CMS’s Proposed Regulations to Integrate MFTs and MHCs Into the Medicare System and the Medicare Fee-for-Service Enrollment Process

Sara Jasper, JD
Staff Attorney
The Therapist
September/October 2023

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In July, the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers all aspects of the Medicare program, including Medicare rules and regulations, released its calendar year (CY) 2024 Medicare Physician Fee Schedule (PFS) proposed rule. This PFS proposed rule outlines how licensed marriage and family therapists (MFTs) and mental health counselors (MHCs)—aka licensed professional clinical counselors (LPCCs) in California—will be integrated into the Medicare (Part B) Fee-for-Service1 system. Once it’s finalized in November, the PFS rule will enable MFTs and MHCs to complete the Medicare Fee-for-Service (FFS) provider enrollment process so they can begin getting reimbursed by the Medicare FFS system as of January 1, 2024. This article provides a high-level summary of the proposed rule and offers information about the Medicare FFS provider enrollment process.

Summary of the CY 2024 Medicare Physician Fee Schedule Proposed Rule

The PFS is a lengthy rule issued annually that provides information on behavioral health codes, services, and reimbursement rates for Medicare providers. Since MFTs and MHCs will be included in the Medicare program starting in 2024, this year’s rule included information on the provider enrollment process. There was a 60-day period during which providers and other stakeholders could submit comments on the PFS rule. CAMFT and its Medicare Mental Health Workforce Coalition partners commented on the proposed rule and will provide information about CMS’s response once the CY 2024 Medicare PFS final rule is published in November.

Big Picture Summary

• The proposed rule includes MFTs and MHCs as Medicare providers, consistent with statute.
• The proposed rule allows MFTs and MHCs to enroll in Medicare after the CY 2024 PFS final rule is published (typically mid- November).
• The proposed rule allows MFTs and MHCs to bill Medicare for services beginning January 1, 2024, consistent with statute.
• The proposed rule subjects MFT and MHC supplier types, like most non-physician practitioner types, to limited-risk screening. To read more about Medicare provider screenings, visit the Medicare FAQs within the Medicare Corner of CAMFT’s website (www.camft.org/medicare).
• The proposed rule defines an MFT at §410.53 as an individual who:
  • Possesses a master’s or doctorate degree which qualifies for licensure or certification as a marriage and family therapist pursuant to State law of the State in which such individual furnishes the services defined as marriage and family therapist services;
  • After obtaining such a degree, has performed at least two years or 3,000 hours of post-master’s degree clinical supervised experience in marriage and family therapy in an appropriate setting such as a hospital, SNF, private practice, or clinic2; and
  • Is licensed or certified as a marriage and family therapist by the State in which the services are performed.
  • The proposed rule establishes the payment rate for services provided by licensed clinical social workers (LCSWs), licensed MFTs, and MHCs as 80 percent of the lesser of the actual charge for the services or 75 percent of the amount determined for clinical psychologist services under the fee schedule.
    (Note: More information about the proposed reimbursement rate is included below).
• The proposed rule recognizes MFTs and MHCs as telehealth practitioners and distant-site telehealth practitioners.
• The proposed rule recognizes MFTs and MHCs as practitioners in rural health clinics (RHCs) and federally qualified health centers (FQHCs.
• The proposed rule allows MFTs and MHCs to bill for monthly care integration services.3 This was a request the coalition made through a letter sent to CMS’s chief innovation officer, Dr. Doug Jacobs, earlier this year.
• The proposed rule updates the hospice conditions of participation to add MFTs and MHCs to the hospice interdisciplinary team and makes corresponding changes to the hospice personnel requirements.
• The proposed rule allows MFTs and MHCs to bill for health behavior assessments and interventions.
• The proposed rule states that MFTs and MHCs who meet the applicable requirements must enroll in Medicare to submit claims for services.
• The proposed rule states that MFTs and MHCs who meet the proposed requirements will enroll in Medicare via the 855 application. (Note: There are different versions of the CMS 855 form. The enrollment form used by individuals is CMS 855I. The enrollment form used by groups and clinics is CMS 855B. As CMS gives MFTs and MHCs access to its online enrollment system, known as PECOS, CAMFT will offer a provider enrollment guide to support and assist members with the process. CMS and the Medicare Administrative Contractors (MACs) that handle provider enrollment and billing for Part B of the Medicare system also offer helpful tutorials that are referenced later in this article.)
• The proposed rule adjusts payment for timed behavioral services.
  • CMS will apply this adjustment to the following time-based psychotherapy codes that describe one-on-one time with the patient:
    • CPT code 90832 (Psychotherapy, 30 minutes with patient)
    • CPT code 90834 (Psychotherapy, 45 minutes with patient)
    • CPT code 90837 (Psychotherapy, 60 minutes with patient)
    • CPT code 90839 (Psychotherapy for crisis, first 60 minutes)
    • CPT code 90840 (Psychotherapy for crisis, each additional 30 minutes—list separately in addition to code for primary service)
    • CPT code 90845 (Psychoanalysis)
    • CPT code 90846 (Family psychotherapy (without the patient present), 50 minutes)
    • CPT code 90847 (Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes)
    • CPT code 90849 (Multiple-family group psychotherapy)
    • CPT code 90853 (Group psychotherapy (other than a multiple-family group) and newly proposed HCPCS codes GPFC1 and GPFC2 (Psychotherapy for crisis furnished in an applicable site of service (any place of service at which the non-facility rate for psychotherapy for crisis services applies, other than the office setting)

Medicare PFS Proposed Reimbursement Rates
Consistent with the Consolidated Appropriations Act, 2023 that establishes MFTs and MHCs as eligible Medicare providers, the PFS proposes reimbursing social workers, MFTs, and MHCs for psychotherapy services at 80 percent of the lesser of the actual charge for the services or 75 percent of the amount determined for clinical psychologist services. To get an idea of what those payments amount to, members can use CMS’s provider payment look-up tool (www.cms.gov/medicare/payment/fee-schedules/physician/lookup-tool) to determine what psychologists and social workers are typically paid for psychotherapy services. For example, prospective Medicare providers can do a search for what a clinical psychologist (CP) is paid for a 50-minute session. Depending on the location and setting, a CP’s payment for a claim with a 90834 CPT code is anywhere from $89 to $114. In Northern California, a CP would receive $114 for a 50-minute session. This means, Medicare would pay MFTs and MHCs 75% of the $114 paid to the CP or $85.50. Keep in mind, the rates under the CY 2024 Medicare PFS final rule may differ slightly.

When reviewing Medicare reimbursement rates, prospective Medicare providers should be aware that psychotherapists who enroll and participate as Medicare providers agree to accept Medicare’s payment as payment in full. This means Medicare participating providers cannot collect more from patients than their Medicare deductibles, co-insurances, and co-payments (i.e., they cannot balance-bill patients). For more information about the three types of relationships providers can have with the Medicare system (i.e. opt-outed provider, participating provider and non-participating provider) and how those relationships impact provider payment, visit CAMFT’s Medicare Corner (www.camft.org/ medicare).
 

What Happens After the CY 2024 Medicare PFS Final Rule Is Published?

Once the final rule is published in mid-to- late November, CMS is proposing to allow MFTs and MHCs to enroll as providers using either the PECOS electronic system or paper applications. MFTs and MHCs who complete the application process promptly and without deficiencies may be reimbursed for Medicare services as of January 1, 2024. Given that 30-35 percent of provider applications require at least one round of corrections, not all MFTs and MHCs who apply will become approved providers at the turn of the new year. CMS strongly encourages providers to use the PECOS system to apply as opposed to submitting a paper application.

There are several benefits to using PECOS:

• The PECOS application begins with a questionnaire to help tailor the content of the application and only show the portions of the application that are relevant to the applicant. The questionnaire creates the appropriate application depending on whether the applicant is an individual, a sole proprietor, a sole owner, or some other entity. Based on the answers to the questionnaire, PECOS either takes the applicant to the CMS 855I content for individual providers or combines the individual application with the application for groups and clinics to ensure that the applicant is properly enrolled.
• PECOS pre-populates the application with any existing information to speed up the application process.
• PECOS checks the application for errors and validates information throughout the application process, thereby reducing the likelihood of errors.
• PECOS enables its users to view and manage all of their information in one location.
• Applicants can track the status of their applications in real-time.
• For those applying for provider status through PECOS, the application process can take 15-50 calendar days. Those who submit a paper application can expect the process to take 30-65 calendar days.
  Note: This processing-time information is provided by Noridian Healthcare Solutions, Inc., California’s Medicare Administrative Contractor (MAC); incomplete applications (e.g., applications with errors, unsigned applications) take longer to process.

PECOS 2.0
CMS had indicated that it would introduce a new version of PECOS, PECOS 2.0, during the summer of 2023, but the update had not debuted by the time this article was prepared for publication. CMS now anticipates introducing PECOS 2.0 sometime in the fall. Once it has debuted, CAMFT will publish information about any PECOS 2.0 trainings within the Medicare Corner of its website.
 

What Clinicians Who Are Considering Becoming Medicare Fee-for-Service Providers Can Do Now

The Medicare fee-for-service provider enrollment process can be broken down into four steps:

Step 1: Register with the Identity and Access Management System (aka the I&A system).
Step 2: Get a National Provider Identifier (NPI).
Step 3: Complete the appropriate Medicare provider enrollment application(s) through PECOS or submit the relevant paper application(s).
Step 4: Work with the appropriate Medicare Administrative Contractor (MAC) to address any application deficiencies.

Although MFTs and MHCs will not be able to enroll until the CY 2024 Physician Fee Schedule is finalized in November, MFTs and MHCs can complete the first two steps of the process now.

Prospective providers can also review the PECOS provider enrollment checklists, which can be found on the Provider Enrollment Information page of CAMFT’s Medicare Corner, gather the necessary documentation, scan and save it to a computer in the correct format. The documents should be saved in .pdf or .tif file format that can be uploaded to PECOS.

Instructions for Completing Step 1 of the Medicare Provider Enrollment Process
Step 1: Register/create an account with the Identity and Access Management System (aka the I&A system). The I&A system allows a user to create one account to manage access to CMS systems such as PECOS.

To register for the I&A system:

1. Go to the National Plan and Provider Enumeration System (NPPES) webpage (https://nppes.cms.hhs.gov/#/) and click “Create or Manage an Account” on the right-hand side
2. Click the “Create Account Now” button on the right-hand side. Enter and confirm an email address, and enter the CAPTCHA text from the image. Then click the “Submit” button. (Tip: Use a unique email address, not a group email address or distribution list.)
3. Create a user ID and password for the account.
4. Select security questions and provide answers. You will have to answer these questions if you forget your password.
5. Click the “Continue” button at the bottom of the page. A webpage will provide fields for entering personal information.
6. Complete the required fields to validate your identity. Then click the “Continue” button. A new screen will appear with specific questions based on the information you provided.
7. Answer the questions, then click “Confirm My Identity Now” at the bottom of the screen. (Tip: Users can postpone this step but must eventually complete it. You can also complete this step by clicking “Verify Identity Now” under My Profile after logging in.)

Instructions for Completing Step 2 of the Medicare Provider Enrollment Process
Step 2: Once registered with the I&A system, visit the NPPES website (https://nppes.cms.hhs. gov/#/) and use your I&A login to get to the electronic NPI application.

All Medicare providers must obtain at least one NPI number. In some cases, more than one NPI is required. For example, a sole owner of a psychotherapy practice needs one Type 1 individual provider NPI and at least one Type 2 organization NPI. To determine whether a registration already exists, users can do a search of the NPI Registry (https://npiregistry.cms.hhs.gov/search). Registrants who need help determining which NPI(s) to apply for can go to the NPI support page (https://med. noridianmedicare.com/web/jeb/enrollment/ npi) on the Noridian Healthcare Solutions, Inc., website (https://med.noridianmedicare. com/web/jeb/enrollment/npi) to obtain more information and access tutorials. Information about NPIs is also available on the Medicare FAQs page within CAMFT’s Medicare Corner.

Medicare Trainings

Although CMS has indicated that it will not offer any trainings or tutorials on how to enroll as a provider until the Medicare PFS final rule is published in November, you can find recordings and slides from the Medicare Mental Health Workforce Coalition’s four-part webinar series on Medicare within CAMFT’s Medicare Corner www.camft.org/medicare). As a member benefit, CAMFT is also scheduled to begin offering a six-part webinar series on Medicare in late September. Please visit the Medicare Corner of CAMFT’s website for more information about the series and how to register.

CMS and Noridian Healthcare Solutions, Inc., the MAC for California Medicare FFS providers, also offer free Medicare trainings. These are featured within the “Enroll in Medicare” portion of Noridian’s website (https://med.noridianmedicare.com/web/jeb/ enrollment/enroll) as well as its “Enrollment on Demand (EoD) Tutorials for Part B Specialties” page (https://med.noridianmedicare.com/web/ jeb/education/tutorials#enroll). Noridian also has a more general “Provider Enrollment” page (https://med.noridianmedicare.com/web/jeb/ enrollment) with additional information about the provider enrollment process.

For a general overview of the Medicare system,CMS offers a Medicare Learning Network web-based training course (https://www.cms. gov/Outreach-and-Education/MLN/WBT/ MLN9329634-WOM/WOM/index.html) titled “World of Medicare.”

Relevant Resources

• CMS’s Medicare Learning Network Booklet NPI: What You Need to Know. (https://www. cms.gov/outreach-and-education/medicare- learning-network-mln/mlnproducts/ downloads/npi-what-you-need-to-know.pdf)
• CMS’s Medicare Learning Network Education Tool on Medicare Provider Enrollment. (https://www.cms.gov/ Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/ EnrollmentResources/provider-resources/ provider-enrolment/Med-Prov-Enroll- MLN9658742.html)

Conclusion

CAMFT and the Medicare Mental Health Workforce Coalition continue to advocate for the full inclusion of MFTs and MHCs in the Medicare system. In addition to working closely with coalition partners, CAMFT is also part of a CMS stakeholder workgroup. Through that connection, CAMFT continues to offer CMS information about and insights into the education, training, and experience of California MFTs and MHCs. For more Medicare news and information, please visit the Medicare Corner of CAMFT’s website.

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Sara Jasper, JD, CAE, is a staff attorney for CAMFT. Sara is available to answer member calls regarding legal, ethical, and licensure issues.

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Endnotes

¹The term “fee-for-service” or “FFS” is a system of health insurance payment in which a doctor or other health care provider is paid a fee for each particular service rendered.
² As part of the CY 2024 Medicare PFS, CMS requested comment from states whose licensure requirements do not align with this requirement. CAMFT and the coalition it belongs to have asked CMS what kind of documentation will be required as proof of having performed at least two years or 3,000 hours of post-degree clinically supervised experience. Given the difficulty licensees could have obtaining documentation that states they’ve met the requirement, CAMFT requested that providers be allowed to attest to having met the eligibility requirements as part of CMS’s provider application process.
³Integrating behavioral health care into primary care is part of CMS’s strategy to improve outcomes for Americans with mental or behavioral health conditions.

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This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.