The AAMFT Blog

Proposed Rule Allows MFTs Greater Flexibility in Providing Care to Medicare Beneficiaries Under Supervision

On July 7, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule for changes starting in 2023 that would expand access to behavioral health services and allow some LMFTs more flexibility in treating Medicare enrollees. Every year, CMS releases a rule, known as the physician fee schedule (PFS), which makes changes to fees CMS pays to Medicare providers and other administrative changes through rulemaking that CMS is proposing for the coming year.

Change to the Medicare “incident to” rule

CMS is proposing several changes to Medicare’s rules pertaining to behavioral health, including one major change pertaining to providing incident to services that impacts MFTs. Under current regulation , an LMFT or LMHC could provide services to Medicare beneficiaries “incident to” the services provided by a physician or other qualified supervising provider (usually a psychologist) if the LMFT or LMHC is under the direct supervision of the supervising physician or other supervising provider. Under Medicare’s current rules , “direct supervision” means that the physician or other supervising provider must be in the same office suite and be immediately available to furnish assistance and direction when the LMFT is providing services to a Medicare beneficiary.

Under the proposed rule, CMS would allow LMFTs and other qualified professionals to provide behavioral health services under the “general supervision” of a physician or other qualified supervising provider. Under the general supervision standards , an LMFT’s incident to services to a Medicare enrollee would be under the overall direction and control of the physician or other supervising provider. However, the general supervision requirements do not require the supervising practitioner to be in the same office suite as an LMFT when the LMFT is providing behavioral health services to Medicare beneficiaries. CMS believes that removing the direct supervision requirement will allow an increase in the utilization of behavioral health services by older adults and other Medicare beneficiaries.

This change, if adopted, will result in additional services to Medicare enrollees starting in 2023. However, due to overall restrictions in federal statute preventing the full and proper utilization of MFTs and MHCs as eligible providers, this change will likely not have a significant impact on the ability of Medicare enrollees to receive necessary behavioral health services or result in a significant increase in the number of LMFTs providing incident to services As most licensed behavioral health providers practice in settings where they are not employed by or working directly with physicians or other qualified supervisors, most LMFTs will not have an opportunity to utilize these new flexibilities. Many potential supervisors might not have the time or the ability to provide general supervision under the incident to standard. Other restrictions also make it difficult for this change in the incident to rule to have a significant impact on behavioral health access for most Medicare beneficiaries. The proposed rule would still not allow Medicare to directly reimburse LMFTs and would still not allow LMFTs to directly bill Medicare for services provided to Medicare enrollees.

Impact of the “incident to” rule change

AAMFT supports the expansion of the overall ability of MFTs and other behavioral health providers to provide incident to services to Medicare enrollees under the general supervision standard. The federal government’s support for expanded access to behavioral health services is reflected in President Biden’s budget for Fiscal Year 2023 , which, if adopted, would provide the largest amount of federal financial support in history for mental health services, and would modernize Medicare mental health benefits by allowing LMFTs and LMHCs to serve as Medicare eligible providers. Under the current CMS Behavioral Health Strategy , one goal is to improve access to and quality of mental health care and services.

AAMFT applauds CMS for doing as much as this agency can under federal law to improve access to behavioral health services for Medicare beneficiaries. In the proposed rule, CMS is doing all that can be done under current federal law to allow MFTs to provide services to Medicare beneficiaries, as CMS clearly states that it does not have the authority to add LMFTs and LMHCs as Medicare billable providers. Since only Congress can change federal statute to add LMFTs as providers eligible for direct reimbursement by Medicare, it is critically important that Congress pass the Mental Health Improvement Act of 2021 (S. 828/H.R. 432). If you have not already done so, please contact your Members of Congress now to urge them to pass the Mental Health Access Improvement Act.

The full text of the proposed rule can be found here . AAMFT will be providing public comments by September 6 to CMS regarding this proposed rule. Please contact AAMFT at [email protected] if you have any questions.

Benefits of Being an AAMFT Approved Supervisor Part II

Read a prior blog post about Approved Supervision.

In AAMFT Supervision courses, we focus on the process of supervision from the time of meeting and interviewing potential trainees, to contracting and determining goals, to using multiple roles and skills to ensure client care and trainee professional growth, to working as a colleague and co-professional in the field. We focus on relationships within the supervisory system, and on roles that supervisors engage in for varying purposes and at varying trainee developmental stages. We also focus on the purpose and appropriate goals for supervision, system concepts, the relationship between one’s approach to therapy and approach to supervision, personal and professional experiences that impact supervision, the process of supervision, formats, ethical and legal training and practice, contextual awareness/sensitivity/competency, and evaluating trainees’ progress.

The interactive portion of the Fundamentals course, whether online or in person, also focuses on the elements mentioned above within a context of discussion among an instructor and other supervisor candidates. These discussions have become quite popular and involve participants from around the country, continent, and globe. Instructors lead discussion on topics assigned each week that complement the Units in the didactic portion of the course (5 in all), topics introduced by participants, and exercises aimed at enhancing learning and practice. Many participants continue interacting with each other after the formal sessions have ended.

The combined course culminates in a personal philosophy of supervision paper, which often seems daunting but, when worked on throughout the course, results in clear thinking about what one thinks about relational supervision as well as how one practices as a supervisor.  I have enjoyed reading these papers and nurturing future AAMFT designated supervisors in this part of their journey. Working on these courses has been stimulating, fun, challenging, and quite rewarding for me.

The AS Refresher course is specially designed for AAMFT Approved Supervisors who wish to renew their designations. It satisfies the requirement of a Refresher course for each 5-year cycle for renewal. In this course, we have a didactic, online portion that focuses on readings and assignments in preparation for the online interactive portion, which is 3 hours, offered many times each month. The didactic portion can be completed whenever one wants, which makes it accessible for busy clinicians and supervisors.

I encourage any of you reading this to consider further training as a relational supervisor. If you have any questions, please consult the AAMFT Approved Supervisor Designation: Standards handbook or contact me at [email protected]. If you are currently an Approved Supervisor, and will be renewing your designation soon, I hope you find the AS Refresher course timely, accessible, friendly, challenging, and useful. 

Learn more about the Approved Supervision courses here.

Thorana S. Nelson, Ph.D. is emerita professor of family therapy at Utah State University. She enjoys training and supervision in marriage and family therapy and Solution-Focused Brief Therapy, and has taught AAMFT courses on the Fundamentals of Supervision, the Approved Supervisor Refresher course, and A Crash Course in Marriage and Family Therapy. She currently teaches the online supervision courses for AAMFT and is a co-author, with Robert E. Lee, of The Contemporary Relational Supervisor, published by Routledge. 

Benefits of Being an AAMFT Approved Supervisor

Find Info about AAMFT Approved Supervision

In the field of marriage and family therapy (MFT), we believe that supervision is a different activity from therapy. Yes, we’re systemic/relational therapists and know about focusing on process over content, but there are some important differences that most supervisors have found to be important to attend to.

I teach the AAMFT online Fundamentals of Supervision and Approved Supervisor (AS) Refresher courses. I have supervised MFTs for nearly 30 years and taught supervision courses for over 20 years. Each time I have taught, I have learned something new or seen a different angle on something that I believe has improved my supervision. You’d have to ask my students and post-graduate trainees about that to be certain, but I know that looking back, I wish I could do some things differently.

The AAMFT AS courses were developed using revised guidelines in 2013. After surveying Approved Supervisors and a few supervisor candidates (those in training to be Approved Supervisors, supervising training therapists under their own supervision or mentoring), we determined a number of things about the AS designation that needed tweaking, including the courses’ content and process. You can find those requirements in the 2014 Approved Supervisor Designation: Standards Handbook. Although daunting, the course requirements help to provide the most recent resources and research to those who wish to achieve and maintain the very high standards that AAMFT has of its designated Approved Supervisors.

I don’t know that this ensures better client care or more competent therapists and therapy, but I believe this is true. Years later, students and training therapists contact me about their appreciation for the supervision provided, and seek to become Approved Supervisors themselves. I don’t claim to be the best supervisor in the field – far from it! – but I do think that what I learned about focusing on trainee development rather than doing therapy through them helped them to develop clarity about their own approaches to therapy and an ability to attend to making their practices better over time.

A number of people have asked why one would want to become an AAMFT Approved Supervisor rather than simply meeting the requirements of the states/provinces in which they practice. The answer is simple: because AAMFT holds designated supervisors to the highest standard of supervision, and trainees will always want quality supervision, even when not required. I live in New Mexico, where supervision by an AAMFT Approved Supervisor is not required, and receive calls from people who want supervision by a designated AS because they believe it will better help them become competent therapists.

Supervision means a number of things that are sometimes challenging: ensuring client care, helping trainees develop confidence and competence, sorting through ethical dilemmas and legal conundrums, and gatekeeping for the field. Some have said in the trainings that they are afraid to continue as supervisors because of the heavy responsibilities and legal liabilities. I believe that AAMFT training as a supervisor helps prevent such liabilities by preparing and providing continuing education and resources, as well as a community of supervisors with whom to interact around common things.

But supervision is more than just challenging and fearing for clients or one’s own license: it’s interesting, keeps us sharp, and contributes greatly to our field. In addition, it’s just plain fun! Some of my best memories as a clinician/supervisor/educator are when working with training therapists and watching them grow, becoming confident and competent colleagues. 

Thorana S. Nelson, Ph.D. is emerita professor of family therapy at Utah State University. She enjoys training and supervision in marriage and family therapy and Solution-Focused Brief Therapy, and has taught AAMFT courses on the Fundamentals of Supervision, the Approved Supervisor Refresher course, and A Crash Course in Marriage and Family Therapy. She currently teaches the online supervision courses for AAMFT and is a co-author, with Robert E. Lee, of The Contemporary Relational Supervisor, published by Routledge.