Counseling Today, Features

Medicare and counselors: Frequently asked questions

Scott Barstow, Christopher Campbell and Brian Altman January 7, 2006

At presstime, Congress was still considering budget reconciliation legislation that included language establishing Medicare coverage of state-licensed professional counselors. American Counseling Association members are strongly encouraged to check www.counseling.org/publicpolicy for updates on the status of this legislation and the possible need for grass-roots support for this provision. This website and the related website at http://capwiz.com/

counseling will include information regarding members of Congress to contact and suggested messages for discussing the issue.

To help familiarize counselors with both Medicare and the legislative process involved in working to gain recognition of counselors under this program, ACA’s Office of Public Policy and Legislation offers a list of “frequently asked questions” (and answers!).

For more information, please contact either Brian Altman (800.347.6647 ext. 242; e-mail: baltman@counseling.org) or Scott Barstow (800.347.6647 ext. 234; e-mail: sbarstow@counseling.org).

Q: What is Medicare? Who are Medicare’s beneficiaries?

A: Medicare is the federally run and financed health insurance program covering an estimated 40 million older Americans (age 65 and older) and Americans with disabilities. Medicare is the single largest health insurance program in the country. It should not be confused with Medicaid, the health insurance program for low-income uninsured children and families funded jointly by states and the federal government. States control their Medicaid programs, including eligibility and benefits criteria, within certain basic federal guidelines. Congress controls Medicare, although the program is administered in each state by one or more intermediaries.

Q: How do I get a Medicare provider number?

A: Right now, you can’t. Currently, psychologists and clinical social workers are the only nonphysician mental health professionals covered under the program. Congress writes Medicare’s benefit package. At presstime, Congress had yet to pass (and the president had yet to sign) legislation establishing Medicare coverage of licensed professional counselors. 

The Senate has passed legislation establishing Medicare coverage of state-licensed professional counselors and state-licensed marriage and family therapists, but this is only the first step in the legislative process. Before any legislation can be enacted, it must be approved in exactly the same text and format by three separate entities: the House of Representatives, the Senate and the president. (The House and Senate can enact legislation by overriding the president’s veto, but this is a rare occurrence.) 

Q: Since Medicare coverage of counselors has passed the Senate, does this mean it’s going to become law in a certain amount of time?

A: No. The Senate has passed legislative language establishing Medicare coverage of counselors before, but without subsequent House approval of the same language. Each chamber (the Senate and the House of Representatives) routinely passes legislation that the other chamber chooses not to approve. Simply because the Senate has passed something doesn’t automatically mean it’s going to become law.

In this case, the Senate included a counselor coverage provision in its broad budget reconciliation bill, S. 1932. The House budget reconciliation bill does not include this provision. At presstime, a group of House and Senate members was working together to reconcile differences between the two bills. As mentioned previously, before a bill becomes law, the same exact language must be passed by both the House and the Senate and then be signed by the president. The House and Senate conferees on the budget reconciliation legislation are working through a long list of contentious issues.

ACA is working alongside the American Mental Health Counselors Association and the American Association for Marriage and Family Therapy to see that the counselor/MFT coverage provision is retained in the conference report (the name for the compromise version of the legislation written by the House-Senate conferees) developed on the budget reconciliation legislation.

Q: If the Medicare language passed by the Senate on counselor coverage is enacted, which counselors would be covered?

A: The provision passed by the Senate would establish Medicare coverage of state-licensed professional counselors who have obtained the highest level of licensure. Thus, the provision would not apply to any mental health counselors in states without licensure (California and Nevada). School counselors would receive reimbursement for services provided to Medicare beneficiaries only if they were licensed in their state as independently practicing mental health counselors.

Q: What groups are opposing this provision?

A: The only groups we know of opposing Medicare coverage of licensed professional counselors and marriage and family therapists are the American Psychiatric Association and the National Association of Social Workers. The opposition of these two groups is disappointing, if not surprising.

The American Psychiatric Association has a long history of opposing efforts to expand direct access to nonphysician providers (including psychologists, clinical social workers and licensed professional counselors) under Medicare and other public health programs.

The National Association of Social Workers appears to share the American Psychiatric Association’s desire to protect its members’ “turf” at the expense of patient access to services. This is despite the strong similarities in counselor and social work training standards and the fact that clinical social workers are routinely licensed with significantly less actual graduate coursework than licensed professional counselors. Many — if not most — graduate programs in social work give students as much as a full year of credit for bachelor’s level coursework.

Q: If counselor coverage is enacted, when would it go into effect?

A: Most likely sometime in 2007. Under the legislation passed by the Senate, coverage of state-licensed professional counselors would begin Jan. 1, 2007. However, House and Senate conferees on the measure could change this date. In addition, the U.S. Department of Health and Human Services and its Centers for Medicare and Medicaid Services will need time to develop regulations implementing this and any other changes in Medicare law. The regulatory process is sometimes painfully slow.

Q: Would getting Medicare coverage affect reimbursement under Medicaid?

A: Only indirectly. As noted above, states control their Medicaid programs and have free reign to cover (or not cover) many services and populations. Under federal law, state Medicaid programs must cover physicians’ services, but they are not required to cover psychologists’ services or those of other nonphysician mental health professionals. Recent budget shortfalls have forced nearly all states to cut back on their Medicaid programs.

However, Medicare coverage will help demonstrate to state officials that counseling is a legitimate mental health profession. This, combined with counselors’ cost-effectiveness, may cause more states to establish or expand coverage of counselors for their Medicaid beneficiaries. 

Q: How would this affect private health plans?

A: Again, only indirectly. Changing the benefit package of one of the primary public health insurance programs doesn’t mean that private sector plans have to change anything. However, they will likely be more inclined to recognize and reimburse licensed professional counselors if they know we’re covered under Medicare. Medicare law prohibits “Medicare+ Choice” managed care plans from discriminating against providers on the basis of their type of license.

Q: How much does Medicare pay?

A: Medicare is not known for its generous reimbursement rates, and one of the major policy discussions taking place is the extent to which Medicare’s small payments to providers are leading them to stop seeing Medicare clients. Medicare pays for services through a complex fee schedule that takes into account the difficulty of the service provided, the resources necessary to provide the service and geographic cost factors.

Medicare generally pays 80 percent of the cost of outpatient treatment, with the beneficiary responsible for the remaining 20 percent. However, for outpatient mental health treatment, Medicare only pays 50 percent of the cost, with the beneficiary responsible for the other half. This inequitable copayment requirement remains unchanged in both the House- and Senate-passed bills. 

The Senate’s bill would pay state-licensed professional counselors and marriage and family therapists at the same rates as clinical social workers. If and when this provision is enacted into law, counselors can find out what Medicare payment rates are for outpatient mental health services in their area by contacting their state’s Medicare carrier.

Q: Can I do anything to help Medicare coverage of counselors become law?

A: We think so! As stated previously, either check the ACA website at www.counseling.org/publicpolicy or contact Brian Altman with ACA’s Office of Public Policy and Legislation at 800.347.6647 ext. 242 or via e-mail at baltman@counseling.org to get an update on the status of this legislation.

If Congress hasn’t already decided on this issue by the time you receive this issue of Counseling Today, we may need you to contact your Representative to ask him or her to contact the respective chairs of the House Ways and Means Committee (Rep. Bill Thomas) and Energy and Commerce Committee (Rep. Joe Barton) to express support for Medicare coverage of licensed professional counselors.

You can find your Representative through the ACA Internet Legislative Action Center at http://capwiz.com/counseling. Since the Senate has already approved our provision, we need to focus on getting House members to support this as well.

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