ACTION ALERT: Medicare Recognition of Mental Health Counselors
AMHCA and MaMHCA have long sought bipartisan support for its Medicare provider status legislation in the U.S. House of Representatives, and on December 5, 2013, HR.3662 was introduced by our new sponsors Rep. Chris Gibson (R-NY) and Rep. Mike Thompson (D-CA). The House bill contains language identical to that used in the Senate version, S.562 (Wyden/Barrasso), which amends Medicare to add the outpatient services of licensed mental health counselors ("LMHCs") and licensed marriage and family therapists ("LMFTs") under part B of the Medicare program.
ACTION REQUESTED: Now is the time to contact your House member to show their support HR. 3662 and request they cosponsor the bill.
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• Lack of Access: Approximately 77 million older adults live in 3,000 mental health professional shortage areas. Fully 50 percent of rural counties in America have no practicing psychiatrists, psychologists, or social workers. Many of these mental health professional shortage areas have LMHCs whose services are underutilized due to the lack of Medicare coverage.
• Medicare Inefficiency: Currently, Medicare is a very inefficient purchaser of mental health services. Inpatient psychiatric hospital utilization by Medicare beneficiaries is extraordinarily high when compared to psychiatric hospitalization rates for patients covered by Medicaid, VA, TRICARE, and private health insurance. One third of these expensive inpatient placements are caused by clinical depression and addiction disorders that can be treated for much lower costs when detected early through the outpatient mental health services of LMHCs.
• Underserved Minority Populations: The United State Surgeon General noted in a report entitled "Mental Health: Culture, Race, and Ethnicity," that "striking disparities in access, quality, and availability of mental health services exist for racial and ethnic minority Americans." A critical result of this disparity is that minority communities bear a disproportionately high burden of disability from untreated or inadequately treated mental disorders.
Advocacy Summary for MEDICARE, TRICARE, and Veterans Affairs Concerns 2013
1. MaMHCA represents Licensed Mental Health Counselors (LMHCs) in the Commonwealth of Massachusetts, who are qualified to diagnose and treat mental disorders. There are currently over 5200 Doctorate and Master LMHCs in the commonwealth, who treat the full spectrum of disorders and age groups, working in both public and private settings.
2. LMHCs are highly skilled Mental Health Professionals. LMHCs (called LPCs in some other states) have education and training very comparable to and sometimes exceeding the minimum standards of LICSWs. Currently, the Master’s training and clinical experience of LMHCs is being greatly underutilized.
3. LMHCs have been mandated providers in Massachusetts since 1996, and receive reimbursement for services from all payers except Medicare. Nationally, most health plans recognize LMHCs/LPCs. Most private insurers and quite a few public health plans, like Medicaid in numerous states, TRICARE and the VA recognize the LMHC/LPC profession.
4. We strongly support Senate Bill 562 which would allow Licensed Mental Health Counselors to participate in Medicare. We believe that it is very important that regulations be written to allow all licensed mental health counselors to participate. This is a matter of honoring the states’ right to determine the qualifications for professional practice.
5. Recent regulatory actions that restrict TRICARE and VA employment to graduates of CACREP (Council for the Accreditation of Counseling and Related Educational Programs) approved graduate programs have vastly reduced the pool of potential providers in these arenas.
Since CACREP itself is relatively new, only a minority of practicing professionals have graduated from CACREP programs.
Only 32% of U.S. master’s programs in counseling and only 11% of 60-credit mental health counseling programs are accredited by CACREP.
There is only ONE CACREP-approved mental health counseling program in Massachusetts whereas Massachusetts LMHC requirements have exceeded the CACREP standards since 1996.
In a 2011 American Counseling Association study, only 13% of New York’s mental health counselors had graduated from CACREP programs.
6. Many mental health counseling programs across the country and in Massachusetts are housed in departments of psychology, or in departments that employ a multidisciplinary faculty. In the U.S., 72 Counseling Psychology Ph.D. programs are accredited by the American Psychological Association (APA). Fifty-nine of these have affiliated master’s-level programs, and their graduates go on to become licensed as professional counselors (LMHCs or LPCs). CACREP does not serve a majority of these schools because of their identification as psychology programs or their multidisciplinary faculty.
7. A new accrediting body, MPCAC (Master’s in Psychology and Counseling Accreditation Council) has emerged to serve the programs that CACREP does not, and will seek CHEA recognition during 2013. CORE (Council on Rehabilitation Education) is also a CHEA-recognized accrediting body; in this case serving programs in Rehabilitation Counseling, many of which meet state professional counseling licensure standards.
8. We are very concerned about CACREP-only rules “spilling over” from TRICARE into Medicare and private insurance plans that would likely follow Medicare’s precedent. This would affect access for hundreds of thousands of seniors and the chronically disabled, in addition to the military and veterans groups now affected.
9. In these times of growing mental health care needs, there are crucial services that LMHCs can provide. But, we are limited or excluded by regulations or lack of law, and we are requesting your support and active assistance to correct this situation. Specifically, we need help with:
Amending the new regulations regarding Licensed Mental Health Counselors (LMHCs) for the Veterans Affairs and TRICARE that will exclude 96% of Massachusetts LMHCs from serving veterans and active duty service personnel and their families.
Inclusion as providers in the Medicare program.
10. There are over 1.2 million veterans, active duty military and families, and seniors in Massachusetts that will not be able to receive much needed services from very able and willing LMHC providers if we cannot amend these regulations and also get added to the Medicare Provider Roster.
1. Make sure that S. 562, the Seniors Mental Health Access Improvement Act of 2013, passes without restrictions in terms of the accrediting body of the provider’s master’s degree program. Make sure that all licensed mental health counselors are allowed to participate in Medicare. They have been successful providers for Medicaid and private insurance for decades. They already have a proven track record for quality services and should be recognized for Medicare as they have been for Medicaid and private insurers. In addition to the law, the regulations need to be consistent with it and allow all licensed mental health counselors to participate in Medicare.
2. Request a change in TRICARE and VA hiring policies to grandfather all currently licensed professional counselors who have taken either the NCE or NCMHCE national standard exam.
3. After a reasonable grandfathering period, request that future professional counselors who have graduated from a master’s degree program that meets state licensure requirements and is accredited by a CHEA-approved accrediting body which includes CACREP be eligible for TRICARE participation and VA employment. The national NCMHCE exam would also be a reasonable requirement for licensure for new graduates.
4. Request a Congressional Study of the IOM’s position of a CACREP-only policy in TRICARE and VA hiring policies. Ask for a study that includes testimony from other accrediting bodies, and considers the impact of restrictions on provision of services to vulnerable populations.
Important Article on the Future of LMHCs with Medicare, TRICARE, & VA:
What you don’t know could hurt your practice and your clients
by Elaine Johnson, Larry Epp, Courtenay Culp, Midge Williams, & David MacAllister
Are you a mental health counselor? If so, you may be only vaguely aware of the ways in which CACREP (Council for Accreditation of Counseling and Related Educational Programs)-only language in hiring, credentialing and reimbursement policies could impact your practice. As practicing mental health counselors and board members of the Maryland and Massachusetts chapters of the American Mental Health Counselors Association, we have watched recent developments with increasing alarm. Our practices and livelihoods are under serious threat, and the public faces greatly reduced access to care, by growing efforts to restrict the practice of mental health counseling to those who attended CACREP-approved graduate programs. It is imperative that professional counselors everywhere understand these developments and take action to protect what we have worked so hard to achieve — our right to practice independently.
The hidden threats to practice
TRICARE is the health care program for all active-duty and retired military personnel and their families. Licensed mental health counselors have served this population for many years but could do so only with physician referral and supervision. “Interim” regulations issued in 2011, based on a study by the Institute of Medicine (IOM), created a new classification of TRICARE providers (TRICARE certified mental health counselors, or CMHCs) who are allowed to practice independently. An interim period was created, during which current providers could ostensibly move to independent status by taking the National Clinical Mental Health Counseling Examination (NCMHCE) and meeting supervision requirements. The goal of the change, according to its announcement in the December 2011 Federal Register, was to increase access to mental health care by eliminating the physician-referral/supervision requirement. Yet, the result is quite the opposite.
TRICARE supervision rules: A major problem lies with the supervision requirement in the interim rule, which states that all of one’s post-master’s supervision hours must have been obtained under a licensed professional counselor. (It has come to our attention that this rule is not being applied consistently. This may be relieving for some, but haphazard enforcement is not a solution to an overly restrictive rule.) If we follow the rule, it prohibits most of the board members of the Maryland and Massachusetts AMHCA chapters from TRICARE participation because at the time we graduated, there were virtually no counselors who could have supervised us (since licensure laws were relatively new). Thus, this rule disqualifies the most-seasoned counselors in many states from becoming CMHCs. The American Counseling Association has requested the removal of this stipulation (for example, in a letter from ACA Executive Director Richard Yep to the assistant secretary of defense for health affairs in February 2012), but it remains on the TRICARE application. We do not believe the IOM intended to create a profound roadblock to CMHC status, but efforts so far to change the regulation have been unsuccessful.
It is also critical to recognize that at the conclusion of the interim period in December 2014, providers who cannot achieve CMHC status will no longer be able to participate in TRICARE at all because the physician-referral provider status will be eliminated. If you are currently a TRICARE provider who cannot meet this supervision requirement, you will either terminate your military clients or go unreimbursed — unless the regulations are changed.
CACREP restriction in TRICARE: The second problem with the TRICARE rules is that once the interim period expires, all graduates from programs not approved by CACREP will be permanently excluded from participation in TRICARE even when duly licensed by their own states. After December 2014, if you did not graduate from a CACREP-approved program, you cannot and will not ever be able to join the TRICARE network.
The CACREP-only rule, in combination with the supervision rule, will disqualify thousands of currently licensed practitioners. For example, ACA’s own 2011 study found that only 13 percent of licensed mental health counselors in New York graduated from CACREP-approved programs. In addition, because only 32 percent of U.S. master’s programs in counseling and only 11 percent of 60-credit mental health counseling programs are accredited by CACREP (see the 2010 text Ethical, Legal and Professional Issues in Counseling by Theodore Remley and Barbara Herlihy), there are undoubtedly thousands of current counseling students in the country who will be permanently excluded. Again, as an example, in Massachusetts and Maryland, 32 programs train mental health counselors. Two (one in each state) are accredited by CACREP.
Our country faces a critical shortage of mental health counselors to serve legions of our veterans, including those from the recent wars. It is a travesty that the majority of current and future mental health counselors will be excluded from providing services to these veterans. They deserve more and better, as opposed to more restricted, access to therapists.
CACREP-only language has moved into regulations in other important areas:
1) The Department of Veterans Affairs (VA) recently created a new job classification for professional counselors. These jobs are open only to graduates of CACREP-approved programs.
2) No state currently requires graduation from a CACREP-accredited program for licensure. Yet, CACREP’s stated goal (see, for example, Barry Mascari and Jane Webber’s article, “CACREP Accreditation: A Solution to License Portability and Counselor Identity Problems,” in the January 2013 Journal of Counseling & Development) is to restrict state licensure to graduates of CACREP-approved programs. Under regulations adopted in New Jersey in 2006 (and ultimately reversed by the grass-roots efforts of licensed counselors and educators), graduation from a CACREP-accredited program would have become a requirement for all new counselors in the state and any counselor moving into New Jersey. State counseling boards are continually lobbied by CACREP to restrict licensure to graduates of programs bearing their accreditation.
3) A bill recently introduced in the U.S. Senate (S. 562) would, if passed, extend Medicare eligibility to licensed professional counselors. Although there are no restrictions by type/accreditation of degree program in this bill, we are very concerned by the precedent that has been set in the regulations we have already described. If a CACREP-only restriction were to be inserted into Medicare regulations, we believe that Medicaid and private insurers would quickly follow suit, and in relatively short order, the practices of all graduates of programs not affiliated with CACREP would be obliterated.
These challenges to the majority of practicing professionals and counseling students in the country need a vigorous response. The rules need to be changed, and further restrictions must be prevented.
What is happening now
Practicing professionals, for whom CACREP may have seemed an “academic” issue, may not be aware that it serves only one slice of master’s- and doctoral-level training programs. The only programs eligible for CACREP accreditation are those in “counseling” or “counselor education.” CACREP does not serve programs that grant degrees with “psychology” in the name (for example, a master’s in counseling psychology) or whose core faculty have degrees in psychology, identify as psychologists or are otherwise interdisciplinary, despite the fact that these graduates are license holders and license eligible in all 50 states.
Ironically, if Carl Rogers wished to hold a core faculty position in a CACREP program today, he would be prohibited due to the requirement that only counselor educators may occupy such positions. Many of us received excellent education and training from psychologists and others whose training was in other disciplines. We do not believe that national certification and reimbursement should be restricted to those who were trained solely or primarily by counselor educators, thus excluding qualified license holders in every state.
We applaud and support the educational standards that CACREP has developed and the efforts to promote these standards nationally. However, other accrediting bodies with equally impressive standards exist that accredit the programs that CACREP does not. Many of our members are graduates of or students in these programs. A notable example is the Council on Rehabilitation Education (CORE).
All accrediting bodies share the same mission — to train and graduate counseling professionals of the highest caliber. We can coexist peacefully and strengthen each other by supporting strong common core training and diversity in faculty background as well as programs’ specialty areas of expertise.
What needs to be done
1) We believe that CACREP-only restrictions should be removed from hiring and credentialing processes for TRICARE and the VA and should not be included in any future regulations (for example, state licensure laws, Medicare and private insurance regulations). Restrictive supervision rules in the TRICARE regulations must also be removed. ACA has consistently requested TRICARE policymakers to expand the original, restrictive criteria, and we ask the leadership to redouble efforts to press for those changes. The TRICARE rules are “interim final rules” and can be changed. Because ACA’s requests of regulators have not been effective to date, we ask the ACA membership to join us in lobbying our congressional delegations to change the rules. Please send an email to your representatives in Congress and urge them to oppose the restrictive TRICARE and VA regulations on your behalf.
2) Until CACREP-only language and the restrictive supervision rule are removed from TRICARE regulations, the current interim rules for transition to CMHC status in TRICARE should remain open. Established and emerging professionals who can meet the supervision requirement should be allowed to move into independent CMHC status.
3) The requirement for CMHC applicants to pass the NCMHCE (the clinical counseling exam) should commence in 2017, giving states that do not currently use this exam a chance to move to it in a reasonable way.
4) Please write (emails are more effective than letters) to your senators and congressional representatives and ask them to support S. 562, which would allow professional counselors to participate in Medicare. We believe it is very important that regulations are written to allow all currently licensed professional counselors to participate. This is a matter of honoring the right of states to determine the qualifications for professional practice and to provide much-needed services to citizens in
5) Regarding training standards, the profession of mental health counseling stands at a historic moment. Importantly, delegates to the 20/20: A Vision for the Future of Counseling initiative did not reach agreement that graduation from a CACREP-accredited mental health counseling or clinical mental health counseling program should be included in model licensure language. We believe that a more inclusive endorsement of educational standards is needed and should be part of all future federal and state credentialing processes. Please join with us in calling on the leadership of ACA and its divisions to recognize and affirm the value that CORE has long brought to the training of professional counselors and that other accrediting bodies bring in providing an alternate route to accreditation for counseling programs in related academic departments. Future initiatives and regulations should recognize and incorporate these accrediting bodies alongside CACREP. In doing so, ACA will affirm and continue its rich and diverse intellectual history and serve the best interests of all of its professional counseling members.
Note: This article was submitted as a joint effort of the boards of the Maryland and Massachusetts chapters of AMHCA.
Elaine Johnson is the graduate program director at the University of Baltimore. Larry Epp and Courtenay Culp are president and executive director, respectively, of the Maryland chapter of AMHCA. Midge Williams and David McAllister are executive director and associate executive director, respectively, of the Massachusetts chapter of AMHCA.
Published July 1, 2013, in "Counseling Today."
MaMHCA is the state-recognized entity for working with third party payers (insurance companies and managed care companies) state agencies and other mental health organizations.
MaMHCA meets regularly with 3rd party payers to discuss practice policy and issues. Importantly, MaMHCA has a seat on critical state governmental committees and panels such as the Children’s Behavioral Health Initiative Advisory, the Mass Behavioral Health Partnership Advisory Committee, Blue Cross and Blue Shield Advisory, the Task Force on Behavioral Health for Payment Reform, and more.
In addition, MaMHCA is an active member of the Massachusetts Mental Health Coalition, an interdisciplinary coalition of mental health providers professional associations, and consumer advocacy groups.
Panels and Advisory Committees: We serve on a number of committees to ensure and promote the health of our profession and those clients that we work with.
Insurance Companies and Managed Care Companies: Our relationship with both insurance and managed care companies is critical to the health of our profession and to the care of our clients. Our on-going work with them is vital.
Massachusetts Mental Health Coalition: MaMHCA has been an active member of this coalition since 1996. Member groups also include Massachusetts Psychological Association, Massachusetts Psychiatric Society, NASW of Massachusetts, Nurses United for Responsible Services, Association of Advanced Practice Registered Nurses, Associates for Behavioral Health, Massachusetts Association of Behavioral Health Systems.
Massachusetts Legislative Activities: MaMHCA takes a leading role in affecting public policy that supports our profession and our clients.
Massachusetts Mental Health Coalition: MaMHCA has been an active member of this coalition since 1996. Member groups also include Massachusetts Psychological Association, Massachusetts Psychiatric Society, NASW of Massachusetts, Nurses United for Responsible Services, Association of Advanced Practice Registered Nurses, Associates for Behavioral Health, Massachusetts Association of Behavioral Health Systems,
How to contact your state legislator: Keeping in contact with your state legislators is an important part of maintaining a healthy and positive environment for both our profession and clients. Contact your representatives and senators and let them know what you do and give them a reason to support our profession. You can find your state senator and representatives here.
Federal Legislature Updates: AMHCA, our national organization, along with support from its state chapters like MaMHCA takes a leading role in affecting federal policy that supports our profession and our clients.
How to contact your U.S. Congressman or U.S. Senator: It is vital that you become involved in voicing your support for federal legislation that affects our profession. Contacting your federal legislators about issues that are important to us and our clients may take only a few minutes but can make a big difference. Our responsibility is to inform and educate them about our profession and the many benefits we bring to our clients. You can find your U.S. senators here and representatives here.