Behavioral health access- A mandate for Medicare Advantage plans in 2025

Behavioral health is now a defining factor in member experience, retention, and CMS oversight. With the 2025 Final Rule, the Centers for Medicare & Medicaid Services (CMS) has made it clear: plans must not only offer behavioral health services, but they must also prove those services are accessible, inclusive, and actively used by the members who need them most.

If you're responsible for network strategy, compliance, or member retention, here's what you need to know and why your response to behavioral health could determine whether your plan leads, lags, or gets left behind.

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‍The growing behavioral health crisis among Medicare members

‍As of 2023, 1 in 4 Medicare beneficiaries, approximately 16.7 million people were living with behavioral health condition.

This is not a new trend, but it’s one that’s accelerating. Mental health and substance use disorders (SUDs) among older adults are rising, fueled by factors such as:

• Chronic social isolation and loneliness, worsened during and after the pandemic

• Rising alcohol and prescription drug misuse in adults over 65

• Limited behavioral health literacy, especially among low-income or rural seniors

• Insufficient provider networks, leaving members without timely or appropriate care

Critically, these needs are not evenly distributed. Dual-eligible beneficiaries and low-income seniors are significantly more likely to experience untreated behavioral health conditions, yet they often face the steepest barriers to care.

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‍The 2025 CMS Final Rule: What’s changing and why it matters

CMS’s 2025 policy updates represent a meaningful shift in how MA plans must structure, validate, and deliver behavioral health services. The rules go beyond theory and into tangible, trackable mandates:

1. Outpatient behavioral health is now a standalone network category

CMS now classifies “outpatient behavioral health” separately for network adequacy reporting. This new category includes:

• Marriage and family therapists (MFTs)

• Mental health counselors (MHCs)

• Addiction medicine specialists

• Opioid treatment program providers

Implication: These are now essential provider types. They must be present in your network and meet time and distance adequacy standards.

2. Verification of active provider status

Plans must confirm that behavioral health providers are actively treating patients, defined as:

Providers must have treated at least 20 patients within the past 12 months, using claims or EHR documentation.

Implication: “Ghost” providers, those who are listed but not actively seeing patients can no longer count toward adequacy. CMS wants proof, not promises.

3. Boosted inpatient behavioral health reimbursement

In 2025, behavioral health facilities will receive a 2.8% increase in inpatient payment rates.

Implication: CMS is aligning MA more closely with traditional Medicare and incentivizing increased access and capacity in inpatient mental health facilities. Plans should revisit partnerships and contracting models to take advantage of this.

The stakes are highest for vulnerable populations

For dual-eligible beneficiaries and low-income seniors, behavioral health access is a lifeline.

• During the early phase of the pandemic, the incidence of behavioral health needs among low-income seniors tripled.

• Dual-eligible individuals are less likely to receive referrals, more likely to experience co-occurring conditions, and more affected by provider shortages, particularly in rural or high-poverty areas.

CMS is explicitly calling on MA plans to use predictive analytics, whole-person care models, and SDoH data to identify and engage high-risk members who are often left behind.

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How leading MA Plans are responding

Plans that are serious about behavioral health in 2025 are moving beyond baseline compliance. They are thinking about access, experience, and equity in tandem. Here’s how:

1. Redesigning provider networks for real-world access

Network expansion now requires more than checking a time-and-distance box. Plans are:

• Recruiting and contracting with diverse, community-based mental health professionals

• Auditing networks to remove inactive or unavailable providers

• Prioritizing cultural and linguistic alignment between providers and members

• Targeting geographic expansion in rural or underserved ZIP codes

Strategic takeaway: Simply adding providers isn't enough. Plans need data-backed strategies to ensure those providers are available, credentialed, and appropriately distributed across populations in need.

2. Bridging physical and behavioral healthcare

Integrated care is no longer a clinical buzzword. Plans are:

• Embedding mental health screening in primary care

• Using shared care plans and coordinated referrals across disciplines

• Piloting collaborative care models that align incentives between PCPs and behavioural health specialists

• Leveraging interoperable platforms to ensure providers have shared visibility into treatment plans

Strategic takeaway: Integration improves outcomes, reduces duplication, and closes care gaps. It also drives higher member satisfaction, especially when care feels seamless.

3. Making benefits visible and understandable to members

Plans cannot assume that members know behavioral health services exist, especially those in high-need groups.

Strong plans are:

• Including behavioral health benefits front and center in onboarding and welcome kits

• Creating educational campaigns tailored to duals, LEP (Limited English Proficiency) members, and rural populations

• Offering navigator or concierge support to help members understand how to access services

• Tracking utilization data to identify where benefit awareness is low

Strategic takeaway: Access isn’t just about building the network. It’s about removing the psychological, linguistic, and cultural friction that keeps people from using what’s available. This is where tools like Mia comes in. Mia reduces member confusion by delivering instant clarity around their health benefits, presented in plain and clear language. Members can easily understand what they’re entitled to, how to access it, and where to go. Mia also helps connect them with nearby, in-network behavioral health providers removing search anxiety and building confidence to seek care.

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‍Why behavioral health access is a competitive advantage‍

What happens when members can actually access high-quality mental health care?

Plans that get behavioral health right are seeing:

• Increased retention, especially among dual-eligible and chronically ill members

• Higher CAHPS and Star ratings, as access, satisfaction, and care coordination improve

• Fewer grievances and appeals, especially related to delays in care or unclear benefit structures

• Improved enrolment positioning, as plans can confidently market their mental health capabilities during AEP

This is no longer about staying compliant. It’s about staying relevant.

Final thoughts: The future of Medicare Advantage hinges on who gets this right

Behavioral health access is the new frontier not because CMS says so but because members demand it, equity demands it, and the industry cannot afford to ignore it any longer.

Plans that build thoughtful, inclusive, and integrated behavioral health systems will define what it means to truly serve seniors, not just enroll them.

If you’re preparing for Annual Enrollment Period, the question isn’t whether you address behavioral health access.
It’s how well you do it and whether your plan will lead the next era of Medicare Advantage or lag behind it.

Summary

What are the key behavioral health changes in the 2025 CMS final rule?

The 2025 CMS final rule introduces several important changes that will directly impact how Medicare Advantage plans structure and deliver behavioral health services. One of the most significant is the creation of a new provider category called "Outpatient Behavioral Health," which includes marriage and family therapists, mental health counsellors, addiction medicine specialists, and opioid treatment providers. Plans are also required to verify that behavioral health providers are active, which CMS defines as having treated at least 20 patients within the past 12 months. This verification must be supported by claims or electronic health record (EHR) data. In addition, inpatient behavioral health facilities will receive a 2.8% reimbursement rate increase. Finally, CMS is placing a stronger emphasis on behavioral health access for dual-eligible and underserved populations, signaling a shift toward more inclusive, equity-focused care delivery.

What does “active provider verification” mean?

Active provider verification is a new CMS requirement aimed at improving the reliability and accuracy of Medicare Advantage provider networks. Under this rule, plans must confirm that each behavioral health provider in their network has treated at least 20 patients over the past 12 months. This verification must be backed by data, either through claims submissions or electronic health records. The intent is to eliminate the use of inactive or “ghost” providers those who are listed in directories but are not currently seeing patients which has long been a barrier to genuine network adequacy.

How should MA plans support behavioral health access for dual-eligible members?

To improve behavioral health access for dual-eligible members, Medicare Advantage plans should take a multi-pronged, data-driven approach. This begins with identifying care gaps using predictive analytics and social determinants of health (SDoH) data to flag high-risk individuals. Plans must then work to expand their provider networks with clinicians who are both culturally competent and geographically accessible. In addition to building the network, it's essential to provide dedicated navigation support to help members understand and access behavioral health services with confidence. Integrating mental health care into existing chronic care models can also drive better engagement and outcomes, as dual-eligible members often experience co-occurring behavioral and physical health conditions.

Will these changes impact star ratings or enrolment?

Yes, the changes introduced in the 2025 CMS final rule are likely to have a significant impact on both star ratings and enrolment. Improved behavioral health access directly contributes to higher CAHPS scores, especially in areas like satisfaction with care, mental health services, and care coordination. Plans that invest in better access are also likely to see lower disenrollment rates, particularly among high-risk and chronically ill populations. Additionally, better behavioral health support reduces the number of complaints and grievances- factors that influence both star ratings and CMS enrolment caps. In short, behavioral health access is now tightly linked to how plans are evaluated and how they grow.

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