Medicare beneficiaries may have trouble accessing behavioral health care, as clinicians in that field make up a sizable portion of all practitioners who opt out of the program.
About 43% of the 28,000 providers who refuse Medicare reimbursement work in behavioral health disciplines such as psychiatry, clinical social work, addiction medicine and psychology, among others according to new data from the Centers for Medicare & Medicaid Services (CMS).
“This means that neither the physician nor the beneficiary submits the bill to Medicare for services rendered,” CMS indicated on its website. “Instead, the beneficiary pays the physician out-of-pocket and neither party is reimbursed by Medicare.”
The data, which CMS updates monthly, applies to individual providers who opt out and doesn’t include facilities or other care institutions.
The three largest segments of behavioral health providers to opt out of Medicare, compared to all providers, were psychologists (16.9%) and psychiatrists (15.1%) of all types and clinical social workers (10.7%).
About 124,400 practitioners in behavioral health-related fields do accept Medicare reimbursements, according to CMS data for 2020, the most recent full-year numbers available. In total, about 1.4 million providers accepted Medicare reimbursement across all specialties in the U.S.
CMS has resolved to study the apparent lack of access to behavioral health providers within Medicare.
At the beginning of the year, CMS released a request for information seeking to better understand why Medicare Advantage plans may struggle to meet network requirements for behavioral health providers. The request was part of a proposed rule that would change how insurers operate Medicare Advantage and Medicare prescription drug plans.
Medicare Advantage is a privately administered version of Medicare, 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.
While CMS doesn’t comment on matters under consideration for future rulemaking, the agency has said that plans are not meeting the network adequacy standards set up in June 2020 — “despite requiring a minimum number of behavioral health providers and encouraging use of telehealth providers.”
Some reasons that Medicare Advantage providers aren’t able to find enough behavioral health providers for their networks include a diminishing psychiatrist workforce in the U.S.; low reimbursement rates; and potential administrative burdens to participating in the program, according to previous reporting by Behavioral Health Business.
