Medicare Advantage: CMS Oversight of Prior Authorization Criteria Should Target Behavioral Health Services

What GAO Found

Medicare covers inpatient and outpatient services for the diagnosis and treatment of behavioral health conditions, which include mental health conditions, such as depression, and substance use disorders, such as opioid use disorder. Medicare Advantage (MA) organizations, which administer Medicare's private plan alternative, may require providers to request and receive approval before providing some services, a process known as prior authorization. MA organizations must use Medicare coverage criteria when making prior authorization decisions. In some cases, MA organizations may also use internal coverage criteria, which include any criteria not in federal law nor developed by the Centers for Medicare & Medicaid Services (CMS) or its contractors. For example, an MA organization might use criteria from a professional society to further define a clinical term in Medicare criteria.

According to CMS, processes like prior authorization are designed to help MA organizations minimize unnecessary services, thereby helping to protect beneficiaries and contain costs. However, studies have indicated that prior authorization and use of internal coverage criteria may hinder MA beneficiaries' access to care. CMS is responsible for ensuring that MA beneficiaries generally receive at least the same coverage of benefits as beneficiaries enrolled in traditional fee-for-service Medicare, which does not currently require prior authorization for any behavioral health services.

GAO found eight of nine selected MA organizations it reviewed reported requiring prior authorization for behavioral health services, particularly inpatient and other specialized care (see table). In deciding whether to authorize inpatient behavioral health services, seven organizations reported using internal coverage criteria, while the use of internal coverage criteria was less common for other services.

Nine Selected MA Organizations' Reported Prior Authorization Requirements and Criteria for Key In-Network Behavioral Health Care Services

Source: Selected Medicare Advantage (MA) organizations. | GAO-25-107342

Note: Transcranial magnetic stimulation is a specialized service used to treat severe depression. For more details, see table 2 and appendix II in GAO-25-107342.

CMS has not targeted behavioral health services in its oversight of MA organization prior authorization. During its annual program audits, CMS reviews MA organization denials of selected authorization requests, including how MA organizations applied any internal coverage criteria used. However, CMS officials said they did not target any behavioral health requests in recent audits even though CMS has a goal of improving access and quality of behavioral health services for beneficiaries in its programs. As a result, CMS does not have enough information to determine whether or to what extent MA organizations' use of internal coverage criteria affects MA beneficiaries' access to behavioral health services. CMS also announced plans to annually review MA organizations' internal coverage criteria for selected services starting in 2026. CMS had not released final plans as of May 2025, including indicating if these reviews will target any behavioral health services.

Why GAO Did This Study

Behavioral health conditions were estimated to affect about one-fifth of U.S. adults age 50 or older in 2023 (the most recent data available).

The Consolidated Appropriations Act, 2023, includes a provision for GAO to review behavioral health benefits and the use of prior authorization in traditional Medicare and MA. This report describes, for behavioral health services, selected MA organizations' prior authorization requirements and use of internal coverage criteria for prior authorization decisions. It also examines CMS's oversight of the use of internal coverage criteria, among other issues.

GAO reviewed information from and interviewed nine selected MA organizations that varied in size, region, and types of plans available and covered about 45 percent of MA beneficiaries in 2024. Specifically, GAO reviewed their reported prior authorization requirements and criteria for behavioral health services. GAO also reviewed CMS guidance and regulations and interviewed CMS officials and provider and beneficiary representatives.