Last week, the Centers for Medicare and Medicaid Services (CMS) issued the calendar year (CY) 2024 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) final rule, which includes the expansion of access to behavioral health services for people with Medicare through coverage of intensive outpatient services, effective January 1, 2024.
In September 2022, Reps. Judy Chu (CA-28), Bill Pascrell, Jr. (NJ-09), and Adrian Smith (NE-03) introduced H.R. 8878 to create a new benefit category within Medicare Part B mental health coverage for intensive outpatient programs. The Consolidated Appropriations Act, 2023, included H.R. 8878, and now CMS’s final rule will ensure intensive outpatient program services are available for both individuals on Medicare with mental health conditions and individuals with substance use disorders in hospital outpatient departments, Community Mental Health Centers, Federally Qualified Health Centers, and Rural Health Clinics.
Intensive outpatient programs refer to outpatient services designed to treat individuals with mental health and substance use disorders that do not require inpatient or residential services, such as medical detoxification or 24-hour supervision. Such individuals require more intensive treatment than available in a typical outpatient setting, often including a specified number of hours of structured treatment each week consisting of individual or group therapy, medication management, and psychoeducation.
“Good health care coverage is about mental health as much as physical health,” said Rep. Pascrell. “Among Medicare beneficiaries, around one in every four have a mental health issue. But because of a pervasive gap in Medicare, Americans are often denied care. It is unfair and unsustainable. Today CMS has taken a major step in closing that gap by heeding our calls to create a benefit category for intensive outpatient services. Because of this change, Medicare coverage will expand to aid millions of Americans with mental health concerns. This is a terrific victory. I was proud to lead on this issue alongside my colleagues Judy Chu and Adrian Smith to keep the pressure up to finally make this happen.”
“Until now, Medicare covered only the extreme ends of the care spectrum when it comes to mental health and substance use disorders, but I am particularly aware as a psychologist that mental health care, like all health care, requires varying levels of care depending on the severity of the disease and what is best for the patient,” said Rep. Chu. “I am elated that my bill with Ways and Means colleagues Reps. Pascrell and Smith became law, closed that gap, and soon Medicare beneficiaries who do not require round the clock care—but who need more robust treatment than a periodic office visit—will have intensive outpatient services covered.”
“The gap in mental health coverage for Medicare beneficiaries who do not meet the inpatient coverage criteria is a significant challenge in Nebraska and around the country, particularly in rural areas,” said Rep. Smith. “By implementing our bipartisan measure to address these coverage gaps, CMS is taking an important step to expand access to care for patients currently at risk of falling through the cracks. I thank my colleagues Reps. Pascrell and Chu for their collaborative work to increase mental health treatment availability for Americans who need it.”
“The final rule reflects CMS’ commitment to ensuring Medicare is comprehensive in its ability to address patient needs by filling critical gaps in behavioral health,” said Deputy Administrator and Director for the Center for Medicare, Dr. Meena Seshamani. “With this final rule, we will ensure people get timely access to quality care in their communities, leading to improved outcomes and better health.”
