CMS 2025 Final Rule: New Behavioral Health Requirements for MA Plans

Mental Health Awareness Month and Summary of New CMS Final Rule

Fitting for Mental Health Awareness Month, the Centers for Medicare & Medicaid Services (CMS) recently released its 2025 Final Rule that, among other things, aims to improve access to behavioral health providers for Medicare Advantage members.

Ready to learn about the CMS 2025 Final Rule and Veda’s strategic approach to its behavioral health network requirements?

The CMS 2025 Final Rule significantly expands the behavioral health network requirements for Medicare Advantage (MA) health plans. As reported by Fierce Healthcare, all Medicare Advantage plans will likely see increased administrative burdens due to the behavioral health network expansion requirements.

Not only is Veda a proven and trusted partner for achieving compliance with CMS requirements, Veda’s solutions are unrivaled in their ability to help health plans verify, expand, improve, and map their behavioral health networks.

Here are the behavioral health requirements covered in the Contract Year 2025 Medicare Advantage and Part D Final Rule and Veda’s approach:

New “Outpatient Behavioral Health” Category Added to Network Adequacy Evaluations 

Building upon CMS’s recent addition of a new benefit category for mental health counselors (MHCs) and marriage and family therapists (MFTs)—and recognizing that many MHCs and MFTs practice in outpatient behavioral health facilities—CMS has expanded its network adequacy requirements to include a new category called “Outpatient Behavioral Health.”

What Can Veda Do?

Veda’s curated dataset includes accurate information for even the hardest-to-validate specialties, credentials, and facility types— requiring no additional burden on health plans and health systems.

Wide Range of Specialists Included in “Outpatient Behavioral Health” Category

More specialties and outpatient care classifications were added to solve behavioral health provider shortages. The specialists in the new “Outpatient Behavioral Health” category include MHCs, MFTs, Opioid Treatment Program providers, Community Mental Health Centers, addiction medicine physicians, nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs).

What Can Veda Do?

Veda offers current and complete outpatient behavioral health provider profiles, on each of the specialties above, containing the necessary details to contract with providers and meet adequacy requirements.

Skill Sets of Certain Behavioral Providers Must Be Verified 

To address concerns that NPs, PAs, and CNSs have the requisite skills and training to address the behavioral health needs of plan members, MA plans must independently verify that the providers they are adding to their network have furnished (or will furnish) behavioral health services to at least 20 patients within a 12-month period using information such as (i) MA plan’s claims data, (ii) prescription drug claims data, (iii) EHRs, or (iv) similarly reliable data.

What Can Veda Do?

Veda partners with customers to develop effective ways to complete the requisite independent verifications, utilizing the best data available in the industry. Our proprietary Vectyr database is updated 24/7 to include the most up-to-date, complete, and accurate provider data in the behavioral health space. This data can help MA plans verify behavioral health providers and comply with CMS’s requirements.

“Outpatient Behavioral Health” Facility Added to Time & Distance Standards and Telehealth Specialty Requirements

CMS now includes the “Outpatient Behavioral Health” facility specialty in the list of specialty types that will receive a 10% credit toward meeting time and distance standards. Additionally, MA plan’s networks must include at least one telehealth provider within the Outpatient Behavioral Health specialty.

What Can Veda Do?

Veda’s nationwide database can identify telehealth providers, flag whether a provider accepts patients at their practice location, and help source providers to meet the new behavioral health requirements. We can also help MA plans ensure compliance with CMS’s time and distance standards.

Veda is Equipped to Meet The Needs Introduced By The 2025 CMS Rule Changes

Veda excels at helping health plans and systems connect members with behavioral health services, treatment facilities, and telehealth providers. The 2025 MA rule changes are an opportunity for health plans and health systems to explore how Veda can help them expand, improve, and map their behavioral health networks and verify the claims data for behavioral health providers.

Veda’s solutions can help connect members to quality behavioral health services more quickly, efficiently, and at less cost than the traditional methods relied on in the past. Armed with the most accurate provider data available, Veda’s solutions contribute to positive member experiences while helping people find the right care for their behavioral health needs.