FAQs On Implementation of Medicare Part B Coverage of MFTs and Counselors
The Mental Health Access Improvement Act which recognizes marriage and family therapists and mental health counselors as approved Medicare Part B providers, has passed as part of the 2023 Omnibus federal budget package that was signed by President Biden on December 29, 2022. Below are frequently asked questions related to this Medicare victory.
ELIGIBILITY AND ENROLLMENT PROCEDURES
Will MFTs and counselors be able to immediately bill Medicare for diagnosing and treating Medicare beneficiaries in their practices?
The effective date of the provisions regarding counselor and MFT inclusion in the Medicare program is January 1, 2024.
How do I know as an MFT if I am an eligible Medicare provider?
The Medicare Physician Fee Schedule Rule 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 to 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 or 3,000 hours of clinical supervised experience in marriage and family therapy; and ‘‘(D) meets such other requirements as specified by the Secretary.
Does the clinical supervised experience (CSE) required for the 2 years or 3,000 hours of post-degree CSE have to be gained under a formal supervisor? Has CMS provided a definition of “formal supervisor”?
CMS did not define the term clinical supervised experience. Instead, they defer to State law and licensure requirements regarding the nature of the 2 years or 3,000 hours of clinical supervised experience.
If applicants cannot obtain the required statements regarding the 2 years or 3,000 hours of post-degree clinical supervised experience, should those applicants expect to have their applications denied or is there another type of documentation CMS or the MACs would be willing to consider?
CMS has provided multiple options for confirming the 2 years or 3,000 hours are met:
- A statement from the provider/supplier at which the MFT/MHC performed the services in question (e.g., hospital, clinic) verifying that the MFT/MHC performed services at that setting for the required number of years or hours.
- A statement verifying that the MFT/MHC meets the year or hour requirements from a (1) licensing or credentialing body for the state in which the MFT/MHC is enrolling or (2) national MFT/MHC credentialing organization.
- If the state already requires, as a condition of licensure or credentialing, the MFT/MHC to meet the clinical supervised experience, a separate statement is not required.
- If the required documentation is not submitted with the enrollment application, the Medicare Administrative Contractor (MAC) will send a development letter to the provider requesting the additional information. The provider will have 30 calendar days to respond. If no response is received, the application will be rejected.
We understand if the state law does not explicitly require the MFT/MHC to have performed, at a minimum, either 2 years or 3,000 hours of post-master’s clinical supervised experience, then the provider will need to provide the additional information. How will CMS determine what states meet the Medicare standard or will CMS let each MAC make these determinations?
The MACs are responsible for verifying the state licensure or certification requirements for the state within their jurisdiction.
Can an MFT or Counselor bill Medicare if they are under supervision and treating a Medicare beneficiary?
Once enrollment opens, an MFT or counselor must be licensed by a State to practice independently in order to enroll as a Medicare provider. MFT and counselor associates, interns, and students are not eligible to enroll as Medicare-eligible providers. This eligibility standard is similar for other Medicare-eligible mental health professions. To enroll in Medicare an MFT must possess a master’s or doctoral degree which qualifies for licensure as an MFT, have two years of clinical supervised experience in marriage and family therapy, and be licensed as an MFT or counselor by a State.
What is the average turnaround time for applications to be approved if all needed forms are correct and in order?
Usually 30-45 days.
What additional resources has CMS put into place to accommodate those providers who wish to enroll?
To learn more about the Medicare program and how to enroll, the CMS Medicare Learning Network (MLN) now offers provider education products designed to promote national consistency of Medicare provider information for CMS initiatives. The CMS’ 60-minute Medicare 101 course titled “The World of Medicare” can be found here and a complete list of MLN’s web-based trainings is here.
The Medicare Learning Network:
Web-based Training:
Becoming a Medicare Provider (World of Medicare):
Weekly Email Newsletter for Medicare Providers:
Will there be a cut-off number of providers that will be accepted by Medicare?
No.
Do MFTs and MHCs need to be supervised by a Medical Doctor in order to be Medicare providers?
Only under incident-to provisions.
How does the incident-to provisions work?
CMS has amended the direct supervision requirement under CMS’ “incident to” regulation to allow behavioral health services to be furnished by MFTs and counselors under the general supervision rather than direct supervision of a physician or non-physician practitioner (“NPP”), so long as CMS’ “incident to” requirements and state licensure requirements are met.
Would a licensed MFT or counselor which may not qualify for payment under the MPFS due to a lack of practice experience, still be able to provide a service “incident to” the care/supervision of a professional counselor/MFT who is eligible under the proposed rule?
No.
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 has provided guidance to MFTs through the MPFS rule on which codes to use for billing for services provided to Medicare beneficiaries:
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.
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.
MEDICARE ADMINISTRATIVE CONTRACTORS
What entity will assist and serve MFTs and counselors in the enrollment process?
Medicare Administrative Contractors (MACs) for your state will be the primary source of contact in the process.
Here is a list of MACs by state and region.
What is a Medicare Administrative Contractor and what are their responsibilities?
Medicare Administrative Contractors (MACs) are private healthcare insurers that have been awarded a geographic jurisdiction by the Centers for Medicare and Medicaid Services (CMS) to process Medicare Part A and Part B medical care and mental health claims for Medicare Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary operational (intermediary) contact between the Medicare FFS program and the providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims.
What Specific Services do MACs provide to practitioners?
Key services that MACs perform include:
- Enrolling providers in the Medicare FFS program
- Processing Medicare FFS claims
- Handling provider reimbursement services
- Responding to provider inquiries
- Educating providers about Medicare FFS billing requirements
- Establishing local coverage determinations (LCD’s)
Providers enroll in Medicare through their designated MAC. You can find your designated MAC and their contact information and mailing address here.
Do providers have to “opt out?” What happens if they don’t opt out?
MFTs and MHCs have two choices -- They can enroll as a Medicare provider or opt out.
- Participating providers accept Medicare and always take assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment.
- Opt-out providers who do not accept Medicare at all must sign an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services to Medicare clients but must follow certain rules to do so.
- Medicare will not pay for care that a beneficiary receives from an opt-out provider (except in emergencies). A beneficiary is responsible for the entire cost of the care that an MHC or MFT provides.
- The MFT/MHC must give the client a private contract describing their charges and confirming that the client understands they are responsible for the full cost of services and that Medicare will not reimburse.
- Opt-out providers do not bill Medicare for services a client receives.
How does a provider opt out of Medicare? If I opt out of Medicare, is that choice permanent?
If you want to opt out of Medicare, Medicare Administrative Contractors (MACs) are now accepting opt-out affidavits. Be aware, each MAC has its own opt-out affidavit form. The forms cannot be faxed or emailed. They must be physically mailed to the appropriate MAC via CERTIFIED mail. If you are seeing any Medicare beneficiaries, and you decide to opt out of becoming a Medicare provider, you are also required to enter into a private contract with your Medicare-eligible client(s).
Medicare opt-out affidavits are good for two years and renew automatically every two years, unless the practitioner notifies the Medicare Administrative Contractor that they wish to enroll as a Medicare provider.
As part of their standard procedures, MACs send out renewal notifications 90 days prior to the opt- out affidavit’s renewal date. Practitioners who do not want their opt-out to automatically renew at the end of a 2-year opt-out period may cancel the renewal by notifying all contractors (MACs) with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period.
Can a practitioner apply as a Medicare Provider and get accepted, but change one’s mind?
Medicare providers may decide they no longer want to provide services to Medicare eligible patients, but in order to no longer be a participating provider, the provider would have to notify their MAC and take the appropriate steps to opt out as a Medicare provider. Those steps include filling out and mailing an opt-out affidavit to the appropriate MAC or MACs and entering into private pay contracts with Medicare eligible clients. Affidavits and private pay contract templates can be accessed through the MACs websites.
Do providers have to reapply if they are already in a Medicare Advantage network?
If you are already enrolled in a network that offers Medicare Advantage services, contact the health plan/network to request that the terms of your contract be expanded to include Medicare services.
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CODING, BILLING, CLAIMS AND REIMBURSEMENT ISSUES
How will MFTs and counselors know which codes are reimbursable and the amounts they can bill for when they treat Medicare clients?
The Medicare Physician Fee Schedule does not provide detailed information on coding and reimbursement amounts. To get an idea on what codes are generally accepted by Medicare please see the link here on page 22-25 .
At what rate will MFTs and counselors be reimbursed?
With respect to marriage and family therapist services and mental health counselor services, the amounts paid shall be 80 percent of the lesser of the actual charge for the services or 75 percent of the amount determined for payment of a psychologist.
Are pre-licensed MFTs and counselors under appropriate supervision eligible to provide services and seek reimbursement?
No.
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TELE-MENTAL HEALTH
What are the telehealth 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.
Medicare beneficiaries can receive tele-mental services in both the Traditional Medicare program and Medicare Advantage plans, including audio-only behavioral health services.
There will more guidance issued in 2024 on how tele-mental health coverage will be addressed.
Sources: Consolidated Appropriations Act, 2023 (PDF), Consolidated Appropriations Act, 2022 (PDF), Consolidated Appropriations Act, 2021 (PDF)
Can a practitioner provide telehealth services only, or does the provider need an actual office practice address?
Does CMS require a physical office location or can fully telehealth providers participate in the Medicare program?
It is possible to be a telehealth-only Medicare provider. However, you will need to include comments within your Medicare provider enrollment application that the practice location address you are listing is for administrative purposes only and that you are a telehealth-only provider.