Behavioral Health Upgrades Proposed in Medicare Advantage Plans and ACA Marketplace Could Lead to More Opportunities and Access | Insights

Investors and practice management companies focused on behavioral health should note two recently proposed rules that, if finalized, should increase access to behavioral health services for beneficiaries enrolled in Medicare Advantage (MA) health plans and Patient Protection and Affordable Care Act (ACA) market. Specifically, on December 21, 2022, the United States Department of Health and Human Services (HHS) issued the Notice of Performance and Payment Parameters for the 2024 Proposed Rule (ACA Market Proposed Rule), and on December 4 2022, The Centers for Medicare & Medicaid Services (CMS) released an advance copy of the policy for the 2024 contract year and technical changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Cost Plan Program Proposed Rule Medicare (rule proposed by MA).

Rule proposed by MA

In the MA Proposed Rule, CMS proposed several ways to expand access to behavioral health services. For instance:

  • CMS proposes to add behavioral health services to its existing standards of access to services, thus requiring MA organizations to maintain and monitor an adequate network of behavioral health providers, including clinical psychologists, licensed clinical social workers and prescribers of medications for the disorders from opioid use.
  • CMS proposes to require MA organizations to extend the same appointment wait time standards for primary care services to appointment wait time standards for behavioral health services (including mental health and use disorder services). of substances (SUD)).
  • The MA’s proposed rule also proposes that MA plans meet stringent enrollee notification requirements when an organization terminates a membership agreement with the Behavioral Health Provider Network.
  • Additionally, CMS proposes clarifying that certain behavioral health conditions qualify as “emergency medical conditions,” for which MA organizations must reimburse a provider for treatment regardless of the emergency care provider’s contractual relationship with the MA organization or if the subscriber has received prior authorization.
  • MA’s proposed rule would require MA organizations to maintain policies and procedures to ensure that enrollees receiving behavioral health services receive coordinated care. Such policies and procedures should include programs for coordinating behavioral health services with community and social services, procedures for ensuring that the MA organization and its network of providers have the information necessary for effective and ongoing patient care, and quality review and procedures to ensure enrollees are taught adequate self-care and informed of health care needs requiring follow-up care.

Rule proposed by the ACA market

The ACA market’s proposed rule also takes steps to increase access to behavioral health services. For example, HHS proposes designating SOUTH mental health facilities and treatment centers as Essential Community Providers (ECPs). This would require medically qualified health plan (QHP) issuers to offer a bona fide contract to at least one available mental health facility and one available SOUTH treatment center that qualify as an ECP in each county of the plan’s service area. CMS also proposes to change the network adequacy requirements so that all plans certified as QHP offer sufficient choice of providers in accordance with a consistent set of criteria for easier comparability across all QHPs. Therefore, if finalized, the proposed changes would better ensure that ACA Market Plan beneficiaries have access to SUD mental health facilities and treatment centers.

Comment period

The ACA Market Proposed Rule was published in Federal Register December 21, and members of the public are invited to submit comments by January 30, 2023. The MA’s proposed rule was published in Federal Register December 27, and comments are welcome through February 13, 2023.

Leave a Comment

Your email address will not be published. Required fields are marked *