Behavioral Healthcare Expansion Under Medicare – CMS Proposed

 Wayne Carter RCM
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Explore the New Updates on CMS Proposed Expansion of Behavioral Healthcare Under Medicare

On July 13, 2023, the Centers for Medicare & Medicaid Services (CMS) unveiled a groundbreaking proposal designed to significantly expand behavioral health coverage under Medicare. This proposal, a vital component of the calendar year 2024 Medicare Physician Fee Schedule (PFS), seeks to bring transformative changes to the landscape of behavioral healthcare for Medicare beneficiaries.

CMS Behavioral Health Strategy

The primary driving force behind these proposed changes is the need for an improved CMS behavioral health strategy that enhances access to mental healthcare and substance abuse treatment. The COVID-19 pandemic has spurred a surge in symptoms of anxiety, depression, and other mental health disorders across the United States. Simultaneously, studies have underscored a substantial increase in substance abuse issues during the pandemic. Recognizing the vulnerability of many Medicare and Medicaid recipients to these issues, CMS is taking proactive steps to expand behavioral healthcare coverage as part of its comprehensive CMS behavioral health strategy.

Current Gaps in Coverage

Currently, CMS covers mental health treatments in both inpatient and outpatient settings, along with prescription drugs for mental health conditions. However, significant Medicare mental health coverage gaps persist and must be addressed comprehensively. For instance, certain mental health practitioners, such as family therapists and mental health counselors, are excluded from enrolling as Medicare providers. This limitation restricts beneficiary access to a broad spectrum of qualified professionals. Moreover, Medicare does not encompass intensive outpatient programs (IOPs), a critical intermediate level of care that bridges the gap between outpatient therapy and hospitalization.

Another pressing challenge is equitable access to mental health services in rural and underserved communities. These areas often grapple with a shortage of mental health practitioners, aggravated by the fact that many practitioners do not participate in public funding programs due to low reimbursement rates.

CMS Behavioral Health Billing Guidelines

The proposed changes outlined in the 2024 PFS aim to address these issues head-on. CMS envisions broadening access to mental health professionals by allowing clinical social workers, marriage and family therapists, and mental health counselors to provide health behavior assessment and intervention services through CMS programs. Additionally, licensed professional counselors, addiction counselors, and marriage and family therapists will be able to enroll in Medicare, significantly enhancing access to mental healthcare providers.

Furthermore, the proposal introduces an entirely new benefit category—an intensive outpatient program (IOP) for behavioral health. This innovative step offers beneficiaries another avenue for mental healthcare, aligning with CMS’s strategy to enhance the scope of services and conform to CMS behavioral health billing guidelines. Moreover, this benefits CMS by providing a cost-efficient alternative to inpatient care.

Mental and Behavioral health CTA

Medicare Behavioral Health Providers and Strategy

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The proposal not only seeks to expand provider access but also addresses another critical concern – Medicare beneficiaries’ access to substance abuse treatment. By allowing certain services to be provided through telehealth and audio-only means, CMS aims to improve access to providers for those seeking opioid addiction treatment. This strategic move is part of CMS’s overall Medicare behavioral health providers and strategy.

Increased Behavioral Health Spending and Quality Measures

In terms of spending, the proposal endeavors to increase payments made under Medicare for a range of behavioral health services. Crisis care, substance use disorder treatments, and psychotherapy will all witness increased payments, conforming to behavioral health quality measures. Notably, the proposal suggests elevating the standard PFS rate by 150% when mental health services are provided in non-traditional healthcare settings during a mental health crisis. This adjustment aims to accurately reflect the true costs associated with providing crisis care services, adhering to CMS regulations for outpatient mental health services.

Additionally, CMS plans to address distortions in Relative Value Units (RVUs) used in conjunction with psychotherapy codes under the PFS. RVUs are instrumental in valuing the cost of medical services, and the proposal aims to correct any distortions in RVUs related to timed mental health services. These adjustments will be phased in over a four-year period, ensuring a seamless transition while adhering to CMS regulations for outpatient mental health services.

Conclusion and Future Implications

The public comment period for these proposals and other updates to the PFS is open until September 11, 2023. Assuming CMS proceeds with the proposals largely intact following the comment period, they are slated to take effect on January 1, 2024. While potential challenges in implementation may arise, the proposals undeniably mark a significant shift in the Medicare behavioral health landscape. They promise increased provider access, adherence to CMS behavioral health billing guidelines, and the introduction of entirely new benefit categories in alignment with CMS’s CMS behavioral health strategy.

As CMS takes these bold steps to address the mental health crisis in the United States, beneficiaries, providers, and stakeholders alike eagerly await the transformation of behavioral healthcare under Medicare, accompanied by rigorous adherence to behavioral health quality measures.

For those seeking further information about the proposed changes, CMS in medical billing, Medicare behavioral health providers, Medicare providers for mental health, and the broader CMS behavioral health strategy, please do not hesitate to contact us.

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Wayne Carter

I've been working in healthcare industry of the United States in various types of departments since 2013. Started my career from the bottom as a Accounts Receivable executive, Practice management team handler, Entire Practice Management and now I'm employed at BillingParadise as a Content Lead. Areas of Expertise: End-to-End Revenue Cycle Management, Content Writing, Digital Marketing, RCM applications and Software, Healthcare Business Development, Healthcare Sales, and Healthcare Automation.

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