The Centers for Medicare & Medicaid Services has prioritized equitable behavioral health care access, proposing a new rule to cap behavioral health costs for Medicare Advantage members.

The proposed rule, scheduled to be published on Dec. 10, would require that Medicare Advantage in-network cost-sharing for mental health and substance use disorder (SUD) care not exceed cost-sharing levels in traditional Medicare.

The American Hospital Association commended CMS for its proposal.

“As enrollment in Medicare Advantage has for the first time reached more than half of all people enrolled in Medicare, it is more important than ever to establish and implement stronger consumer and beneficiary protections and curtail practices that can impede patient access to care,” Ashley Thompson, AHA Senior Vice President, said in a statement. “We appreciate that CMS’ proposed rule builds upon prior rulemaking to strengthen limitations on commercial insurer use of internal or proprietary coverage criteria that are more restrictive than Traditional Medicare and can compromise enrollee access to Medicare-covered services.”

CMS aimed to strike a balance between affordable and timely care while minimizing disruptions to Medicare Advantage enrollees’ access to care and coverage options, according to the proposed rule.

The published proposal requests comments on whether the behavioral health rule should go into effect in 2026 or 2027 and if the organization should instate a transition period. CMS also requested comments regarding how its proposed rule would impact Medicare Advantage plans’ ability to satisfy current requirements that necessitate cost-sharing to be actuarially equal to Traditional Medicare costs.

The proposal would also require Medicare Advantage plans to make provider directory information easily accessible through the Medicare Plan Finder tool and improve CMS’ oversight of Medicare Advantage marketing and communication materials, among other listed changes.

As well as mandating behavioral health care affordability, the rule aims to remove “inappropriate” prior authorization use and implement guardrails for artificial intelligence in health care. It also includes language that would expand access to weight-loss medications.

CMS has released or finalized several rules in 2024 with the potential to impact the behavioral health industry.

In August, CMS took aim at the psychiatry workforce shortage with a final rule funding new graduate medical education slots. 

In July, a new rule increased Medicare payments for inpatient psychiatric facilities. The same month, CMS increased payments for electroconvulsive therapy (ECT).

In April, CMS strengthened Medicare Advantage enrollee protections around behavioral health services.