Medicare Overview The Nuts & Bolts which Providers Need to Know
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Gerontology A Training Resource By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
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Key Steps to Becoming a Medicare Provider
Step 2. Get an NPI: If you already have an NPI, skip this step and proceed to Step 3.
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Preface
Good News is that on December 23, 2022, Congress passed the Mental Health Access Improvement Act (S.828/H.R.432), a bill which expanded Medicare coverage to include two new groups of mental health providers: Licensed Mental Health/Professional Counselors and Licensed Marriage and Family Therapists. This legislation signed by President Biden goes into effect January 2024 and adds marriage and family therapists and mental health counselors to the list of health care practitioners who can accept payment from Medicare Part B health insurance. Part B is the component of Medicare that covers outpatient services, such as doctor visits. To help these professionals prepare to work with this population we are presenting this overview of Medicare and its Policies and Regulations to help them better understand how this system works.
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The Medicare Mental Health Workforce Coalition's Lobbying - Got this Done!
Through the collaborative efforts of the coalition, counselor inclusion in the Medicare program was accomplished in December 2022. The members of the coalition are:
1. American Association for Marriage and Family Therapy
2. Association for Behavioral Health and Wellness
3. American Counseling Association
4. American Mental Health Counselors Association
5. California Association of Marriage and Family Therapists
6. Centerstone
7. Center for Medicare Advocacy
8. The Jewish Federations of North America
9. Michael J. Fox Foundation for Parkinson’s Research
10. National Association of Community Health Centers
11. National Association of County Behavioral Health and Developmental Disability Directors
12. National Association for Rural Mental Health
13. National Board of Certified Counselors
14. National Council on Aging
15. National Council for Mental Wellbeing
16. Network of Jewish Human Service Agencies
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Facts About Medicare
Medicare beneficiaries are 20% of the U.S. Population.
Medicare is 10% of the Federal Budget at: $689 billion.
Medicare serves 65 million people ages 65 and older and younger adults with long-term disabilities.
It is a social insurance program, with defined benefits, financed by payroll taxes, premiums, and general revenues.
In 2021, Medicare accounted for:
- 21% of total national health spending
- 26% of hospital spending
- 26% of physician and clinical spending
- 32% of retail prescription drug sales
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What Benefits Are Covered by Medicare?
Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health services.
- Part A deductible: $1,600 per benefit period in 2023
- Inpatient copay: No copay up to 60 days; $400/day for 61-90 inpatient days; $800/day after 90 days
- SNF: No copay for up to 20 days; $200/day for days 21-100
Part B covers physician services, outpatient hospital care, preventive services, some home health, diagnostic procedures, and durable medical equipment (e.g., wheelchairs).
- The standard Part B premium is $164.90 per month in 2023
- Deductible of $226 in 2023 and 20% coinsurance on many services
Part C (Medicare Advantage) provides Medicare-covered benefits (Parts A and Band often Part D) through private plans that contract with Medicare, such as HMOs and PPOs.
Part D covers prescription drugs provided by private plans that contract with Medicare, including stand-alone prescription drug plans and Medicare Advantage plans.
- The average premium is an estimated $33/month in 2023, not weighted by enrollment
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Some on Medicare Enjoy Good Health,
But Many Have Significant Health Impairments and Limited Financial Resources
50% of Medicare Beneficiaries have Income of less than $30,950 per person
50% of Medicare Beneficiaries have Savings of less than $82,550 per person
27% of Medicare Beneficiaries have 1 or more Functional Impairment-Activity of Living limitations
22% of Medicare Beneficiaries have Fair or Poor self-reported health
18% of Medicare Beneficiaries have Cognitive/mental impairment
13% of Medicare Beneficiaries Under age 65 have disabilities
Overview of Medicare Advantage Plans
52% of Eligible Medicare Beneficiaries Are Projected to Be Enrolled in Medicare Advantage Plans in 2023 and by 2032 62% will be enrolled in Medicare advantage plans
More Than Half of Black, Hispanic, and Asian/Pacific Islander Medicare Beneficiaries Were
Enrolled in Medicare Advantage in 2020
There are now 43 Medicare Advantage Plans as of 2023
The companies which have the Medicare Advantage Plans by percentage are: 23% United Healthcare 18% Humana 14% Blue Cross Blue Shield 11% CVS Health/Aetna 6% Kaiser Permanente 5% Centene 2% Cigna 16% Other Firms
Most Medicare Advantage Enrollees (69%) Are in Plans
With No Supplemental Premium
(Other Than the Part B Premium)
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Coverage of Mental Health and Substance Use Disorder Services in Medicare Advantage
• Medicare Advantage plans are required to cover all Medicare Part A and B services that traditional Medicare covers but have flexibility to modify cost sharing for most A and B services.
• Most plans also include Part D, which covers outpatient drugs needed for these services.
• Plans may provide supplemental benefits specifically for these services that are not covered by traditional Medicare.
• Medicare Advantage plans can require provider referrals and impose prior authorization for these services.
• Enrollees in Medicare Advantage plans are limited to receiving care from providers in their network or must pay more to see out-of-network providers (in most cases).
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Almost All Medicare Advantage Enrollees Are in Plans That Offer Supplemental Benefits
Vision 99%
Hearing 98%
Fitness 98%
Dental 96%
Over the Counter Medications 84%
Meal Benefit 71%
Transportation 39%
In Home Support 2%
Bathroom Support 9%
Part B Rebate 7%
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Medicare Advantage: Tradeoffs for Beneficiaries
Potential Advantages
- Lower premiums than supplements to traditional Medicare (Medigap + Part D)
- Out-of-pocket limits for benefits covered under Medicare Parts A and B (unlike traditional Medicare)
- Extra benefits such as hearing and dental
- Simplicity: only one plan needed
- Potential for better-coordinated care
- Greater likelihood of receiving preventive services and having a usual source of care
Potential Disadvantages
- Narrower networks of physicians and hospitals
- More utilization review than traditional Medicare, like prior authorization of high-cost services
- Potential for higher out-of-pocket costs for certain services
- No ability to select a separate drug plan
- Limited ability to switch back to traditional Medicare and purchase Medigap for people with pre-existing conditions, creating somewhat of a lock-in
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The Mental Health Access Improvement Act allows mental health counselors and marriage and family therapists to:
- diagnose and treat older adults and people with disabilities who are covered by the Medicare program for their mental health care needs.
- diagnose and treat people with substance use disorders (SUDs) who are covered by the Medicare program for their behavioral health care needs.
- serve individuals who rely on Medicare plus another form of health insurance (e.g., dual-eligible beneficiaries, veterans).
- receive payment under the Medicare Part 8 program for providing covered mental health services to Medicare beneficiaries beginning Jan. 1, 2024.
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Medicare Coverage of Mental Health and Substance Use Disorder Services
(Medicare Service Medicare Beneficiary Cost Sharing)
Part A Services Inpatient hospitalizations at psychiatric or general hospital - Lifetime limit of 190 days in psychiatric hospital Part A deductible ($1,600 in 2023) per benefit period; daily copays for extended stays.
Part B Services Individual/group psychotherapy, family counseling, psychiatric evaluation, medication management, Part B drugs, telehealth Part B deductible ($226 in 2023) and 20% coinsurance apply.
Yearly Depression Screening No cost sharing if provider accepts assignment.
“Welcome to Medicare” Visit No cost sharing if provider accepts assignment (covered in first 12 months).
Annual “Wellness” Visit No cost sharing if provider accepts assignment.
Partial Hospitalization After meeting deductible, beneficiaries pay coinsurance for each day of partial hospitalization services they receive.
Opioid Use Disorder Treatment No cost sharing if received from provider enrolled in Medicare. However, deductible still applies for supplies or medications received through provider.
Alcohol Misuse Screening No cost sharing if provider accepts assignment.
Tobacco Cessation Counseling No cost sharing if provider accepts assignment.
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Medicare Telehealth Coverage of Mental Health and Substance Use Disorder Services
Before COVID-19 pandemic, telehealth services were available only to Medicare beneficiaries in rural areas originating from a health care setting, such as a clinic or doctor’s office. – These rules did not apply to individuals diagnosed with a substance use disorder for the purposes of treatment of such disorder or co-occurring mental health disorder (as of July 1, 2019). – These geographic and originating site limitations do not apply to Medicare Advantage plans (as of 2020).
Medicare has since permanently removed these restrictions for telehealth mental health services and also covers audio-only visits for mental health and substance use disorder services, subject to limitations.
Though Medicare does impose some in-person requirements in tandem with coverage of these telehealth mental health services, these requirements have been delayed as part of the Consolidated Appropriations Act (CAA), 2023, until Jan. 1, 2025.
Expanded coverage of non-mental health services will expire Dec. 31, 2024, as part of CAA.
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Mental Health Counselors and MFTs will be eligible Medicare Part B providers in:
- Agency and private practice settings
- Federally Qualified Health Centers (FQHCs)
- Rural Health Clinics (RHCs)
- Medicare hospice interdisciplinary teams
- Medicare Integrated Behavioral Health and Primary Care Programs
- Medicare Innovative Delivery and Payment Programs
- Telehealth services, as these continue to be adjusted by CMS
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Rates of Reimbursement
- Services will be reimbursed at 80% of the lesser of the actual charge for the services, or 75% of the amount determined for payment of a psychologist.
- Commensurate with rate received by licensed clinical social workers.
- Rates determined annually with release of Physician Fee Schedule (PFS).
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Implications for Professionals
- Improved provider pool for underserved clients
- New population of clients to serve.
- Enhanced continuity of care
- Parity among mental health professionals
- Expanded professional opportunities for Mental Health Counselors and MFTs.
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How to Enroll in the Medicare Program
Enrollment at CMS website at: Become a Medicare Provider or Supplier:
https://www.cms.gov/medicare/enrollment-renewal/providers-suppliers
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Additional Medicare Information Sites
Medicare Physician Fee Schedule
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Medicare CPT Billing Codes for Mental Health
Medicare Telehealth Services
or
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Additional Informational Sites:
NBCC's Medicare Fact and Information
2. Frequently asked questions about Medicare at: https://www.nbcc.org/govtaffairs/medicarefaq
Medicare Series of Training
sponsored by: Members of the Medicare Mental Health Care Workforce Coalition:
- American Association for Marriage and Family Therapy
- Association for Behavioral Health and Wellness
- American Counseling Association
- American Mental Health Counselors Association
- California Association of Marriage and Family Therapists
- Centerstone
- Center for Medicare Advocacy
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The Jewish Federations of North America
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Michael J. Fox Foundation for Parkinson’s Research
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National Association of Community Health Centers
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National Association of County Behavioral Health and Developmental Disability Directors
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National Association for Rural Mental Health
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National Board of Certified Counselors (NBCC)
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National Council on Aging
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National Council for Mental Wellbeing
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Network of Jewish Human Service Agencies
Medicare 101:
Policy experts and staff from the Centers for Medicare & Medicaid Services (CMS) present an introduction to the Medicare program for counselors and marriage and family therapists. This webinar covers key components of the Mental Health Access Improvement Act and its implications for counselors.
- YouTube Video of Presentation: https://www.youtube.com/watch?v=VoeQp6m_IC8&t=1s
- Slides of Presentation: https://www.nbcc.org/assets/governmentaffairs/Medicare_101_Webinar_Presentation.pdf
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Medicare 201:
Panelists from the Centers for Medicare & Medicaid Services (CMS) provide an inside look at the process leading up to provider registration. This webinar covers the new regulatory process for implementing Medicare Part B coverage.
- YouTube Video of Presentation: https://www.youtube.com/watch?v=3RSjz4RH7a0&t=1s
- Slides of Presentation: https://www.nbcc.org/assets/governmentaffairs/Medicare_201_Webinar_Presentation.pdf
Medicare 301:
Experts from the Centers for Medicare & Medicaid Services (CMS) and the law firm of Weintraub Tobin discuss the implementation features of the Medicare Part B coverage of counselors and marriage and family therapists, as well as the implications for providers. This webinar covers an overview of the major steps providers will need to take to enroll in the traditional Medicare fee-for-service program.
- YouTube Video of Presentation: https://www.youtube.com/watch?v=V1z4D6rCz1w&t=7s
- Slides of Presentation: https://www.nbcc.org/assets/governmentaffairs/Medicare_301_Webinar_Presentation.pdf
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Medicare 401:
Specialists from the Centers for Medicare & Medicaid Services, the law firm of Weintraub Tobin, and the Government Affairs Department at NBCC discuss the proposed rule for the Medicare Physician Fee Schedule and answer questions previously submitted by practitioners from across the country.
- YouTube Video of Presentation: https://www.youtube.com/watch?v=P4fpcZ8XGr8
- Slides of Presentation: https://www.nbcc.org/assets/governmentaffairs/Medicare_401_Webinar_Presentation.pdf
Medicare 501:
The MMHWC and the National Council for Mental Wellbeing come together to explore the primary roles that community behavioral health centers play in providing mental health and substance use services to improve quality of life for older adults with mental health conditions and the skills and experience of MFTs and counselors and how they can address the needs of county behavioral health directors in serving Medicare beneficiaries with mental health conditions.
- YouTube Video of Presentation: https://www.youtube.com/watch?v=hJIR-823kIY&t=2s
- Slides of Presentation: https://www.nbcc.org/assets/governmentaffairs/Medicare_501_Webinar_Presentation.pdf
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Medicare 601:
Representatives from the Centers for Medicare & Medicaid Services and the law firm of Weintraub Tobin review the 2024 Medicare Physician Fee Schedule final rule, provide step-by-step enrollment procedures, and answer frequently asked questions related to enrollment and opt-out procedures for mental health counselors and marriage and family therapists.
- YouTube Video of Presentation: https://www.youtube.com/watch?v=g31KkGQ0vQk
- Slides of Presentation: www.nbcc.org/assets/governmentaffairs/Medicare_601_Webinar_Presentation.pdf
The Role of Medicare Administrative Contractors: Enrollment to Payment:
Representatives from Medicare Administrative Contractors (MACs) explain the MACs’ responsibilities and how they interact with Medicare-enrolled mental health counselors and marriage and family therapists including enrollment, claims processing, payment, and other procedures.
- YouTube Video of Presentation: https://www.youtube.com/watch?v=4_3gOeW7u9c
- Slides of Presentation: https://www.nbcc.org/assets/governmentaffairs/Feb1_MAC_Webinar.pdf
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