The Facts on Medicare

The Mental Health Access Improvement Act, which recognizes mental health counselors as approved Medicare Part B providers, passed as part of the end-of-the-year congressional omnibus federal budget legislative package that was signed by President Biden on Dec. 29, 2022.The official name of the legislation is "The Consolidated Appropriations Act, 2023 (H.R. 2617) - Public Law No.117-328."

Medicare Part B Coverage for NCCs

The key provisions of the Mental Health Access Improvement Act embodied in the 2023 congressional omnibus legislative package allow counselors to do the following:

• Receive payment under the Medicare Part B program for providing covered mental health services to Medicare beneficiaries beginning Jan. 1, 2024. Counselors will be able to bill Medicare directly for covered services rendered to beneficiaries over the age of 65 and people with disabilities who receive health care benefits from Medicare.
• Be reimbursed 80% of the lesser of the actual charge for the services or 75% of the amount determined for payment of a psychologist.
• Be 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 include community health centers, migrant health centers, health care for the homeless health centers, public housing primary care centers, and health center program “lookalikes.” They also include outpatient health programs or facilities operated by a tribe or tribal organization or by an Urban Indian Organization . FQHCs are paid based on the FQHC Prospective Payment System (PPS) for medically necessary primary health services and qualified preventive health services furnished by an FQHC practitioner. FQHCs provide comprehensive services (either on-site or by arrangement with another provider), including preventive health services and mental health and substance abuse services.
• Be 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 can be public, non-profit, or for-profit health care facilities. They are required to use a team approach of physicians working with nonphysician providers such as counselors to provide services. The clinic must be staffed at least 50% of the time with a nurse practitioner or physician assistant. RHCs are required to provide outpatient primary care services such as behavioral health care. The main advantage of RHC status is enhanced reimbursement rates for providing Medicare and Medicaid services.
• Be required team members for Medicare hospice interdisciplinary teams. The hospice interdisciplinary team (IDT) serves an important function in hospice care. It includes physicians, nurses, home health aides, mental health providers, chaplains, and trained volunteers who work together to address a hospice patient's physical, emotional, and spiritual needs.
• Diagnose and treat people with disabilities who are covered by the Medicare program for their mental health care needs. Many individuals living with Parkinson’s disease (PD) experience mood disorders such as anxiety and depression. These are often debilitating clinical symptoms that profoundly impact the individual’s health, quality of life, and independence. Up to half of all people with PD suffer from a mental health disorder at some point during the course of their disease. The Mental Health Access Improvement Act strengthens the capabilities and effectiveness of the health care workforce to better meet the needs of older and disabled individuals with medically complex conditions, especially those coping with mental illness and/or substance use disorder (SUD) along with conditions such as diabetes, lung disease, cardiovascular disease, and other comorbidities associated with early mortality, disability, and impairments in psychosocial functioning. Counselors who frequently practice in multidisciplinary settings are well-positioned to play a key role in collaborative care designed to improve medical and mental health outcomes.
• Diagnose and treat people with substance use disorders (SUDs) and serious mental illnesses (SMIs) who are covered by the Medicare program for their behavioral health care needs. The Substance Abuse and Mental Health Services Administration (SAMHSA) has recognized that those who currently work most frequently with older Americans (e.g., primary care physicians, assisted living and nursing home staff, emergency department staff, inpatient hospital staff, and caregiver/family members) are not routinely trained to recognize or effectively address SMIs. Counselors are trained in the treatment and prevention of mental health disorders and SUDs and routinely coordinate care with medical providers and other health care professionals. They will bring much-needed skills and integrative care experience to the delivery of coordinated, person-centered care. These integrated approaches are vital to improving health outcomes for older and disabled individuals and reducing the overall burden of mental and physical disease. Older adults can be particularly vulnerable to the negative effects of substances such as alcohol and prescription drugs. Individuals with cognitive impairments such as dementia may have more difficulty using alcohol or prescription drugs safely and are at greater risk of falls and accidents, as well as adverse effects from drug interactions.
• Bill for telehealth services, to include certain individual psychotherapy services for Medicare beneficiaries. Medicare reimburses practitioners for specified services provided via telehealth to eligible beneficiaries under Current Procedural Terminology (CPT) codes 90804 through 90809 for insight-oriented, behavior-modifying, or supportive psychotherapy in offices or other outpatient facilities.
• 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 (behavioral health integration, or BHI) an effective strategy for improving outcomes for millions of Americans with mental or behavioral health conditions. Medicare makes separate payments to physicians and nonphysician practitioners for BHI services they provide to patients over a calendar-month service period. BHI is a type of care-management service.
• Participate in Medicare Innovative Delivery and Payment Programs. For example, Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. The goal of coordinated care is to ensure that patients get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, the ACO will share in the savings achieved for the Medicare program.
• Work with Dual-Eligible Beneficiaries (those who qualify for both Medicare and Medicaid). The previous lack of recognition of counselors as Medicare providers meant those who age into Medicare eligibilty such as veterans or Medicaid recipients could not be treated by counselors for reimbursement, therefore disrupting the care or decreasing access to care.

Implications of Medicare Part B Coverage for Counselors

The ability of MFTs and counselors to bill Medicare for treating seniors with mental health conditions in their practices or the agencies where they work is the cornerstone of the Mental Health Access Improvement Act embodied in the omnibus legislation.

For counselors and MFTs who referred their clients to other providers and in many cases saw a disruption in their care (or their clients struggled to find another provider), those individuals will be able to continue to receive services for their conditions, and MFTs and counselors will receive Medicare reimbursement. We know based on recent surveys that a large percentage of counselors and MFTs provided pro bono services to clients over age 65 to prevent gaps in care. That will no longer be necessary, as continuity of care will remain in place, maintaining the critically important long-term engagement imperative.

The legislation creates parity between counselors and MFTs and other mental health providers under Medicare and other public insurance programs, as well as private payers. This new kind of recognition will not only open the private practice door for new and current clients but provide opportunities to participate in several innovative Medicare mental health programs (many multidisciplinary team-based approaches) highlighted above, such as accountable care organizations, patient-centered health homes, integrated care systems, and other demonstration programs developed by the Center for Medicare & Medicaid Innovation (CMS Innovation Center).

The key provision in the Mental Health Access Improvement Act allows mental health counselors and marriage and family therapists to receive payment under the Medicare Part B program for providing covered mental health services to beneficiaries beginning Jan. 1, 2024. Counselors will be able to bill Medicare directly for covered services rendered to beneficiaries over age 65 and people with disabilities who receive Medicare benefits.

Medicare Part B (medical insurance) helps cover mental health services that a beneficiary receives generally outside of a hospital (like in a clinic, doctor’s office, or therapist’s office) and services a hospital provides in its outpatient department.

All health care and mental health providers who participate in Part B must accept assignment. An assignment is an agreement by the provider or other supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill beneficiaries for any more than the Medicare deductible and coinsurance.

Part B helps pay for these outpatient mental health services:

• individual and group psychotherapy
• family counseling
• testing
• psychological evaluation
• diagnostic tests
• medication management
• certain prescription drugs that aren’t usually "self-administered"
• partial hospitalization
• a one-time “Welcome to Medicare” preventive visit for a beneficiary within the first 12 months they have Part B

Medicare covers opioid use disorder treatment services in opioid treatment programs. The services include medication (e.g., naloxone), counseling, drug testing, individual and group therapy, intake activities, and periodic assessments. Medicare covers counseling, therapy services, and periodic assessments both in person and, in certain circumstances, by virtual delivery.

Medicare covers one alcohol misuse screening each year for adults (including pregnant individuals) who use alcohol but don’t meet the medical criteria for alcohol dependency.

For more information about mental health benefits—and health care benefits—that Medicare beneficiaries are entitled to receive, please see the following sources:

• Medicare and Your Mental Health Benefits
• Medicare Mental Health
• Medicare Beneficiary Handbook

Centers for Medicare & Medicaid Services (CMS)

To gain a better understanding of how NCCs become eligible for formal Medicare participation and enroll in the program this year, NBCC representatives have initially met with officials from the Centers for Medicare & Medicaid Services (CMS), which administers Medicare Part A through Part D (and the federal portion of the Medicaid program).

CMS is the agency within the U.S. Department of Health and Human Services (HHS) that administers the nation’s major health care programs. CMS oversees programs including Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the state and federal health insurance marketplaces under the Affordable Care Act (ACA). CMS collects and analyzes data, produces research reports, and works to eliminate instances of fraud and abuse within the health care system. The agency aims to provide a health care system with better care, access to coverage, and improved health. CMS releases updated Medicare premium and deductible information each year.

NBCC has learned that there will be several CMS departments involved in the implementation of Medicare Part B coverage of counselors (These descriptions come from the CMS website. Visit for more information.):

1. Provider Relations Group With the CMS Office of Communications: Provides outreach to national stakeholders and facilitates webinars involving CMS leadership.

   This group serves as CMS’s focal point for internal and external strategic and tactical communications, providing leadership for CMS in the areas of customer service; website operations; traditional and new media, including web initiatives such as social media supported by innovative, increasingly mobile technologies; media relations; call center operations, consumer materials; public information campaigns; and public engagement. It coordinates with external partners including the Department of Health and Human Services (HHS) and the White House on key communication and public engagement initiatives, leveraging CMS resources to strategically support these activities.

2. Center for Program Integrity: Works with suppliers, vendors, and providers.

   This center serves as CMS’s focal point for all national and state-wide Medicare and Medicaid programs and CHIP integrity fraud and abuse issues. It promotes the integrity of the Medicare and Medicaid programs and CHIP through provider/contractor audits and policy reviews, identification, and monitoring of program vulnerabilities, and providing support and assistance to states.

3. Center for Clinical Standards and Quality: Handles clinical and provider issues.

   This center serves as the focal point for all quality, clinical, medical science issues, survey and certification, and policies for CMS’s programs. Provides leadership and coordination for the development and implementation of a cohesive, CMS-wide approach to measuring and promoting quality and leads CMS’s priority-setting process for clinical quality improvement. It coordinates quality-related activities with outside organizations and monitors the quality of Medicare, Medicaid, and the Clinical Laboratory and Improvement Amendments (CLIA). It evaluates the success of interventions and develops best practices and techniques in quality improvement. Implementation of these techniques will be overseen by appropriate components.

4. Center for Medicare: Overall operations and coordination

   This center serves as CMS’s focal point for the formulation, coordination, integration, implementation, and evaluation of national Medicare program policies and operations. It identifies and proposes modifications to Medicare programs and policies to reflect changes or trends in the health care industry, program objectives, and the needs of Medicare beneficiaries. It serves as CMS’s lead for management, oversight, budget, and performance issues relating to Medicare Advantage and prescription drug plans, Medicare fee-for-service providers, and contractors.

   The center oversees all CMS interactions and collaboration with key stakeholders relating to Medicare (i.e., plans, providers, other government entities, advocacy groups, Consortia ) and communication and dissemination of policies, guidance, and materials to understand their perspectives and to drive best practices in the health care industry. The Hospital and Ambulatory Policy Group—specifically the Division of Ambulatory Services (DAS)—within the center, will also be a key entity in the implementation of Medicare Part B coverage of counselors. The group is responsible for setting Medicare fee-for-service payments for a wide range of health care and mental health services and is responsible for national fee-for-service (FFS) provider education development.

CMS holds webinars/chats with specific national stakeholder groups to discuss implementation issues and any questions or issues that CMS can address.

NBCC has learned that CMS medical directors are interested in Part B coverage of counselors and that they host online forums the first Friday of every month. We have indicated that NBCC would like to participate in these sessions and include our issues in the agenda of upcoming meetings.

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Additional Resources

NBCC has reviewed the following online resources, and we think they may be of interest or help to counselors who want to learn more about Medicare in preparation for 2024.

• Learn about Medicare Administrative Contractors from CMS: What's a MAC | CMS
• The Medicare Physician Fee Schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician or other provider on a fee-for-service basis. Read about important changes in the 2023 Physician Fee Schedule: Calendar Year (CY) 2023 Medicare Physician Fee Schedule Final Rule.
• In order to provide an idea of what codes may be reimbursable under Part B coverage of counselors, we have looked at coding issues for psychologists and clinical social workers. View a list of codes used for behavioral health services under Medicare (apaservices.org).
• For detailed information about mental health coverage under Medicare, consult this booklet from CMS’s Medicare Learning Network.
• For a refresher on the fundamentals of Medicare, read AARP’s Medicare Basics - Medicare Part A, B, C and D (aarp.org).
• For information on Medicare coverage of mental health benefits, including telebehavioral health, and on mental health parity laws and Medicare, view the Kaiser Family Foundation’s FAQs on Mental Health and Substance Use Disorder Coverage in Medicare.

To learn more about the Medicare program and how to enroll (counselors will likely be able to enroll in November 2023), CMS’s Medicare Learning Network (MLN) now offers provider education products designed to promote national consistency of Medicare provider information for CMS initiatives. CMS’s 60-minute introductory 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

Example Rule

On an annual basis, CMS issues a notice of proposed rulemaking (NPRM) for the Medicare Physician Fee Schedule (MPFS) in early July and accepts comments on the NPRM before issuing a final rule in the fall. The calendar year 2024 MPFS (developed in the summer 2023) will include all of the language and guidance on participatory requirements for counselors in the Medicare program.

To help provide counselors with an example of how information is presented in a MPFS, the calendar year 2020 MPFS Final Rule offered some guidance on how CMS could potentially conduct rulemaking for Part B coverage of counselors.

In 2020, CMS added a new Enrollment Process Category for Opioid Treatment Providers (OTPs) to the Fee Schedule. The following paragraph, from the 2020 MPFS Final Rule, describes the process of adding a new category.

New Enrollment Category Created for Opioid Treatment Providers in 2020

In furtherance of its objectives to help individuals recover from opioid addiction, the SUPPORT Act established a new Medicare benefit category for OTPs for the purposes of furnishing opioid use disorder treatment services. Prior to the Final Rule, OTPs were not recognized as Medicare providers, meaning that beneficiaries receiving medication-assisted treatment (“MAT”) at OTPs for their opioid use disorder had to pay out of pocket. In the Final Rule, CMS sets forth the eligibility definitions and requirements for OTP enrollment under this newly created benefit category, which will enable OTPs that meet applicable requirements to bill and receive payment under the Medicare program for such services, thereby promoting expanded access to care. For purposes of enrollment, the SUPPORT Act and the Final Rule require that OTPs enroll under Section 1866(j) of the Social Security Act, which requires the entity to enter into a provider agreement that meets standard Medicare requirements. The Final Rule also specifically directs an OTP to have a provider agreement that meets the requirements of Section 1866(a) of the Social Security Act. All typical enrollment processes (e.g., completing an enrollment application) will apply to OTP enrollment, as well as Medicare enrollment regulations designed to give CMS discretion and gatekeeper tools for program integrity purposes to prevent unqualified or potentially fraudulent individuals and entities from being able to enter and inappropriately bill the Medicare program. The Final Rule creates a new regulation at 42 C.F.R. § 424.67 that incorporates these general enrollment requirements and procedures and further establishes specific enrollment requirements that OTPs must meet in order to bill Medicare for the provision of opioid use disorder treatment services. These requirements include submission of a Form CMS-855B with program-specific supplemental information attached, including (i) a list of all physicians and other eligible professionals who are legally authorized to prescribe, order, or dispense controlled substances on behalf of the OTP to enable CMS to screen such providers qualifications and prescribing practices; and (ii) a certification that the OTP meets and will continue to meet specific requirements and standards.