I receive many calls concerning whether or not a marriage and family therapist can take on Medicare clients, and if so, what would that look like. AAMFT has been working diligently for many years to get MFTs recognized by the federal government as eligible providers of covered services to Medicare enrollees. However, this has not yet occurred. So, can MFTs see Medicare clients, and if so, how can MFTs charge for their services?
The difference between Medicaid and Medicare
First, it is important to know the difference between Medicaid and Medicare.
Medicaid is the federal program designed to help people with low income obtain medical care, and is the largest provider of mental health services in the United States. Although a federal program, Medicaid is controlled by each individual state. Every state has established their own Medicaid plan and guidelines for eligibility, providers, and payments. The rules surrounding Medicaid generally fall to the states, within the restrains of rules issued by the Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees the Medicare program and enforces federal law pertaining to Medicaid.
Medicare is the federal program designed to help adults 65 years or older, and adults under 65 with certain disabilities, obtain medical care. This is solely a federal program, and is not regulated by the states at all. In compliance with federal law, CMS determines who is eligible, who can be a provider, what services are covered, and payments for those services. At the time this blog is being published, marriage and family therapists are not a recognized provider in the Medicare program. This means no claim for services, even if it is a covered service, would be accepted by Medicare coming from an MFT.
For Medicaid purposes, MFTs should check with their state’s Medicaid department to determine what the rules apply. If an MFT wants to accept a client who is covered under Medicaid, the first question is whether or not MFTs are a recognized provider by your state’s Medicaid program. It is best to contact them to ask whether MFTs are recognized, and if so, how, as some areas of service accept MFTs while other do not.
If an MFT has a potential client coming into their office, and that person is on Medicaid, the MFT needs to determine if they can provide the services sought under their state’s Medicaid program. The MFT will need to determine whether they must be registered under Medicaid as a provider and whether the specific services to be provided will be covered.
Medicare clients are people who, as described above, are 65 years of age or older, people under the age of 65 with certain disabilities, and people of all ages with End-Stage Renal Disease. Medicare is broken up into four parts: Part A is hospital insurance, Part B is medical insurance, Part C is medical insurance provided through a private health plan, known as Medicare Advantage, and Part D is prescription drug coverage.
Under federal law, only certain types of providers and certain services are accepted by Medicare coverage. According to CMS, “Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury.” Specifically, mental health care in an outpatient setting is limited under Part B coverage. Mental health treatment under Medicare is limited to the following practitioners: psychiatrists or other doctors; clinical psychologists; clinical social workers; clinical nurse specialists; nurse practitioners; and physician assistants. These professionals must have an agreement with Medicare in order to accept Medicare patients.
These professionals can choose to be a participant or nonparticipant of the Medicare program. A nonparticipating professional cannot charge the Medicare recipient more than the charge limit, but they may accept an assignment on a case-by-case determination. Those that are participants get reimbursed more than nonparticipants, but must accept the clients assigned to them.
The types of services are also limited, but include individual and group psychotherapy, family counseling if to help with treatment of a medical condition; psychiatric evaluation; and diagnostic testing, among other services. It is true that MFTs perform these services if allowed to under the scope of practice in your state, but MFTs are not recognized as a provider of these services by the Medicare program.
Many MFTs have also asked me about billing “incident to” another recognized professional. This, too, is very limited. According to CMS, “’Incident to’ services are defined as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.”
There are many caveats when trying to bill Medicare as a non-recognized provider “incident to” a recognized provider – either a physician or clinical psychologist (social workers are not eligible). First, the physician or psychologist must have performed the initial service, and be actively involved during the course of treatment. Further, the physician or psychologist must provide direct supervision over the non-recognized provider. Lastly, the physician or psychologist must be present within the office suite when the MFT, as the non-recognized provider, performs the services. This also means that the billing goes through the recognized provider, not the MFT performing the services.
What does this mean for MFTs?
As non-recognized providers under the Medicare program, there are a few consequences.
This means that an MFT can see a client who has insurance under Medicare, but who can afford to pay out of pocket. Since MFTs are not recognized providers, they cannot go through Medicare at all. Further, according to the Kaiser Family Foundation (KFF), even with Medicare coverage, recipients are spending 41%, on the rise to 50%, on out-of-pocket health care coverage. Seeing a provider outside of the Medicare coverage would increase this amount, and likely steer a client to a Medicare provider instead. If a Medicare recipient is still interested in an MFT’s services, it is wise that if the client has secondary insurance, to attempt a claim through them if you are a covered provider under that policy. However, it is not guaranteed that the claim will be accepted by the secondary insurer.
But what about the millions of Medicare recipients who cannot afford to see an MFT out of pocket? Sadly, it means they probably cannot see an MFT, unless other options arise, such as pro bono or sliding scale. This is the barrier to client care that the profession has been facing. The lack of access of Medicare recipients to a full range of mental health care is worrisome. This is also a large part of the client market that MFTs do not have access to.
What are we doing about getting MFTs as recognized providers in Medicare?
There are many reasons why MFTs should be recognized as providers under Medicare, including improving access for Medicare recipients to mental health care.
AAMFT is advocating that Congress amend federal law to recognize MFTs as Medicare providers. It is not just AAMFT that must advocate, but you, as an MFT, should be participating as well. If you are looking to participate and help advocate for MFT recognition, then join the AAMFT Family TEAM, the network in AAMFT that leads the way in state and federal advocacy issues.
Centers for Medicare and Medicaid Services website, https://www.cms.gov/
Federal Medicare mental health coverage webpage, https://www.medicare.gov/coverage/outpatient-mental-health-care.html
Medicare Enrollment for Physicians, NPPs, and Other Part B Suppliers, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_PhysOther_FactSheet_ICN903768.pdf
CMS, MLN Matters, “Incident to” Services, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf
KFF, Henry J. Kaiser Family Foundation, https://www.kff.org/medicare/
Stefanie Frank, Esq. is Associate Counsel at AAMFT, where she provides legal and ethics consultations to AAMFT members, is liaison for the AAMFT Ethics Committee, and performs other ethics and legal tasks. For more information about the consultations as an MFT benefit, visit https://www.aamft.org/Legal_Ethics/Consultations.aspx.