CMS Looking to Hold Medicare Advantage Plans Accountable for Members’ Behavioral Health Needs

Private insurers offering Medicare plans to seniors may soon have more rigorous behavioral health requirements to follow.

The U.S. Centers for Medicare & Medicaid Services (CMS) on Wednesday unveiled a newly proposed rule for Medicare Advantage (MA) meant to emphasize “the invaluable role that access to behavioral health plays in whole-person care.” The move comes just two days after the federal agency released a different proposal requiring marketplace health plans to cover certain mental health and substance use disorder treatment services.

Specifically, Wednesday’s proposed rule seeks to strengthen behavioral health network adequacy requirements by adding clinical psychologists, licensed clinical social workers and prescribers of medication for opioid use disorder (OUD) to the list of evaluated specialties under MA.


“CMS released a proposed rule today that takes important steps to hold Medicare Advantage plans accountable for providing high-quality coverage and care to enrollees,” CMS Administrator Chiquita Brooks-LaSure said in a statement.

In addition to strengthening network adequacy requirements, the proposed rule seeks to set new minimum wait time standards for behavioral health and primary care services, along with more specific notice requirements from MA plans to their members when providers are dropped from their networks.

On top of that, CMS is proposing to require that most types of MA plans include behavioral health services in care coordination programs.


“These proposed protections are commonsense and critical to the physical, mental and financial stability of millions of people who choose a Medicare coverage option each year,” CMS Deputy Administrator and Director of the Center for Medicare Dr. Meena Seshamani added.

In July, CMS put forth a public request for information asking Medicare stakeholders how the program could be improved. That request, which drew almost 4,000 comments, informed Wednesday’s proposal.

Among other behavioral health-related provisions in the 957-page proposed rule, CMS is looking to “clarify that some behavioral health services may qualify as emergency services and, therefore, must not be subject to prior authorization.” That, in turn, could accelerate the delivery and reimbursement of services under MA.

CMS is additionally proposing to add a new required provider directory data element for certain providers that offer medications for OUD.

“Access to [OUD medications] can be life-saving, but too often, patients do not know how to access this type of care,” the proposed rule reads. “MA enrollees may have little insight as to which providers can provide [medications]. This problem is especially urgent, as overdose deaths from opioids have skyrocketed during the COVID-19 pandemic.”

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