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Mental Health Coverage

What you Need to Know

This article explains guidelines for payment of mental health services including qualification requirements for mental health providers (physicians, non-physician practitioners and suppliers), and incident to services. 

Mental Health Services That are Covered

Mental health services that may be covered under the Medicare program include: 

  • Alcohol misuse screening and counseling
  • Alcohol treatment
  • Behavioral health integration
  • Caregiver training
  • CHI services
  • Digital mental health treatment (DMHT)
  • Electroconvulsive therapy (ECT) 
  • Hypnotherapy 
  • Medications for substance use disorders (SUDs)
  • Narcosynthesis
  • PIN services
  • PIN-peer support services
  • Psychiatric evaluation
  • Psychoanalysis
  • Psychological and neuropsychological tests 
  • Psychotherapy:
    • Family psychotherapy (with or without the patient present and the primary purpose is treatment of the individual’s condition); 
    • Individual or group psychotherapy 
    • Interactive psychotherapy
  • Psychotherapy for crisis
  • Safety planning intervention (SPI)
  • Screening, brief intervention, and referral to treatment (SBIRT)

Mental Health Services That are not Covered

Mental health services that are not covered under the Medicare program are: 

  • 24-hour in-home care
  • Adult day health program
  • Biofeedback training
  • Environmental intervention 
  • Experimental treatments including hemodialysis for treating schizophrenia
  • Massage therapy
  • Geriatric day care programs 
  • Pastoral counseling 
  • Preparing reports 
  • Transportation to appointments 

Eligible Professionals (EP) 

Medicare recognizes the following providers who are eligible under Part B to furnish diagnostic and/or therapeutic treatment for mental, psychoneurotic, and personality disorders as well as Medicare SBIRT (screening, brief intervention and referral to treatment) services, to the extent permitted under State law: 

  • Physicians (MDs and DOs), particularly psychiatrists
  • Clinical psychologists (CPs) 
  • Clinical social workers (CSWs)
  • Clinical nurse specialists (CNSs)
  • Nurse practitioners (NPs) 
  • Physician assistants (PAs) 
  • Certified nurse-midwives (CNMs)
  • Independently Practicing Psychologists (IPPs)
  • Certified registered nurse anesthetists (CRNAs) (supervision of diagnostic psychological and neuropsychological tests)
  • Marriage and family therapists (MFTs)
  • Mental health counselors (MHCs), including certified alcohol and drug counselors

Required Qualifications

EP Required Qualifications Coverage Payment
Physicians
  • Is a MD or a DO.
  • Is legally authorized to practice medicine in the state where the services are provided.
  • Is acting within the scope of his or her license.
  • Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary.
  • He or she may perform the general supervision assigned to diagnostic psychological and neuropsychological tests
  • Services and supplies may be furnished incident to his or her professional services.
  • Payment for assigned services is made at 100% of the Medicare Physician Fee Schedule.
CP
  • Has a doctoral degree in psychology.
  • Is licensed or certified at the independent level in the state where practicing and directly provide diagnostic, assessment, preventive, and therapeutic patient services.
  • Services are not otherwise precluded due to a statutory exclusion, and the services must be reasonable and necessary.
  • He or she may perform the general supervision assigned to diagnostic psychological and neuropsychological tests.
  • Services and supplies may be furnished incident to his or her professional services. 
  • Unless the patient's primary care or attending physician referred the patient, inform the patient that the CP would like to consult their physician. 
  • Document in the medical record if the patient consented to or declined the consultation. 
  • If the patient consents to the consultation, document in the medical record, either the consultation date or the unsuccessful date tried to consult their physician and the method used. 
  • Services are paid at 100% of the amount a physician is paid under the Medicare Physician Fee Schedule only if assignment is accepted.
CSW
  • Has a master's or doctoral degree in social work.
  • Has performed at least 2 years of supervised clinical social work.
  • Is licensed or certified as a CSW by the State in which the services are performed.
  • If the individual practices in a State that does not provide for licensure or certification, has completed at least 2 years or 3,000 hours of post master's degree supervised clinical social work practice under the supervision of a master's level social worker in an appropriate setting (for example, a hospital, skilled nursing or clinic.)
  • Reasonable and necessary services performed to diagnose and treat a mental illness if they aren't precluded by law and if legally authorized to practice clinical social work in the state where services are provided. 
  • CSW services furnished to hospital outpatient are covered for CSW services under the CSW benefit category when hospitals bill under the CSWs NPI. 
  • Services not covered under the CSW benefit category are: 
  • Hospital inpatient services.
  • Services to patients under a Partial Hospitalization Program (PHP) or an Intensive Outpatient Program (IOP) performed at a hospital outpatient department or Community Mental Health Center (CMHC).
  • Services to SNF inpatients and patients in Medicare-participating ESRD facilities if the services are under the respective provider's participation requirement.
  • Incident to services that CSWs furnish for physicians, CPs, CNSs, NPs, PAs, or CNMs may be covered
  • Incident to services provided for CSW personal professional services are not covered. 
  • Assignment must be accepted.
  • Services are paid at 75% of the amount a CP is paid under the Medicare Physician Fee Schedule (MPFS).
  • For Method II critical access hospitals (CAHs) 80% of the lesser of the actual charge for the service or 75% of the CPs MPFS payment if reassigned the billing rights to the CAH. 
CNS
  • Is a registered nurse (RN) currently licensed to practice in the State where the individual practices and is authorized to furnish the services of a CNS in accordance with State law.
  • Has a Doctor of Nursing Practice or master's degree in a defined clinical area of nursing from an accredited educational institution.
  • Is certified as a CNS by a recognized national certifying body with  established CNS standards.
  • Reasonable and necessary services  if they aren't precluded by law and if legally authorized to practice medicine  in the state where services are provided while working in collaboration with a physician. 
  • Services are the type considered physicians’ services if furnished by a MD or a DO.
  • Assistant-at-surgery services furnished by a CNS are covered.
  • He or she may personally perform diagnostic psychological and neuropsychological tests in collaboration with a physician as required under the CNS benefit and to the extent permitted under State law.
  • He or she many supervise the performance of diagnostic tests according to state law and scope of practice.
  • Incident to services may be covered.
  • Assignment must be accepted. 
  • Professional services are paid a 80% of the lesser of the actual charge or  85% of the amount a physician is paid under the Medicare Physician Fee Schedule (MPFS).
  • Payment is made directly to the CNS for assistant-at-surgery services at 85% of 16% of the amount a physician is paid under the MPFS for assistant-at-surgery services.
NP
  • Is a registered nurse (RN) and authorized according to state law, by the state in which the services are furnished 
  • Is a registered professional nurse who's authorized by the state where services are provided as an NP by December 31, 2000.
  • Obtained Medicare billing privileges as a NP for the first time on or after January 1, 2003: 
  • Is certified as a NP by a recognized national certifying body that has established standards for NPs.
  • Has a master's degree in nursing or a doctor of nursing practice doctoral degree.
  • Obtained Medicare billing privileges as a NP for the first time before January 1, 2003, and meets the certification requirements 
  • Obtained Medicare billing privileges as a NP for the first time before January 1, 2001.
  • Reasonable and necessary services not precluded by law and legally authorized to practice medicine in the state where services are provided while working in collaboration with a physician. 
  • Services are the type considered physicians’ services if furnished by a MD or a DO.
  • Assistant-at-surgery services furnished by a NP are covered.
  • He or she may personally perform diagnostic psychological and neuropsychological tests in collaboration with a physician as required under the NP benefit and to the extent authorized by state law.
  • Incident to services and supplies may be covered.
  • Payment is made only on an assignment basis.
  • Services are paid at 80% of the lesser of the actual charge or 85% of the amount a physician is paid under the MPFS. 
  • Payment is made directly to the NP for assistant-at-surgery services at 85% of 16% of the amount a physician is paid under the MPFS for assistant-at-surgery services.
PA
  • Is licensed by the State to practice 
  • Have graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or it's predecessor agencies, the Commission of Accreditation of Allied Health Education programs and the Committee on Allied Health Education and Accreditation.) 
  • Has passed the national certification examination administered by the National Commission on Certification of Physician Assistants.
  • Reasonable and necessary services not precluded by law if met all PA qualifications and are legally authorized to practice medicine in the state where services are provided. 
  • Services are performed under the general supervision of a MD or a DO.
  • Services are the type considered physicians’ services if furnished by a MD or a DO.
  • Assistant-at-surgery services furnished by a PA are covered.
  • He or she may personally perform diagnostic psychological and neuropsychological tests under physician supervision as required under the PA benefit category and as authorized by state law. 
  • He or she may supervise the performance of diagnostic tests according to state law and scope of practice. 
  • Incident to services may be covered.
  • Must accept assignment. 
  • Bill under NPI.
  • Reimbursement for services directly as for NPs and CNSs services
  • May reassign service payment rights and incorporate as a group of only practitioners in your specialty and bill Medicare like NPs and CNSs. 
  • Payment may be made for: 
  • Professional services, including services and supplies provided incident to.
  • Professional services provided in all rural and non-rural settings areas. 
  • Services at 80% of the lesser of the actual charge or 85% of the amount a physician is paid under the MPFS.
  • Assistant-at-surgery services at 85% of 16% of the amount a physician is paid under the MPFS.
  • Services provided incident to a PA outside a hospital at 85% of the amount a physician gets under the MPFS. 
  • Payment only if no facility or other provider charges or no payment was made for any other service amount provided. 
  • When billing for a hospital service (inpatient or outpatient) directly, the payment will be unbundled and paid directly to the PA. 
CNM
  • Is a registered nurse who is legally authorized to practice as a nurse-midwife in the state where services are performed.
  • Has successfully completed a nurse-midwives program of study and gotten clinical experience accredited by an accrediting body approved by the U.S. Department of Education.
  • Is certified as a nurse-midwife by the American College of Nurse-Midwives 
  • Reasonable and necessary services not precluded by law and legally authorized to practice medicine in the state where services are provided. 
  • Services are the type considered physicians services if furnished by a MD or a DO.
  • Services are performed without physician supervision and without association with a physician or other health care provider, unless otherwise required by State law.
  • He or she may personally perform diagnostic psychological and neuropsychological tests without physician supervision or oversight as authorized under the CNM benefit and to the extent authorized under State law.
  • Incident to services and supplies may be covered.
  • Assignment must be accepted.
  • Services are paid at 80% of the lesser of the actual charge or 100% of the amount a physician is paid under the MPFS.
  • Incident to services provided outside a hospital are paid at 100% of the amount a physician is paid under the MPFS. 
IPP
  • Is a psychologist who is not a CP. 
  • Meets one of the following criteria:
  • Practices independently of an institution, agency, or physician’s office and is licensed or certified to practice psychology in the state or jurisdiction where the services are performed.
  • Is a practicing psychologist who performs services in a jurisdiction that does not issue licenses.
  • Reasonable and necessary services not precluded by law.
  • Definition of practicing independently: 
  • Provides services on his or her own responsibility, free of the administrative and professional control of an employer (for example, a physician, an institution, or an agency).
  • Treats own patients. 
  • Can bill directly and collect an retain service fees. 
  • He or she can be classified as an IPP when he or she practices in an office that is located in an institution:
  • The office is confined to a separately identified part of the facility that he or she uses solely as an office and cannot be construed as extending throughout the entire institution.
  • He or she conducts a private practice (services are furnished to patients outside the institution as well as to institutional patients).
  • He or she may perform diagnostic psychological and neuropsychological tests when a physician or certain NPPs order such tests.
  • Diagnostic psychological and neuropsychological tests are not subject to assignment; however, the name and address of the physician or NPP who ordered the tests must be included on the claim form.
  • Payment is made to the IPP at 100% of the MPFS.
CRNA
  • Be licensed as a registered professional nurse by the state where services are performed.
  • Meet any licensure requirements the state imposes on non-physician anesthetists.
  • Have graduated from a nurse anesthesia educational program that meets Council on Accreditation of Nurse Anesthesia Education Programs (COA) standards or another accreditation organization the HHS secretary designates.
  • With 24 months of graduation, have passed a certification exam from the National Board of Certification & Recertification for Nurse Anesthetists or another certification organization the HHS secretary designates.
  • Reasonable and necessary services not precluded by law and legally authorized to practice medicine in the state where services are provided. 
  • Personally perform diagnostic psychological and neuropsychological tests under physician supervision as required under the CRNA benefit category and as authorized by state law.
  • May supervise the performance of diagnostic tests according to state law and scope of practice

 
  • Must accept assignment. 
  • Payment is made at 100% of the MPFS as determined by the level of required supervision
  • Payment may be made directly to the CRNA or to another person or entity (for example, hospital, CAH, physician, group practice, or ambulatory surgical center) with which there is employment or contractual arrangements.
MFT
  • Have a master's or doctoral degree that qualifies for licensure or certification as an MFT according to state law where services are provided.
  • Be licensed or certified as an MFT in the state where services are provided.
  • Have at least 2 years or 3,000 hours of post-master's degree clinical supervised experience in marriage and family therapy in an appropriate setting (for example, a hospital, SNF, or clinic)
  • He or she must be legally authorized to practice as an MFT in the state where services are provided.
  • Beginning January 1, 2024 may be enrolled in Medicare and bill Medicare independently
  • May cover ancillary MFT services when provided as auxiliary personnel incident to the personal profession services of a physician, CP, CNS, NP, PA, or CNM.
  • Services provided incident to personal MFT professional services are not covered.
  • MFT services can be provided through an acceptable telehealth mental health disorder service site.
  • Assignment must be accepted. 
  • Payment is 75% of the MPFS amount for CPs.
  • For Method II critical access hospitals (CAHs) 80% of the lesser of the actual charge for the service or 75% of the CPs MPFS payment if reassigned the billing rights to the CAH.
  • Payment is not allowed under the MFT benefit category for MFT services a hospital outpatient department or CMHC provides to patients under a PHP or an IOP. 
  • MFT services provided to SNF residents are excluded from consolidated billing: 
  • Include the SNFs Medicare provider number when billing for these Part B services.
MHC
  • Have a master's or doctoral degree that qualifies for licensure or certification as an MHC according to state law where services are provided. 
  • Be licensed or certified in the state where services are provided as 1 of these:
  • An MHC
  • A clinical professional counselor
  • An addiction, alcohol, or drug counselor
  • A professional counselor
  • Have at least 2 years or 3,000 hours of post-master's degree clinical supervised experience in mental health counseling.
  • Must be legally authorized to practice as an MHC in the state where services are provided.
  • Since January 1, 2024, be enrolled in Medicare and bill Medicare independently.
  • Cover ancillary MHC services when provided as auxiliary personnel incident to the personal professional services of a physician, CP, CNS, NP, PA, or CNM. 
  • Incident to services to the MHC personal professional services are not covered.
  • MHC services can be provided through an acceptable telehealth mental health disorder service site.
  • Addiction counselors or alcohol an drug counselors who meet the applicable MHC requirements can enroll in Medicare as MHCs. 
  • Must accept assignment. 
  • Payment is 75% of the MPFS amount of CPs. 
  • Payment is not allowed under the MHC benefit category for MHC services a hospital outpatient department or CMHC provides to patients under a PHP or an IOP. 
  • MHC services provided to SNF residents are excluded from consolidated billing: 
  • Include the SNFs Medicare provider number when billing for these Part B services.

Incident to Provision

Incident to a physician’s professional services means the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness. 

A physician, CP, CNS, NP, PA, or CNM may have outpatient psychiatric services and supplies furnished incident to his or her professional service. To be covered under the Incident to provision, the following requirements must be met: ™

  • The services and supplies must be an integral part of the patient’s normal course of treatment during which the physician or other listed NPP has personally performed an initial service and remains actively involved in the course of treatment. ™
  • The services and supplies are commonly furnished without charge (included in the physician’s or other listed NPP’s bill). ™
  • The services and supplies are an expense to the physician or other listed NPP.
  • The services and supplies are commonly furnished in the physician’s or other listed NPP’s office or clinic; and ™
  • The physician or other listed NPP provides direct supervision, which means he or she is present in the office suite and immediately available if needed.

Note: Under the MPFS, it is not payable for physicians or NPPs to provide incident to services in an institutional setting (hospital or SNF). 

Behavioral health services provided by auxiliary personnel are exempt from the direct supervision requirement for incident to services. Incident to behavioral health services can be provided under the general supervision of a physician or an NPP. Under general supervision, the physician or NPP may be contacted by phone, if necessary, as the physician’s or NPP’s presence isn’t required during the service.

Services and supplies furnished by CPs, CSWs, CNSs, NPs, PAs, CNMs, MHCs and MFTs may also be covered when furnished as an incident to the professional services of a physician or other specified NPP if they would have been covered when furnished incident to the services of a MD or a DO.

References