Behavioral Health Network Adequacy: Why MA Filings Fail Twice

Behavioral health network adequacy in Medicare Advantage is scored on four HSD types: Psychiatry (029), Clinical Psychology (036), Clinical Social Work (037) and the Outpatient Behavioral Health facility type (068). Each has its own time and distance standard, and at least 90% of beneficiaries in Large Metro and Metro counties, or 85% in Micro, Rural and CEAC counties, must have one of each type within reach under 42 CFR 422.116. On the builds we've run, behavioral health is where filings break, and it usually breaks for two reasons at once.

The supply is thin. And the roster mislabels the supply you do have.

The first problem is real and it is national. When the HHS Office of Inspector General looked at 2021 data in selected counties, it found fewer than 5 active behavioral health providers per 1,000 enrollees in both Medicare and Medicaid. Nobody recruits their way out of that in one filing cycle. The second problem is yours, it is fixable this month, and in our experience it is the one teams skip because it looks like housekeeping. Our position: classification discipline and telehealth designed in from the start will close more behavioral health gaps than another round of cold calls.

Four types, added across three rules

Psychiatry is the old one. The other three are recent, and plenty of roster logic in the field was written before they existed.

Clinical Psychology (036) and Clinical Social Work (037) became provider types in the CY2024 final rule (CMS-4201-F), published April 12, 2023 and applicable to coverage beginning January 1, 2024. The same rule made both eligible for the telehealth credit. Outpatient Behavioral Health (068) came a year later, as a facility type, in the CY2025 final rule (CMS-4201-F3 and CMS-4205-F), published April 23, 2024 with an applicability date of January 1, 2025. The regulation now lists 29 provider types and 14 facility types. If a desk procedure or an old training deck still says 27 and 13, it is out of date on both counts.

One type didn't survive. The CY2024 rule also proposed a standalone specialty for prescribers of medication for opioid use disorder, and CMS did not finalize it. The Consolidated Appropriations Act, 2023 ended the X-waiver, and with it went the SAMHSA list CMS had planned to use to populate the supply file. So there is no MOUD prescriber type on your HSD table. MOUD prescribing shows up inside the OBH definition instead, through opioid treatment programs, addiction medicine physicians, and nurse practitioners, physician assistants and clinical nurse specialists who prescribe for substance use disorders.

The standards, side by side

Here are the base standards for the four types. Time is in minutes, distance in miles.

HSD type	Large Metro	Metro	Micro	Rural	CEAC	Minimum count
Psychiatry (029)	20 / 10	45 / 30	60 / 45	75 / 60	110 / 100	0.14 per 1,000 (0.12 in Micro, Rural, CEAC)
Clinical Psychology (036)	20 / 10	45 / 30	60 / 45	75 / 60	145 / 130	0.15 per 1,000 (0.13)
Clinical Social Work (037)	20 / 10	30 / 20	50 / 35	75 / 60	125 / 110	0.25 per 1,000 (0.22)
Outpatient Behavioral Health (068)	20 / 10	40 / 25	55 / 40	60 / 50	110 / 100	1 per county

These are the base tables in 422.116, and they match the Master tab of the 2026 HSD Reference File. CMS customizes thousands of county and specialty pairs a year, and customization only ever loosens a standard, so check the file for your actual counties.

Two things in that table catch people out. Clinical Social Work is tighter than Psychiatry in Metro counties: 30 minutes and 20 miles, against 45 and 30. And OBH in a Rural county, at 60 minutes and 50 miles, is tighter than Psychiatry or Clinical Psychology at 75 and 60. The newest type is not the easy one.

The minimum count is the other half of the test, and it is where teams underestimate. CMS multiplies the county's Medicare beneficiaries by a 95th percentile base population ratio to get "beneficiaries required to cover," then applies the specialty ratio per 1,000 and rounds up to the next whole number. The 2026 file puts Baldwin County, Alabama, a Metro county, at 6,873 beneficiaries required to cover. Running the regulation's ratios against that figure (our arithmetic, for illustration): Clinical Social Work is 0.25 × 6.873 = 1.72, so 2. Psychiatry is 0.14 × 6.873 = 0.96, so 1. Clinical Psychology is 0.15 × 6.873 = 1.03, which rounds up to 2. Three hundredths of a psychologist costs you a second contract. (The full mechanics are in how CMS scores Medicare Advantage network adequacy.)

Who counts as Outpatient Behavioral Health

OBH is the catch-all the field asked for, and it comes with rules. Under 422.116(b)(2)(xiv), these count:

• Marriage and family therapists and mental health counselors, as defined in section 1861(lll) of the Social Security Act
• Opioid Treatment Programs
• Community Mental Health Centers
• Addiction medicine physicians
• Outpatient mental health and substance use disorder treatment facilities
• Physician assistants, nurse practitioners and clinical nurse specialists who regularly furnish behavioral health counseling or therapy, including psychotherapy or prescription of medication for substance use disorders

The last group carries a test. An NP, PA or CNS counts only if they furnished the qualifying psychotherapy or substance use disorder prescribing services to at least 20 patients within a 12-month period. The plan has to verify that every year, using claims, prescription claims, EHR data or something similar, or have a "reasonable and supportable basis" when the history is thin. CMS can ask for the evidence. The qualifying services and HCPCS codes are listed in the HSD Reference File.

That annual check is a data job, not a credentialing job. On builds we've run, nobody owns it until someone asks for the evidence.

One provider, one bucket

Here is the rule that trips rosters: a provider submitted under Psychiatry, Clinical Social Work or Clinical Psychology cannot also be submitted under OBH. It sits in the Notes tab of the HSD Reference File for code 068, and in the preamble to the CY2025 rule.

So every behavioral health clinician who could plausibly sit in more than one type needs one assignment, made on purpose. The trade-off is real. If Psychiatry passes comfortably in a county and OBH fails on time and distance, a clinician who genuinely qualifies for both is worth more in OBH there. If Psychiatry is sitting at its minimum, moving that same clinician opens a hole somewhere else. Make the call county by county, with the gap report open, and write down why, because the next person to touch the file will not remember.

Then there are the plain mislabels. These are the patterns we see most often:

1. Marriage and family therapists and licensed counselors coded as Clinical Social Work because they are "therapists." The regulation names them in OBH.
2. Nurse practitioners filed under OBH with no 20-patient evidence anywhere on record.
3. The same NPI under 037 and 068 because two teams built two files and nobody merged them.
4. Clinicians listed at a billing or administrative address. CMS guidance says to list providers at the office where they see patients for consultations, and to submit names and addresses identically every time.
5. Telehealth-only clinicians carried on the table as if they counted toward the minimum.

None of these need a new contract. Every one of them can move a county from fail to pass, or from pass to a finding.

Telehealth earns a credit, never a count

Under 422.116(d)(5), a plan gets a 10 percentage point credit toward the share of beneficiaries within time and distance, for a given specialty and county, when its network includes one or more providers furnishing additional telehealth benefits under 422.135 in that specialty. All four behavioral health types are on the credit list: Psychiatry, Clinical Psychology, Clinical Social Work and Outpatient Behavioral Health.

Read the limits closely. The credit applies to the percentage test only. It does nothing for the minimum count. And a telehealth-only provider never counts toward the minimum, under (e)(1)(ii).

A worked example on a fictional county shows why this matters. Say 79% of sampled beneficiaries in a Rural county have a clinical social worker within 75 minutes and 60 miles. The standard is 85%, so the county fails. Add the telehealth credit and 79 becomes 89, and the percentage test passes. Now say the county's minimum is 2, and you have one in-person LCSW in range plus three telehealth-only clinicians. You still fail the count. The credit moved one test and left the other exactly where it was.

So design telehealth in rather than bolting it on at the end. Where supply can't close the gap, contract real telehealth access in each behavioral health type so it earns the credit, and spend recruiting effort on in-person clinicians who carry the count. A provider counts toward the minimum if at least one sampled beneficiary is within range, so a clinician at the far edge of a county can still do that job. Out of supply entirely? That is what exception requests are for.

Seven business days, and who actually answers the phone

Since the CY2024 rule, 42 CFR 422.112(a)(6)(i) sets appointment wait-time standards in MA for primary care and behavioral health. Urgently needed or emergency services: immediately. Services that need medical attention but are not urgent: within 7 business days. Routine and preventive care: within 30 business days.

The automated criteria check doesn't test any of that. A behavioral health network whose listed clinicians aren't taking new patients can't meet a 7-business-day standard, however green the ACC report looks. (Medicaid plans have their own federal clock coming; see Medicaid wait-time standards and secret shoppers.)

Two federal reviews should change how you read your own roster.

In May 2023, the Senate Finance Committee's majority staff ran a secret shopper study of 12 MA plans in six states: 10 listed mental health providers per plan, 120 calls. Staff got an appointment 22 times out of 120, or 18%, and that counts six calls routed to a third-party matching service. Thirty-nine of the 120 (33%) were non-working numbers, wrong numbers or calls never returned. The report's headline was that more than 80% of listed in-network mental health providers were "ghosts."

In October 2025, the OIG looked at 40 MA plans and 20 Medicaid managed care plans in 10 counties (OEI-02-23-00540). On average, 55% of the behavioral health providers listed by MA plans, and 28% of those listed by Medicaid plans, served no enrollees of the plan in 2023. Of the sampled inactive providers, OIG found 72% should not have been listed at all. MA networks averaged 16% of the county behavioral health workforce, against 31% for Medicaid plans. Providers told OIG why they stay away: administrative burden and low payment rates.

Put those side by side. A roster where half the names saw none of your members last year is a list of contracts, and the HSD table will count every one of them because they are contracted and in range. Members can't book with a contract. More on the directory side of this in ghost networks and directory compliance.

A classification pass to run before your next upload

Do this before anyone makes another recruiting call:

1. Pull every behavioral health NPI on the HSD file into one list, across 029, 036, 037 and 068.
2. Flag any NPI that appears under more than one of those types. Pick one assignment per the one-bucket rule and record the reason.
3. Check license type against assignment. Marriage and family therapists and mental health counselors go to OBH. Social workers go to 037, psychologists to 036.
4. For every NP, PA and CNS under OBH, attach the 20-patient evidence from the last 12 months, and put the re-verification date on a calendar.
5. Confirm each address is where the clinician sees patients, not where the practice bills.
6. Separate telehealth-only clinicians. Keep them for the credit, and take them out of your minimum-count math.
7. Pull 12 months of claims and list contracted behavioral health providers with zero encounters for your members. Call them. Some are new and fine. Some are ghosts.
8. If the cleanup ends in terminations, remember that 422.111(e) requires enrollee notice 45 calendar days before the effective date for behavioral health providers.
9. Rerun adequacy by county and type. Only then decide where to recruit.

The order is the point. Recruiting against a mislabeled roster sends your contracting team after gaps that don't exist and straight past the ones that do, and in our experience it is a common reason a network passes internally and fails at CMS.

Classify first. Then recruit the clinician who closes the most uncovered members, starting in the rural counties where behavioral health fails first.

Blueprint scores adequacy on the same provider records your recruiting and credentialing teams already work in, so a reclassification changes the county score without a separate spreadsheet. Distance is straight-line today, so a pass reads as "unconfirmed" until it is measured on roads; the recruit what-if runs on sample data at /network-map.