health payments.
The term does not include direct payments to Indian Health Service facilities, Tribal health programs, urban Indian organizations, federally qualified health centers, rural health clinics, or other non-State entities unless the payment is administered by the State.
C. “Covered outpatient mental health service”
“Covered outpatient mental health service” means any outpatient service, visit, consultation, treatment, procedure, program, or encounter covered under a mental health, behavioral health, or substance use disorder benefit that would be covered if delivered in person.
The term includes, but is not limited to:
-
psychiatric evaluation;
-
psychiatric diagnosis;
-
medication management;
-
psychotherapy;
-
mental health therapy;
-
individual counseling;
-
family counseling;
-
group counseling;
-
behavioral health treatment;
-
substance use disorder counseling or treatment;
-
crisis prevention;
-
safety planning;
-
care coordination;
-
case management;
-
intensive outpatient services;
-
partial hospitalization services when clinically appropriate for telehealth delivery;
-
community mental health center services;
-
federally qualified health center behavioral health services;
-
rural health clinic behavioral health services;
-
school-based mental health services; and
-
any substantially similar outpatient mental health or behavioral health service.
D. “Health plan”
“Health plan” means any insurer, health maintenance organization, nonprofit health service corporation, Medicaid managed care organization, managed care organization, state employee health plan, public employee health benefit plan, or other entity subject to State regulation that provides, administers, or pays for health care coverage.
The term includes third-party administrators and self-funded plans to the maximum extent permitted by federal law.
E. “Secretary”
“Secretary” means the Secretary of Health and Human Services.
F. “State”
“State” means each of the 50 States, the District of Columbia, Puerto Rico, the United States Virgin Islands, Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, and any other territory or possession of the United States receiving covered federal mental health payments.
G. “TREAT-compliant law”
“TREAT-compliant law” means a State law, regulation, or enforceable statewide policy that satisfies the minimum requirements described in Section 5 of this Act.
Section 5. Minimum Requirements for State TREAT Compliance
A State shall be considered compliant with this Act only if the State has in effect and enforces a TREAT-compliant law that, at minimum, provides the following protections.
A. Telehealth as Default Access
The State shall make telehealth the default mode of access for covered outpatient mental health services when the service can be delivered by telehealth consistent with the applicable standard of care.
B. Prohibition on In-Person Requirements
The State shall prohibit any provider, health plan, utilization review entity, licensing board, State agency, Medicaid managed care organization, or State-funded program from requiring an in-person visit as a condition of providing, covering, authorizing, renewing, continuing, prescribing for, or reimbursing a covered outpatient mental health service, unless a narrow exception applies.
C. Permitted Exceptions
The State may permit in-person requirements only for:
-
electroconvulsive therapy;
-
inpatient psychiatric hospitalization;
-
residential psychiatric treatment requiring physical presence;
-
crisis stabilization requiring physical supervision;
-
emergency detention, involuntary commitment, or custody proceedings requiring physical control, transport, or examination under State law;
-
laboratory testing, imaging, toxicology testing, vitals collection, or physical examination when physically necessary and not otherwise obtainable;
-
a service for which federal law expressly requires an in-person encounter;
-
an individualized clinical determination, documented by the treating provider, that telehealth cannot meet the applicable standard of care for that patient and service; or
-
a patient’s affirmative request for in-person care when in-person care is available.
D. Coverage Parity
The State shall require every health plan subject to State authority, every Medicaid managed care organization, the State Medicaid program, and every State-funded mental health program to cover a covered outpatient mental health service delivered by telehealth if the same or substantially equivalent service would be covered when delivered in person.
E. Payment Parity
The State shall require reimbursement for covered outpatient mental health services delivered by telehealth at a rate not less than 100 percent of the rate paid for the same or substantially equivalent service when delivered in person.
Payment parity shall apply to:
-
psychiatric evaluation and management;
-
psychiatric diagnostic evaluation;
-
psychotherapy;
-
counseling;
-
mental health therapy;
-
medication management;
-
family therapy;
-
group therapy;
-
behavioral health treatment;
-
substance use disorder counseling and treatment;
-
crisis services;
-
case management;
-
care coordination;
-
intensive outpatient services;
-
partial hospitalization services when clinically appropriate for telehealth delivery;
-
community mental health center services;
-
federally qualified health center behavioral health services;
-
rural health clinic behavioral health services;
-
bundled payments;
-
per-diem outpatient program rates;
-
professional components;
-
facility or clinic components when payable for comparable in-person care; and
-
any other covered outpatient mental health service, visit, procedure, or program.
F. Audio-Only Protection
The State shall require coverage and reimbursement of audio-only telehealth for covered outpatient mental health services when clinically appropriate or necessary for access.
Audio-only telehealth shall be protected when:
-
the patient lacks video technology;
-
the patient lacks reliable broadband;
-
the patient cannot use video technology because of disability, symptoms, privacy concerns, device limitations, language access needs, or other access barriers;
-
the patient does not consent to video communication;
-
the patient reasonably prefers audio-only communication; or
-
the treating provider determines that audio-only care is clinically appropriate.
G. No Originating-Site or Geographic Restrictions
The State shall prohibit geographic, rural-area, county-based, distance-based, facility-based, or originating-site restrictions on covered outpatient mental health services delivered by telehealth.
A patient’s home, school, workplace, shelter, community setting, residential setting, correctional setting, or any other safe and private location may serve as the originating site.
H. Provider-Patient Relationship by Telehealth
The State shall allow a provider-patient relationship for outpatient mental health care to be established by telehealth.
A prior in-person relationship shall not be required.
I. Prescribing by Telehealth
The State shall permit prescribing, ordering, and managing medication through telehealth for outpatient mental health treatment to the fullest extent permitted by federal law.
The State shall not impose an in-person requirement for prescribing unless expressly required by federal law or by an individualized clinical determination documented by the treating provider.
J. Patient Choice
The State shall preserve a patient’s right to request telehealth and a patient’s right to request in-person care when in-person care is available.
K. Enforcement
The State shall provide meaningful enforcement mechanisms, including complaint rights, appeal rights, penalties for payer noncompliance, payment of underpaid claims, and protection against retaliation.
Section 6. State Certification
-
Not later than 18 months after enactment of this Act, each State receiving covered federal mental health payments shall submit to the Secretary a certification stating whether the State has enacted and implemented a TREAT-compliant law.
-
The certification shall include:
a. the text of the State law, regulation, or enforceable statewide policy;
b. an explanation of how the State satisfies each requirement in Section 5;
c. identification of the State agencies responsible for enforcement;
d. the State’s process for patient and provider complaints;
e. the State’s process for health plan enforcement;
f. the State’s Medicaid tele-mental health coverage and payment policies;
g. the State’s audio-only telehealth policies;
h. documentation of stakeholder consultation, including consultation with mental health providers, patients, disability advocates, rural health advocates, Medicaid beneficiaries, and community mental health providers; and
i. any other information the Secretary determines necessary.
-
A State shall update its certification annually.
-
The Secretary shall publish each State certification and compliance determination on a public website.
Section 7. Federal Review and Determination of Compliance
-
The Secretary shall review each State certification and determine whether the State has enacted and implemented a TREAT-compliant law.
-
The Secretary shall issue a preliminary determination not later than 120 days after receiving a State certification.
-
If the Secretary determines that a State is not compliant, the Secretary shall provide written notice identifying each deficiency.
-
A State shall have 180 days after receiving notice to cure the deficiency.
-
After the cure period, the Secretary shall issue a final compliance determination.
-
A State may request administrative reconsideration of a final noncompliance determination in accordance with procedures established by the Secretary.
-
A State law that substantially adopts the model State TREAT Act shall be deemed compliant unless the Secretary identifies a specific conflict with the requirements of this Act.
Section 8. Ten Percent Withholding for Noncompliant States
-
Beginning with the first fiscal year that starts at least 24 months after enactment of this Act, if the Secretary determines that a State has failed to enact and implement a TREAT-compliant law, the Secretary shall reduce covered federal mental health payments to that State by 10 percent for that fiscal year.
-
The 10 percent reduction shall apply only to covered federal mental health payments.
-
The reduction shall continue for each fiscal year in which the State remains noncompliant.
-
The Secretary shall restore full covered federal mental health payments beginning with the first fiscal quarter after the Secretary determines that the State has enacted and implemented a TREAT-compliant law.
-
A reduction under this section shall not be construed to authorize a State, health plan, Medicaid managed care organization, provider, or contractor to reduce, deny, delay, or terminate medically necessary mental health care for any individual.
-
A State subject to a reduction under this section shall maintain coverage, reimbursement, and access for eligible patients using State funds or other available funds.
-
A State may not reduce provider reimbursement, narrow eligibility, reduce covered benefits, or impose new patient cost sharing as a means of offsetting a reduction under this section.
-
A State subject to a reduction shall submit to the Secretary a corrective access plan explaining how the State will prevent harm to patients and providers during the period of noncompliance.
Section 9. Reallotment and Use of Withheld Funds
-
Amounts withheld under Section 8 shall remain available to the Secretary for grants to compliant States, local governments, Tribal organizations, community mental health centers, federally qualified health centers, rural health clinics, school-based mental health programs, and nonprofit providers to expand tele-mental health access.
-
Priority shall be given to projects that:
a. expand tele-mental health access in rural areas;
b. expand access for disabled patients;
c. expand audio-only access for patients without broadband or video technology;
d. support community mental health providers;
e. reduce wait times for outpatient mental health care;
f. improve access for Medicaid beneficiaries;
g. expand culturally competent and language-accessible mental health services;
h. support school-based mental health services;
i. improve telehealth access for older adults;
j. improve telehealth access for children and adolescents; or
k. support technology and workflow improvements for small and safety-net mental health providers.
-
Withheld funds shall not revert to the Treasury if they can be used to expand tele-mental health access under this section.
Section 10. Maintenance of Effort
-
A State receiving covered federal mental health payments shall maintain State expenditures for outpatient mental health services, behavioral health services, and substance use disorder services at a level not less than the average level of such expenditures for the two fiscal years preceding the fiscal year for which payment is sought.
-
A State may not use federal funds made available under this Act to supplant State funds.
-
The Secretary may waive all or part of the maintenance-of-effort requirement for a fiscal year if the Secretary determines that extraordinary economic conditions in the State justify the waiver and that the waiver will not reduce access to outpatient mental health care.
Section 11. Protection of Individual Benefits
-
Nothing in this Act shall be construed to reduce an individual’s entitlement to Medicaid, the Children’s Health Insurance Program, or any other federal health benefit.
-
No individual shall be denied eligibility, coverage, treatment, medication, therapy, counseling, crisis care, or other medically necessary mental health care because a State is subject to a reduction under Section 8.
-
No provider shall be denied payment for a covered service furnished to an eligible individual solely because a State is subject to a reduction under Section 8.
-
The Secretary shall enforce this section to ensure that any funding reduction is borne by the noncompliant State and not by patients or providers.
Section 12. Medicaid and CHIP State Plan Requirements
-
As a condition of receiving covered federal mental health payments under Medicaid or the Children’s Health Insurance Program, a State plan or waiver shall provide that covered outpatient mental health services may be delivered by telehealth when clinically appropriate.
-
A State Medicaid program and Children’s Health Insurance Program shall not impose in-person requirements for covered outpatient mental health services except as permitted under Section 5(C).
-
A State Medicaid program and Children’s Health Insurance Program shall reimburse covered outpatient mental health services delivered by telehealth at a rate not less than 100 percent of the rate paid for the same or substantially equivalent service delivered in person.
-
Medicaid managed care organizations and CHIP managed care organizations shall comply with this Act as a condition of contracting with the State.
-
The Secretary may issue guidance, regulations, State Medicaid Director letters, and model State plan amendment language to implement this section.
Section 13. Private Insurance and ERISA Savings Clause
-
A State shall apply its TREAT-compliant law to all health plans subject to State regulation.
-
Nothing in this Act shall be construed to limit a State’s authority to regulate insurance, health maintenance organizations, Medicaid managed care organizations, public employee health plans, or any other health coverage subject to State law.
-
This Act applies to self-funded employee benefit plans only to the extent permitted by federal law.
-
Nothing in this Act shall be construed to reduce or preempt any stronger State law that provides broader telehealth access, stronger payment parity, broader audio-only protection, or greater mental health coverage.
Section 14. Rulemaking
-
Not later than 180 days after enactment, the Secretary shall issue interim final regulations to implement this Act.
-
Final regulations shall be issued not later than 1 year after enactment.
-
Regulations shall include:
a. model State TREAT Act language;
b. certification procedures;
c. compliance review procedures;
d. public reporting requirements;
e. withholding procedures;
f. reallotment procedures;
g. Medicaid and CHIP implementation guidance;
h. enforcement procedures;
i. patient and provider complaint processes; and
j. standards for determining whether audio-only telehealth is protected.
-
The Secretary shall consult with:
a. State mental health authorities;
b. State Medicaid agencies;
c. State insurance regulators;
d. mental health providers;
e. community mental health centers;
f. federally qualified health centers;
g. rural health clinics;
h. disability rights organizations;
i. patient advocates;
j. Tribal health organizations;
k. youth mental health advocates;
l. substance use disorder treatment providers; and
m. privacy and civil rights experts.
Section 15. Annual Reports to Congress
-
Not later than 2 years after enactment, and annually thereafter, the Secretary shall submit a public report to Congress on implementation of this Act.
-
The report shall include:
a. each State’s compliance status;
b. States subject to withholding;
c. amounts withheld from each noncompliant State;
d. amounts reallotted under Section 9;
e. tele-mental health utilization data;
f. audio-only telehealth utilization data;
g. outpatient mental health wait-time data, where available;
h. Medicaid and CHIP tele-mental health access data;
i. complaint and enforcement data;
j. provider network adequacy data;
k. rural access data;
l. disability access data;
m. recommendations for improving tele-mental health access; and
n. recommendations for additional congressional action.
Section 16. Enforcement
-
The Secretary may enforce this Act through audits, corrective action plans, payment reductions, grant conditions, Medicaid and CHIP oversight, civil monetary penalties where authorized, and any other remedy available under federal law.
-
The Secretary may require a State to submit documents, claims data, plan documents, provider manuals, reimbursement schedules, utilization management criteria, Medicaid managed care contracts, and other materials necessary to determine compliance.
-
A State that knowingly submits a false certification under this Act shall be subject to all remedies available under federal law.
-
The Secretary shall establish a public complaint process through which patients, providers, advocates, and health plans may report State noncompliance.
-
The Secretary shall investigate credible complaints and publish aggregate complaint data annually.
Section 17. No Retaliation
-
A State, health plan, Medicaid managed care organization, provider, contractor, or other entity shall not retaliate against any patient, provider, facility, program, or advocate for asserting rights under this Act.
-
Prohibited retaliation includes termination, nonrenewal, reduced reimbursement, denial of claims, exclusion from a network, adverse licensing action, adverse credentialing action, harassment, or any other penalty related to asserting rights under this Act.
Section 18. Construction
-
This Act shall be liberally construed to promote access to outpatient mental health care.
-
Nothing in this Act shall be construed to:
a. require telehealth when telehealth would violate the applicable standard of care;
b. prohibit a patient from requesting in-person care;
c. prohibit a provider from offering in-person care;
d. authorize a service prohibited by federal law;
e. authorize prescribing prohibited by federal law;
f. reduce privacy protections under federal or State law;
g. reduce mental health parity protections under federal or State law;
h. reduce disability rights protections under federal or State law;
i. reduce Medicaid or CHIP beneficiary protections; or
j. preempt stronger State telehealth protections.
-
If another federal or State law provides broader telehealth access, stronger payment parity, broader audio-only protection, or greater mental health access, the more protective provision shall control.
Section 19. Severability
If any provision of this Act, or the application of any provision to any person, entity, State, program, payment, or circumstance, is held invalid, the invalidity shall not affect any other provision or application of this Act that can be given effect without the invalid provision or application.
Section 20. Effective Date
-
This Act shall take effect on the date of enactment.
-
State certification requirements shall begin 18 months after enactment.
-
The 10 percent withholding under Section 8 shall begin with the first fiscal year that starts at least 24 months after enactment.
-
The Secretary may issue implementation guidance immediately upon enactment.
