What the new CMS marketplace proposal means for behavioral health providers, payers

The U.S. Centers for Medicare & Medicaid Services (CMS) is seeking to expand access to behavioral health services by converting mental health facilities and substance use disorder treatment centers into essential community providers (ECPs).

The changes, part of the 2024 Notice of Benefits and Payment Parameters proposal, would mean that health plans offered through federal and state marketplaces must cover these behavioral health providers.

If passed, the changes could make it easier for patients to receive behavioral health services. It may also put pressure on payers to contract with behavioral health providers.

“Adding mental health and substance use facilities to the list of essential community providers would make sense in several ways,” Michelle Guerra, senior consultant for population health and health equity at RTI Health Advance, told Behavioral Health Business. “First, it will expand access to behavioral health care for members of marketplace plans. And second, it sends a clear message that behavioral health is an essential type of health care, reducing the stigma surrounding behavioral health.”

The proposal would affect approximately 14.5 million people enrolled in health plans through the Marketplace, the majority of whom are individuals who are not eligible for Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP) coverage. That number could grow as the Public Health Emergency (PHE) ends and states begin re-determining Medicaid eligibility.

The proposal could reduce the number of out-of-network behavioral health facilities, potentially lowering costs for patients, according to Guerra. In fact, she noted, behavioral health facilities are five times more likely to be out-of-network than medical-surgical inpatient facilities, according to research by risk management, benefits and technology firm Milliman.

It’s not just patients who will be affected by the proposal. In response, payers may need to increase their contracts with mental illness and substance use disorder providers in their service area.

“This may mean going to some mental health and substance use facilities [that] have been unable or unwilling to enter into a contract in the past – perhaps due to unattractive reimbursement or difficult pre-authorization requirements,” Guerra said. “This is a chance for payers and out-of-network facilities to come back to the table and work out a contract that can meet the needs of both parties.” Payers will likely need to be more flexible in their contracting efforts to include more of these facilities, such as considering higher reimbursements or other incentives.

The new proposal also seeks to expand the current general threshold of 35% provider participation to federally qualified health centers (FQHCs) and family planning providers (FPPs). FQHCs and FPPs are two of the six types of care providers designated as ECPs.

“FQHCs and FFPs may already include integrated behavioral health services or partnerships with other community behavioral health providers,” Guerra said. “Requiring payers to increase their contracting efforts with FQHCs and FFPs can increase access to behavioral health services for members, closing the large gap between the demand for behavioral health services and the shortage of providers.”

In addition to changes to behavioral health providers, the proposal also includes provisions aimed at streamlining the marketplace’s health plan selection process and making enrollment easier for individuals who lose their Medicaid or CHIP coverage. Specifically, the rule would allow people who lose coverage to enroll in a marketplace health plan 60 days before or 90 days after losing coverage.

Up to 18 million people are at risk of losing their Medicaid coverage when PHE ends, according to Urban Institute research. An estimated 4 million people currently enrolled in Medicaid will remain uninsured, the study predicts. In addition, about 3.2 million children will switch from CHIP to another health plan.

The federal government has launched a number of initiatives aimed at expanding access to behavioral health services for Medicare and Medicaid beneficiaries.

For example, earlier this month CMS announced a new Medicare Advantage (MA) proposal that would add psychologists, licensed clinical social workers, and opioid use disorder (OUD) prescribers to the list of evaluated MA specialties. The proposal also includes new standards for behavioral health wait times.

In addition, CMS is finalizing new rules that allow behavioral health providers to bill for visits by licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs). The rules also allow hospital outpatient departments to bill for home telebehavioral health services.

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