National Council for Behavioral Health

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Today, approximately 50 million people are enrolled in Medicare, with nearly 20% receiving benefits because of a disability. Of all Medicare beneficiaries, nearly one in five are living with one or more mental health or substance use conditions. However, less than 40% of those older adults actually receive treatment. By 2030, it is projected that the adult population age 65 and older will total more than 72 million.


The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) makes sweeping reforms to payments under Medicare Part B. Click here to learn more, access resources and most importantly get guidance on how to prepare for the reforms.

Part D Six Protected Classes

In 2003, Congress created the Medicare Part D prescription program. When the program was implemented, CMS required Part D plans to include on their formularies “all or substantially all” drugs within six classes: antidepressants, antipsychotics, anticonvulsants, antineoplastics, antiretrovrials and immunosuppressants. This policy has been instrumental in ensuring Medicare beneficiaries with complex or severe mental health needs can access clinically appropriate treatment without undue burdens.

In January of 2014, CMS announced a proposed rule that would eliminate protected status for antidepressants, antipsychotics and immunosuppressants. After a vocal outpouring of opposition from consumer and provider groups, spearheaded by the Partnership for Part D Access, of which the National Council is a member, CMS announced it would not finalize its proposed changes to the protected classes. However, CMS left the door open for future rulemaking, leaving advocates concerned the agency may revisit this harmful proposed change. The National Council and the Partnership for Part D Access are continuing to advocate for maintaining beneficiary access to the full range of available medications under Medicare Part D.

Marriage and Family Therapists and Licensed Professional Counselors

Legislation has been introduced to expand Medicare coverage to include behavioral health services provided by marriage and family therapists and licensed professional counselors. According to SAMHSA’s 2013 Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce Issues, 77 percent of U.S. counties have a severe shortage of mental health workers, including both prescribers and non-prescribers. This shortage is most common in counties with low per capita income and in rural areas.

Legislation expanding Medicare coverage to include these services includes:

–          The Mental Health Access Improvement Act (H.R. 3662/S. 562)

The National Council strongly supports including marriage and family therapists’ and licensed professional counselors’ services as reimbursable under Medicare. We urge Congress to take action on this important issue.

Quality Initiatives and Physician Quality Reporting System

CMS has been taking leadership to transform itself from a passive payer of services into an active purchaser of higher quality, affordable care. CMS now has 26 separate quality initiatives in various stages of implementation, tracking 1,152 measures. One of these initiatives is the Physician Quality Reporting System (PQRS), a pay-for-reporting program that uses a combination of incentive payments and downward payment adjustments to promote reporting of quality information by eligible professionals.

Read the new National Council report, A Place at the Table, on how mental health and addiction treatment providers can engage in the PQRS.

Additional Resources

–          Medicare Access for Patients Rx Coalition 2015 Open Enrollment Brochure.

In The News:

The National Council continues to advocate for increased access to mental health and addiction services through Medicare. For recent news about Medicare, visit Capitol Connector.