Funding for initiatives focused on improving mental health access within the Medicare program is part of the Biden administration's fiscal year 2023 budget plan. One of these initiatives would modernize the Medicare program by covering care provided by licensed mental health counselors and licensed marriage and family therapists, thus providing Medicare recipients access to the full range of mental health professionals.

(Editor's note: the Mental Health Improvement Act of 2021 resulted in expansion of Medicare coverage of mental health services.)

The case for modernizing mental health care for Medicare

Nationwide, most mental health services are provided by an array of allied graduate-level professionals including psychiatrists, psychologists, licensed clinical social workers, licensed mental health counselors (LMHCs), licensed marriage and family therapists (LMFTs), and psychiatric nurses. All insurance programs except Medicare provide access to these professionals as a means of maximizing access to mental health services.

However, existing Medicare provider policy, which was last updated in 1989,¹ presently restricts a significant number of these mental health professionals from working with Medicare beneficiaries, which includes older adults and younger people with disabilities. Currently, there are an estimated 225,000 LMHCs and LMFTs who have similar training and scope of practice to current Medicare-approved providers (i.e., psychiatrists, psychologists, clinical social workers, psychiatric nurses), but have historically been ineligible to offer services to Medicare beneficiaries. Nationwide, this amounts to approximately 40% of the behavioral health workforce being unavailable to Medicare beneficiaries. In rural areas, where Medicare-excluded providers such as LMHCs and LMFTs comprise a larger proportion of the mental health workforce, the lack of Medicare-eligible providers is even more problematic.²

As Medicare rolls have grown, number of mental health providers not increasing

Since 1989, the number of Medicare beneficiaries has nearly doubled,^3,4 but there has been no similar increase in the number of approved mental health providers. Simultaneously, many Medicare-eligible mental health providers opt out of providing services Medicare beneficiaries. Psychiatrists are more likely than any other type of physician to opt out of participation in the Medicare program, comprising 42% of all physicians who elect not to accept Medicare.⁵ Additionally, an estimated 40% of practicing psychologists do not accept Medicare,⁶ further limiting the pool of available providers for older adults and making it difficult for them to find the services necessary for meeting their mental health needs.

The combination of provider restrictions, growing number of beneficiaries, and reduced availability of eligible providers has resulted in a steady worsening of mental health access for older adults over the past 30 years.

Recent analyses suggest that older adults who reside in Health Resources & Services Administration-designated rural localities are even less likely to have access to Medicare-eligible providers,⁷ creating an undue burden in terms of out-of-pocket costs for services or transportation to a locale where they may be able to find a covered mental health provider. Inaccessibility of mental health services for racial and ethnic minorities^{8, 9} may also be due to a limited provider pool, particularly given the challenges faced by racially diverse older adults in finding culturally competent and accessible care.¹⁰ Limitations to the provider pool caused by present Medicare policy may make it challenging or even impossible to find a provider who is available to address their needs.

Consequences of outdated Medicare policy

This Medicare policy-related barrier directly limits older adults’ ability to access their Medicare mental health benefits. This creates a challenge when Medicare beneficiaries try to use mental health services, as there is evidence that they encounter long waitlists, a lack of eligible providers in their communities, or the need to start over with a new provider during the course of treatment once Medicare eligibility commences.¹¹ This may lead to disruptions in mental health treatment,^{12, 11} increased hospitalizations due to lack of preventive mental health care,¹³ and poorer physical health outcomes.¹⁴

Recent studies with mental health providers have revealed troubling information about the ways current Medicare policy disrupts or prevents mental health care for older adults. For example, in a national survey of practicing counselors, 70% of respondents had turned away potential clients due to Medicare policy, referred existing clients who became Medicare-eligible during the course of treatment, or adjusted their fee structure to accommodate these individuals.¹¹ These findings broadly suggest that Medicare beneficiaries are being denied or experience disruptions in accessing mental health care as a result of the current policy.

Even older adults who hold supplemental insurance policies report being unable to use these benefits because they are unable to attain a denial-of-service letter from the Centers for Medicare and Medicaid Services (CMS), which regulates the Medicare program.¹² Researchers also found that referrals to a new provider were more common for older adults in rural areas, likely leading to disruptions in care.⁷ Therefore, current Medicare policy may be particularly problematic for older adults living in rural communities,¹⁵ increasing existing inequalities in health outcomes for this population.

Limited mental health care access: An alarming problem

The result of the concerns outlined above is that mental health care access is limited for the millions of older adults who rely upon Medicare.

Limited access to services is especially alarming in the context of the COVID-19 pandemic, given both the present mental health concerns for older adults¹⁶ and the expected long-term impact to older adults’ mental health.¹⁷ CMS has responded to the pressing needs of the pandemic, including by temporarily expanding its coverage of telehealth services, including those rendered by covered mental health providers.^18,19 This reflects willingness to respond to emerging needs of Medicare beneficiaries, such as the limitation presented by current Medicare policy. Furthermore, Congress passed a bipartisan COVID-19 relief bill in December 2020—the Consolidated Appropriations Act of 2021—that increased funding for Medicare.

These recent developments indicate there is bipartisan support for legislation that will support older adults’ mental health needs during and after the COVID-19 pandemic. Bipartisan bills that would expand the Medicare mental health workforce (S.B. 828 & H.R. 432) have strong support in the 117th Congress, but have not yet been passed into law.

In light of the Biden administration recommending in its budget that LMHCs and LMFTs be added to the Medicare program, there is great potential to expand the availability and accessibility of mental health services to individuals who rely on Medicare for their health care. All eyes are now on Congress to see how lawmakers will respond.

NCOA hosts the annual Older Adult Mental Health Awareness Day to highlight critical issues in addressing mental health needs as we age. 

This article is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $5 million with 100% funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.

Sources

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2. Larson, et al. Supply and Distribution of the Behavioral Health Workforce in Rural America. Data Brief. Rural Health Research & Policy Centers. September 2016. Found on the internet at https://depts.washington.edu/fammed/rhrc/wp-content/uploads/sites/4/2016/09/RHRC_DB160_Larson.pdf

3. An Overview of Medicare. Kaiser Family Foundation. Feb. 13, 2019. Found on the internet at https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/

4. Mariano LA. Growth of the Medicare population. Health Care Financ Rev. 1989;10(3):123-124. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4192958/

5. Nancy Ochieng, Karyn Schwartz, Tricia Neuman. How Many Physicians Have Opted Out of the Medicare Program? Kaiser Family Foundation. Oct. 22, 2020. Found on the internet at https://www.kff.org/medicare/issue-brief/how-many-physicians-have-opted-out-of-the-medicare-program/

6. Many psychologists opt out of Medicare. Monitor on Psychology. American Psychological Assocation. May 2010. Found on the internet at https://www.apa.org/monitor/2010/05/medicare

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8. Conner, Kyaien O et al. American older adults. Aging Ment Health. 2010;14(8):971-983. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3060025/

9. Neighbors, Harold W et al. “Mental health service use among older African Americans: the National Survey of American Life.” The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry vol. 16,12 (2008): 948-56. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4846982/

10. Conner, Kyaien O et al. “Barriers to treatment and culturally endorsed coping strategies among depressed African-American older adults.” Aging & mental health vol. 14,8 (2010): 971-83. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3060025/

11. Matthew C. Fullen, Gerard Lawson, Jyotsana Sharma. Analyzing the Impact of the Medicare Coverage Gap on Counseling Professionals: Results of a National Study. Journal of Counseling & Development. 08 March 2020. Found on the internet at https://onlinelibrary.wiley.com/doi/10.1002/jcad.12315

12. Matthew C. Fullen, Jonathan D. Wiley, Amy A. Morgan. The Medicare Mental Health Coverage Gap: How Licensed Professional Counselors Navigate Medicare-Ineligible Provider Status. The Professional Counselor. 2019. Found on the internet at https://tpcjournal.nbcc.org/category/volumes/volume-9/volume-9-issue-4/

13. Chen, Jie et al. “Reducing Preventable Hospitalization and Disparity: Association With Local Health Department Mental Health Promotion Activities.” American journal of preventive medicine vol. 54,1 (2018): 103-112. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5807070/

14. Michael B. Friedman, LMSW; Lisa M. Furst, LMSW; and Kimberly A. Williams, LMSW. Physical and Mental Health Nexus. Aging Well. Vol. 3 No. 4 P. 16. Found on the internet at https://www.todaysgeriatricmedicine.com/archive/110310p16.shtml

15. Elder Health in Rural America. National Rural Health Association. Found on the internet at https://www.ruralhealth.us/getattachment/Advocate/Policy-Documents/ElderHealthinRuralAmericaFeb2013.pdf.aspx

16. Half of Rural Aduts in Worse Health Have Reported Anxiety or Depression During the COVID Pandemic. Kaiser Family Foundation. Oct. 12, 2020. Found on the internet at https://www.kff.org/medicare/slide/half-of-older-adults-in-worse-health-have-reported-anxiety-or-depression-during-pandemic/

17. Elizabeth Cooney. Long after the fire of a COVID infection, mental and neurological effects can still smolder. STAT. Aug. 12, 2020. Found on the internet at https://www.statnews.com/2020/08/12/after-covid19-mental-neurological-effects-smolder/

18. Medicare & Coronavirus. Found on the internet at https://www.medicare.gov/medicare-coronavirus

19. Seema Verma. Early Impact of CMS Expansion of Medicare Telehealth During COVID-10. Health Affairs Forefront. July 15, 2020. Found on the internet at https://www.healthaffairs.org/do/10.1377/forefront.20200715.454789/full/