Private insurers offering Medicare plans to seniors may soon face more rigorous Medicare Advantage behavioral health requirements. The U.S. Centers for Medicare & Medicaid Services (CMS) unveiled a proposed rule for Medicare Advantage (MA) on Wednesday, emphasizing the essential role behavioral health plays in whole-person care. This announcement comes just two days after CMS released a separate proposal requiring marketplace health plans to cover certain mental health and substance use disorder services, signaling a broader effort to strengthen access to behavioral health care across multiple insurance programs.
Expanding Provider Networks
The proposed rule aims to improve Medicare Advantage behavioral health access by expanding the range of providers that MA plans must include. Specifically, CMS plans to add clinical psychologists, licensed clinical social workers, and prescribers of medication for opioid use disorder (OUD) to the list of evaluated specialties. This step formally recognizes these providers as essential to delivering comprehensive Medicare Advantage behavioral health care for seniors. Access to qualified mental health professionals has long been a challenge in MA networks, and CMS is holding plans accountable for closing these gaps.
Minimum Wait Times and Notice Requirements
CMS Administrator Chiquita Brooks-LaSure emphasized the intent behind the proposal: “CMS released a proposed rule today that takes important steps to hold Medicare Advantage plans accountable for providing high-quality coverage and care to enrollees.” The rule goes beyond expanding provider networks. It also seeks to set minimum wait time standards for behavioral health and primary care services, ensuring that seniors are not forced to wait weeks—or even months—for critical Medicare Advantage behavioral health care. Additionally, MA plans would be required to provide clear notice to members whenever providers are removed from a network, helping patients make informed decisions and maintain continuity of care.
Integration into Care Coordination Programs
A key component of the proposed rule is the integration of behavioral health into care coordination programs for most MA plans. Embedding Medicare Advantage behavioral health services into care coordination ensures that mental health and substance use disorder services are addressed alongside other aspects of a patient’s care. CMS Deputy Administrator Dr. Meena Seshamani described these protections as “commonsense and critical to the physical, mental and financial stability of millions of people who choose a Medicare coverage option each year.”
Stakeholder Feedback and Emergency Services
The proposal was informed by nearly 4,000 comments from stakeholders responding to a public request for information in July. These comments addressed challenges in provider accessibility, telehealth services, and behavioral health coverage, helping CMS shape the 957-page rule. Among the provisions, CMS clarifies that some behavioral health services may qualify as emergency services and, therefore, should not be subject to prior authorization. This could accelerate access to Medicare Advantage behavioral health care and streamline reimbursement processes, ensuring patients receive timely intervention during crises.
Access to Opioid Use Disorder Medications
CMS is also proposing a new requirement for MA provider directories, adding a specific data element for providers who prescribe medications for OUD. The rule notes, “Access to [OUD medications] can be life-saving, but too often, patients do not know how to access this type of care.” With opioid overdose deaths surging during the COVID-19 pandemic, ensuring that seniors can identify providers offering these services is a critical public health priority. Improving provider visibility supports better outcomes for patients seeking Medicare Advantage behavioral health services.
Implications for Seniors and Insurers
The broader implications of CMS’s proposed rule are significant. By strengthening network adequacy, improving care coordination, and clarifying emergency coverage, the agency ensures Medicare Advantage behavioral health is no longer treated as a secondary concern. For seniors, caregivers, and providers, these changes could mean shorter wait times, broader provider options, and more coordinated care. For insurers, the rule represents an opportunity to demonstrate commitment to whole-person care while meeting stricter standards for coverage and service delivery.
Looking Ahead
While the rule is not yet final, it signals CMS’s ongoing commitment to enhancing Medicare Advantage behavioral health access. The final implementation of this proposal could reshape the MA landscape, ensuring mental health and substance use disorder services receive the attention they deserve.
