Medicare Coverage for Counseling

Will MFTs and counselors be able to immediately bill Medicare for diagnosing and treating Medicare beneficiaries in my practice?

The effective date of the provisions regarding counselor and MFT inclusion in the Medicare program is January 1, 2024.  At that time, you will be able to bill for services provided to Medicare beneficiaries.

The 2022-23 federal budget legislation (called Omnibus) included the Mental Health Access Improvement Act language that allows mental health counselors and marriage and family therapists (MFTs) to receive payment under the Medicare Part B program for providing covered mental health services to Medicare beneficiaries, beginning January 1, 2024.

How do I know as a MFT or counselor if I am eligible Medicare provider?

The Mental Health Access Improvement Act specifically spells out who is eligible based on the following language:

The term ‘marriage and family therapist’ means an individual who ‘‘(A) possesses a master’s or doctor’s degree which qualifies for licensure or certification as a marriage and family therapist pursuant t State law of the State in which such individual furnishes the services described in paragraph; ‘‘(B) is licensed or certified as a marriage and family therapist by the State in which such individual furnishes such services; ‘‘(C) after obtaining such degree has performed at least 2 years of clinical supervised experience in marriage and family therapy; and ‘‘(D) meets such other requirements as specified by the Secretary.

“The term ‘mental health counselor’ means an individual who—‘(A) possesses a master’s or doctor’s degree which qualifies for licensure or certification as a mental health counselor, clinical professional counselor, or professional counselor under the State law of the State in which such individual furnishes the services described in  the above paragraph; (B) is licensed or certified as a mental health counselor, clinical professional counselor, or professional counselor by the State in which the services are furnished; (C) after obtaining such a degree has performed at least 2 years of clinical supervised experience in mental health counseling; and ‘(D) meets such other requirements as specified by the HHS Secretary.’’

How and when will I be able to apply for Medicare-approved provider status?

The Centers for Medicare and Medicaid Services (CMS) – the federal agency that administers all aspects of the Medicare Program and issues rules and regulation – will begin to develop guidance in 2023 to MFTs and counselors on how to apply for Medicare recognition. CMS needs this period to provide guidance to counselors as new Medicare providers.  Medicare Mental Health Workforce Coalition representatives will be working with CMS on this process and timing, and will provide information as soon as that application process is completed by CMS.

How will I know which mental health service codes are eligible for reimbursement that I have provided to older clients?

In addition to the provider application process, CMS will also provide guidance in 2023 to counselors on which codes to use for billing for services provided to Medicare beneficiaries. NBCC will also discuss this process in our meetings with CMS officials. The Mental Health Access Improvement Act does provide guidance as well on this issue with the following language:

The term ‘marriage and family therapist services’ means services furnished by a marriage and family therapist for the diagnosis and treatment of mental illnesses (other than services furnished to an inpatient of a hospital), which the marriage and family therapist is legally authorized to perform under State law (or the State regulatory mechanism provided by State) of the State in which such services are furnished.

“The term ‘mental health counselor services’ means services furnished by a mental health counselor (as defined below for the diagnosis and treatment of mental illnesses (other than services furnished to an inpatient of a hospital), which the mental health counselor is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are furnished.

Although I am not licensed as a “Mental Health Counselor” or “Marriage and Family Therapist” in my state as we have different designations, will I be eligible to participate in the Medicare program?

Yes, as long as you meet the requirements as described in the legislation. The provisions are similar to licensing at that state level.

How can practitioners opt out of the Medicare program?

Counselors and MFTs will need to complete a form in 2023 to opt out. A silver lining in the Medicare Access and CHIP Reauthorization Act of 2015. which was signed into law in mid-April 2015 to repeal the sustainable growth rate (SGR), is a provision in the bill that also repeals the irritating requirement of having to renew an opt-out status every two years. Practitioners opting out of Medicare after June 16, 2015, will need to file an affidavit to opt out of Medicare only once, and it will have permanent effect. The practitioner will no longer need to renew his opt-out every two years thereafter.

Are Medicare enrolled providers subject to site visits?

Rarely. The National Site Visit Contractor (NSVC) at CMS conducts unannounced site visits for all Medicare Part A and B providers and suppliers, including DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies) suppliers. A site visit helps prevent questionable providers and suppliers from enrolling or staying enrolled in the Medicare Program. 

What entity serves as the Medicare Administrative Contractor (MAC) for our state/region?

Here is a list of MACs by state and region:

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/MACs-by-State-June-2019.pdf

In addition to MFTs and counselors directly billing Medicare for services provided to older clients in their private practices, will there be other opportunities for counselors to participate and receive reimbursement in other settings?

Yes. MFTs and Counselors are now eligible Medicare Part B providers in Federally Qualified Health Centers (FQHCs).  FQHCs are safety net providers that primarily provide services typically furnished in an outpatient clinic. FQHCs provide comprehensive services including preventive health services and mental health and substance abuse services. Counselors also are now eligible Medicare Part B providers in Rural Health Clinics (RHCs). The Rural Health Clinic (RHC) program increases access to primary care services for patients in rural communities. RHCs are required to provide outpatient primary care services such as behavioral health care. As part of the Mental Health Access Improvement Act counselors are now required team members for Medicare hospice interdisciplinary teams. The hospice interdisciplinary team includes physicians, nurses, mental health providers, chaplains, and trained volunteers who work together to address a hospice patient's physical, emotional, and spiritual needs.

How should a provider submit Medicare claims if they have more than on license (e.g., if a psychologist is also a LPMHC or LPMFT would Medicare reimburse them based on the psychologist rate or the LPMHC or the LPMFT rate?

This question will be addressed in the 2024 Medicare Physician Fee Schedule (MPFS), but it is likely that if the practitioner has already been billing Medicare as a Psychologist, he/she will continue to bill as that provider designation. The MPFS will include several provisions on enrollment, coding and billing issues that go into effect on January 1, 2024 for MFTs and counselors.

Now that MFTs and counselors provide treatments to Medicare clients, will that change address funding for services for incarcerated individuals for MFTS and counselors serving them currently and in the future?

This question will be addressed in the 2024 Medicare Physician Fee Schedule (MPFS).

Are pre-licensed MFTs and counselors under appropriate supervision eligible to provide services and seek reimbursement? If yes, what are the requirements?

Yes, and the requirements will be spelled out in the in the 2024 Medicare Physician Fee Schedule (MPFS).

What is the time frame for Medicare to process claims?

For clean claims that are submitted electronically, they are generally paid within 14 calendar days by Medicare. 

Are providers required to submit electronic claims?

The Administrative Simplification Compliance Act (ASCA) requires that Medicare claims be sent electronically unless a provider qualifies for an exception waiver.

What Other Federal Programs recognize and provide reimbursement to MFTs and counselors?

Many federal programs already recognize mental health counselors including: The National Health Service Corps, Department of Veterans Affairs, U.S. Army and TRICARE.

What will the provider grievance/appeals process look like?

The Medicare appeals process is detailed in the attached link – Medicare Parts A and B Appeals Process.

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/medicareappealsprocess.pdf

What are the tele-health policies for provision of behavioral health services to Medicare beneficiaries?

Medicare patients can receive telehealth services for behavioral health care in their homes in any part of the country. This includes most behavioral health services, such as counseling, psychotherapy, and psychiatric evaluations. The in-person visit requirements before a  client may be eligible for tele-behavioral health care services is delayed through December 31, 2024.

Sources:  Consolidated Appropriations Act, 2023 (PDF),  Consolidated Appropriations Act, 2022 (PDF),  Consolidated Appropriations Act, 2021 (PDF)

If providers have concerns or questions related to Medicare, is there an ombudsman or entity they can engage?

You can call CMS at Member Services at 1-877-739-1370. The Office of the Managed Care Ombudsman offers free assistance.

If a provider, air ambulance provider, or health care facility believes a health plan isn’t complying with the dispute resolution process, then they may contact the No Surprises Help Desk at 1-800-985-3059 to submit a question or complaint. Or, they can submit a complaint online. Supporting documentation may be required. CMS will send a confirmation email to the practitioner when CMS receives their complaint to notify them of next steps and let them know if additional information is required.

Is there a Medicare provider directory for behavioral health practitioners? 

Medicare has an online provider directory tool that can be accessed at:

https://www.medicare.gov/forms-help-other-resources/find-compare-health-care-providers

Will there be opportunities to engage in the CMS implementation process this year?

Yes. As Medicare Coalition representatives meet with CMS representatives in 2023, we will be soliciting questions and comments from MFTs and counselors on any concerns about implementing rules on Medicare recognition of MFTs and counselors.  Further, the Coalition plans to hold a series of training sessions this year on Medicare application procedures and coding issues, and regular updates into 2024 and beyond.

How will Medicare recognition of counselors affect the new Counseling Compact and vice versa?

The relationship between CMS regulations and the Counseling Compact will be provided in the MPFS.

Will CMS provide guidance to providers when they treat dual eligibles?

MFTs and counselors must accept assignment for Part B-covered services provided to dually eligible beneficiaries. Assignment means the Medicare Physician Fee Schedule (PFS) amount is payment in full. Special instructions apply when you provide an Advance Beneficiary Notice (ABN) to a dually eligible beneficiary, based on the expectation that Medicare will deny the item or service because it isn’t medically reasonable and necessary or is custodial care. ● You can’t bill the dually eligible beneficiary up front when you provide an ABN. The Medicare Physician Fee Schedule will provide more guidance when engaging dual eligibles.

Are there other ways that MFTs and counselors will be able to participate in Medicare behavioral health program initiatives and delivery systems?

The Mental Health Access Improvement Act will open several doors including opportunities to participate in Medicare Integrated Behavioral Health and Primary Care Programs. Public and private insurance programs now widely consider integrating behavioral health care with primary care an effective strategy for improving outcomes for millions of Americans with mental or behavioral health conditions. Medicare makes separate payment to physicians and non-physician practitioners for BHI services they supply to patients over a calendar month service period. Counselors also will be able to participate in “Medicare Innovative Delivery and Payment Programs” such as Accountable Care Organizations (ACOs).

Will counselors be able to provide treatments in 2024 to previous clients who were forced to switch providers when they turned 65 years of age?

Yes. If those clients would like to return to previous providers, they can access any eligible provider.

GENERAL QUESTIONS ABOUT THE MEDICARE PROGRAM

What are the main differences between Original Medicare and Medicare Advantage?

As older adults think about how Medicare will cover their health care needs, their first major decision is whether to enroll in the federally run original Medicare that has been in place since 1966, or select a Medicare Advantage Plan.

Original Medicare

• Original Medicare includes Part A (hospital services) and Part B (physician and other provider services).
• A beneficiary can join a separate Medicare drug plan to get Medicare drug coverage (Part D).
• A beneficiary can use any doctor or hospital that takes Medicare, anywhere in the U.S.
• To help pay out-of-pocket costs in Original Medicare (like your 20% coinsurance), a beneficiary can also buy supplemental coverage, like Medicare Supplement Insurance (Medigap), or have coverage from a former employer or union, or Medicaid.

      Medicare Advantage (also known as Part C)

• Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D.
• In most cases, a beneficiary will need to use doctors who are in the plan's network.

• Plans may have lower out-of-pocket costs than Original Medicare.
• Plans may offer some extra benefits that Original Medicare doesn’t cover — like vision, hearing, and dental services.

For more information go to:  https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/your-coverage-options/compare-original-medicare-medicare-advantage

What mental health and substance use disorder benefits does Medicare Part B cover for beneficiaries?

Medicare Part B covers one depression screening per year, a one-time “welcome to Medicare” visit, which includes a review of risk factors for depression, and an annual “wellness” visit, where beneficiaries can discuss their mental health status. Part B covers individual and group psychotherapy services provided by several licensed professionals, and depending on state rules, family counseling is covered if the main purpose is to help with treatment, psychiatric evaluation, medication management, and partial hospitalization.

Part B also covers outpatient services related to substance use disorders. These include opioid use disorder treatment services, such as medication, counseling, drug testing, and individual and group therapy. Medicare covers one alcohol misuse screening per year, and for beneficiaries determined to be misusing alcohol, four counseling sessions per year. Medicare also covers some telehealth services, including for mental health and substance use disorder services as well as non-mental health related services, on both a permanent basis and on a temporary basis as part of the COVID-19 public health emergency.

STEP I: GET AN NPI

STEP II: COMPLETE THE MEDICARE ENROLLMENT APPLICATION

STEP III: WORK WITH YOUR MEDICARE ADMINISTRATIVE CONTRACTOR (MAC)

On December 23, 2022, Congress passed the Mental Health Access Improvement Act (S.828/ H.R.432) and was signed into law by President Biden. This bill allows LPCs and MFTs to enroll as providers in the Centers for Medicare and Medicaid Services as Medicare providers. Now that the bill has passed, we have moved to program implementation. This resource is designed to guide professional counselors and help them prepare for program enrollment. As we move closer to 2024, ACA will provide several resources to help you make informed decisions for yourself and your clients.

• Why is the passage of the Mental Health Access Improvement Act important  to counselors and clients?
  USAFACTS.org estimates 122 million Americans live in a mental health access shortage area. In many of these areas, you will find LPCs that are available to help but were not eligible to work with clients who are part of the Medicare population. The passage of the Mental Health Access Improvement Act means that counselors can provide services to those receiving Medicare, granting access to mental health services for millions of Americans.
• Who does this impact?
  The passage of this legislation impacts License Professional Counselors, Marriage and Family Therapists, and the clients that they serve.
• What services are covered under the  new legislation?
  As of January 1, 2024, LPCs and MFTs will be able to bill Medicare Part B and be reimbursed for approved services in accordance with Medicare reimbursement rates. ACA will provide additional information on services covered as we are advised to do so by CMS.
• When will counselors be able to sign up as Medicare providers?
  Counselors should be able to sign up to the Medicare providers program by January 1, 2024. ACA will continue working with the Center for Medicaid and Medicare services (CMS) to refine guidance surrounding the legislation.
• Where will counselors need to go to sign up as Medicare providers?
  This is still being determined. ACA will provide you with a  link in which to sign up for the Medicare provider program once it becomes available. We expect that the process to sign up for Medicare provider program will be similar to the current process. If you are currently a Medicaid provider, you have to:
  • Obtain a National Provider Identifier (NPI)
  • Complete the Medicare Enrollment Application
  • Select a Specialty Designation. Although it hasn’t been updated for LPCs and MFTs at this time, you may go to Become a Medicare Provider or Supplier | CMS which provides you with tentative information on how to become a Medicare provider. ACA will continue to monitor the progress of CMS and will provide member updates prior to the enrollment date of January 1, 2024.
• How did the bill pass?
  • ACA members successfully advocated to amend the Substance Use-Disorder Prevention  that Promotes Opioid Recovery and Treatment for Patients and Communities Act  (SUPPORT ACT) to allow LPCs to provide services to Medicare clients in Federal Substance Use Disorder Centers.
  • ACA sponsored a briefing to Congress along with members of the Medicare Mental Health Workforce Coalition to further educate Congress on the Medicare bill. This briefing resulted in an increase in congressional meetings from staffers inquiring to learn more about the bill, in turn we were able to bring in additional co-sponsors.
  • ACA made numerous recommendations to CMS in support of the profession. These recommendations contributed to the CMS decision to propose allowable “general supervision”  under the physician fee schedule. The rule is now final and went into effect in January 2023. This rule will improve Medicare eligible client wait time and increase access to care in certain settings. This was the only action CMS is allowed to take without bill passage.
  • CMS assists the U.S. Department of Health and Human Services in drafting the WH Administration’s Budget, which includes LPCs as Medicare providers. *This action lowered the CBO score from 1.2 Billion over ten years to 902 Million over ten years* Ultimately, Congress voted to pass the 1.7 trillion-dollar fiscal year (FY) 2023 omnibus package, H.R.2617, entitled the Consolidated Appropriations Act, 2023. Among the provisions included in the omnibus was the Mental Health Access Improvement Act (S.828/H.R.432), which would  create greater access to mental health services for millions  of Americans.
• Will ACA host training on how to sign up as a Medicare provider?
  Yes, ACA will offer training on how to sign up for the Medicare provider program. ACA will send out updates on all scheduled training courses, and they will be recorded for those unable to attend.
• How do I know if I am eligible to sign up?
  There are an estimated 200,000 Mental Health professionals that are now eligible to become Medicare Providers and will be able to serve Medicare eligible clients aged 65 and above, and those with disabilities that are currently enrolled in the Medicare program. As a Licensed Professional Counselor or a Marriage and Family Therapist, you are eligible to sign up as a Medicare provider under  this legislation.
• Why will it take a year for CMS to allow LPCs and MFTs to enroll in the program?
  This process may take 12 months for the Centers for Medicare and Medicaid Services to update regulatory language and internal systems that will accept LPCs as Medicare providers
• My state does not use the term Licensed Professional Counselor or Mental Health Counselor, would I be eligible to enroll as a Medicare Provider?
  Yes, you are eligible as long as you meet the general requirements for the Medicare system. Unlike other mental health professionals, Counselors have different titles in each state, your title in your state does not negatively affect your eligibility to enroll as a provider.
• Can I serve Medicare clients prior to January 2024?
  Yes, you can serve Medicare clients now if they are paying out of pocket. Currently, professional counselors are unable to receive reimbursement through Medicare until 2024, when the Mental Health Access Improvement Act takes effect

• ACA Medicare Issue Brief
• ACA Media Sheet
• Baby Boomers Discover That Therapy on Medicare Doesn’t Come Easy, Wall Street Journal, November 2021
• Western Governors’ Association Letter in support of increasing access to mental health care
• ACA RFI Letter
• ACA Bennet Cornyn Letter
• Coalition RFI Letter
• Coalition Bennet Cornyn Letter
• Coalition Form Letter to Senator
• Coalition Form Letter to Representative
• Legal Action Center: Markup of Worker and Family Support and Health Legislation
• RHC Letter to Senate Finance Leadership
• Medicare Facts by State
• Physician Fee Schedule Reimbursement Percentages for LPCs
• ACA's comments in response to CMS's "incident to" proposed rule
• Coalition comments in response to CMS's "incident to" proposed rule
• American Foundation for Suicide Prevention: Congressional Letter in Support of the inclusion of LPCs/MFTs in the Medicare Program

• Substance Abuse and Mental Health Services Administration, “ Older Adults Living with Serious Mental Illness: The State of the Behavioral Health Workforce” (2019)
• SAMHSA, “ Treating Substance Use Disorder in Older Adults” (2020)
• Health Solutions, Office of National Drug Control Policy, August 2011; Bailie, M., et al., “ Confronting Rural America’s Health Care Crisis,” Bipartisan Policy Center, Rural Mental Health (April 21, 2020) (recommending that LMFTs and LPCs be added to the list of Medicare providers as a method of increasing access to care, emphasizing that ensuring an adequate rural health workforce will help stabilize and reform the rural health infrastructure)
• Fullen, M., Lawson, G., Sharma, J., “ Analyzing the Impact of the Medicare Coverage Gap on Counseling Professionals: Results of a National Study,” Journal of Counseling and Development, Vol. 98 (March 8, 2020) (38.8% of the counselors surveyed referred existing clients to Medicare-covered when they became eligible for the program, and 39.9% agreed to see a Medicare-enrolled client pro bono or on a sliding scale)
• A recent PAN Foundation poll of 1,000 Medicare-covered older adults found that 67% said they would be comfortable seeking and receiving mental health care, despite one in five responding that their family members, friends, and acquaintances attached stigma to seeking treatment for mental health. In addition, 71% said they had never been screened by their providers for a mental health condition. PAN Foundation, “ Addressing the Gaps in Mental Health Coverage for Medicare Beneficiaries,” June 3, 2021
• Report to Congress, “ The Way Forward: Federal Action for a System That Works for All People Living with SMI and SED and Their Families and Caregivers,” SAMHSA, Interdepartmental Serious Mental Illness Coordinating Committee (2017), Recommendation 2.8(d), p.83
• “ The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes,” Center for Health Care Strategies and Mathematica Policy Research, Health Home Information Resource Center (May 2013)
• Substance Abuse and Mental Health Services Administration, “ Older Adults Living with Serious Mental Illness: The State of the Behavioral Health Workforce” (2019)
• American Association for Marriage and Family Therapy, “ About Marriage and Family Therapists,” 2019
• American Counseling Association, “ Choosing a Career in Counseling” (updated July 15, 2021)
• Kaiser, Older Adults, 2020. According to a study from the National Academies of Sciences, Engineering, and Medicine, 43% of adults over 60 reported feeling lonely in February 2020, just before the scope of the pandemic became clear. National Academy of Sciences, “ Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System,” National Academies Press (February 27, 2020) 
• Institute of Medicine, “ The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?,” The National Academies Press (2012)
• Journal of Counseling & Development,  The impact of excluded providers on Medicare beneficiaries' mental health care, (2021)

Licensed Professional Counselors that do not want to become Medicare providers do need to Opt-Out of the program. Prior to deciding not to become a Medicare provider, counselors should be aware of the following information to make an informed decision on opting out of the Medicare Provider list.

Once a person opts-out how many days does the provider have to remove their opt-out status and apply to become a Medicare Provider?

• The opt-out period runs for 2 years and renews automatically. To cancel opt-out, the practitioner needs to submit a written notice to the Medicare Administrative Contractor(s) (MAC) where they would ordinarily file claims, not later than 30 days before the end of the 2-year opt-out period (i.e., indicating that the practitioner does not want to extend the opt-out affidavit that they signed). Note, practitioners also may terminate opt-out early (e.g., if they change their mind), if they have never opted out of Medicare previously (referred to as “early termination” of opt-out). To do so, the practitioner must notify the MACs of the termination no later than 90 days of the effective date of the opt-out affidavit. Counselors must follow some other rules (e.g., notify beneficiaries with whom they have entered into private contracts; refund payment collected in excess of what Medicare allows or the coinsurance/deductible, if they already have furnished services to such privately contracted beneficiaries).

If a provider makes an informed decision to opt-out of Medicare, may they bill other types of health insurance?

• Medicare does not technically prohibit a practitioner who has properly opted-out from billing private insurers outside the Medicare program. It does, however, prohibit Medicare or MA plans from making payment to the opted-out practitioner or to any entity that they have assigned their right to bill (e.g., a group practice or organization may not bill Medicare or be paid by Medicare for the services of a member practitioner that has opted-out). The opt-out rules may indirectly affect things. For example, if a practitioner is part of a network with other insurance plans, their contracts might require them to remain in-network with Medicare (i.e., other payers or Medicaid might nevertheless require Medicare enrollment). This would depend on the contract and insurer.

Is there any information a provider should consider or be aware of that will allow them to make an informed decision on opting out?

• ACA has additional resources linked below. It is recommended that counselors considering the opt-out rules and procedures, including what CMS furnishes In particular, if one is considering opt-out, it would be important to understand how to properly opt-out and maintain opt-out, and the consequences (both from a compliance perspective and what it means to opt-out). If one opts-out and enters into private contract(s) with Medicare beneficiaries, the practitioner is not subject to Medicare’s rules and may decide what to charge the beneficiary
  (which may be more than what Medicare would have allowed or paid). However, the opted-out professional may not bill Medicare (such services under their private contract(s) with Medicare beneficiaries are not covered under Medicare and no payment may be made by Medicare, directly or indirectly, except for certain emergency services). Ultimately, this decision really will depend on the individual, their practice, and other considerations (e.g., opting out may free the practitioner of Medicare claims filing/billing rules, mandatory assignment, and Medicare rates, but they forgo payment from one of the largest insurers and may lose Medicare patients who do not enter into private contracts; etc.).

• See above. General Medicare enrollment information that might outline some benefits to joining the program.

• Opt-out/Private Contract Regulations – 42 CFR Part 405, Subpart D
• Medicare Benefit Policy Manual, Chapter 15, Section 40 – Effect of Beneficiary Agreement Not To Use Medicare Coverage
• 2024 Medicare Participation Announcement
• Medicare Provider/Supplier Enrollment Page
• Medicare Opt-Out Page