Medicare Recognition of Counselors FAQs

Medicare Administrative Contractors (MACs) are private health care insurers that has been awarded a geographic jurisdiction by the Centers for Medicare and Medicaid Services (CMS) to process Medicare Part A and Part B medical care and mental health claims for Medicare Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary operational (intermediary) contact between the Medicare FFS program and the providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims.

Key services that MACs perform include:

• Enrolling providers in the Medicare FFS program
• Processing Medicare FFS claims
• Handling provider reimbursement services
• Responding to provider inquiries
• Educating providers about Medicare FFS billing requirements
• Establishing local coverage determinations (LCD's)
• Providers enroll in Medicare through their designated MAC. You can find your designated MAC and their contact information and mailing address here.

Medicare opt-out affidavits are good for two years and renew automatically every two years, unless the practitioner notifies the Medicare Administrative Contractor that they wish to enroll as a Medicare provider.

As part of their standard procedures, MACs send out renewal notifications 90 days prior to the opt- out affidavit's renewal date. Practitioners who do not want their opt-out to automatically renew at the end of a 2 year opt-out period, may cancel the renewal by notifying all contractors (MACS) with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period.

Medicare providers may decide they no longer want to provide services to Medicare eligible patients, but in order to no longer be a participating provider, the provider would have to notify their MAC and take the appropriate steps to opt out as a Medicare provider. Those steps include filling out and mailing an opt-out affidavit to the appropriate MAC or MACs and entering into private pay contracts with Medicare eligible patients. Affidavits and private pay contract templates can be accessed through the MACs' websites.

A provider who has opted out of Medicare will still be able to participate as a provider with all health plans that are not Medicare managed care plans.

If you are already enrolled in a network that offers Medicare Advantage services, contact the health plan/network to request that the terms of your contract be expanded to include Medicare services.

It is possible to be a telehealth-only Medicare provider. However, you will need to include comments within your Medicare provider enrollment application that the practice location address you are listing is for administrative purposes only and that you are a telehealth-only provider.

There is an exception to the annual in-person visit requirement. You can read more about the exception on page 26 of CMS's Medicare Learning Network booklet titled, "Medicare and Mental Health." 42 CFR 405.2463(b)(3) says there must be an in-person visit 6 months before providing telehealth mental health services and there must be an in-person, non-telehealth service within 12 months of each mental health telehealth service unless the physician and patient agree the risks and burdens outweigh in-person visit benefits and it's documented in the medical record.

Pursuant to current Medicare sub-regulatory guidance, the provider must be enrolled in the state or states where they provide services, such as the provider's office location and/or home location if they provide services from their homes. Current CMS guidance indicate that the provider need not enroll in each state where the beneficiary resides. However, CMS currently indicates that the provider must be licensed in both the states where they are delivering services (new office/home location) and also the state where the beneficiary is receiving the services. We recommend that providers stay up to date on CMS guidance as it emerges and also the final Medicare Physician Fee Schedule Rule expected to be released in November!

If a provider moves to a new state, he or she would need to get licensed there and also enroll in the location where they reside if that is the location from which they will deliver services.

Yes. The 2022–23 federal budget legislation (called the omnibus) included the Mental Health Access Improvement Act language that allows mental health counselors and marriage and family therapists (MFTs) to receive payment under the Medicare Part B program for providing covered mental health services to Medicare beneficiaries.

Yes. Counselors who referred their older clients who enrolled in Medicare to other providers will be able to resume providing treatment to those clients—as long as the clients have terminated services with the referred provider.

During 2023, the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers all aspects of the Medicare program and issues rules and regulations, will develop guidance on how to apply for Medicare recognition. CMS will offer guidance to counselors as new Medicare providers prior to 2024. NBCC will work with CMS and share information as soon as that application process is open for counselors.

Yes. NBCC will be collecting questions and comments from NCCs about rule development and implementation on Medicare recognition of counselors. Further, NBCC plans to hold a series of training sessions this year on Medicare application procedures and coding issues, and regular updates into 2024 and beyond.

Many federal programs already recognize mental health counselors, including the National Health Service Corps, Department of Veterans Affairs, U.S. Army, and TRICARE.

Yes, as long as you meet the requirements described in the legislation. The provisions are similar to licensing at the state level.

No. However, the individual will need to make sure that a reassignment of benefits occurs. The updated version of CMS's internet-based application system, PECOS 2.0, reportedly combines the individual CMS-855I form with the CMS-855R (reassignment of benefits) form where necessary and appropriate. PECOS 2.0 reportedly tailors the application to the applicant based on a questionnaire the applicant answers at the outset of the online enrollment process.

In those states that require 3,000 hours of supervised clinical experience for license eligibility, licensure would be one form of proof that the 3,000 hours requirement was met.

The short answer is no; hospices will likely not be able to bill for Part B services on top of their hospice per diem for services rendered by MFTs. Clinical Social Workers are not able to bill for Part B services on top of the per-diem rates, unless they are providing treatment for conditions unrelated to their terminal illness. They can receive SIA payments (defined below) for care rendered in the final 7 days of a hospice patient's life.

Generally, when hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an attending physician not employed by the hospice (which may include a nurse practitioner or physician assistant.) (Medicare Claims Processing Manual Chapter 11, Section 10.) Other than this narrow exception, Medicare payment for hospice care is made at one of four predetermined rates for each day that a Medicare beneficiary is under the care of the hospice. The four rates are prospective rates; there are no retroactive adjustments other than the application of the statutory “caps” on overall payments and on payments for inpatient care. The four rates are called: routine home care, continuous home care, inpatient respite care, and general inpatient care. (Medicare Benefit Policy Manual Chapter 9, Section 40.)

A hospice service intensity add-on payment (“SIA payment”) may apply when social workers or nurses provide care, during routine home care, in the last seven days of life. (https://hospicenews.com/2019/05/20/medicare-service-intensity-add-on-underused-by-hospices/).

CMS expects all Medicare providers to have functional compliance programs to address Medicare requirements of all kinds, including financial, documentation, coding, and quality issues.

Services provided by mental health counselors are for the diagnosis and treatment of mental illness (not for services for an inpatient in a hospital) that the mental health counselor is legally authorized to perform in the state where they practice.

The effective date of the provisions regarding counselor inclusion in the Medicare program is Jan. 1, 2024. At that time, you will be able to bill for services provided to Medicare beneficiaries.

The Mental Health Access Improvement Act specifically spells out who is eligible based on the following language:

The legislation defines a mental health counselor as holding a master's or doctoral degree as a mental health counselor, clinical professional counselor, or professional counselor in the state where they are licensed to provide services, and the counselor must have performed at least 2 years of supervised experience in mental health counseling.

In addition to the provider application process, CMS will provide guidance to counselors on which codes to use for billing for services provided to Medicare beneficiaries. NBCC will also discuss this process in our meetings with CMS officials.

Medicare Part B covers one depression screening per year; a one-time “welcome to Medicare” visit, which includes a review of risk factors for depression; and an annual “wellness” visit where beneficiaries can discuss their mental health status. Part B also covers individual and group psychotherapy services provided by several licensed professionals, and depending on state rules, family counseling is covered if the main purpose is to help with treatment, psychiatric evaluation, medication management, and partial hospitalization.

Additionally, Part B covers outpatient services related to substance use disorders. These include opioid use disorder treatment services such as medication, counseling, drug testing, and individual and group therapy. Medicare covers one alcohol misuse screening per year, and for beneficiaries determined to be misusing alcohol, four counseling sessions per year. Medicare also covers some telehealth services, including for mental health and substance use disorder services as well as services unrelated to mental health, on both a permanent basis and on a temporary basis as part of the COVID-19 public health emergency.

Yes. Counselors are now 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 provide comprehensive services, including preventive health services and mental health and substance abuse services.

Counselors are also now eligible Medicare Part B providers in Rural Health Clinics (RHCs). The RHC program increases access to primary care services for patients in rural communities. RHCs are required to provide outpatient primary care services such as behavioral health care.

As part of the Mental Health Access Improvement Act, counselors are now required team members for Medicare hospice interdisciplinary teams. The hospice interdisciplinary team includes physicians, nurses, mental health providers, chaplains, and trained volunteers who work together to address a hospice patient's physical, emotional, and spiritual needs.

The legislation will provide opportunities to participate in Medicare Behavioral Health Integrated (BHI) services and primary care programs. Public and private insurance programs now widely consider integrating behavioral health care with primary care an effective strategy for improving outcomes for millions of Americans with mental or behavioral health conditions. Medicare makes separate payment to physicians and non-physician practitioners for BHI services they supply to patients over a calendar month service period. Counselors also will be able to participate in "Medicare Innovative Delivery and Payment Programs" such as Accountable Care Organizations (ACOs).