Proposed Medicare Advantage Rule Includes Counselors in Provider Network Adequacy Standards

Mental health counselors and marriage and family therapists are now eligible to enroll as providers in the Medicare program (in the traditional fee-for-service program and individual Medicare Advantage plans) and to bill for services provided to Medicare clients beginning Jan. 1, 2024. 

The Centers for Medicare & Medicaid Services (CMS) is taking several steps to improve access to behavioral health care services specifically for Medicare Advantage (MA) plan enrollees by proposing updates to provider network adequacy standards, effective Jan. 1, 2025. Specifically, in a continued effort to address access to behavioral health services within MA networks, CMS is proposing to add mental health counselors to the list of provider specialties and add corresponding time and distance standards. The proposed rule was issued on Nov. 6. 

Currently, 51% of Medicare beneficiaries—31 million people—are enrolled in MA health plans, and enrollment continues to grow each year. 

To help ensure that beneficiaries enrolled with a MA plan have access to behavioral health providers, including newly enrolled providers such as mental health counselors and marriage and family therapists, CMS is proposing to add a range of behavioral health providers under one category called “Outpatient Behavioral Health” as a facility specialty for which CMS sets MA plan provider network adequacy standards.  

Specialists under this Outpatient Behavioral Health category will include counselors, marriage and family therapists, opioid treatment program providers, community mental health centers, addiction medicine physicians, and other providers who furnish addiction medicine and behavioral health counseling or therapy services. MA organizations will need to contract with these types of providers to furnish basic benefits as required by legislation and regulations. 

In addition to meeting the network adequacy evaluation requirements, MA organizations are required to maintain and consistently monitor their provider networks to ensure they are sufficient to provide adequate access to covered services. This also helps MA organizations maintain a complete and accurate health plan provider directory, as required by regulations.  

In addition, CMS is proposing to add this Outpatient Behavioral Health facility specialty to the list of specialty types that receive a 10% credit if the MA organization’s contracted network of providers includes one or more providers of that specialty type who provide telehealth benefits for covered services. 

NBCC will be submitting comments to CMS in response to the proposed network adequacy standards to facilitate maximum access for counselors to MA plan networks and insurance panels.  

For more information on Medicare Part B Coverage of counselors, please visit our website.