The U.S. Centers for Medicare & Medicaid Services (CMS) has unveiled a new proposal aimed at expanding CMS behavioral health coverage for millions of Americans. The proposed rule would require health plans offered through federal and state-based marketplaces to cover mental health facilities and substance use disorder treatment centers. By designating these facilities as essential community providers (ECPs), CMS aims to ensure that vulnerable populations have access to the care they need.
Currently, six types of providers are recognized as ECPs: federally qualified health centers (FQHCs) and look-alikes, family planning providers (FPPs), Ryan White HIV/AIDS Program providers, Indian Health Providers, hospitals, and certain condition-specific facilities. Including mental health and substance use disorder treatment centers in this list is a significant step forward in expanding CMS behavioral health coverage and improving access to critical services. The proposal also extends the existing 35% provider participation threshold to FQHCs and FPPs, ensuring that a broad range of providers are included in marketplace plans.
Targeting Vulnerable Populations
This rule is particularly aimed at individuals who may not qualify for Medicare or Medicaid due to age or other eligibility restrictions. In 2022, 14.5 million Americans enrolled in marketplace health plans, underscoring the importance of affordable coverage options. By expanding CMS behavioral health coverage, the proposal seeks to support people who might otherwise face barriers to mental health and substance use treatment.
CMS Administrator Chiquita Brooks-LaSure emphasized the importance of these efforts: “We know that access to affordable health care is a concern across the nation. Continuing to propose policies that help make it easier for consumers to choose and maintain the health coverage that best fits their needs is vital. If finalized, this proposed rule does just that.” For vulnerable populations, such as low-income families, older adults, and individuals with chronic behavioral health conditions, the expansion of CMS behavioral health coverage could be life-changing.
Broader Behavioral Health Initiatives
The proposal is part of a larger CMS effort to improve access to behavioral health services in Medicare and Medicaid. Other initiatives include loosening telehealth restrictions for behavioral health services and adjusting supervision requirements for certain types of practitioners. These changes, combined with expanded CMS behavioral health coverage, aim to address longstanding access barriers, particularly in rural and underserved areas. By allowing more behavioral health professionals to provide services with fewer restrictions, CMS hopes to make mental health and substance use treatment more readily available to those who need it.
Special Enrollment Period for Those Losing Medicaid
Another key feature of the proposed rule is the creation of a special enrollment period for individuals losing Medicaid coverage. Under this provision, enrollees could select a marketplace plan 60 days before or 90 days after losing Medicaid. This is particularly timely as millions of Americans, including an estimated 6.7 million children, are at risk of losing Medicaid coverage following the end of the federal public health emergency. By providing this window, the proposal ensures continuity of CMS behavioral health coverage for those affected by coverage changes.
The Potential Impact
If finalized, these proposed changes could have a major impact on behavioral health care access in the United States. By designating mental health and substance use disorder treatment centers as ECPs and extending participation requirements to FQHCs and FPPs, CMS is taking meaningful steps to expand CMS behavioral health coverage in underserved communities. These measures, combined with telehealth expansions and special enrollment periods, could help millions of Americans maintain access to essential mental health and substance use services.
Through these initiatives, CMS demonstrates its commitment to a more inclusive, accessible health care system. Expanding CMS behavioral health coverage not only improves health outcomes for vulnerable populations but also helps reduce disparities in access to mental health and substance use care.
