Figure · the path to Medicare
Six years of asking, then the door opened.
Counselors were the largest licensed mental health workforce Medicare would not pay. This is how that changed, as documented in the manual.
2018
The problem gets a name
Counselors are the largest licensed mental health workforce Medicare will not reimburse, sidelined in the medical settings that need them most.
2019 to 2020
The coalition forms
State associations, including Michigan’s, align with national groups around one priority: Medicare recognition for counselors.
2021 to 2022
The hard years
Budget objections and committee stalls. The case gets sharper: access gaps, provider shortages, and a workforce already trained and licensed.
December 2022
The law passes
The Mental Health Access Improvement Act rides the year-end omnibus. Counselors and marriage and family therapists become recognized Part B providers.
January 1, 2024
Counselors bill Medicare
Enrollment opens. Eligible counselors and MFTs bill under their own NPI. Medicare pays 75 percent of the clinical psychologist amount.
2025 to 2026
The rules keep moving
Post-2025 updates narrow incident-to in office settings and push toward team models. The second edition of the manual tracks it.
Figure · covered services
What Medicare Part B pays a counselor to do.
Since January 2024, under a counselor’s own NPI at 75 percent of the clinical psychologist amount, or inside the arrangements the main page explains.
Individual psychotherapy
The core of outpatient treatment.
Group psychotherapy
Payable, with its own codes.
Family counseling
When it serves the patient’s treatment.
Psychiatric diagnostic evaluation
The intake that starts a course of care.
Depression and alcohol screening
Preventive, at no cost to the patient.
Alcohol and substance use treatment
Including counselor-delivered care.
The Welcome to Medicare visit
Where behavioral needs first surface.
Annual wellness visits
A yearly opening to catch what changed.
Intensive outpatient programs
Expanded settings, expanded access.
Telehealth
Behavioral health kept its telehealth access.
As catalogued in the manual from CMS coverage rules, true as of its 2025 sources. Educational information, not billing advice.
Two gates stand between a clinician and a paid visit, and they are moving in opposite directions.
The first gate asks whether you are allowed to see the person. The second asks whether anyone will pay you for it. Most of the confusing rules on this site come from these two being mistaken for each other.
Permission
Whether you may see the person
Courts are loosening the rules on practicing across state lines. A federal court has treated counseling as protected speech, and the Counseling Compact keeps adding states.
- Protected-speech rulings are spreading
- The Compact adds portability
- You still have to check each state
Payment
Whether anyone pays for it
Payers and Medicaid are closing the old solo and incident-to billing paths. The money is moving toward integrated, supervised structures.
- Incident-to is closing for limited-license clinicians
- Medicaid is tightening in several states
- Money now moves through structure
Figure · the Counseling Compact
One license, most of the country.
The Compact lets a licensed counselor practice across member states without relicensing, which is half of the story: permission opening while payment tightens.
40
jurisdictions had enacted the Compact by August 2026.
7
were issuing privileges: Arizona, Arkansas, Georgia, Indiana, Louisiana, Minnesota, Ohio.
100,000+
licensed professional counselors eligible as the rest come online.
Figures as compiled in the manual’s sources. Membership keeps growing; the Compact’s own site is the authority as states flip on. You still have to follow each state’s rules while practicing there.
Figure · collaborative care by state
Does this work in my state?
Medicare pays for collaborative care everywhere. State Medicaid is the part people get wrong. Thirty-six states and the District of Columbia pay for it. Fourteen states do not. If you are in one of the fourteen, the model still works for your Medicare patients. It just will not carry your Medicaid ones.
What incident-to billing actually is, and why its closing is not a footnote.
A physician sets the treatment plan. A qualified clinician on the physician’s staff carries it out, visit by visit, with the doctor in the office. The claim goes out under the physician’s name.
That is incident-to. It is how a counselor could work inside a doctor’s practice, and how the practice could bill for the visits. National Medicare rules still recognize qualifying arrangements. What is closing is the commercial and Medicaid version of it for limited-license clinicians, which is the version most practices were actually using.
The physician starts it
The first visit and the treatment plan are the physician’s.
The plan is the boundary
Every counselor visit happens inside that plan. A new problem means a new physician visit.
The physician stays involved
Ongoing and documented. Not a signature at the bottom of the month.
Someone is in the suite
Direct supervision. A supervising physician on site while the visit happens. This is the condition collaborative care does not impose.
It is all written down
Documentation that ties each visit back to the plan, in a line a reviewer can follow.
Figure · one visit, six sets of rules
The same visit. Six payers. Six different claims.
A supervised clinician sees a patient. Same hour, same note, same supervisor. Then the claim goes out, and each of these six payers wants it built differently. One wants a modifier. One wants a different modifier. One wants none. One wants the supervisor physically in the building. Nobody publishes this side by side, so here it is.
The lesson underneath the table is not the modifiers. It is that a practice with four payer contracts needs four different claim rules for one clinical service, and the rules are moving in opposite directions at the same time. That is the cost nobody prices in when they say the model is simple.
You hired five limited-license counselors. The payer just stopped paying for them.
Say you run a counseling practice in Michigan. Your supervisors are certified. You brought on limited-license counselors as staff, and their sessions billed incident-to under your supervising licensee. That path is closing. Here is the same practice, rebuilt, with nobody let go.
Nobody gets let go
The same people fill new seats. Your limited-license counselors become care managers, the payable engine of collaborative care. Their supervised hours become the minutes the codes are built on.
Partner with medicine
The claim needs a doctor’s name on it. Partner with a primary care office, a pain clinic, or any physician group that already has the patients. The physician bills. General supervision applies, so nobody has to be in the building.
Your supervisors keep their job
Licensure supervision continues exactly as before, on its own record. The certification you already hold is the half of this model most medical practices do not have.
Rent the psychiatrist
The weekly caseload review takes a few hours, not a hire. A psychiatric consultant contracts for the panel, and their review time counts toward the month.
The claim goes out under the physician’s NPI, on codes Medicare, Michigan Medicaid and the Blues already pay. Your counselors’ work funds the arrangement. Where the line sits between a counseling practice and a medical practice, and whether a management services organization is the right structure for joining them, is state law, and it changes by state. This is the shape of the arrangement, not legal advice. Before you build it, have a healthcare attorney in your state review the structure and have your payer confirm in writing that it will pay claims from it.
One is written. One is being written. One belongs to the nonprofit.
We would rather tell you exactly where each one stands than say coming soon. Publishing status, checked 10 August 2026.
Written. Second edition in revision.
The Medicare Guide to Incident-To Billing
How counselors got paid inside medical settings
Coverage, billing, and the templates you can put to work the week you read it. The first edition is written and we will send it. The second edition is in revision for the 2026 rules, including the changes that close the office path for limited-license clinicians.
Ask and we send the current edition. You get the new one when it publishes, at no charge and without asking again.
Being written.
The Collaborative Care Book
How to integrate mental health care and get paid for it
What replaces incident-to. The team, the codes, the two supervisors kept separate, and standing it up in 30, 60 and 90 days. Its appendices are the working instruments: consent language, the registry, the time log.
No publication date yet, and we will not invent one. Ask and we write to you once, when it is ready.
Published.
ICD-11 in America
A clinical guide to the future of diagnosis
Foundations, clinical domains, and what United States adoption will ask of clinicians. Published by the Integral Neuroscience Initiative, the related nonprofit, not by the Center.
Available now from the Initiative.
One reply from a person. We write when a book is ready, and when we publish something worth your time. That is the whole list.
Four roles, and only one of them is a hire.
This is the operational detail behind the team figure on the main page. Two of these roles are rented by the hour. One is a role your existing staff already fill. One is the physician you partner with.
Does the work
The care manager
Sees the client, tracks the minutes, keeps the registry. This is where a limited-license clinician fits.
Reviews weekly
The psychiatric consultant
Reviews the caseload each week and recommends changes. Rented a few hours a week, not hired.
Oversees licensure
The supervising LPC
A fully licensed counselor who oversees clinical work toward licensure. Contracted, often a few hours a month.
Bills it
The physician or other billing provider
The name on the claim. The billing that funds the two rented roles.
The two supervisors are not the same person, and not the same job.
The psychiatric consultant
Required by the Collaborative Care model. Reviews the caseload with the care manager every week and recommends changes. Usually never meets the patient.
Part of the billing. Their time counts toward the month.
The licensure supervisor
A fully licensed counselor overseeing a limited-license clinician’s path to full licensure, under your state board’s rules.
Nothing to do with billing. Different person, different record.
Questions practices ask us.
We are not in Michigan. Does any of this apply to us?
Yes. The codes are Medicare codes, which are national, and most state Medicaid programs and many commercial payers follow them. What varies by state is on the coverage map above and in the dated log.
Does this only work for Medicare patients?
No. Medicare established the codes, and most state Medicaid programs and major commercial payers, including Blue plans, pay them too. Whether yours does is written in your contract, and Aetna now says so in its own newsletter.
Do we stop seeing patients the old way while we set up?
No. Collaborative care runs alongside your existing visits, which keep billing the way they always have. The three months of setup are paperwork and habits, not a pause in care.
Our state has not joined the Compact. Does that block this?
No. The Compact is about where a license travels. Collaborative care is about how a team gets paid inside one practice, and it works in states that never join.
What does it cost to find out whether this works for us?
Nothing. The argument is on this site, the guides and the books are free, and every figure names the primary source behind it so you can check us. If you get to the point of wanting help building it, that is a separate conversation you start.
The reference shelf
Check us against the sources.
Everything we publish points back to a primary source. These are the ones we cite most, free and official.
The CMS booklet on behavioral health integration services. The CoCM codes, the minute thresholds, the supervision rules. The document this whole site keeps citing.
Where the actual dollar amounts live, by code and locality. Run 99492 to 99494 for your area before you believe anyone’s revenue math, including ours.
The Compact’s own site: the live membership map, privilege applications, and state-by-state status.
The University of Washington center that built and validated Collaborative Care. Implementation guides, the evidence base, and the registry tools.
The Michigan Collaborative Care Implementation Support Team. Training and payer guidance for Michigan practices standing up CoCM.