Federal regulations announced this month show the current administration’s ongoing commitment to improving behavioral health access. Last week, the Centers for Medicare & Medicaid Services (CMS) finalized its regulations governing Medicare Advantage (MA) plan participation in 2025, imposing new requirements to broaden access to behavioral health networks and regulate ghost networks. This is the latest in the administration’s push to prioritize behavioral health access and reimbursement, as highlighted in President Biden’s 2025 Budget. It also follows an increased focus by Congress on Medicare and Medicaid members’ lack of access to behavioral health.
Medicare already regulates access for four behavioral health provider types in Medicare Advantage: Psychiatry, Clinical Psychology, Clinical Social Work and Inpatient Psychiatric Facility services. Regulations published this month establish a new facility-specialty category of “Outpatient Behavioral Health,” which must meet the same time and distance requirements and minimum number standards as other facility types. This category will include Marriage and Family Therapists, Mental Health Counselors, Opioid Treatment Program providers, Community Mental Health Centers, addiction medicine physicians and other providers.
Federal regulators also took their first steps to regulate ghost networks in Medicare Advantage. CMS will require that for any advanced practice practitioners listed for Outpatient Behavioral Health, MA plans must submit information sufficient to verify that the provider has or will furnish one or more of the specified psychotherapy or medication prescription to at least 20 patients within a 12-month period. Note how Medicare is imposing heightened participation requirements on behavioral health networks. Expect more scrutiny in this space as regulators and lawmakers consider the role of the federal government to enforce higher standards for network adequacy.
These developments are consistent with the recent spotlight of behavioral health access in federal regulatory strategy. The president’s proposed 2025 budget is a key example of this, in which the administration asked Congress for an investment of $72 billion over 10 years in behavioral health. These investments and focus areas included mental health parity enforcement, behavioral health information technology and interoperability, and infrastructure for community-based mental heath care. The budget also contains noteworthy examples of the administration’s intent to expand its authority. CMS requested that Congress apply the Mental Health Parity and Addiction Equity Act to Medicare (an exclusion that dates back nearly 30 years) and confer authority to modernize the Medicare mental health benefits package.
“The future of behavioral health will rest upon a bedrock of technology that drives interoperability, care management and access to care.”
Nick Bluhm, JD – Vice President of Legal & Regulatory
The Biden administration is not alone in its focus on behavioral health access. The Office of Inspector General (OIG), a congressional agency, released a report last month calling on regulators to take steps to encourage more behavioral health providers to serve Medicare and Medicaid enrollees. The OIG suggested that Medicare consider benefit design and network adequacy standards as potential tools to increase the use of behavioral health covered by Federal Health Care Programs. In these suggestions, bipartisan agreement was clear.
At Lucet, we believe that these are significant advancements that complement the ongoing regulatory activity in exchange marketplaces and commercial insurance to advance mental health parity and network adequacy. The future of behavioral health will rest upon a bedrock of technology that drives interoperability, care management and access to care. Health plans will reconsider how they offer behavioral health benefits and networks, approaching this challenge in response to three forces:
- Increased regulatory expectations, reporting and restrictions on the use of traditional managed care tools,
- next-generation provider partnerships to enable access and quality, and
- the increased adoption of technology tools to match individuals to appropriate benefits, outpatient providers, and extended clinical programs.
Nick Bluhm, JD is vice president of legal and regulatory at Lucet, The Behavioral Health Optimization Company.
