Search For:

The purpose of this bulletin is to inform providers that effective January 1, 2024, Medicare began covering intensive outpatient services (mental health and ASAM 2.1) and making payment for the services of marriage and family therapists (MFT) and mental health counselors (MHC). In Virginia, MFTs and MHCs are licensed by the Virginia Board of Counseling at the Virginia Department of Health Professions (DHP) and referred to as licensed marriage and family therapists (LMFTs) and licensed professional counselors (LPCs). Additionally, this bulletin describes what DMAS (Fee-For-Service) and Cardinal Care Managed Care (CCMC) managed care organizations (MCOs) are required to do to facilitate the transition of Medicare becoming the primary payer for these services.

On December 14, 2023, the Centers for Medicare & Medicaid Services (CMS) issued an informational bulletin making states aware that beginning January 1, 2024, Medicare would begin covering the behavioral health services noted above. This change in coverage means that Medicare has become the primary payer for dually eligible beneficiaries only (those enrolled in both Medicare and Medicaid) who receive Medicaid coverage of outpatient psychiatric and ASAM 1.0 services furnished by LMFTs and LPCs and intensive outpatient (IOP) services (mental health and ASAM 2.1) effective January 1, 2024. Provider requirements for these behavioral health services are located in the Mental Health Services, Addiction and Recovery Treatment Services (ARTS) and Psychiatric Services provider manuals located online here: Provider Manuals Library | MES (virginia.gov)

In the informational bulletin, CMS also notes it is likely not all providers of these services will be enrolled with and able to bill Medicare on January 1. 2024. To prevent any disruption in IOP services and services provided by MFTs and MHCs for dually eligible beneficiaries CMS provided states two options to facilitate a smooth transition and requested states provide guidance to MCOs and providers on how we will implement these changes. To that end, please see the following guidance and DMAS and MCOs requirements:

1. DMAS recommends that all providers of these services that are enrolled with and able to bill Medicare should start doing so immediately. While DMAS and the MCOs will continue to pay these services as though Medicaid is the primary payer for a period of time (see #3 below) it will be more efficient for all parties if providers bill Medicare as soon as possible. 

2. Providers that are not enrolled with Medicare can, but are not required to, hold claims for the provision of these services until you become enrolled with Medicare. As noted in #1, DMAS and the MCOs will continue to pay for these services as though we are the primary payer for a period of time, if you find holding your claims until you become a Medicare enrolled provider is preferable to #3 you are able to do so.  

3. Providers that are not enrolled with Medicare and who elect not to hold claims until they become enrolled with Medicare (see #2 above), DMAS and the MCOs will:

   1. Continue to reimburse for these services through April 30, 2024, as though we are the primary payer.

   2. Beginning May 1, 2024, DMAS and the CCMC MCOs will deny claims for these services if billed as the primary payer. 

   3. Beginning May 1, 2024, DMAS and the CCMC MCOs will begin paying as the secondary payer (co-insurance) for these services. 

   4. Beginning May 1, 2024 and concluding no later than June 30, 2024, DMAS and the MCOs will recoup (“chase”) all Medicaid payments from the service provider back to the effective date of the MFT’s, MHC’s, or IOP provider’s Medicare provider enrollment, and advise the provider to bill Medicare to receive payment for these services. 

DMAS is issuing guidance to the CCMC MCO’s to inform them of the change in coverage and the steps they are required to take. Please refer to the CMS Bulletin for more information about this change in service coverage and how to become a Medicare enrolled provider. Additionally, see the contact information below if you have further questions.