TRICARE is the health care program for military personnel and their families. For more than a decade, NBCC, in coalition with other counseling organizations, advocated for independent practice authority for counselors under TRICARE and elimination of the requirement for counselors to obtain physician referral and supervision when serving TRICARE beneficiaries, a burdensome requirement not placed on other mental health professions.
The effort encompassed several bills and two federally mandated studies, including the Institute of Medicine’s Provision of Mental Health Counseling Services under TRICARE. Success was achieved when the National Defense Authorization Act (NDAA) for Fiscal Year 2011 directed the Department of Defense (DoD) to establish requirements for counselor independent practice. In December 2011, DoD released an interim final rule establishing these requirements. Credentialing for the newly created provider category—TRICARE Certified Mental Health Counselor (TCMHC)—began mid-2012 and is administered by the TRICARE regional contractors Health Net Federal Services for TRICARE North, Humana Military for TRICARE South, and TriWest Healthcare Alliance for the West region.
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.During the transition period from December 27, 2011, to December 31, 2014, recognition as a CMHC requires the following:
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:
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:
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 firstname.lastname@example.org.
Thank you for your support.
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.