Nov 06, 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 increasingly clear that we must swiftly improve access to effective mental health and substance use disorder (collectively called behavioral health) treatment in order to meet the growing demand for such services. For older Americans and people 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. As doctors, we have seen first-hand how behavioral health treatment can improve the health and well-being of our patients. The Centers for Medicare & Medicaid Services (CMS) is pleased to announce new finalized policies that create some of the most significant changes to promote access to behavioral health in the history of the Medicare program. 

These new policies are part of the Calendar Year 2024 Physician Fee Schedule Final Rule, Calendar Year 2024 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Final Rule with Comment Period, and Contract Year 2025 Proposed Medicare Advantage and Part D rules.

Expanding the Behavioral Health Workforce

It is imperative that we use an all-hands-on-deck approach to the behavioral health needs of Americans. This requires the help of every behavioral health practitioner to meet the behavioral health needs of every person covered by 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 has finalized procedures to allow Marriage and Family Therapists and Mental Health Counselors (including addiction counselors or alcohol and drug counselors who meet all the requirements to be a Mental Health Counselor) to enroll as Medicare providers. More than 400,000 Marriage and Family Therapists and Mental Health Counselors are now able to independently treat people with Medicare and be paid directly. For people with Medicare Advantage, we are also focused on ensuring adequate access to these newly enrolled behavioral health practitioners. CMS has recently proposed a new requirement that Medicare Advantage plans include an adequate number of Outpatient Behavioral Health facilities, which can include Marriage and Family Therapists, Mental Health Counselors, Opioid Treatment Providers, and other practitioners providing therapy and substance use disorder treatment in their provider networks.

CMS is also finalizing payment 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 professionals can create lasting impacts to help individuals with behavioral health conditions. For example, incorporating a peer support specialist with lived experience and knowledge of substance use disorders into a person’s substance use disorder treatment can inspire hope that recovery and effective treatment are possible and can help motivate a person to reach treatment goals. In fact, people receiving care from these professionals are less likely to be hospitalized for substance use disorder. These types of professionals can also help a person navigate unmet social needs that can negatively impact a person’s mental and physical health if not addressed. In the final rule, CMS has made specific changes to ensure peer support specialists' work is appropriately recognized in response to comments. 

Covering Gaps in Access to Behavioral Health

These new rules 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. Sometimes, patients need a more intense service than traditional outpatient therapy but less than the hospital-level care a hospitalization would provide. For example, a patient with debilitating depression may struggle with daily tasks but, at the same time, does not require hospitalization. For the first time, thanks to Congressional action, CMS has finalized payment 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 finalizing payments for intensive outpatient services provided by Opioid Treatment Programs (OTPs). This new benefit category would significantly expand access to behavioral health services to meet the unique needs of the patient. 

CMS has also finalized changes to promote access to behavioral health for underserved communities. We have changed the required level of supervision for behavioral health services performed at federally qualified health centers and rural health clinics to allow for “general” supervision rather than “direct” supervision. Practically speaking, this means that these behavioral health practitioners would be able to provide services without a doctor or non-physician practitioner such as a physician assistant or nurse practitioner physically on site, expanding access to behavioral health services like counseling and cognitive behavioral therapy in additional communities, particularly rural or underserved communities where care can be hard to find all the while maintaining high-quality care. 

Additionally, we've continued to allow OTPs to furnish periodic assessments 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 will implement changes to value and pay for behavioral health services more accurately. 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 essential and effective. Through the implementation of legislation, CMS will 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 will also increase payment for certain timed behavioral health services, including psychotherapy, and increase the payment rate for substance use disorder treatment furnished in the office setting in order to better reflect the costs of the counseling services.

Finally, significant amounts of the nation’s behavioral health care services are provided by primary care providers. Still, the complexity of primary and other longitudinal care has not always been reflected in Medicare payments. CMS will begin to provide additional, appropriate payments for physicians and other practitioners delivering primary and longitudinal care, which could help ensure patients get appropriate treatment and referrals for behavioral health care.


Individually, each of the changes as described here would help to make an essential contribution towards expanding access to 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.