Government Relations Issues and Updates

Dear NCCs,

NBCC, ACA and AMHCA are pleased to announce that on July 26, 2011, Secretary of the Army John M. McHugh signed Army Directive 2011-09, Employment of Licensed Professional Counselors as Fully Functioning Army Substance Abuse Program Practitioners. This directive authorizes “the Army Substance Abuse Program to employ licensed professional counselors and licensed mental health counselors as independent practitioners with a well-defined scope of practice.”

The directive also establishes credentialing and privileging standards for licensed counselors who seek employment through the Army Substance Abuse Program (ASAP). The criteria include the following:

• Successful completion of a master’s degree in counseling from a regionally accredited college or university that has its counseling program accredited by the Council for Accreditation of Counseling and Related Education Programs (CACREP) (Counselors who are already employed with ASAP or who have already entered the application process for an ASAP counseling position prior to the effective date of the directive do not have to meet the accreditation requirement.)
• Possession of a state license as a professional counselor or mental health counselor
• Achievement of the highest clinical level offere by their state licensure board
• Passage of th National Clinical Mental Health Counseling Examination

The directive became effective upon signature by Secretary of the Army McHugh on July 26, 2011.

We have been told that the directive is a temporary policy that allows counselors to practice independently until the TRICARE regulations are completed as directed by the FY 2011 National Defense Authorization Act (P.L. 111-383).

You may recall that the TRICARE regulations were due out by June 20, 2011, but the deadline was missed and we were told that it may be another six months or more. There is no requirement that the final TRICARE regulations establish the same criteria as this directive. NBCC, ACA and AMHCA continue to urge the Department of Defense to adopt broad TRICARE regulations that recognize all qualified professional counselors.

Qualifying counselors who are interested in ASAP positions should act quickly. The Army is in dire need of more counselors and recently launched a national hiring initiative described here: www.dodlive.mil/index.php/2011/08/army-urgent-to-hire-130-substance-abuse-counselors-asap/. The job announcements reference social workers and psychologists, but we have confirmed with ASAP leadership that these positions are available to professional counselors.

ASAP vacancies are posted here for interested counselors:http://medcell.army.mil/spotlight.asp?id=20

Our organizations are pleased with this step forward, but continue to encourage recognition of all qualified professional counselors. We invite counselors to report back on any challenges or successes they experience as the result of this new policy and employment opportunities.

On January 10, 2012, NBCC participated in a roundtable hosted by the White House Joining Forces initiative. First Lady Michelle Obama and Dr. Jill Biden created Joining Forces to improve the lives of service members, veterans and their families. NBCC was invited to the roundtable along with the leadership for more than 30 major health care associations.

The roundtable was a forum to discuss health care issues, with a focus on post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). Joining Forces teamed with the Joint Chiefs of Staff to address short-term opportunities for expanding collaborative partnerships between the Department of Defense (DoD), the Department of Veterans Affairs (VA) and the private sector. The meeting was preceded by a tour of the National Intrepid Center of Excellence (NICoE) located in Bethesda, Maryland. NICoE is DoD’s world-class facility for wounded care, and a leader in advancing TBI and psychological health treatment research and education. Among the distinguished speakers at the event was Admiral James Winnefeld Jr., vice chairman of the Joint Chiefs of Staff.

First Lady Michelle Obama opened the roundtable with a passionate discussion of the need to honor our service members and veterans. Dr. Robert Petzel, VA undersecretary for health, and Dr. Jonathan Woodson, assistant secretary of defense for health affairs, also spoke of their departments’ commitments to this cause. NBCC is committed to the White House initiative and to ensuring that counselors are properly trained in the treatment of PTSD, TBI and other issues affecting military personnel.

Paris 2008 – NBCC has used its official status with the United Nations Educational, Scientific and Cultural Organization (UNESCO) to advocate for counseling as a component of the agency’s education policies and programs.

Executive Vice President Ted Iliff represented NBCC at the biennial General Conference held at UNESCO headquarters during the last half of October. NBCC was invited to participate in the conference because of its status as a non-governmental organization (NGO) partner in official relations.

While attending the Education Commission strategy and planning meetings, Iliff noted that UNESCO documents and statements concerning its keystone “Education for All” (EFA) initiative spoke of a holistic approach to fostering education. However, they made almost no reference to any form of guidance or counseling.

During the commission’s debate on EFA, Iliff raised the issue of counseling’s benefits to the more than 60 national delegations attending the session.

“Counseling is a set of skills that can be taught at various levels of complexity to fit a school’s cultural, social and economic environment,” Iliff said.

“Training in counseling skills can help teachers and other school personnel identify signs of stress, trauma, depression, addiction, abuse and many other mental health problems that threaten a child’s development. Add career or vocational counseling, and you enter into the realm of sustainable development.”

Iliff quoted from a UNESCO report on EFA progress that cited concerns about gender inequality, poor attendance and high drop-out rates, among others. He said counseling can help educators deal with all those problems.

UNESCO’s new assistant director-general for education, Nicholas Burnett, later told Iliff that he welcomed the comments about the value of counseling and would consider those points as he formulates new policies related to achievement of EFA goals.

Medicare recognition of counselors and MFTs remains mired in the politics of debt and jobs. While the cost of the proposal is modest in the context of the overall budget, every expense is highly scrutinized by legislators. Consequently, moving Medicare legislation has been a challenge.

While there is a bipartisan Senate bill providing Medicare recognition of counselors and MFTs (S. 604), the coalition continues to search for a House sponsor of a stand-alone bill. Having a sponsor from the majority party is critical to moving through that chamber, so the coalition has met with almost every House Republican on the committees of jurisdiction, as well as almost every Republican freshman. While there is interest and support from many, no representative has yet offered to sponsor. The coalition will continue to seek a champion and position the issue for inclusion in any viable health care proposal.

On September 15, 2011, Rep. Barbara Lee (D-CA) introduced H.R. 2954, which includes a provision to extend Medicare reimbursement to professional counselors and marriage and family therapists. Rep. Lee sponsored the bill on behalf of the Congressional Tri-Caucus—comprised of the Congressional Hispanic Caucus, the Congressional Black Caucus and the Congressional Asian Pacific American Caucus. The legislation has 71 cosponsors and includes a host of health care priorities for the three caucuses.

H.R. 2954 is the first House bill to provide Medicare recognition to counselors in the 112th Congress. The coalition of counseling and MFT groups has been lobbying for a stand-alone House bill since S. 604 was introduced by Sen. Ron Wyden (D-OR). Several representatives have expressed interest in the legislation, but the coalition is seeking strong bipartisan support before introduction.

On October 11, 2011, Sens. Kent Conrad (D-ND) and John Barrasso (R-WY) introduced the Craig Thomas Rural Hospital and Provider Equity Act of 2011, S. 1680. This bill was filed on behalf of the Senate Rural Health Caucus to identify health care priorities for rural legislators. Cosponsors include Sens. Tom Harkin (D-IA), James Inhofe (R-OK), Tim Johnson (D-SD), Amy Klobuchar (D-MN), Pat Roberts (R-KS) and Chuck Schumer (D-NY). The caucus recognizes the need for increased access to mental health professionals and included language providing Medicare recognition to counselors and MFTs in section 17 of the bill. S. 1680 provides another vehicle for moving this legislation and brings the total number of Medicare bills to three.

The struggling economy has complicated the prospects for Medicare legislation this year. Congressional energy is consumed by the debt crisis and the need to grow jobs and turn around the financial system. Before taking its August recess, Congress passed legislation to increase the debt limit by $2.4 trillion coupled with $900 billion in immediate cuts and $1.5 trillion to be cut by a supercommittee of 12 legislators (three House Democrats, three Senate Democrats, three House Republicans, three Senate Republicans). If the supercommittee fails to enact the required savings by November 23, automatic cuts will occur on December 23. The supercommittee has been meeting to identify areas of agreement.

All legislation is considered within the context of Congress’ focus on cutting spending and increasing revenue. While the counselor-MFT Medicare legislation is scored by the Congressional Budget Office to cost only $100 million over five years (inconsequential in budgetary terms), it is still viewed critically for increasing spending. Legislators have been hesitant to sponsor the legislation for fear of seeming indifferent to the budget situation. However, sweeping health care proposals to address the financial crisis also may represent opportunities for including the coalition’s Medicare language. The threshold for inclusion in any package remains high, but not impossible. The coalition will be exploring all avenues and seeking opportunities to include its legislation in any moving vehicle.

On March 17, 2011, Sen. Ron Wyden (D-OR) introduced S. 604, the Seniors Mental Health Access Improvement Act of 2011. S. 604 is identical to past Medicare bills and adds licensed professional counselors (LPCs) and marriage and family therapists (MFTs) to the list of recognized Medicare mental health providers.

S. 604 has six original cosponsors, including Sens. Barrasso (R-WY), Begich (D-AK), Brown (D-OH), Durbin (D-IL), Inouye (D-HI) and Johnson (D-SD). Sens. Boxer (D-CA) and Conrad (D-ND) signed on as cosponsors after introduction. The bill must pass the Senate Finance Committee, where Sens. Wyden and Conrad serve as members.

The coalition of counseling and MFT organizations is seeking to add cosponsors to S. 604, as well as identify a House champion. Several representatives have expressed an interest in a House bill and a sponsor is expected to be named soon.

The prospects for passage of the Medicare bill are unclear. The very tight budget environment creates a higher threshold for passing any legislation with an associated cost. While the cost of our provision is modest compared to the overall budget, every issue will be given increased scrutiny. The most likely vehicle for inclusion is legislation to halt increases in the physician payment scale that will be on the congressional agenda later in the year.

On Sunday, March 21, the House of Representatives passed the Senate health care reform bill, sending it to President Obama for signature. While language adding counselors to the list of Medicare providers made it through a preliminary vote in the House Budget Committee, it didn’t survive compromise with the Senate in the Rules Committee, thus ending its chance for inclusion in the final package.

NBCC, along with ACA, AMHCA, AAMFT, and CAMFT worked aggressively to get and keep our language in the reform package throughout the process. While the original House-passed legislation included our provision, the Senate bill did not. Development of the final product became a highly political process that hinged heavily on budgetary issues. Our cost was modest compared to the overall reform price tag, but all new spending was closely scrutinized and many similar provisions did not make it through this screening--including the social work Medicare priority relating to skilled nursing facilities. Success of the reform package was uncertain until the very end, when the House marshaled the votes to pass the Senate bill 219-212, along with a “reconciliation” bill on a vote of 220-211 that incorporates the House-Senate compromises. The reconciliation bill must still pass the Senate, but only 50 votes are required so approval is almost certain. Both measures will be sent to the President for signature.

While we did not succeed in final passage, we have again moved the ball even closer to the goal. We will continue our push for inclusion of Medicare counselor coverage in all relevant health care vehicles, and potential opportunities this year are already being rumored. Your advocacy efforts helped bring us to the brink of success and we hope you will keep up the calls and letters in our next big push. We cannot succeed without your help and will not stop until we get the ball across the goal line. If you have any questions, please contact NBCC at advocacy@nbcc.org.

Thank you for your support and perseverance.

Sincerely,

Dave Bergman
NBCC VP for Legal and External Affairs

The health care reform debate is in the final stages and Medicare recognition of licensed professional counselors remains under consideration. The congressional leadership is putting the final touches on legislation to be voted on in the House this week, and if passed, referred to the Senate and ultimately the President. While NBCC recognizes that NCCs hold a variety of positions relating to the overall health care reform proposals, we believe all counselors can support legislation that provides Medicare reimbursement to counselors. To make this happen, we urge all NCCs to contact your U.S. Representative and Senators to request inclusion of our Medicare provision in the final health care reform package.

To find your legislators, go to the following link and put in your zip code: www.congress.org/communicate. Then call the Capitol Hill switchboard (202-224-3121) and ask to be referred to your Representative and Senators. Not sure what to say? We’ve included a sample message (below):

“My name is [name] and I am a National Certified Counselor living in [city and state]. I am calling to urge inclusion of language providing Medicare coverage of professional counselors and MFTs in the health care reform package, as provided in Section 1308 of the House reform legislation.”

If you have any questions, please contact NBCC at advocacy@nbcc.org.

Thank you for your support.

Sincerely,
Thomas W. Clawson, Ed.D., NCC, LPC

Overview

The U.S. House of Representatives passed a health care reform bill (H.R. 3962) on November 7, 2009, that includes language adding professional counselors to the list of eligible Medicare providers. The Senate released its health care reform bill (substituted for H.R. 3950) on November 18; however, it does not include counselors as Medicare providers. NBCC continues to press to have Medicare recognition language included in the final health care reform package and urges all NCCs to contact their senators to help make this happen.

Background

Legislation adding counselors to the list of eligible Medicare providers passed the Senate in 2003 and 2005, and the House in 2007 and 2009. It has, however, never passed both chambers at the same time.

Health care reform legislation (H.R. 3200) with language providing Medicare reimbursement to counselors and marriage and family therapists (MFTs) passed three House committees of jurisdiction in July 2009. The three House bills were merged into H.R. 3962 and the combined legislation was passed on November 7, 2009.

Efforts to get similar language in the Senate Finance Committee bill (S. 1796) fell short in October 2009. The Senate HELP Committee, which doesn’t have jurisdiction over this issue, did not include it in the legislation (S. 1679) passed in September 2009. The two Senate bills were combined and placed in a House bill (H.R. 3950) that has been referred to the Senate. This bill does not contain counselor inclusion in Medicare, but changes will be made to it on the floor.

A critical procedural vote on Saturday, November 20, 2009, obtained the 60 votes needed to bring H.R. 3950 up for debate. Once revised on the floor, the legislation will need another 60 votes to pass the Senate. If approved, the Senate bill (H.R. 3950) and House bill (H.R. 3962) will be merged in conference and referred back to each chamber for final passage.

Action Needed

It is critical that senators understand the importance of including language providing Medicare reimbursement of counselors in the final health care reform legislation. This can happen on the Senate floor and during the conference negotiations. Senators need to hear from NCCs urging support for inclusion of Medicare reimbursement of counselors in the health care reform legislation.

Sample Message for Senators

“My name is [name] and I am a National Certified Counselor living in [city and state]. I am calling to ask Senator [name] to urge inclusion of language providing Medicare coverage of professional counselors and MFTs in the health care reform package.”

Health care reform has been a top priority for Congress and the Obama Administration during the summer and fall months. House and Senate committees have passed health reform legislation, and at the time of this writing, the committee process is ending and floor consideration will soon begin. As part of this process, NBCC, the American Counseling Association (ACA), the American Mental Health Counselors Association (AMHCA), the American Association for Marriage and Family Therapy (AAMFT), and the California Association of Marriage and Family Therapists (CAMFT) have been working as a coalition to get language providing Medicare reimbursement to counselors and marriage and family therapists (MFTs) included in the reform legislation.

Five congressional committees have jurisdiction over health care reform legislation, including three House (Ways and Means, Energy and Commerce, and Education and Labor) and two Senate (Health, Education, Labor and Pensions (HELP), and Finance) committees. The three House committees passed their reform legislation (H.R. 3200) in July, as did the Senate HELP Committee (S. 1679). H.R. 3200 includes language recognizing LPCs and MFTs in Medicare, but S. 1679 does not because the committee lacks jurisdiction. The final committee to consider health care reform legislation is the Senate Finance Committee. Markup on its America’s Healthy Future Act of 2009 began in mid-September. Despite significant coalition advocacy, the original mark introduced by the Chairman, Senator Max Baucus (D-MT), did not include Medicare coverage of counselors. Senator Blanche Lincoln (D-AR), sponsor of the stand-alone Medicare bill S.671, filed an amendment to add the language during markup, but was not able to get a vote on it. The Senate Democrats likely have the votes to move legislation out of the Finance Committee and to the Senate floor. Before this can happen, the Finance Committee bill will need to be merged with the HELP Committee bill. The content of the combined legislation will be critical to how it is received in the Senate and whether it can muster the 60 votes needed to avoid a filibuster.

On the House side, the three committee bills will also be merged together and brought to the floor. The House bills have greater similarity than the Senate bills, so that negotiation process won’t be as challenging. However, there are significant divisions between Democratic liberals and moderates in the House, so the final version will also face obstacles based on its content. If the two bills can be approved on their respective floors, they will be sent to conference for reconciliation. This too will be a complicated and political process that will help shape the future of health care and determine the final bill’s likelihood for adoption. While there is language in all three House bills providing Medicare recognition of counselors, it will be a fight to keep the language in conference.

NBCC will be working with our certificants and coalition members to see this through to passage.

After years of lobbying by NBCC, the Department of Defense (DoD) has finally released an interim final rule granting independent practice authority to licensed counselors serving TRICARE beneficiaries. These regulations, published December 27, 2011, are a long-awaited step toward parity with other mental health professions. Counselors were previously required to receive physician referral and supervision in order to provide services under TRICARE, the health care program for uniformed service members, retirees and their families.

The regulations create a new category of independent practitioner called “certified mental health counselor” (CMHC). The rule establishes two sets of criteria for the CMHC, with transitional standards in effect from December 27, 2011, to December 31, 2014, and permanent standards beginning January 1, 2015. Counselors who do not meet the requirements may continue to provide services under physician supervision and referral through December 31, 2014, but there will be no supervised practice level after that date.

• A state license for independent practice in mental health counseling issued by the jurisdiction in which the individual is practicing. In jurisdictions with two or more licenses allowing for differing scopes of independent practice, the licensed mental health counselor may only practice within the scope of the license he or she possesses.
• A master’s degree or higher from a mental health counseling education and training program accredited by the Council for Accreditation of Counseling & Related Educational Programs (CACREP) and a passing score on the National Counselor Examination for Licensure and Certification (NCE),

• A master’s or higher-level degree from a mental health counseling education and training program from either a CACREP-accredited program or a regionally accredited institution, and a passing score on the National Clinical Mental Health Counseling Examination (NCMHCE).
• A minimum of two years of post-master’s degree supervised mental health counseling practice that includes at least 3,000 hours of supervised clinical practice and 100 hours of face-to-face supervision. Required supervision must be provided by a mental health counselor who is licensed for independent practice in mental health counseling in the jurisdiction in which he or she is practicing and must be conducted ina manner that is consistent with the American Mental Health Counselors Association guidelines for supervision.

• Possession of a state license for independent practice in mental health counseling issued by the jurisdiction in which the individual is practicing. In jurisdictions with two or more licenses allowing for differing scopes of independent practice, the licensed mental health counselor may only practice within the scope of the license he or she possesses.
• Possession of a master’s degree or higher from a mental health counseling education and training program accredited by CACREP.
• A passing score on the NCMHCE or its successor as determined by TRICARE.
• A minimum of two years of post-master’s degree supervised mental health counseling practice that includes at least 3,000 hours of supervised clinical practice and 100 hours of face-to-face supervision. Required supervision must be provided by a mental health counselor who is licensed for independent practice in mental health counseling in the jurisdiction in which he or she is practicing and must be conducted in a manner that is consistent with the AMHCA guidelines for supervision.

The regulations are the culmination of over a decade of lobbying by NBCC, the American Counseling Association (ACA) and the American Mental Health Counselors Association (AMHCA). These efforts previously led to several stand-alone bills to provide counselors with independent practice rights, as well as language in multiple defense authorizations. Congress mandated two independent reports to study the issue: a 2005 RAND report and 2009 report by the Institute of Medicine. The initiative finally achieved congressional approval when language was included in the Fiscal Year 2011 National Defense Authorization Act (NDAA), which was signed by the president on January 7, 2011. The law directed the secretary of defense to issue regulations granting counselors independent practice authority by June 20, 2011. While the DoD missed the deadline, regulations were released before the end of 2011, completing a long and hard-fought effort to grant counselors the same practice rights as the other mental health disciplines under TRICARE.

To facilitate the participation of counselors in the military health system, NBCC has created a new registration option for the NCMHCE and is considering a similar process for the NCE. (See “Helping NCCs Meet New TRICARE Requirements,” page 9.) Interested candidates can obtain more information at www.nbcc.org/Exams.

The original release of the interim final rule in the Federal Register can be viewed at www.federalregister.gov/articles/2011/12/27/2011-33109/tricare-certified-mental-health-counselors#p-3. The TRICARE rule was put into effect immediately; however, TRICARE did accept comments through the end of February 2012. NBCC recommended rule revisions to improve the requirements and increase access to the qualified counselors.

While the rule is currently in effect, TRICARE has informed NBCC that it will take two or more months to modify internal policies and structures to begin credentialing counselors as CMHCs. Counselors interested in independent practice should contact the appropriate regional contractor to determine timing and process, as only TRICARE can determine eligibility. Your region can be found on TRICARE’s Web site at http://tricare.mil/mybenefit/home/overview/Regions/RegionsUS.

On July 12-14, 2011, Tim Holloman represented NBCC at an organizational meeting for the Marriage and Family Counseling Collaborative (MFCC). The MFCC was formed to support service members, veterans and their families through education and training of behavioral health providers. The organization is comprised of representatives from the major behavioral health associations in partnership with service and VA providers, university staff and civilian community providers.

At the July meeting, the MFCC changed its name to the Alliance of Military and Veteran Family Behavioral Health Providers (AMVFBHP or Alliance). The group also adopted a mission statement and is considering incorporating as a 501(c)(3), launching a new Web site and conducting a survey of clinicians.

The National Defense Authorization Act for Fiscal Year 2011 (NDAA), P.L. 111-383, directed the Secretary of Defense to prescribe regulations granting counselors independent practice authority under the TRICARE program by June 20, 2011. The deadline passed with no regulations and a tentative new time frame of up to six additional months was established. NBCC continues to press for regulations authorizing all qualified counselors to practice independently.

On January 6, 2011, Rep. Tom Rooney (R-FL) and Rep. Larry Kissell (D-NC) introduced H.R. 208 to modify statutory language to grant counselors independent practice rights under TRICARE. This bill is a reintroduction of H.R. 3839, the CARES Act, from the 111th Congress.

H.R. 208 was introduced as a backup to a provision passed this January in H.R. 6523, the National Defense Authorization Act (NDAA). The NDAA language required the adoption of regulations allowing for independent practice by counselors, but it did not change existing statute. The NDAA language will likely be sufficient to address the limitations on counselors, but H.R. 208 provides an option for continued advocacy if the regulations are not adequate.

NBCC also represented the counseling profession in a White House meeting on “Enhancing the Well-Being and Psychological Health of the Military Family” in March 2011. The meeting included senior staff from the first lady’s and vice president’s office, as well as leaders from the mental health and medical fields. The meeting was followed by a White House press event on April 12 that included President Obama and Vice President Biden, and launched the Joining Forces initiative. The first lady, Michele Obama, and the vice president’s wife, Dr. Jill Biden, created the initiative to mobilize all sectors of society to support and honor servicemembers, veterans and their families. NBCC is a partner in the initiative and will be participating in future events.

On April 29, NBCC also participated in a conference call for the Marriage and Family Counseling Collaborative (MFCC). The collaborative is made up of behavioral health associations, military services, federal agencies and universities, and seeks to serve as a venue for clinical providers who wish to collaborate and share resources relating to the psychological health and well-being of military and veteran families.

On May 14, 2010 Sens. Lieberman (I-CT), McCaskill (D-MO) and Collins (R-ME) introduced legislation (S. 3371), which removes the onerous requirement that counselors obtain physician referral and supervision before seeing TRICARE beneficiaries. S. 3371 is similar to the House bill (H.R. 3839) introduced in 2009 by Reps. Rooney (R-FL) and McMahon (D-NY), except that it includes criteria from the Institute of Medicine (IOM) report released in February 2010.

The IOM study was mandated by Congress in the FY2008 Defense Authorization legislation. Thepurpose of the study was to evaluate counselors’ role in TRICARE. The IOM committee spent a year researching the issue and completed its report in February 2010. The committee specifically recommended the removal of the physician referral and supervision requirements for counselors in TRICARE with the following criteria:

1. A master’s (or higher) degree in mental health counseling from program accredited by the Council for Accreditation of Counseling and Related Education Programs (CACREP);
2. Obtained state licensure in mental health counseling at the “clinical” or highest level available;
3. Passed the National Clinical Mental Health Counselor Examination (NCMHCE); and
4. Have a well-defined scope of practice sufficient to permit a counselor to see TRICARE beneficiaries absent primary care physician supervision and referral.

While NBCC was pleased with the recommendation to grant independent practice authority to counselors under TRICARE, we do not support the inclusion of additional criteria. NBCC believes that licensure is the most appropriate standard for determining which professionals are qualified to practice independently. Currently, there are many counselors who have passed the National Counselor Examination for Licensure and Certification (NCE) or graduated from a non-CACREP–accredited mental health counseling program who are capable of providing high-quality services to servicemen and women and their families.

The IOM report has helped build support for removing the supervision and referral requirements in Congress, but because the committee included bullet point criteria, it has also created a political challenge. At this time, the House bill does not contain the IOM bullet point criteria and the Senate bill does. However, it is important for counselors to support both bills. S. 3371 is the only language that will pass the Senate. The sponsors of S. 3371, Sens. Lieberman, McCaskill and Collins, do not believe the criteria are necessary but included them to gain the support of the Senate Armed Services Committee (SASC). SASC support is required if we want to include our language in the Senate National Defense Authorization Act (NDAA), which is the only realistic path for final passage of this legislation. Including language in both the House and Senate NDAA bills provides the best likelihood for final removal of the referral and supervision requirements. If successful, we can seek to adopt the House language in the conference where they reconcile the differences between the two bills. In that conference, NBCC will continue to push for the least restrictive language, as will our House and Senate sponsors. However, to get to that point, we must build support for both bills and get them included in the NDAA.

There has been a lot of confusion over the status of the TRICARE legislation, and it is important to understand that the process is constantly changing and no final legislation has been approved. Consequently, there is no way for NBCC to presently provide any clarification as to how the law will be interpreted. We do not know what is going to be in the final bill, and even after it passes (if it passes), it will be up to the Defense Department to develop regulations interpreting the law.Without a law and regulations, we do not know if it would include grandparenting or exceptions to exams or accreditation. Even if the Senate language is adopted, counselors who do not meet the IOM criteria should be able to provide services under the referral and supervision requirements. In other words, the bill would add an option and not close any doors that are currently open. Regardless, we can assure you that NBCC will continue to work to include the broadest pool of professional counselors in the final legislation.

The counseling profession took a significant step forward with the introduction of Senate legislation (S. 3371) that will make it easier for TRICARE beneficiaries to see a professional mental health counselor. TRICARE is the health care system for servicemembers and their dependents, and licensed professional counselors are the only mental health professionals still required by law to see beneficiaries following physician referral and under physician supervision.

Senators Joseph Lieberman (I-CT), Claire McCaskill (D-MO) and Susan Collins (R-ME) jointly introduced the TRICARE Mental Health Care Access Act, S. 3371 to allow licensed professional counselors to independently treat and diagnose TRICARE beneficiaries. The National Board for Certified Counselors, the American Counseling Association and the American Mental Health Counselors Association applaud the senators for sponsoring this legislation, as it is a much-needed step forward in giving TRICARE beneficiaries better access to highly skilled outpatient mental health professionals. Our three organizations are working closely together to gain the enactment of legislative language providing counselors independent practice rights as part of this year’s National Defense Authorization Act (NDAA).

Introduction of S. 3371 comes on the heels of a recently released Institute of Medicine (IOM) report that recommends independent practice of mental health counselors in TRICARE. The Institute of Medicine’s report, titled “Provision of Mental Health Counseling Services under TRICARE,” was conducted pursuant to a request by Congress contained in the National Defense Authorization Act for Fiscal Year 2008. The IOM panel recommended granting independent practice authority for counselors who have:

• A master’s (or higher) degree in mental health counseling from a program accredited by the Council for Accreditation of Counseling and Related Education Programs (CACREP);
• Obtained state licensure in mental health counseling at the “clinical” or highest level available;
• Passed the National Clinical Mental Health Counselor Examination (NCMHCE); and
• Have a well-defined scope of practice sufficient to permit a counselor to see TRICARE beneficiaries absent primary care physician supervision and referral.

Representatives Tom Rooney (R-FL) and Mike McMahon (D-NY) introduced a similar bill, H.R. 3839, last October. The Rooney-McMahon legislation would let any counselor participating in the TRICARE program practice independently, just like clinical social workers and marriage and family therapists have done for years. The legislation is currently being cosponsored by Reps. Bordallo (GU), Courtney (CT), Israel (NY), Jones (NC), Kilpatrick (MI), McMorris Rodgers (WA), Rodriguez (TX) and Shuster (PA).

AMHCA, ACA, and NBCC are working with members of the House and Senate Armed Services Committees to gain adoption of legislative language based on H.R. 3839 and S. 3371 as part of the defense authorization legislation being considered over the coming weeks. We urge counselors to contact their representatives to ask them to cosponsor H.R. 3839, and to contact senators to ask for cosponsorship of S. 3371. The more cosponsors we have on the legislation, the greater our chances of establishing independent practice authority for as many counselors as possible within the TRICARE system.

If you have any questions, please contact NBCC at advocacy@nbcc.org.

Thank you for your support.

Sincerely,
David M. Bergman, J.D.
Vice President of Legal and External Affairs/CLO

The Institute of Medicine held its second meeting of the Committee on the Qualifications of Professionals Providing Mental Health Counseling Services under TRICARE on July 7, 2009. Panelists presented on the role of counselors in the federal and private sector, as well as their existing role in TRICARE. The meeting was very productive and the Committee heard from experts about the merits of removing the physician referral and supervision requirements under TRICARE.

Dr. Scott Walton, a licensed professional counselor with experience working with military families, provided a practitioner’s perspective of how counselors are educated and trained to provide independent mental health services and did an excellent job of demonstrating how unnecessary standards limit access to quality care. The other panelists also seemed to support removal of the supervision and referral requirements. Medical directors from CIGNA and MHN discussed how counselors have unfettered practice rights in their private networks but are unnecessarily required supervision and referral when delivering care through TRICARE. TRICARE representatives even suggested that the supervision and referral requirements were an anachronism established decades ago for a lay counseling workforce. When queried by the Committee, not one of the panelists indicated that they believed the supervision and referral requirement should be continued. Several suggested it was unnecessary. While the positive tenor of the meeting will certainly be considered by the Committee members, it does not guarantee a favorable recommendation.

NBCC will continue working with the Committee to obtain a positive report, and has begun working with Congress to lay the foundation for legislation to address the TRICARE issue.

On November 15, 2011, the coalition of counseling and MFT organizations met with Dr. Robert Zeiss from the Department of Veterans Affairs (VA) Office of Academic Affiliations. The meeting was to discuss inclusion of counselors and MFTs in the VA trainee support program that provides funding for associated health professions serving in VA facilities. Neither counselors nor MFTs are currently eligible to participate in the funded program.

The meeting was informative and provided background on the program and process. The VA confirmed that counselors and MFTs are eligible for unpaid internships in VA facilities, but are not eligible for trainee funds. The trainee funds are limited to certain professions, including psychology and social work. While the organizations urged a change in policy to include the two disciplines, the VA declined to take that step, citing a lack of funding and limited demand for counselors and MFTs. The coalition was dissatisfied with the VA response and will be seeking congressional support for a change in policy.

The coalition also met with Dr. Madhulika Agarwal, the deputy undersecretary for health for health policy and services, on November 29. Discussion was focused on three issues: utilization of counselors and MFTs in the Readjustment Counseling Service that oversees vet centers, the slow pace of hiring, and the VA trainee support program. The coalition will maintain communication with Dr. Agarwal to address these ongoing issues.

On August 22, 2011, NBCC staff participated in the Department of Veterans Affairs (VA) Office of Mental Health Services (OMHS) stakeholders meeting. The meeting brings together representatives from veteran service organizations, consumer groups, professional associations and VA staff to share information about the VA mental health system. The meeting provided an informal forum to discuss issues of interest to the VA and represented organizations, including integration of counselors and MFTs.

On the following day, August 23, NBCC attended the VA national mental health conference, entitled “Improving Veterans Mental Health Care for the 21st Century.” The conference provided information about the ongoing transformation and improvement in veterans mental health care, including discussions on the mental health initiative research-informed practices, clinical innovations, and educational efforts for networks, local medical centers, clinics and the community. Participants included more than 1,000 clinicians, educators and researchers from VA facilities. NBCC, the American Counseling Association (ACA) and the American Association for Marriage and Family Therapy (AAMFT) were granted space to provide information to conference participants about the two professions in an effort to increase education and hiring.

The two meetings afforded NBCC and its coalition allies the opportunity to discuss the slow pace of hiring counselors within the veterans health system. NBCC shared concerns about the limited job vacancies for the profession and the fact that most positions were in vet centers and not medical centers. NBCC organized a productive coalition meeting with Dr. Mary Schohn, the newly promoted director of mental health operations, to discuss ways to accelerate the integration of counselors and MFTs into the VA. NBCC also worked with VA Director of Program Policy Implementation Stacey Pollack on revising the new solicitation for representatives on the National Licensed Professional Mental Health Counselor Professional Standards Board (NLPC-PSB). Counselors working for the VA OMHS are encouraged to contact NBCC if they would be interested in serving on the NLPC-PSB.

NBCC and the American Counseling Association (ACA) met with senior mental health staff from the Department of Veterans Affairs (VA) on May 2 to discuss the implementation of the new qualification standards and employment of counselors. Monitoring of jobs has demonstrated that counselors are only slowly being hired into the VA system, and the objective was to identify deficiencies and streamline the process.

The VA staff was unaware of the slow pace of implementation and was attentive to our concerns about specific problems. They agreed to increase education of VA mental health staff about hiring policies and to ensure counselors were being appropriately considered for positions. The VA also offered to facilitate information sharing between the organizations and administration mental health staff. NBCC will continue to monitor the process and work with the VA to address concerns and opportunities. NCCs who are interested in job opportunities with the VA are encouraged to reach out to local facilities and educate staff about the counseling profession and the new qualification standards. NCCs who apply for jobs should report any problems, or successes, to NBCC.

Implementation of the law making counselors eligible for employment in the Department of Veterans Affairs (VA) is reportedly on track for completion in September 2010. While no official documentation has been provided, VA staff has indicated that the internal subject matter expert workgroup has completed its first draft of the qualification standards and it is being reviewed internally. There are multiple stages in the review process, including negotiations with the unions. It has also been reported that the draft standards allow for independent practice on par with other master’s-level mental health professionals. It is impossible to confirm the accuracy of these reports without written documentation, but NBCC remains cautiously optimistic.

NBCC is continuing to press for implementation of P.L. 109-461, which authorizes the employment of professional counselors by the Veterans Administration. On September 24, 2009, NBCC participated in a meeting with John Sepulveda, the assistant secretary for human resources and administration for the Department of Veterans Affairs (VA), and numerous staff to discuss the status of this issue. The meeting was called and attended by congressional staff from the majority and minority side of the House and Senate Veterans’ Affairs Committee. Representatives from ACA, AMHCA, AAMFT and CAMFT also participated in the meeting.

The meeting provided insight into the timing and process for implementation of the law. Assistant Secretary Sepulveda and his personnel responded to questions by congressional staff and coalition representatives about what’s been happening and what needs to happen. While there was some frustration about the pace and direction of the activities to date, Mr. Sepulveda offered commitments to do better in the future. He offered a tentative deadline of September 2010 for completion of the process. Coalition participants were hoping for a more expeditious timeframe, but were pleased to get some detail and clarity. Coalition members also pressed to ensure separate qualification standards and creation of new Occupational Series by the Office of Personnel Management, which seemed to be accepted. While there are no guarantees that the VA will follow through on its commitments, the coalition at least has a framework for moving forward. The VA also promised greater collaboration with coalition members, which should help facilitate the process and increase accountability.

Washington, Feb. 17 – The U.S. Department of Veterans Affairs (VA) has approved the creation of a new occupational category for Licensed Professional Counselors and Marriage and Family Therapists.

VA staff notified the National Board for Certified Counselors, Inc., that the agency’s undersecretary for health signed off on the classification process, but it has not been determined whether each profession will get an individual classification or a shared one.

NBCC has been unyielding in its efforts to implement the 2006 law recognizing counselors in the VA. Proper implementation requires the creation of a federal occupational classification for mental health counselors by the Office of Personnel Management.

An NBCC statement said the organization was pleased with “this step forward,” but remains vigilant in our pursuit of a separate classification.

“NBCC acted independently by meeting with senators, representatives and committee staff on over 50 occasions,” the statement said. “We believe that consistent pressure from a counseling organization was a key factor in keeping the issue alive and before policy makers.”

The statement added the process for establishing qualification standards may take a year to complete, but “the VA has at least provided a light at the end of the tunnel.”

The statement noted help from former VA Chief Network Officer Dr. Jule Moravec and from David Gorman, executive director of the Disabled American Veterans. It also expressed appreciation for separate advocacy efforts on the issue by the American Association for Marriage and Family Therapy, the American Counseling Association, and the American Mental Health Counselors Association.

The National Board for Certified Counselors (NBCC) is calling for the Veterans Administration to implement a new law designed to deal with the mental health care crisis facing American veterans.

Kristi McCaskill, counseling advocacy coordinator for the Greensboro-based organization, presented the case for hiring counselors in testimony prepared for the health subcommittee of the House Committee on Veterans Affairs on Capitol Hill Thursday (Oct. 18).

For the hearing titled “Health Care Profeessionals – Recruitment and Retention”, McCaskill cited a presidential task force study that estimated a fourth of all veterans returning from Afghanistan and Iraq have suffered psychological injuries.

However, she said, the study also found the number of licensed clinical psychologists serving service men and women has fallen 22 percent. This has left 1,839 VA psychologists available for 24.3 million veterans from previous wars plus the growing number from current conflicts.

McCaskill said NBCC is ready to help establish “a mechanism to allow licensed counselors to serve veterans who not only have given of themselves to protect our country, but who now need our help.”

“NBCC is prepared and capable of connecting licensed counselors with the VA so that together we can provide for the increasing mental health needs of veterans,” McCaskill said.

But first, she said, the VA must create a formal job classification for counselors so they can be hired in compliance with federal employment requirements. A law authorizing VA employment of counselors passed last December but has never been implemented.

More than 42,000 counselors in the United States hold NBCC certification. The voluntary credential signifies that the counselor has demonstrated mastery of the skills and knowledge needed at the highest levels of the profession.

Media contact: Ross Harris (336) 908-7171

WASHINGTON – A bipartisan group of House and Senate members wants the Veterans Administration to explain delays in implementation of a law requiring the credentialing and employment of mental health counselors by that agency. NBCC spearheaded the effort to build interest and support for the letter.

The 2006 legislation (pl 109-461) was intended to help the VA meet a growing demand for mental health services to veterans. In a letter dated Oct. 7 to VA Secretary James Peake, two senators and four congressmen raised questions about his agency’s implementation of the law, citing “the delays and seeming misdirection it has taken.”

The law ordered the VA to create a new job classification specifically for mental health counselors within the list of professions approved by the federal Office of Personnel Management. The letter accused the VA of resisting the will of Congress while preserving “the status quo, which has resulted in counselors not being able to provide clinical services to our veterans.”

As an example, the letter cited a VA survey of veterans’ centers and mental health facilities asking about the need for counselors, in effect ignoring the congressional mandate to hire more of them.

“We want to see the VA move expeditiously to implement the law and begin employing counselors in independent clinical positions," the letter said. “We believe the employment of mental health counselors will be a positive step towards ensuring our nation’s bravest are provided the care that they so justly deserve.”

The letter was signed by Sen. Ron Wyden (D-OR), Sen. Gordon Smith (R-OR), Rep. Patrick Kennedy (D-RI), Rep. Jim Ramstad (R-MN), Rep. Zachary Space (D-OH), and Rep. David Hobson (R-OH).

The National Board for Certified Counselors (NBCC), based in Greensboro, NC, has been active in drawing attention to the VA’s response to the law.

Nearly a year ago, Kristi McCaskill, NBCC’s counseling advocacy coordinator, testified before a House subcommittee on the VA’s inaction regarding the law. Since then, NBCC has been working closely with members of Congress to ensure that the VA understands the intent of Congress and implements the law accordingly.

More than 42,000 counselors in the United States hold NBCC certification. The voluntary credential signifies that the counselor has demonstrated mastery of the skills and knowledge needed at the highest levels of the profession.

On November 1, 2011, NBCC, along with the American Counseling Association (ACA), the American Mental Health Counselors Association (AMHCA), the American Association for Marriage and Family Therapy (AAMFT), and the California Association of Marriage and Family Therapists (CAMFT), met with staff from the U.S. Office of Personnel Management (OPM). The meeting was with the Manager of Classification and Assessment Policy to discuss the creation of occupational series for the counseling and MFT professions. Without their own occupational series, counselors and MFTs employed by the federal government are often limited in pay and promotion, and hold titles that do not accurately reflect their professional identity, training and education.

The meeting was requested in response to a May 31 letter from OPM to the Department of Veterans Affairs (VA) indicating that the agency would not be immediately creating an occupational series for our professions. OPM indicated that it is in the process of reviewing occupational groups and would consider development of new series when the 100 series is reviewed. Seeking clarity and a stronger commitment, the coalition of counseling and MFT organizations contacted the House Oversight and Government Reform Committee and the Senate Homeland Security and Government Affairs Committee. Committee staff helped facilitate a meeting between the coalition and OPM.

The meeting was very productive and helped educate OPM about the counseling and MFT professions. While there was no formal commitment to create new occupational series, there seemed to be an inclination to at least explore it. The coalition will continue to work with the OPM to facilitate the process and encourage the development of new series.

On May 31, 2011, the U.S. Office of Personnel Management (OPM) issued a letter to the Department of Veterans Affairs (VA) indicating that the agency would not immediately be creating an occupational series for professional counselors or marriage and family therapists (MFTs). The OPM indicated that it is in the process of reviewing occupational groups and would consider development of new series when the 100 series is reviewed.

NBCC has been a strong proponent of the development of an occupational series for professional counselors since before the profession was legally recognized within the VA. Creation of an occupational series for counselors is integral to federal government employment and national parity. Failure to create an occupational series forces counselors who work for the federal government to be employed in:

• Generic series with no professional identit
• Established nonclinical series lacking independent practice rights with limited pay and promotion.
• Social work or psychologist series that are not available to most counselors and misrepresent their training and education.

The effort to obtain an occupational series took a big step forward in 2006 when Congress enacted legislation authorizing the employment of counselors in the VA. To create a series, a federal agency must request one from OPM. NBCC pressed VA Assistant Secretary for Human Resources and Administration John Sepulveda for an occupational series during a group meeting on the new law in September 2009. Mr. Sepulveda committed to the issue and followed through on that commitment, submitting a request to OPM in 2010.

NBCC is dissatisfied with the open-ended time line and has been pressing for more timely action. The coalition of counseling and MFT organizations has communicated with the staff of the House Oversight and Government Reform Committee and the Senate Homeland Security and Government Affairs Committee to discuss legislative and administrative options. The committee staff helped to facilitate a coalition meeting with OPM staff on November 1. The meeting was very productive and the groups were given a tentative time frame of fiscal year 2013 for potential commencement of the development process. While OPM did not guarantee that it will create the series, and the timeline is tentative at best, the process is moving in the right direction and the coalition will continue to press for prompt action.

Presently, counselors are not recognized as health care providers by the Indian Health Service (IHS) and are not eligible for funding through the IHS Scholarship Program. NBCC decided to take action on this issue after a report was released in September 2011 showing a shortage of mental health professionals in American Indian and Alaska Native (AI/AN) communities and revealing a hodgepodge of “counselors” (licensed and unlicensed) serving this population.

While the issue is new, NBCC has had meetings with the offices of several members from the Senate Indian Affairs Committee. The Senate meetings were productive and uncovered some early interest and support. However, because the IHS is no longer reauthorized every six years, the language must move through a stand-alone bill or some other omnibus bill that includes this type of provision.

NBCC has invited the American Counseling Association (ACA) and the American Mental Health Counselors Association (AMHCA) to participate in the initiative, and the three groups are collaborating on a strategy for success. The issue will take some time to develop and mature, but the foundation is being laid to allow American Indians increased access to the behavioral health services of professional counselors.