The Centers for Medicare and Medicaid Services (CMS) finalized reforms to Medicare payment for 2024 that will expand access to behavioral health care services. Notably, the reforms increase coverage for services provided by community health workers (CHWs) and peer support specialists. CHWs live in the same communities as the people they serve and use their lived experiences to help identify health concerns and connect people with resources, while peer support specialists help people with behavioral health conditions reach their recovery goals. CMS’s payment changes provide important reforms for Medicare beneficiaries and send signals to Medicaid and commercial insurers, who look to Medicare when making coverage and reimbursement decisions.
Changes to Medicare to Support Behavioral Health
The policy changes provide more flexibility in the types of providers that are eligible to be reimbursed by Medicare and also provide additional resources for both early intervention and crisis intervention services. The reforms also elevate the importance of addressing the social needs of beneficiaries and encourage and support the provision of community-based care. By creating the capacity and flexibility to implement culturally and linguistically effective services, the policies also can help to promote racial equity. Examples of included provisions designed to expand access to behavioral health services include:
- allowing licensed marriage and family therapists and mental health counselors to bill Medicare directly for services
- enabling providers to bill for behavioral health crisis services as part of mobile crisis teams at appropriate rates
- allowing more types of clinicians such as social workers and mental health counselors to bill for the treatment of behavioral health needs related to physical health problems, such as the mental health challenges that come with managing sickle cell disease
- increasing the amount that Medicare pays for psychotherapy codes and some related behavioral health services
- supporting peer support specialists and CHWs to be a part of care teams by covering services that reflect their specific work
- implementing reimbursement for caregiver training services, and
- extending flexibilities to provide some parts of opioid treatment through audio-only telecommunications.
New Opportunities for Community Health Workers and Peer Support Specialists
Medicare’s coverage for peer support specialist and community health worker services can help advance equitable access to behavioral health care. The new payments support peer specialists and CHWs in coordinating care and other services, helping people identify and meet recovery goals, and providing social and emotional support. In 2024, these new codes pay almost $80 per hour, adjusted based on region and site of service. Over the course of the year, assuming a peer support specialist or CHW saw approximately six people per day for hour-long appointments, they could bill more than $100,000. This is a critical potential financing stream for these services and a significant acknowledgment of the contributions of CHWs and peer support specialists to care.
Under the Medicare payment changes, health care practices could offer competitive compensation for peer support specialists and CHWs. A growing body of evidence demonstrates the effectiveness of CHWs and peer support specialists as part of care teams and their importance to the continuum of services. Integrating these practitioners also would support small and underserved health care practices financially, as many of the activities covered are provided currently but not always billed for, such as care coordination and health education.
Most states currently cover peer support services in Medicaid and an expanding number cover CHWs. Medicare coverage offers a clear national template for how to code and value these services across states, signaling to commercial health insurers to align their payment practices as well. With these reforms, reimbursement policies now support widespread access to CHWs and peer support specialists as part of the mainstream behavioral health workforce. The qualifications for peer support specialists and CHWs focus on shared lived experience with populations served, which can increase the cultural and linguistic relevance of care. In addition, peer support specialists and CHWs can be recruited in communities that otherwise face shortages of behavioral health providers, which will help to extend access and expand employment options as well.
Next Steps for Health Care Practitioners
Practices across the country should begin planning now to integrate peer support specialists and community health workers into their array of behavioral health care services. They also can advocate with Medicaid and commercial insurers to promote payment alignment to bolster financial sustainability. Having Medicare coverage of these roles strengthens the argument for commercial health insurers to cover them as well.
The Substance Abuse and Mental Health Services Administration offers resources to support practices in integrating peer support specialists; the U.S. Department of Health and Human Services does as well. By leveraging this payment policy change, practices can more equitably expand access to behavioral health care.
