Medicare Reimbursement for Counselors and MFTs

Most 80-year-olds who’ve worked in the mental health field have long been retired, content to reflect on their life’s work and partake in some well-deserved rest and relaxation.

Erika Bekermeier isn’t one of them.

For the last eight years, the retired marriage and family therapist has worked tirelessly as a member of an advisory council advocating for senior citizens, part of the Rogue Valley Council of Governments, an association of cities, counties, and districts based in her home state of Oregon. With her fellow councilmembers, she’s helped raise awareness of the unique mental health issues facing seniors and adults with disabilities, participating in webinars for area government officials, spreading the word on local television, and meeting with local and federal lawmakers to garner support. “I never really retired,” she says with a laugh. “I’ve always thought that if you’re not using your brain and resources, you’re dying on the vine.”

On the evening of December 23rd, Bekermeier, like many people around the country, was in the thick of holiday planning, preparing Christmas dinner with her family. It had been several days since she’d received news that a piece of legislation she’d spent years pushing for was up for consideration, included in President Biden’s Consolidated Appropriations Act of 2023, which would provide nearly $1.7 trillion in funding for a slew of government agencies and initiatives.

The bill was vast, with a sizeable chunk of that funding—$120.7 billion—going toward the U.S. Department of Health and Human Services, and by extension, to Medicare, Medicaid, the National Institutes of Health, and the Centers for Disease Control and Prevention. But Bekermeier and countless other therapists were fixated on a small piece of legislation tucked inside, known as the Mental Health Access Improvement Act. Its crown jewel: permitting counselors and MFTs to receive Medicare reimbursement for services provided to clients 65 and older, veterans, and those with disabilities, putting an end to nearly 33 years of exclusion.

Bekermeier had been trying to keep her expectations realistic. A version of the bill had been introduced in almost every congressional cycle since the early 2000s. It had also been backed by the Medicare Mental Health Workforce Coalition, an impressive lineup of 11 high-profile mental health associations, including the American Counseling Association, the American Association for Marriage and Family Therapy, the American Mental Health Counselors Association, the California Association of Marriage and Family Therapists, and the National Council for Mental Wellbeing. But despite widespread support and a handful of close calls, it had always failed to pass, mainly due to budget concerns: incorporating counselors and MFTs into Medicare reimbursement was estimated to cost nearly $900 million over a 10-year period, according to the Congressional Budget Office.

The latest version of the act under consideration had been introduced in the House and Senate in 2021, with bipartisan support.

Maybe, Bekermeier thought, this time would be different. She was excited, but nervous too. “I told myself to breathe,” she says. “To breathe some good energy into the bill and hope it makes it.”

Maybe it worked, because when she stepped away from the kitchen to take a break from holiday cooking and decided to check her email, she saw a message from John Curtis, the former chairman of her advocacy committee. “Guess what!” read the opening line. The bill had just passed. A wave of elation coursed through her body. Wow, she thought. It actually happened.

For America’s nearly 140,000 mental health counselors and 55,000 marriage and family therapists, as well as the countless clients in need of their services, the holiday season had just taken a very merry turn.

A Long Time Coming

Although Medicare has covered psychologists, psychiatrists, and clinical social workers since 1989, when its mental health provider regulations were last updated, licensed professional counselors and MFTs had not been added to the list. In the 33 years since, the demand for mental health services has swelled. The population of Medicare-eligible Americans has doubled over this period, from nearly 30 million to 60 million adults—this amid a shortage of psychiatrists, psychologists, and social workers in rural areas, according to the National Rural Health Association. Now, thanks to the new law, counselors and MFTs can step in and help serve the approximately 30 million Americans living in rural counties with no access to mental health treatment. Their help is needed to battle two epidemics deeply affecting Medicare-eligible populations: post-pandemic anxiety and depression and the opioid crisis. (Medicare is currently the single largest payer for opioid-related hospitalizations.)

So if this bill was so important for counselors and MFTs, then why did it take so long to pass? For one, member organizations like the American Psychological Association and American Psychiatric Association predate their counselor and MFT counterparts—the American Counseling Association (ACA) and American Association for Marriage and Family Therapy—by almost a century, so at the time of the 1989 Medicare update, they had a more established professional history to draw upon. Budget constraints and early misconceptions about counselors’ roles and responsibilities have been suggested as additional culprits.

But the mental health workforce has changed considerably since 1989. Counselors and MFTs are now among the fastest-growing healthcare professions. According to the U.S. Bureau of Labor Statistics, the number of counselors and MFTs is expected to grow by 22 and 14 percent, respectively, over the next decade—much faster than the average growth rate of five percent.

“In the past, the advocacy strategy wasn’t focused on demonstrating that counselors could greatly assist with our nation’s challenges,” says Brian Banks, the chief government affairs and public policy officer at the ACA. “But this time around, we addressed that. We shined a positive light on counseling during our country’s darkest times.”

Banks was sitting in his home office in Washington, DC, when the bill passed, his eyes glued to C-SPAN. “I needed to see every vote,” he recalls, “and I kept my hopes up, knowing ACA had done everything it needed to do to ensure this bill’s success this time.” Although he and his colleagues “had a great feeling” that the bill would pass, there was trepidation, too. After all, in 2021, he’d witnessed the bill get put on the back burn­er again. “It was a running theme,” he says. “Make a little progress, and then get denied a seat at the table.” Thankfully, he says, ACA and the rest of the coalition continued working with the Biden administration to get the act included in the budget proposal. “I’m thankful for the strong network of counselor advocates,” Banks says.

Matthew Fullen is one of those advocates, an associate professor at Virginia Tech, who’s spent the last 10 years working closely with a handful of counselor organizations, including the ACA, to push for the new law. Like Banks, Fullen spent days watching C-SPAN and listening to congresspeople argue over the budget package. The act’s inclusion in the bill had happened suddenly, when the proposed budget was released in the Senate on December 20th. “We knew we were up for consideration, but we didn’t know we were officially included in the proposal until a few days before,” Fullen says. “From there, we were white-knuckling it while the House haggled and voted.” Then, on December 23rd, the bill was passed and sent to Biden, essentially guaranteeing it would be signed into law. “Getting to this point is a historic achievement,” he says, “the fruit of decades of hard work. We’re really thrilled that it all came together.”

Ultimately, Fullen says, the bill passed thanks to the tireless advocacy of the coalition, counselors and MFTs, and even noncounselor organizations like the National Council on Aging, the National Alliance on Mental Illness, and disability groups like the Michael J. Fox Foundation. These groups presented elected officials with a sizeable body of research about the coverage gap, what was at stake, and how the law would impact their Medicare constituents. “There seemed to be a new, emerging consensus that mental health needed more of an investment,” Fullen says. “Over the last couple years, a more diverse coalition was saying ‘This makes sense. We need to prioritize this.’”

Call it psychotherapy’s David and Goliath moment. “We were this little footnote in the larger budget document,” he says, “but a lot of advocacy work had been done to build momentum. And it worked.”

The News Spreads

For some therapists, like Tennessee-based counselor Courtney Armstrong, who’s currently training Veterans Affairs clinicians in clinical hypnosis for trauma and chronic pain, the passage of the bill opens up a world of possibility. “This is great news for our VA and our veterans,” she says. “A lot of people in rural areas don’t have access to mental health professionals, and since Covid, we’ve been seeing much higher levels of depression, suicide, and suicidal ideation in seniors.”

Armstrong, who’s been a counselor for nearly 25 years, recalls working at a geriatric psych unit in Louisiana earlier in her career. She’d loved treating seniors, but she’d seen how hard it was for them to get help because of the Medicare barrier. When she moved to work with the VA, that barrier persisted. “The VA covers some services,” she says, “but they also bill Medicare, so for a long time only psychologists and social workers were hired at the VA.”

Over the years, Armstrong followed the act’s journey in ACA bulletins and wrote to her congressman on several occasions to offer support, but saw little progress until recently. Now that the law has been passed, she says she’s looking forward to getting back to working more with seniors. It also opens doors for counselors interested in working in integrated care settings. “Primary care physicians have wanted to bring counselors on staff at integrated-care settings for a while,” she says, “but Medicare has been a barrier.”

For other therapists, the new legislation is both professional and personal. “The passage of this bill is great news,” says Rita Schulte, a licensed counselor and grief and loss specialist based in Virginia. “We’re in a mental health crisis right now, and every person, especially the elderly, should have access to treatment.” The suicide rate has skyrocketed in recent years, she adds, and “as a suicide-loss survivor, I can’t imagine not being able to get the help I so desperately needed after my husband’s death due to financial reasons.”

What Comes Next

Although the new law won’t go into effect until a year from now (the Centers for Medicare and Medicaid services will need time to fully implement the new policy), Fullen says the hard part is finished, and what’s left is to make sure the new system is properly set up so counselors and MFTs can get seamlessly onboarded.

There’s plenty of work to be done, with 10 thousand people turning 65 every day and approximately 60 million Americans currently on Medicare. But Fullen says it’s an exciting opportunity, and the counselor and MFT community is ready to get started. Plus, now that the career path for aspiring counselors and MFTs interested in working with older adults or people with long-term disabilities is clearer, students can focus their training on health and aging without having to worry that this choice could limit their ability to make ends meet.

Like Armstrong, Fullen expects this will change the landscape of integrated care, creating a more efficient pathway for referrals. Now, instead of long waitlists—even when plenty of capable counselors are available to see waitlisted clients—he believes the healthcare system will become more efficient, and care will be driven more by clients’ personal preferences or the best fit for their therapy journey, and less by antiquated billing issues.

In short, he says, the change “is a win for clients and a win for professionals.”

Back at her home in Oregon, Bekermeier flips through a stack of papers. “I know it’s here somewhere,” she mumbles, sifting through the pile. “Ah, here it is!” she says, settling on a page. It’s a letter from Richard, a member of her advocacy committee, written three years ago. Sandy, Richard’s wife of 44 years, passed away on New Year’s Day in 2018, eight months after being diagnosed with leukemia. For her, those months were marked by intense periods of depression, grief, and dread. Looking to help her, Richard reached out to therapists again and again, but was always turned away. The PhDs and LCSWs had full caseloads, and the counselors had their hands tied: they weren’t recognized by Medicare. Sandy died without ever getting the mental health treatment she desperately needed.

Erika unfolds the letter and begins to read it.

I want to thank you for the wisdom and effort that was required to have the simple story of someone’s life and death morph into what could be used in a national movement. . . . You took action, and I have seen the result. This has started a path to some outcome from which many will benefit. It takes a village, yes, but somebody built the roads in the village for actions to take place.

Happy New Year,

Richard

The letter still brings tears to Bekermeier’s eyes. “Hearing stories like this makes you feel like your work has some merit,” she says, “like all the energy paid off. I know that even if I don’t get a pat on the back, I’ve done good work, and that’s more important to me than anything.”

PHOTO © ISTOCK / BILL OXFORD