MEDICARE ADVANTAGE AND BEHAVIORAL HEALTH INTEGRATION

Recognizing mental health as a key component of overall wellness is not just a change in societal attitudes but also a critical factor in improving healthcare delivery. The Centers for Medicare & Medicaid Services (CMS) made it clear: high-quality behavioral health services are essential and, therefore, are now a mandated facet of care for Medicare beneficiaries.

CMS BEHAVIORAL HEALTH STRATEGY

CMS plays a vital role in developing and implementing policies tailored to Medicare Advantage beneficiary needs. This initiative is exemplified by the CMS Behavioral Health Strategy, which aims to ensure that high-quality behavioral health services and supports are accessible to CMS beneficiaries and consumers. Central to this effort is the expansion of behavioral health services that Medicare Advantage (MA) organizations must provide.

EXPANSION OF COVERED BEHAVIORAL HEALTH SERVICES

Over the past few years, CMS has broadened the scope of behavioral health services covered under Medicare Advantage plans to include:

1. Clinical Psychology
2. Clinical Social Work
3. Outpatient Behavioral Health

These services are in addition to Psychiatry and Inpatient Psychiatric Facility care.

NETWORK ADEQUACY REQUIREMENTS

CMS evaluates behavioral health specialties according to Medicare Advantage Network Adequacy standards, which include provider and facility requirements.

PROVIDER SPECIALTY STANDARDS

For the behavioral health provider specialty types Psychiatry, Clinical Psychology, and Clinical Social Work, CMS enforces network adequacy standards that include:

• Maximum time and distance
• Minimum number of providers in each county type
• Minimum ratios

PROVIDER MAXIMUM TIME AND MAXIMUM DISTANCE REQUIREMENTS

FACILITY SPECIALTY STANDARDS

For the facility specialties, Inpatient Psychiatric Facility Services and Outpatient Behavioral Health, the evaluation criteria include:

• Maximum Time and Distance
• Minimum Number of Facility-Specialty Type in Each County

SPECIAL CIRCUMSTANCES

Telehealth Credit: Psychiatry, Clinical Psychology, Clinical Social Work, and Outpatient Behavioral Health services are eligible for a 10% credit towards the percentage of beneficiaries residing within the published network adequacy time and distance standards. This credit applies if an MA organization’s contracted network includes telehealth providers who offer additional telehealth benefits beyond those required by statute for covered services.

Exception Requests: Submitting an exception request to CMS is permitted when network adequacy requirements aren’t fulfilled due to a lack of providers or facilities.

New or Service Area Expansion Applicant Allowances

During the review phase of an Initial Application or a Service Area Expansion, MA organizations may use allowances to assist in meeting network adequacy standards.

• 10-Percentage Point Credit: Applicants can leverage the 10-percentage Point Credit towards the percentage of beneficiaries residing within the published time and distance standards for new or expanded service area applicants.
• Letter of Intent: A Letter of Intent (LOI) that meets regulatory requirements can be used to fulfill network standards during the review of the application.
Applicants must fully comply with network adequacy standards by January 1 of the contract year.

A CLOSER LOOK AT OUTPATIENT BEHAVIORAL HEALTH

Outpatient Behavioral Health encompasses a range of mental health specialties.

• Marriage and Family Therapists
• Mental Health Counselors
• Opioid Treatment Programs
• Community Mental Health Centers
• Psychotherapy or Prescription of Medication for Substance Use Disorders, including:
• Addiction Medicine Physicians
• Outpatient Mental Health and Substance Use Treatment Facilities

— Physician Assistants (PAs)
— Nurse Practitioners (NPs)
— Clinical Nurse Specialists (CNSs)

All applicable state and federal laws about the practice of medicine and delivery of healthcare services must be met, and specific healthcare professionals must be appropriately licensed or certified to furnish the applicable services.

OUTPATIENT BEHAVIORAL HEALTH REQUIREMENTS

In light of the increasing focus on ghost networks and actions from legislators like the pending legislation, The Requiring Enhanced & Accurate Lists of Health Providers Act, CMS introduced additional regulations to verify the accuracy of provider listings, specifically targeting Outpatient Behavioral Health. These measures are designed to improve behavioral health services.

PROVIDER SERVICE REQUIREMENTS

To be recognized as regularly providing behavioral health services, a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS), must demonstrate that they have provided services to at least 20 patients in the last 12 months.

20 PATIENTS IN THE LAST 12 MONTHS

ANNUAL VERIFICATION RESPONSIBILITIES

MA organizations must independently verify that these standards are met by every PA, NP, and/or CNS they intend to include for Outpatient Behavioral Health purposes. This verification can be accomplished by analyzing:

• MA organization’s claims data
• Prescription drug claims data
• Electronic health records
• Similar data

This data verification must be conducted annually, focusing on services provided during the last 12-month period, and completed before the CMS evaluation process.

ADDRESSING INSUFFICIENT PREVIOUS PRACTICE EXPERIENCE

If there is insufficient evidence of providers having previous practice experience sufficient to meet the threshold of 20 patients within a recent 12-month period, MA organizations must have a reasonable and supportable basis for concluding that the provider will meet the threshold in the next 12 months.

If a PA, NP, and/or CNS is new to independent practice (and therefore doesn’t have the appropriate claims record in previous years), has received psychiatry or addiction medicine specialized training, and is listed as a psychiatry or addiction medicine PA, NP, and/or CNS on public-facing websites, this would be a reasonable and supportable basis for concluding that the practitioner would meet the requirement in the next 12 months, and therefore be able to be utilized towards meeting network adequacy standards for Outpatient Behavioral Health.

SUBMISSION OF EVIDENCE TO CMS

MA organizations are required to submit corroborated evidence to CMS upon request. This documentation should substantiate that the PA, NP, and/or CNS has delivered or is expected to deliver at least one of the specified psychotherapy or medication prescriptions to a minimum of 20 patients. All submitted documentation must adhere to the format and guidelines specified by CMS, ensuring a standardized evaluation process.

HEALTH SERVICE DELIVERY TABLE SUBMISSION

GUIDELINES FOR BEHAVIORAL HEALTH SPECIALTIES

MA organizations are subject to network adequacy evaluations at critical junctures: during an initial application, when applying for service area expansion, and at a triennial network adequacy review. An essential part of this evaluation process is the submission of network data through Health Service Delivery (HSD) tables. MA organizations must submit two HSD tables for each contract:

• A provider HSD table that lists individual behavioral health providers
• A facility HSD table that lists behavioral health facilities

LIMITS ON PROVIDER SUBMISSIONS

MA organizations are restricted from using a single provider to fulfill multiple provider network requirements. For example, a provider cannot be listed as a psychiatry, clinical social work, or clinical psychologist provider specialty, and also as an Outpatient Behavioral Health facility.
A provider cannot be double-counted across different provider categories in HSD tables.

FULFILLING MULTIPLE PROVIDER

Find More
HSD Table Resources

DR. JOPLIN IS FULFILLING ONLY ONE PROVIDER NETWORK REQUIREMENT

MEDICARE ADVANTAGE

PROVIDER DATA

ACCURACY

REQUIREMENTS

As part of behavioral health requirements, MA organizations are required to provide transparent and accurate portrayals of their provider networks. Integral to this is the upkeep of up-to-date online and printed directories.

DIRECTORY AVAILABILITY AND UPDATE REQUIREMENTS

Online and Printed Directories: Online and printed directories must be available by October 15th annually, within 10 days of a new member’s enrollment, and on request throughout the year.

Searchable Provider Directory: The online provider directory must be searchable by every data element required in the model provider directory. This includes information such as name, location, specialty, and the provider’s cultural and linguistic capabilities.

Quarterly Verification: At a minimum, providers verify every 90 days the accuracy of their listed information in the directory.

Immediate Updates: Any changes in provider information must be reflected in the directories within 30 days of receiving notification.

MANDATORY PROVIDER DATA ELEMENTS TO VERIFY AND UPDATE

The specific data elements that must be regularly verified and updated include:

• Provider Name
• Provider Specialty
• Whether or Not the Provider Accepts New Patients
• Practice Address
• Phone Number
• Provider Offers Telehealth Services
• Provider’s Cultural and Linguistic Capabilities, Including Languages and American Sign Language

CMS OVERSIGHT AND COMPLIANCE MONITORING

To ensure compliance with these standards, CMS engages in active monitoring through several methods:

Periodic Online Provider Directory Reviews: Conducted as needed to assess the accuracy of the health plan’s provider directories.

Triennial Network Adequacy Review: A comprehensive review consistent with CMS’s efforts to oversee compliance with provider directory requirements.

Decisions regarding enforcement action are made on a case-by-case basis, factoring in a health plan’s effectiveness in implementing required policies.

TRANSFORMING COMPLIANCE INTO A STRATEGIC ADVANTAGE

As the landscape evolves, MA organizations can leverage compliance requirements to their advantage. By employing dynamic network management approaches and integrating
Quest Enterprise Services^®, organizations can efficiently address regulatory mandates while enriching their offerings to meet the contemporary needs of members seeking comprehensive behavioral health services.