Medicare Revolutionizing Behavioral Health Access: What Providers Need to Know

In the wake of the global COVID-19 pandemic, the intricacies of healthcare have taken on a new dimension, revealing gaps and areas in need of fortification. Among these critical concerns, mental and behavioral health has emerged as a vital aspect that requires heightened attention. The pandemic underscored the profound impact that psychological well-being has on overall health, highlighting the necessity for comprehensive care.

As the world gradually emerged from the COVID-19 crisis, it became increasingly evident that healthcare systems must evolve to address the full spectrum of health, including mental and emotional dimensions. CMS (Centers for Medicare & Medicaid Services) has therefore come up with new policies as a part of the Physician Fee Schedule and Hospital Outpatient Prospective Payment System rules. From expanding the workforce to embracing community health integration and improved payment structures, these proposed policies will create some of the most significant changes to enhance access to behavioral health in the recent history of CMS. This blog delves into these new policies, and the potential implications for healthcare providers, and the broader impact on the industry that will follow once the policies are enforced.  

These proposed changes, part of the Physician Fee Schedule and Hospital Outpatient Prospective Payment System rules, include the following main points

Expanding the Behavioral Health Workforce: CMS is putting forth a proposal to address the shortage of behavioral health providers. This includes allowing Marriage and Family Therapists, Mental Health Counselors, and qualified Addiction Counselors to enroll as Medicare providers. This move has the potential to benefit more than 400,000 practitioners. These professionals would be able to treat Medicare beneficiaries independently and receive direct payment for their services. This expansion of the workforce could significantly improve access to behavioral health care. 

Community Health Integration and Principal Illness Navigation Services: CMS recognizes the importance of addressing not only medical needs but also social determinants of health. To this end, they propose paying for services provided by community health workers and peer support specialists. These workers can play a crucial role in helping individuals with behavioral health conditions, as well as addressing unmet social needs that impact overall health. For example, involving peer support specialists who have personal experience with substance use disorders can inspire hope and encourage individuals to reach treatment goals. It’s noteworthy that individuals receiving care from these workers are less likely to be hospitalized for substance use disorder. 

Covering Gaps in Access to Behavioral Health: CMS acknowledges that there are gaps in coverage for certain levels of behavioral health care. While Medicare historically covered services like psychiatric hospitalization, partial hospitalization, and outpatient therapy, an intermediate level of care has been lacking. This intermediate level, known as the “Intensive Outpatient Program” (IOP), is proposed to be covered for the first time. This would cater to patients who require more intense treatment than outpatient therapy but do not need hospitalization. The proposed coverage of IOP services extends to various healthcare settings, including hospital outpatient departments and mental health clinics, effectively expanding access to much-needed services. 

Access for Underserved Communities: The numerous challenges faced by underserved communities in accessing behavioral health care are a sad reality. To address this, CMS proposes changing the supervision requirements for behavioral health services provided in specific settings like Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). This change would allow general supervision instead of direct supervision, potentially expanding access to counseling and cognitive behavioral therapy. Additionally, CMS suggests continuing to allow certain services to be delivered via telephone or audio-only technology. This accommodation aims to improve access to care, particularly in areas where stable broadband options are limited. 

Accurate Payment for Services: CMS recognizes the importance of accurate payment for behavioral health services. They propose increasing payment rates to better reflect the value of services provided. For crisis services provided outside clinical settings, CMS suggests raising the payment value for psychotherapy to 150% of the usual Physician Fee Schedule rate. This increase is intended to better align payment with the costs that practitioners incur while delivering these critical services. Similarly, CMS aims to raise payment rates for substance use disorder treatment and psychotherapy services, acknowledging the significance of these services in behavioral health care. 

Primary Care Providers and Behavioral Health Care: Primary care providers play a crucial role in delivering behavioral health care. They propose additional payments to account for the complexity of providing primary and longitudinal care. This change is aimed at ensuring that patients receive appropriate treatment and referrals for behavioral health care within the Medicare system. By appropriately compensating primary care providers, CMS aims to encourage better integration and coordination between PCPs and behavioral health care. All of this to ultimately help Medicare beneficiaries receive proper benefits. 

These changes are still in their proposed stages and CMS has given a timeline up till September 11, 2023, for public comments. But we can say for sure that these changes (with minor modifications after public comments) will eventually transform into real regulations and declarations. Let’s look at how it affects the providers and other stakeholders in the industry.  

Implications of these Policies  

Every change in regulations brings with it a barrage of new tasks. These new tasks, integrations, and upgrades are necessary to incorporate the changes in regulations. Here are some examples:  

  • EHR updates: With the expansion of the workforce to include Marriage and Family Therapists, Mental Health Counselors, and qualified Addiction Counselors as Medicare providers, providers may need to adapt their technology systems to accommodate these additional practitioners. This will involve updating electronic health records (EHR) systems, and communication tools to ensure seamless but also compliant integrations, of new providers into their workflows. 
  •  Integrations with systems: Incorporating community health workers and peer support specialists into the care team may necessitate the implementation of communication and collaboration tools to facilitate coordination between different types of providers. Providers will need to adopt technology platforms that allow for the secure sharing of patient information and updates, ensuring that all team members are on the same page regarding patients’ progress and needs. 
  •  Telehealth and RPM: The introduction of coverage for the “Intensive Outpatient Program” (IOP) and the expansion of access in various healthcare settings will require providers to establish or enhance telehealth capabilities. Telehealth platforms and remote monitoring tools need to be integrated to support the delivery of IOP services, especially in cases where patients cannot physically attend sessions due to distance or other factors. 
  •  Compliance and quality changes: The proposed changes in supervision requirements and the allowance for telehealth services will prompt providers to evaluate and upgrade their technology infrastructure. This will involve enhancing telehealth platforms, and ensuring that all audio-only and video services are HIPAA-compliant.  
  •  Reconfigured RCM system: As payment rates are set to increase for various behavioral health services, providers will need to update their billing and documentation systems to reflect these changes. This involves reconfiguring billing codes and reimbursement processes in existing RCM solutions. All to ensure that providers receive appropriate compensation for the services they deliver. 
  •  Connecting PCPs with behavioral health care: Providers delivering primary and longitudinal care will likely need to coordinate with a behavioral healthcare practitioner to make sound judgments and vice-versa. They will have to integrate behavioral health data into existing EHR systems, ensuring that behavioral health information is accessible and visible to primary care providers, and vice versa.   

Stepping into the Future 

In conclusion, CMS’s proposed changes aim to significantly improve behavioral health care for Medicare beneficiaries. These changes collectively address workforce expansion, service coverage gaps, accurate payment, and access for underserved populations. The public comment period for these proposed policies ends on September 11, 2023. Feedback is encouraged to shape these changes and strengthen behavioral health care for all Medicare recipients. 

As a provider or a HIT vendor these changes can result in a lot of technological changes to their systems. We, at Nalashaa have to expertise to accurately evaluate your system and develop the necessary changes and integrations. Connect with us at 

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Mitrajit Das

Mitrajit Das

A writer with a keen interest in the Healthcare domain and B2B content marketing. He enjoys writing and creating pieces around the latest Healthcare IT trends using the simplest of words.
Mitrajit Das

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