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What do CMS’ New MPFS and OPPS Proposed Rules Mean for Mental and Behavioral Health Providers?

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The Centers for Medicare and Medicaid Services (CMS) recently announced proposed changes to the Medicare Physician Fee Schedule (MPFS) and the Outpatient Prospective Payment System (OPPS). These changes have significant implications for mental and behavioral health providers and aim to promote health equity, access to care, and compliance with hospital price transparency rules. In this blog post, we will explore the key provisions outlined in these proposed rules and discuss their potential impact on mental and behavioral health providers.

Changes to the MPFS:

Under the proposed rule, CMS suggests a reduction in MPFS payment rates by 1.25% in the calendar year (CY) 2024 compared to CY 2023. This trend continues the reduction in payment rates despite physicians’ concerns about inflation. Despite this overall reduction, CMS has also proposed specific payment increases for primary care and other types of direct patient care. This is an encouraging development for mental and behavioral health providers who often provide critical primary care services alongside their specialty services. It also highlights continued efforts to integrate mental and behavioral health within primary care as the shift to whole-person care gets underway.

CMS has also focused on increasing health equity by proposing coding and payment for new services to support underserved communities. These include caregiver training programs, community health integration services, principal illness navigation services, and social determinants of health risk assessments.

In terms of behavioral health, CMS has made significant strides by allowing marriage and family therapists and mental health counselors to enroll in Medicare and bill for their services. This change opens up new opportunities for mental and behavioral health providers to serve Medicare beneficiaries. Furthermore, proposed payment increases for crisis care, substance use disorder treatment, and psychotherapy reinforce CMS’ commitment to improving access to behavioral healthcare.

Changes to the OPPS:

The OPPS proposed rule introduces a 2.8% increase in payment rates for CY 2024. This increase is based on a projected hospital market basket percentage increase of 3%, with a small productivity adjustment. While this increase is generally positive, it is crucial to consider the financial challenges that mental and behavioral health providers face on a regular basis. Some groups argue that because of inflation and increasing costs of providing healthcare, this increase is insufficient.

One notable provision within the OPPS proposed rule is the creation of a new benefit category called the Intensive Outpatient Program. This program aims to provide Medicare beneficiaries with mental health services that require frequent but less intensive care than what is typically provided in hospitals. This change recognizes the need for specialized, community-based care and offers mental and behavioral health providers the opportunity to expand their services in a more accessible setting. Outpatient programs tend to be more cost-effective for clients and allow them to maintain employment and daily routine. While they’re not suited for every client, outpatient programs can also reduce strain on hospitals and help clients get more individualized care.

CMS has also proposed updated payment rates for the partial hospitalization program, which serves as an alternative to psychiatric hospitalization. This program plays a vital role in providing comprehensive care for patients with mental health conditions, and the proposed changes aim to ensure adequate reimbursement for the services provided.

The proposed rules introduced by CMS have the potential to positively impact mental and behavioral health providers. The inclusion of payment increases, expansion of services, and emphasis on health equity demonstrate CMS’ commitment to improving access to care in these essential areas.

However, it is essential to acknowledge the concerns raised by medical groups regarding the proposed payment reductions and their potential impact on providers’ financial stability. The final rule, expected in November, should provide more clarity on these matters. Overall, mental and behavioral health providers should closely monitor these proposed rules and actively participate in the comment period, which runs until September 11. The input and feedback from providers will play a crucial role in shaping the final rule and ensuring that the needs of the mental and behavioral health community are addressed and supported.

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