A new report by the U.S. Government Accountability Office (GAO) found that the Centers for Medicare & Medicaid Services (CMS) doesn’t focus on behavioral health services in its audits of prior authorization criteria to determine impact on Medicare Advantage members’ access to care.
The GAO conducted the study from January 2024 to May 2025 in response to a provision of the Consolidated Appropriations Act 2023, which required the watchdog to review behavioral health benefits and the use of prior authorization in traditional Medicare and Medicare Advantage.
Behavioral health conditions affected about one-fifth of U.S. adults ages 50 or older in 2023. Many Medicare Advantage members need behavioral health care for conditions like depression and substance abuse.
To conduct the study, the GAO used information and interviews from nine selected Medicare Advantage organizations that varied in size, region, and types of plans available and covered about 45 percent of Medicare Advantage beneficiaries in 2024. The GAO said it reviewed the plans’ reported prior authorization requirements and criteria for behavioral health as well as CMS guidance and regulations and interviews with CMS officials and representatives for providers and Medicare Advantage members.
Plan representatives told the GAO that prior authorization can help ensure members receive medically necessary care. However, they said requirements can adversely affect a member’s timely access to care and create additional administrative burdens for providers.
In the GAO review, eight of the nine selected Medicare Advantage plans required prior authorization before members received services. However, CMS oversight of prior authorization criteria doesn’t target behavioral health services in audits to determine the impact on members’ access to care.
CMS officials told the GAO that they didn’t focus on behavioral health requests in recent audits despite the agency’s goal of improving access and quality of behavioral health services for beneficiaries. Therefore, CMS doesn’t have enough information to determine whether a Medicare Advantage organization’s internal coverage criteria affects a member’s access to services.
GAO recommends that CMS focus on behavioral health services in program audit prior authorization denial reviews and planned reviews of internal coverage criteria. But CMS said it couldn’t commit to doing so because the services make up a small percentage of Medicare Advantage services. Instead, the agency told GAO that it would take the recommendation under advisement in the future.