Five Ways the 2023 Medicare Physician Fee Schedule Promotes Behavioral Health and Holistic Care


On November 1, 2022, the U.S. Department of Health and Human Services (HHS) Centers for Medicare & Medicaid (CMS) finalized changes that are expected to significantly expand access to behavioral health care and other services. CMS published a behavioral health strategy in 2022, which included improving access to and quality of mental health care services.[1] Calendar Year (CY) 2023 Physician Fee Schedule (PFS) Final Rule includes changes that better align with Biden Administration and CMS initiatives, namely addressing the current crisis mental health using what the agency calls “whole person” support. and services through Medicare.[2] The Final Rule’s focus on “whole person” care puts the health system on a better trajectory to provide affordable, high-quality care and achieve equitable outcomes. Additionally, the PFS 2023 Final Rule ensures that individuals receive coordinated care with adequate access to substance use prevention and treatment services, mental health services, crisis intervention and support. pain treatment.[3] Here are some of the ways the Final Rule supports whole-person care:

  1. Behavioral health clinicians will work under the general supervision of Medicare practitioners

Currently, Medicare beneficiaries are in dire need of better access to behavioral health services. In recent years, CMS has considered regulatory revisions to reduce barriers to care and better utilize behavioral health professionals, including Licensed Marriage and Family Therapists (LMFT) and Licensed Professional Counselors (LPC). With the promulgation of the final rule, CMS is adding an exception to the direct supervision requirement under the “incident to” rule at 42 CFR 410.26, which will allow ancillary personnel to provide diagnosis and treatment of a mental health or addiction. under the “general supervision” of a physician or non-physician practitioner (NPP) rather than under direct supervision.

This exception aligns with Behavioral Health Strategy 2022 by strengthening and expanding accessibility for Medicare beneficiaries to receive critical behavioral health treatments and services from LPCs and LMFTs (among other behavioral health clinicians). It also mobilizes behavioral health workers to practice to the fullest extent of their license, even without the physical presence of a physician or nurse practitioner. In addition, CMS is making permanent a public health emergency rule to allow clinical staff in hospital outpatient departments to provide remote behavioral health services to patients in their homes. Because of these changes under the final rule, behavioral health services like counseling and cognitive therapy will become more accessible in rural or underserved areas.

  1. Medicare pays for opioid treatment and addiction programs

As part of Behavioral Health Strategy 2022, the Final Rule improved behavioral health services and treatment for opioid use disorder. To better reflect the costs of individual therapy services, CMS is increasing payment rates to opioid treatment programs. To expand access in rural and other underserved areas, CMS clarifies in the final rule that opioid treatment programs may charge for opioid use disorder treatment services provided by mobile units , such as vans, in accordance with the Substance Abuse and Mental Health Services Administration (SAMHSA) and Drug Enforcement Agency (DEA) Guidelines. This clarification will improve access to treatment for less accessible populations, such as those in rural communities or the homeless. Medicare will also begin paying for opioid treatment programs that use telecommunications with patients to initiate buprenorphine treatment. Based on feedback from the proposed rule, the final rule offers payment to opioid treatment programs for periodic assessments provided by audio-only phone calls through the end of 2023.

  1. Medicare will pay behavioral health clinicians as part of a primary care team

Integration of care is another desired improvement for behavioral health services. CMS reiterated the intent “to increase the detection, effective management and/or recovery of mental health conditions through coordination and integration between primary and specialist care providers.”[4] Determined to offer a “whole-body” model of care, the final rule policies will pay licensed clinical psychologists and clinical social workers to provide integrated behavioral health services as part of a primary care team in addition to their own services. . This coordination and integration of specialty care through existing primary care provider networks is designed to facilitate the process of receiving behavioral health services for Medicare beneficiaries.

Due to the increased need for mental health services as well as comments from previous PFS regulations, CMS is implementing a new general BHI code outlining service personally performed by clinical psychologists or clinical social workers to accommodate integration monthly care where the behavioral health services provided by these clinicians serve as the focal point of care integration. This is an improvement for behavioral health services because CMS previously did not allow professionals such as clinical psychologists or clinical social workers to report approved initiation visit codes to Medicare. CMS is also completing a revised policy to allow a psychiatric diagnostic assessment to be the initial visit for BHI’s new general service.

  1. Medicare will pay for chronic pain treatment and management

Employing the “whole person” approach, Medicare will provide a new monthly payment for comprehensive treatment and management services for patients with chronic pain. Although Medicare has not historically used a comprehensive, team-based approach to chronic pain and pain management, CMS recognizes that person-centered coordination between providers is often needed to manage pain in order to maximize positive results. This will be the first time Medicare has provided payments for this comprehensive, team-based treatment for chronic pain management.

  1. Medicare Shared Savings Program to Provide High-Quality Behavioral Health Care

Medicare performs an essential function in implementing person-centered behavioral health care, as evidenced by the fact that there are nearly $1 trillion in claims covering over 63 million Americans.[5] The Shared Savings Program builds Whole Person Capabilities of Accountable Care Organizations (ACOs) by making advanced Shared Savings payments to smaller, newer ACOs, who in turn can use the funds in advance to integrate behavioral health practitioners. Finally, CMS intends to address payment for new codes outlining caregiver behavior management training in the CY 2024 rulemaking. For future policies, CMS is also looking at ways to further engage staff behavioral health by providing the opportunity to connect with people in different ways, such as intensive management in a community setting. The PFS 2023 Final Rule, which strives to create a more equitable healthcare system that results in greater accessibility, quality, affordability and innovation, comes into effect on January 1, 2023.

For more information on the Behavioral Health Final Rule, click here.

For more information on the 2023 Medicare Physician Fee Schedule, click here.


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