Congressman Tim Ryan Demands Trump Administration Fix Medicare Reimbursement Issue for Mental Health Providers

The Honorable Seema Verma, MPH Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
200 Independence Avenue SW, Room 445-G
Washington, DC 20201

Dear Administrator Verma:

I write with an urgent request to fix a problem that mental health providers are having with Medicare reimbursement during this pandemic health emergency. This is particularly problematic during a time when, according to a recent survey by the Kaiser Family Foundation, nearly half of all Americans have said the pandemic has affected their mental health. In short, we are experiencing a nationwide psychological trauma, and I urge you to take immediate action to ensure Medicare beneficiaries are able to receive access to mental health services.

Recently, private providers of behavioral healthcare and counseling in my congressional district reached out to my office for assistance. These providers brought to my attention two separate Medicare rules which are creating a severe obstacle to the provision of telehealth services during this time of stay-at-home orders:

1) Under normal circumstances, “direct supervision” rules require that therapists have a qualified supervisor physically present in the same office building where the service is delivered. This is fine under normal circumstances, but oftentimes impossible now when therapists and supervisors are working from home and calling patients at their homes. At least one Medicare contract administrator (CGS Administrators) has stipulated that for providers to satisfy the “direct supervision” requirementwithin a telehealth context, both the therapist AND the qualified supervisor have to be “on the communication” together. In practice, this means a three-way Zoom/Skype/Facetime videocall with the therapist counseling the patient and a supervisor listening in. I have been told by providers that this rule interpretation is detrimental in three ways: A) Supervisors are not able to administer counseling to theirown caseload of patients if they are forced to join in another therapist’s Zoom call. B) Therapists must reduce their own provision of services in order to wait for one of the limited number of supervisors to become available to join a videocall. C) Patients are naturally averse to having a third party listening in on a conversation which would normally be had only between the patient and their usual therapist.

The providers I have spoken with employ independently licensed counselors (LPCC), which I understand constitute a large number of mental health therapists in Ohio. These are Master’s Degree therapists that normally, except for Medicare, do not require supervision. Telehealth requirements for

other 3rd party insurers and Medicaid have no restrictions to these counselors to prevent the provision of telehealth counseling. The Medicare rule requiring direct supervision is highly disruptive to needed mental health services at this time of heightened stress, especially for the vulnerable Medicare beneficiaries.

2. Medicare’s emergency telehealth rules during the COVID epidemic now provide various waivers to loosen the normal restrictions on telehealth services. However, the rules still require (with some limited exceptions) that all telehealth be conducted via audio AND video communication. However, many older Medicare beneficiaries are not competent in the use of software such as Zoom/Skype/Facetime. Indeed, many only possess landline phones. With stay-at-home orders in effect, this population could be unable to receive any mental health counseling. Furthermore, traditional 3rd party insurers in Ohio, as well as Medicaid, permit telephone calls for the provision of therapy services. It would seem unreasonable to deny Medicare patients the same flexibility granted to Medicaid patients

While I understand there exist some Medicare billing codes for short-duration check-in visits (30 minutes or less), these codes do not account for audio-only therapy sessions that are just as time and resource intensive as typical in-person session or even audio-visual telehealth sessions through an app.

As a consequence of the abovementioned challenges, I urge you to allow, as a temporary alternative, that supervisors be immediately accessible by telephone, rather than required to be “on the communication”with the patient. I also urge you to temporarily allow audio-only counseling sessions that have billing parity with audio/visual telehealth sessions and in-person sessions. These allowances—which should be retroactive to the start of the public health emergency, can expire once the emergency is declared

over. These rules, if not changed soon, will unnecessarily and substantially reduce Medicare patients’access to medically necessary counseling.

Thank you for your work during this difficult time, and please do not hesitate to reach out to me or my staff.

Sincerely,