The behavioral health needs of older adults—those ages 65 and older—often go untreated and underdiagnosed. Despite growing behavioral health needs among this population, Medicare is not acting at its fullest capacity to make behavioral health services more accessible. Marriage and family therapists (MFTs) and mental health counselors (MHCs) are qualified behavioral health providers that are not currently covered by Medicare. Below, we highlight the importance of MFTs and MHCs becoming Medicare-eligible providers, how they can address gaps in the behavioral health needs of older adults, and the current legislation under consideration that can make this possible.
Behavioral Health Needs Of Older Adults
In 2019, one in every seven Americans was older than the age of 65, with a total of approximately 54 million older adults. This population is rapidly growing and is expected to reach more than 94 million by 2060. Older adults have been disproportionately affected by the COVID-19 pandemic, experiencing higher mortality rates than other age groups, disruptions in health care services, difficulties using new technologies, and increased social isolation. Preliminary literature suggests that older adults have reported an increase in depression and anxiety during the pandemic, although older adults may also be more resilient than younger age groups to behavioral health disorders. It is important to continue exploring the long-term effects of the pandemic on the behavioral health needs of older adults.
Discussions surrounding behavioral health concerns are often focused on adolescents and young adults rather than older adults. Yet, older adults die from suicide at a much higher rate and are more vulnerable to the effects of substance use disorders than young adults and adolescents. A 2012 report from the Institute of Medicine estimated that nearly one in five older adults (5.6 to 8.0 million) have at least one diagnosed behavioral health disorder or other condition. Furthermore, the symptoms of behavioral health disorders for older adults are often misattributed to the aging process and are consequently not properly identified.
The behavioral health needs of older adults often go untreated, with the majority of older adults not using any behavioral health services. With a large portion of behavioral health services being delivered via telehealth during the pandemic, technological and insurance barriers could further alienate a group in need of services. There is a persistent gap in the literature focusing on the behavioral health needs of older adults, how these needs might go underreported and underdiagnosed, how to best improve access to care, and how behavioral health care impacts quality of life for older adults.
Role Of Medicare
In 2019, more than 61 million individuals were enrolled in a Medicare plan, which is about 19 percent of the US population. More than 86 percent of Medicare beneficiaries were 65 years of age or older, approximately 54 percent were females, and 73 percent identified as non-Hispanic White. Medicare enrollment numbers have been steadily increasing as baby boomers reach age 65. Consequently, the aging of the US puts a higher burden on the Medicare system and increases the cost of care. This increased demand on the Medicare system creates a heightened need for the delivery of cost-effective, quality health care services.
Medicare benefits are broken down into four plans:
- Medicare Part A covers inpatient hospital stays, skilled nursing facility stays, hospice care, and some home health visits.
- Medicare Part B covers outpatient and preventive services.
- Medicare Part C, or Medicare Advantage, is a private plan that members can enroll in to receive the benefits of Medicare Part A, B, C, and D.
- Medicare Part D is a voluntary outpatient prescription drug plan through private plans contracted with Medicare.
Most outpatient behavioral health services are covered under Medicare Part B. However, Medicare Part B will only cover these behavioral health services if they are provided by one of the following health care providers:
- Clinical psychologists
- Clinical social workers
- Clinical nurse specialists
- Nurse practitioners
- Physician assistants
This list excludes MHCs and MFTs as Medicare-eligible providers, even though these providers are qualified to treat mental illnesses. Medicare has the opportunity to better serve older adults by making MFTs and MHCs Medicare-covered providers.
Why Marriage And Family Therapists And Mental Health Counselors Must Become Medicare Eligible
MFTs and MHCs are licensed providers in all 50 states and Washington, DC. Including these well-qualified providers in Medicare would increase the pool of qualified providers that beneficiaries can see. The education, training, and practice rights MFTs and MHCs achieve are equivalent to or greater than existing covered Medicare providers: MFTs and MHCs must obtain a Master’s or Doctoral degree in a mental health discipline; complete two years of post-graduate, supervised clinical experience; and pass a clinical exam. Current Medicare policy interferes with beneficiaries’ ability to access behavioral health services by compounding existing barriers to care.
The shortage of qualified professionals such as psychiatrists in combination with geographic limitations only exacerbates the mental health crisis among older adults. Furthermore, MFTs and MHCs are prevalent in rural and underserved areas where access to care may be limited. Granting Medicare eligibility to MFTs and MHCs would increase the geographic availability of care for older adults.
The addition of MFTs and MHCs to Medicare could result in long-term financial savings. Research indicates that care delivered by clinical-level professionals, such as MFTs and MHCs, may be more time efficient and cost-effective than inpatient care for treating some behavioral health conditions, such as mood disorders and substance use disorders. Effective treatment of behavioral health disorders can mitigate the individual and societal costs associated with medical care: An estimated $52 billion could be saved annually through greater integration of medical and mental health care. Older adults with behavioral health conditions experience a higher likelihood of costly, poor health outcomes, and increased hospitalization and emergency department visits. The ramifications of unmet behavioral health needs have additional widespread consequences beyond the cost of care, including increased morbidity, mortality, and reduced quality of life. Adding MFTs and MHCs to Medicare would increase the number of providers available to address behavioral health needs.
Granting MFTs and MHCs Medicare eligibility would not change these providers’ scope of practice. Federal law dictates that only certain types of providers and services are accepted by Medicare coverage if they are reasonable and necessary for the diagnosis or treatment of illness or injury. Because MFTs are not recognized under Medicare, only the clients who can afford to pay out of pocket for care can obtain services from these providers, thus limiting access for many older aged communities. Medicare coverage would offer a correction of the inequity that restricts beneficiaries’ access to qualified MFTs, rather than expanding the scope of Medicare-covered behavioral health services or expanding the MFT scope of practice. Making MFTs Medicare-eligible providers will maintain the quality of available Medicare-covered behavioral health services, increase access to these services, and lower the cost of care.
Attempts To Expand Access To Mental Health Providers For Medicare Beneficiaries
Medicare was established in 1965 under the Social Security Act to provide health care to older Americans. This statute must be amended to add MFTs and MHCs as Medicare-eligible providers.
Efforts to add MFTs and MHCs as Medicare-eligible providers first started in the 1980s. Legislation to include MFTs as Medicare providers has been introduced in every Congress since the introduction of H.R. 2945, the Seniors Mental Health Access Improvement Act of 1999, during the 106th Congress. Since 1999, legislation to add MFTs and MHCs as Medicare providers has passed the Senate twice (2003 and 2005) and the House twice (2007 and 2009). This legislation has not been enacted into law yet mainly due to the dearth of significant mental health legislation moving through Congress, as well as some concerns about the increased cost of including these mental health professionals in the Medicare system.
In recent years, support for legislation to add MFTs and MHCs as Medicare-eligible providers, now known as the Mental Health Access Improvement Act, has increased among members of Congress. During the 116th Congress, the Mental Health Access Improvement Act of 2019, introduced in the House of Representatives by Representatives Mike Thompson (D-CA) and John Katko (R-NY) as H.R. 945 and in the Senate by Senators John Barrasso (R-WY) and Debbie Stabenow (D-MI) as S. 286, achieved a record number of cosponsors for this legislation as compared to prior years. At the end of the 116th Congress, H.R. 945 had 123 cosponsors and S. 286 had a total of 31 cosponsors.
In September 2020, the House Energy and Commerce Committee voted to pass and move to the full House of Representatives H.R. 945. This was the first committee vote on legislation to add MFTs and MHCs as Medicare-eligible providers since 2009, and the first time that a congressional committee has passed this legislation as a standalone item.
In addition to greater support by Congress, several policy makers and other parties have recommended the inclusion of MFTs and MHCs as Medicare-eligible providers in recent years, including the Interdepartmental Serious Mental Illness Coordinating Committee and the Bipartisan Policy Center task force.
Implementation of policy changes that will resolve the Medicare mental health service coverage gap will require more advocacy efforts from MHCs and MFTs themselves. Encouraging these professions to become educated on the consequences of the coverage gap, and to advocate for Medicare’s inclusion in the federal parity law to ensure mental health coverage, could garner greater action from policy makers.
Momentum continues for legislation to add both MHCs and MFTs as Medicare-eligible providers. The Mental Health Access Improvement Act of 2021 was introduced as H.R. 432 by Representatives Mike Thompson (D-CA) and John Katko (R-NY) and as S. 828 by Senators John Barrasso (R-WY) and Debbie Stabenow (D-MI). As of July 12, 2022, H.R. 432 has 87 cosponsors and S. 828 has 30 cosponsors.
The Mental Health Access Improvement Act (S. 828/H.R. 432) would add licensed MFTs and MHCs as providers of covered mental health services under Medicare Part B. This legislation would allow licensed MFTs and MHCs to receive payments from Medicare for services provided to Medicare beneficiaries. In addition, this legislation allows rural health clinics and federally qualified health centers to receive reimbursement from Medicare for covered mental health services provided by MFTs and MHCs. The Mental Health Access Improvement Act does not add new services that Medicare must cover or expand the scopes of practice of MFTs or MHCs.
Congress has expressed current interest in addressing the ongoing behavioral health crisis, which has been exacerbated by the COVID-19 pandemic. In September 2021, the Senate Finance Committee, the committee with jurisdiction over Medicare, Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act Marketplace plans, released a request for information asking stakeholders for information on proposals that will improve access to health care services for Americans with behavioral health disorders. This letter asked many questions, including any ideas to strengthen the behavioral health workforce and improve provider participation in Medicare. In December, the Finance Committee reported that it received 321 responses from organizations and 229 responses from individuals. Many organizations that responded to this request for information recommended that Congress include MFTs and MHCs as Medicare providers, including the American Association of Retired Persons (AARP), the American Foundation for Suicide Prevention, Cigna, the Michael J. Fox Foundation for Parkinson’s Research, the National Alliance on Mental Illness, the National Association of Community Health Centers, and the National Rural Health Association. In March, the Finance Committee released a report summarizing the major findings from these responses and outlining a case for the federal government to address this mental health crisis. This report stated that MFTs and MHCs make up 61 percent of the total rural mental health workforce yet are not recognized as Medicare-eligible providers. The Finance Committee is expected to release a comprehensive behavioral health legislative package for consideration by Congress by summer 2022.
The executive branch also supports the inclusion of MFTs and MHCs as Medicare providers. President Joe Biden’s budget for Fiscal Year (FY) 2023 includes several legislative proposals, including the recommendation that Congress modernize Medicare’s mental health services by adding MFTs and MHCs as Medicare-eligible providers. This proposal would allow MHCs and MFTs to receive payment from Medicare for providing covered mental health services to Medicare beneficiaries. Support for MFTs as Medicare providers in President Biden’s FY 2023 budget makes it more likely that Congress will consider this request.
Older adults’ behavioral health needs often go undertreated. Medicare has the opportunity to address barriers to care by making licensed, well-qualified MFTs and MHCs eligible providers. The inclusion of these providers as Medicare-eligible providers will not change the scope of coverage but will increase access to care and lower the long-term cost of care. There is a shortage of Medicare-eligible mental health providers who can treat Medicare beneficiaries. MHCs and MFTs make up an estimated 40 percent of the licensed mental health workforce and are recognized as eligible providers by almost all other Medicaid plans and other public and private health plans, except for Medicare. Congress needs to pass the Mental Health Access Improvement Act of 2021 (S. 828/H.R. 432) to allow Medicare beneficiaries to receive covered services from MFTs and MHCs.
This article was supported by the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services (HHS) as part of an award totaling approximately $900,000. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the US government. For more information, please visit HRSA.gov. Roger Smith, JD, is director of government and corporate affairs and general counsel with the American Association for Marriage and Family Therapy (AAMFT). Smith is employed by AAMFT, and he oversees AAMFT’s advocacy efforts, including AAMFT’s advocacy for the inclusion of marriage and family therapists (MFTs) as Medicare providers. AAMFT advocates to Congress for the passage of the Mental Health Access Improvement Act of 2021 (H.R. 432 and S. 828). In past Congresses, AAMFT advocated for the passage of prior versions of the Mental Health Access Improvement Act and similar legislation, including the three prior versions of this legislation referenced in this article. AAMFT also has provided information to public and private entities in support of adding MFTs as Medicare providers, including information to the Bipartisan Policy Center’s Rural Health Task Force prior to the release of the task force report referenced in the article. AAMFT partners with several other behavioral health and related associations to advocate for the inclusion of MFTs and mental health counselors as Medicare providers. AAMFT works with the University of Michigan Behavioral Health Workforce Research Center (BHWRC). AAMFT participates in a BHWRC partner consortium with several other behavioral health organizations. AAMFT has participated in some BHWRC projects. Smith has served as the AAMFT liaison with the BHWRC since the creation of the BHWRC’s partner consortium. He has worked with three other authors on some BHWRC projects and related projects over the past seven years. Neither AAMFT nor Smith have received any financial compensation from the BHWRC, Health Affairs, nor any other entity for researching and writing this article. Participating in writing this article is within the normal duties of his employment at AAMFT. AAMFT does receive a small annual stipend from the BHWRC for participating in its partner consortium, but this stipend is not related to this article and is not any sort of compensation for participating in reaching and writing this article. On behalf of AAMFT, Smith has been an online subscriber to Health Affairs.