CMS Looks for Guidance as Medicare Advantage Plans Struggle to Build Behavioral Health Networks

The Centers for Medicare and Medicaid Services is looking into why Medicare Advantage plans have apparently struggled to add behavioral health providers to their networks.

Last week, CMS announced that it issued a proposed rule that would change how insurers operate Medicare Advantage and Medicare prescription drug plans.

But within the same proposed rule, CMS also said that it was requesting information from industry stakeholders about why Medicare Advantage plans struggled to meet previously issued requirements to have behavioral health providers in their networks of providers.


Medicare Advantage is a privately administered version of the government health plan for those aged 65 and older. Over 27 million people receive health benefits through a Medicare Advantage plan, according to CMS. The three largest operators in the Medicare Advantage space are UnitedHealth Group Inc. (NYSE: UNH), Humana Inc. (NYSE: HUM) and the Blue Cross Blue Shield plans.

In June 2020, CMS issued a rule that required Medicare Advantage plans to offer more providers in their network for enrollees even if that meant offering them via telehealth for certain specialties. This included access to psychiatrists and inpatient psychiatric facility services.

“However, despite requiring a minimum number of behavioral health providers and encouraging use of telehealth providers, CMS understands that [Medicare Advantage] organizations may experience difficulties when building an adequate network of behavioral health providers,” CMS states in the proposed rule.


The comments that CMS receives will help the top federal health care regulator understand the specific challenges Medicare Advantage plans have when providing enrollees access to behavioral health specialties.

CMS states in its proposed rule that comments can include issues related to geographic provider supply issues, challenges with wait times for appointments, unwillingness or inability of providers to participate in Medicare Advantage plans, the impact that other CMS policies have on building behavioral health networks and the extent to which behavioral health networks matter to prospective enrollees.

The proposed rule also calls for comments to include “opportunities to expand services for the treatment of opioid addiction and substance use disorders.”

The proposed rule states that comments must be provided by March 7.

This latest rule announcement is just one of many actions taken by the federal government meant to impact how Medicare enrollees experience behavioral health.

The inspector general’s office of the U.S. Health and Human Services Department, CMS’ parent organization, released a report in August that found Medicare Medicare beneficiaries could be struggling to access medication-assisted treatment (MAT) and opioid overdose reversal drugs like naloxone. Earlier that month, CMS announced a reimbursement raise for inpatient psychiatric facilities. 

In November, CMS changed how and where Medicare beneficiaries could receive telehealth services for behavioral health conditions. Many in the industry saw the move as a signal of wider and permanent adoption of telehealth in behavioral and an indication that all payers would welcome telehealth in the future.

Last month, CMS released data from 2020 that shows a 3,090% increase in the number of behavioral health visits that were facilitated by telehealth compared to 2019 — which was driven by the coronavirus pandemic.

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