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The Legal Department articles are not intended to serve as legal advice and are 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 the article.
This article offers an overview on how LMFTs and Registered Interns can provide services to Medi-Cal beneficiaries, the situations in which LMFTs can
provide services to Medicare beneficiaries in California, and CAMFT’s recent advocacy efforts with respect to Medicare.
Ann Tran-Lien, JD
Managing Director of Legal Affairs
Given the similarities in the spelling of two large government programs, Medicare and Medi-Cal, there has been some confusion by providers. The programs, however, mainly serve different populations and have different rules about who is an eligible provider. This article offers an overview on how LMFTs and Registered Interns can provide services to Medi-Cal beneficiaries, the situations in which LMFTs can provide services to Medicare beneficiaries in California, and CAMFT’s recent advocacy efforts with respect to Medicare.
Medi-Cal is California’s Medicaid health care program. Medi-Cal reimburses for a variety of medical and behavioral health services for children and adults with limited income and resources. Currently, approximately 13.5 million Californians are covered by Medi- Cal. In January 2014, the Department of Health Care Services (DHCS) implemented significant changes to the Medi-Cal system and the delivery of behavioral health services in California. Currently, the Medi-Cal system has three pathways to services for eligible Medi-Cal beneficiaries who have behavioral healthcare needs. These pathways include: 1) County Mental Health Plans (MHPs) who are responsible for providing services to Medi-Cal enrollees with severe behavioral health needs; 2) Medi-Cal Managed Care Plans (MCPs) who are responsible for providing services to beneficiaries with mild to moderate behavioral health issues, and 3) the State’s Fee-For-Service who provide services to beneficiaries with mild to moderate distress or mental, emotional or behavioral functioning.
LMFTs are now recognized as eligible providers through all three pathways. Within the county system, LMFTs and Registered MFT Interns provide services to Medi-Cal clients who seek services through the County Mental Health Plans as a result of either an employment or volunteer relationship with the MHPs. Medi-Cal Managed Care Plans throughout the state contract with LMFTs to provide services to their enrolled Medi-Cal clients.
On May 2, 2014, as a result of CAMFT’s advocacy efforts, LMFTs and Registered Interns were added to the list of eligible Medi-Cal providers per State Plan Amendment, SPA 14-012 (approved by the Centers for Medicare and Medicaid Services). This means LMFTs may enroll as Fee-For- Service providers directly with the State’s Medi-Cal system.
As a result of the SPA, Registered Interns, who are being supervised by a qualified supervisor, are eligible to treat Medi-Cal clients in all three pathways. However, the SPA allows the County Mental Health Plans and Medi-Cal Managed Care Plans discretion as to when and how to utilize and reimburse for Registered Intern services. Thus, CAMFT strongly recommends for supervisors and employers to check with their Plan Provider Relations/Network to determine the eligibility and reimbursement policies for Interns as rendering providers prior to allowing their Interns to render services under the contract.
For further reading on how LMFTs and Registered Interns fit into the California Medi-Cal system as providers of mental/ behavioral healthcare, see “Pathways to Becoming a Medi-Cal Provider” by Sara Jasper, CAMFT Staff Attorney (Jan/Feb 2015, The Therapist).
Due to the budget resolution that was passed by Congress on January 13, 2017, and the federal discussions about the replacement of the Affordable Care Act (ACA), CAMFT has received many questions pertaining to the future of the Medi-Cal program in California and how access to mental/behavioral healthcare may be affected. Members with questions or concerns are free to contact CAMFT for further discussion. Members are also encouraged to contact elected officials and communicate any concerns about any changes that impact Medi-Cal patients’ access to—and coverage of—mental health care.
Medicare is a federally-funded insurance program for eligible participants 65 or over. Currently, Medicare does not recognize LMFTs as eligible providers of mental/behavioral healthcare to Medicare beneficiaries. Nevertheless, there are two ways that LMFTs may bill for services provided to Medicare beneficiaries. One way is through an insurance plan that is “supplemental” to the Medicare plan. For example, a treating LMFT may provide services to a patient who is a Medicare beneficiary and is also covered by a regular insurance plan (secondary to Medicare). The treating LMFT can bill the secondary insurance plan directly for the services rendered. As of 2012, Medicare no longer offers a Medicare explanation of benefits (EOMB) denying the services rendered by a treating LMFT. Insurance plans are also aware of this and should have a system in place that does not require LMFT providers submit the EOMB along with the claim. However, patients who have a Medicare Supplemental policy with an insurance plan can only see providers that are eligible as Medicare providers. Thus, it is recommended LMFT treating providers check with the secondary payer for Medicare patients to see if the policy is a “Medicare supplemental” policy or a regular policy.
Another way LMFTs may treat Medicare beneficiaries and obtain reimbursement is through “incident-to” billing. In some cases, however, Medicare will cover services by LMFTs if those services, although incidental, are considered an integral part of the services performed by physicians when treating their patients. In other words, a physician may submit claims for services rendered by an LMFT if those services are essential and fundamentally related to the services provided by the physician to the patient. These claims are reimbursed at 85 percent of the physician fee schedule. To bill “incident-to,” the physician must see new patients for an initial visit so that a physician-patient relationship can be established. Once the initial visit has occurred and the physician-patient relationship has been established, LMFT providers may render services to the patient during and after the initial visit, as long as the physician provides ongoing services to the patient that are of a frequency that demonstrate the physician’s active involvement in the patient’s care. There are other requirements that need to be met in order for physicians to bill for “incident-to” services by LMFTs. Those requirements are:
For further reading on “incident-to billing,” see “What Therapists Should Know about Incident-To and Second Party Payer Medicare Reimbursements” by Sara Jasper, CAMFT Staff Attorney (Mar/Apr 2012 The Therapist).
CAMFT Advocacy Efforts on Medicare
Adding LMFTs as Medicare providers has been the focus of CAMFT’s advocacy efforts in Washington, DC for many years. In the 114th Congress, H.R. 2759 was introduced by Rep. Gibson (R-NY) and Rep. Thompson (D-CA -5). S. 1830 was introduced with Sen. Barrasso (R-WY) and Sen. Stabenow (D-MI) as lead co-sponsors. These bills would have provided for LMFTs to be eligible providers under the Medicare program. In August 2015, CAMFT initiated a grassroots campaign to encourage CAMFT members contact their Representatives to co-sponsor this legislation. During the last Congress, CAMFT members sent more than 2,500 emails and garnered 18 Californian co-sponsors for H.R. 2759. This is double the amount of California co-sponsors from the previous Congress! CAMFT is hopeful that the advocacy and grassroots efforts from 2015 and 2016 will serve as a basis for our efforts to have a Medicare bill introduced and attached to 2017 legislation on mental health. Starting in January 2017, CAMFT jointed with the American Association for Marriage and Family Therapy (AAMFT) to combine federal advocacy efforts in order to advance legislation that would allow MFTs to treat Medicare enrollees. According to Jill Epstein, CAMFT’s Executive Director, “With so many powerful lobbying interests on Capitol Hill, it is critical that the MFT community works closely together in order to lobby for reimbursement and recognition, as well as to fight off threats to the profession. This MFT federal advocacy initiative combines forces and leverages the resources of both organizations to better amplify the MFT voice in Washington.”
To access information about how to bill for “incident to” services, see the Centers for Medicare and Medicaid Services’ publication at https://www. cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/SE0441. pdf (rev. 8/2016).
For more information about CAMFT’s advocacy efforts with respect to Medicare, visit www.camft.org and click on “Advocacy.”
Ann Tran-Lien, JD, is a staff attorney and the Managing Director of Legal Affairs at CAMFT. Ann is available to answer member calls regarding legal, ethical, and licensure issues.
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.