Jul 14, 2023

Important New Changes to Improve Access to Behavioral Health in Medicare

Meena Seshamani, MD, PhD, and Douglas Jacobs, MD, MPH

As we emerge from the COVID-19 public health emergency, it is abundantly clear that our nation must improve access to effective mental health and substance use disorder (collectively called “behavioral health”) treatment and care. For older Americans and individuals with disabilities enrolled in Medicare, many individuals have felt the effects of worsening depression and anxiety or have struggled with the use of substances like opioids or alcohol. And, as doctors, we have seen first-hand how behavioral health treatment can improve the health and well-being of our patients.

This is why the Centers for Medicare & Medicaid Services (CMS) is pleased to announce new proposed policies that, if finalized, will create some of the most significant changes to promote access to behavioral health in the history of the Medicare program. These new policies are proposed as part of the Physician Fee Schedule and Hospital Outpatient Prospective Payment System rules.

Expanding the Behavioral Health Workforce

We need the help of every behavioral health practitioner to meet the behavioral health needs of every person with Medicare. Marriage and Family Therapists and Mental Health Counselors provide essential services, such as psychotherapy and group therapy — but to date, they could not enroll as Medicare providers. Following Congressional action, CMS is proposing procedures to allow Marriage and Family Therapists and Mental Health Counselors (including Addiction Counselors who meet all the requirements to be a Mental Health Counselor) to enroll as Medicare providers, which means that the more than approximately 400,000 Marriage and Family Therapists and Mental Health Counselors would now be able to independently treat people with Medicare and be paid directly.  

CMS is also proposing to pay for community health integration and principal illness navigation services that can be provided by community health workers and peer support specialists when unmet social needs, such as food, housing, or transportation problems interfere with health care. These workers can significantly help individuals with behavioral health conditions. For example, incorporating a peer support specialist who has lived experience and knowledge of substance use disorders into a person’s substance use disorder treatment can inspire hope that recovery and effective treatment is possible and can help motivate a person to reach treatment goals. In fact, people receiving care from these workers are less likely to be hospitalized for substance use disorder. These types of workers can also help a person navigate unmet social needs that can negatively impact a person’s mental and physical health if not addressed.

Covering Gaps in Access to Behavioral Health

CMS’ proposals would also close the gap in the types of behavioral health services covered by Medicare. Medicare has historically covered and will continue to cover services such as psychiatric hospitalization for people with acute psychiatric needs, partial hospitalization (a service that allows a patient to get inpatient hospital-level treatment during the day), and outpatient therapy. But sometimes patients need a more intense service than outpatient therapy, but less than the level of hospital-level care a hospitalization would provide — for example, a patient with debilitating depression, which causes them to struggle with daily tasks, but at the same time does not require hospitalization. For the first time, thanks to Congressional action, CMS is proposing to pay for this intermediate level of care, called “Intensive Outpatient Program” (IOP), which can be performed by hospital outpatient departments, community mental health clinics, Federally Qualified Health Centers, or Rural Health Clinics. CMS is also proposing to provide payments for intensive outpatient services provided by opioid treatment programs. This new benefit category would significantly expand access to behavioral health services.

CMS is also proposing changes to promote access to behavioral health for underserved communities. We are proposing to change the required level of supervision for behavioral health services furnished “incident to” a physician or NPP’s services at RHCs and FQHCs to allow general supervision, rather than direct supervision. We believe this could expand access to counseling and cognitive behavioral therapy, particularly in rural or underserved communities where care can be hard to find. Additionally, we propose to continue to allow opioid treatment providers to provide certain services via telephone or audio-only technology, which could improve access to care, particularly in rural and other underserved areas challenged by stable broadband options.

Paying More Accurately for Behavioral Health Services

Finally, CMS is proposing changes to more accurately value and pay for behavioral health services. When a person has significant psychological distress, crisis services may be necessary. Crisis services outside of clinical settings — where behavioral health practitioners meet patients in crisis where they are — can be especially important and effective. Through the implementation of legislation, CMS is proposing to increase the value of psychotherapy for crisis services to pay 150% of the usual Physician Fee Schedule rate when this crisis care is provided outside of health care settings, which better reflects the costs that behavioral health practitioners incur to provide these services. CMS is also proposing to increase the payment rate for substance use disorder treatment in order to better reflect the costs of the counseling services and to increase payment for psychotherapy services.

Finally, significant amounts of the nation’s behavioral health care services are provided by primary care providers. Still, CMS has not always accounted for the complexity of primary and other longitudinal care with Medicare payments. CMS is now proposing to provide additional, appropriate payments for providers delivering primary and longitudinal care, which could help ensure patients get appropriate treatment and referrals for behavioral health care.


Individually, each of the proposed changes we have described here would help to make an essential contribution towards strengthening behavioral health care for people with Medicare, and taken as a whole, we are optimistic that we can make a profound and sustained difference in the behavioral health treatment of millions of Americans.

But the best, most informed path forward is only possible with thoughtful feedback. The comment period for each rule expires in 60 days, ending on September 11, 2023 for the Physician Fee Schedule and September 11, 2023 for the Outpatient Prospective Payment System. Please submit comments before then, so that together we can best strengthen behavioral health care for everyone with Medicare.