We recently wrote about how the Centers for Medicare and Medicaid Services (CMS) Final Rule changes redefined how MAOs approach member communications–but CMS changes aren’t stopping there.
Recognizing the urgent need for better access to mental health services, CMS has recently implemented a comprehensive Behavioral Health Strategy. This strategy zeroes in on:
- Expanding substance use disorder treatment
- Ensuring effective pain management
- Improving overall access to mental health care for Medicare beneficiaries
For Medicare Advantage Organizations (MAOs), this strategy marks a transformative shift in how they approach behavioral health services—and signals an opportunity to better support members through integrated mental health care.
The Mental Health Care Access Crisis for Medicare Beneficiaries
The growing need for more expansive mental health support among Medicare beneficiaries is clear, with nearly one in four Medicare participants experiencing mental health conditions such as depression, anxiety, and schizophrenia. However, only 40% – 50% of these individuals receive treatment, leaving a significant portion of the population underserved. The COVID-19 pandemic further exacerbated mental health challenges, increasing anxiety, depression, and substance use across the board.
This surge in mental health conditions among Medicare enrollees is compounded by a lack of accessible care and services.
Currently, only about 60% of psychiatrists are accepting new patients, which is 21% lower than the general/family practice acceptance rate. Additionally, a larger percentage of psychiatrists have opted out of Medicare entirely compared to other specialists, leaving fewer options for those seeking mental health care under Medicare plans.
For Medicare Advantage (MA) beneficiaries, these access issues are particularly acute. A significant portion must seek care from out-of-network providers, which raises costs and limits availability. Rural beneficiaries, meanwhile, often face even greater challenges in finding in-network providers nearby.
These access issues underscore the importance of CMS’s recent changes, which aim to bridge these gaps and improve mental health outcomes for Medicare beneficiaries.
CMS’s Behavioral Health Strategy: Key Areas of Focus
CMS’s Behavioral Health Strategy aligns with its broader commitment to four core health outcome domains: coverage and access, quality of care, equity and engagement, and data and analytics. The strategy targets three primary areas to address the lack of adequate mental health care:
- Substance Use Disorder Prevention and Recovery: CMS is prioritizing expanded access to substance use disorder (SUD) treatment, recognizing the increasing use of alcohol and opioids among older adults.
- Pain Management: Effective pain management has been a long-standing need for many Medicare beneficiaries. CMS’s approach includes broadening treatment options that are less reliant on opioids and more focused on comprehensive pain care.
- Enhanced Mental Health Services: CMS is implementing policies to integrate mental health services more fully into overall care strategies, improving access to mental health professionals and expanding coverage for telehealth and other services.
CMS Changes Impacting Mental Health Care
CMS includes several specific changes designed to enhance access to mental health services for Medicare beneficiaries. These updates are especially relevant for MAOs as they prepare to implement changes that bring behavioral health care in closer alignment with physical health care.
Expanded Telehealth Services
CMS made permanent the expanded telehealth coverage, which was initially introduced during COVID-19. MA plans now have increased flexibility to offer telehealth services, making mental health care more accessible than ever for members who struggle with in-person appointments. This flexibility allows MAOs to offer behavioral health services beyond the traditional scope, which is critical for those in rural or underserved areas.
New Network Adequacy Standards for Behavioral Health Providers
CMS has added three new specialties to its network adequacy standards for MA plans: Licensed Clinical Social Workers, Clinical Psychologists, and Outpatient Behavioral Health providers. By setting specific network adequacy requirements for these specialties, CMS seeks to ensure that beneficiaries have better access to qualified mental health professionals. This change highlights the agency’s emphasis on creating a robust mental health care network within MA plans.
Reimbursement for Licensed Professional Counselors
In a significant shift, CMS is now extending reimbursement to licensed professional counselors, including marriage and family therapists, addiction counselors, and mental health counselors. This change opens access to more than 400,000 additional providers, which is expected to help alleviate the provider shortage in mental health. This policy aims to broaden the scope of mental health care available to Medicare beneficiaries, ultimately helping to bridge longstanding gaps in access.
Intensive Outpatient Program (IOP) Coverage
Starting in 2024, CMS began covering Intensive Outpatient Programs (IOPs), which provide structured treatment for individuals requiring 9-19 hours of therapeutic services per week. IOPs fill the gap between standard outpatient therapy and more intensive inpatient care, offering services such as individual and group counseling, crisis intervention, and medication management. This change allows Medicare beneficiaries access to a continuum of care tailored to varying levels of need, promoting whole-person care for those with mental health and substance use disorder conditions.
Increased Payment for Crisis Services
Recognizing the importance of behavioral health crisis care, CMS will now reimburse crisis intervention services at 150% of the usual fee when provided outside of clinical settings. This change acknowledges the value of meeting patients where they are and ensures that providers are fairly compensated for this essential type of care.
MA Plan Benefits: A Look at Mental Health Coverage
MA plans have the flexibility to offer additional benefits beyond those covered by traditional Medicare. While this flexibility allows MA plans to tailor benefits for members, the availability of specific mental health and substance use disorder benefits remains limited. For instance, in 2022, only 12% of MA enrollees had access to plans offering extra psychiatric hospital services, and just 6% were in plans with reduced cost sharing for mental health conditions such as mood disorders or opioid use disorders.
Additionally, while MA plans can offer Chronic Condition Special Needs Plans (C-SNPs) focused on serious mental illnesses, the number of these plans is quite small. As of 2024, only four of the 1,200 available C-SNPs specifically serve beneficiaries with severe mental health conditions, covering around 1,800 enrollees in total. This limited scope highlights a potential area for growth within the MA market to better meet the needs of beneficiaries with chronic mental health conditions.
The Consolidated Appropriations Act of 2023 also requires the Government Accountability Office (GAO) to release a report by 2025 that will provide insights into behavioral health benefits in both traditional Medicare and MA plans. This report will review cost-sharing structures, the scope of mental health benefits, and CMS oversight, which could further influence the mental health services offered by MA plans in the future.
CMS’s increased focus on mental health care presents MAOs with new opportunities to enhance the services they provide to beneficiaries. By aligning with CMS’s updated policies, expanding telehealth options, and strengthening provider networks, MAOs can play a meaningful role to improve access to mental health care.
How Toppan Merrill Can Help
Toppan Merrill helps MAOs prepare annual member-facing and marketing materials each year, so your sales force and membership have the necessary resources. From document creation and management to sales enablement, omnichannel communications, printing services, and more, we deliver best-in-class solutions that help you respond quickly to changes in regulations, member needs, and markets.
