I 
109TH CONGRESS 
1ST SESSION H. R. 1946 
To amend title XVIII of the Social Security Act to expand and improve 
coverage of mental health services under the Medicare Program. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 27, 2005 
Mr. STARK introduced the following bill; which was referred to the Committee 
on Ways and Means, and in addition to the Committee on Energy and 
Commerce, for a period to be subsequently determined by the Speaker, 
in each case for consideration of such provisions as fall within the juris-
diction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to expand 
and improve coverage of mental health services under 
the Medicare Program. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) IN GENERAL.—This Act may be cited as the 
‘‘Medicare Mental Health Modernization Act of 2005’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
Sec. 2. Findings. 
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TITLE I—ESTABLISHING PARITY FOR MENTAL HEALTH 
SERVICES 
Sec. 101. Elimination of lifetime limit on inpatient mental health services. 
Sec. 102. Parity in treatment for outpatient mental health services. 
TITLE II—EXPANDING COVERAGE OF COMMUNITY-BASED 
MENTAL HEALTH SERVICES 
Sec. 201. Coverage of intensive residential services. 
Sec. 202. Coverage of intensive outpatient services. 
TITLE III—IMPROVING BENEFICIARY ACCESS TO MEDICARE- 
COVERED SERVICES 
Sec. 301. Excluding clinical social worker services from coverage under the 
medicare skilled nursing facility prospective payment system 
and consolidated payment. 
Sec. 302. Coverage of marriage and family therapist services. 
Sec. 303. Coverage of mental health counselor services. 
Sec. 304. Study of coverage criteria for Alzheimer’s disease and related mental 
illnesses. 
SEC. 2. FINDINGS. 
Congress finds the following: 
(1) Older people have the highest rate of suicide 
of any population in the United States, and the sui-
cide rate of that population increases with age, with 
individuals 65 and older accounting for 20 percent 
of all suicide deaths in the United States, while com-
prising only 13 percent of the population of the 
United States. 
(2) Disability due to mental illness in individ-
uals over 65 years old will become a major public 
health problem in the near future because of demo-
graphic changes. In particular, anxiety, dementia, 
depression, schizophrenia, among other conditions, 
will all present special problems for this age group. 
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(3) Major depression is strikingly prevalent 
among older people, with between 8 and 20 percent 
of older people in community studies and up to 37 
percent of those seen in primary care settings expe-
riencing symptoms of depression. 
(4) Anxiety disorders rival depression in their 
prevalence among older people with a rate of 11.4 
percent in persons aged 55 and older. 
(5) Almost 20 percent of the population of indi-
viduals age 55 and older, experience specific mental 
disorders that are not part of normal aging. 
(6) Unrecognized and untreated depression, 
Alzheimer’s disease, anxiety, late-life schizophrenia, 
and other mental conditions can be severely impair-
ing and may even be fatal. 
(7) Substance abuse, particularly the abuse of 
alcohol and prescription drugs, among adults 65 and 
older is one of the fastest growing health problems 
in the United States, with 17 percent of this age 
group suffering from addiction or substance abuse. 
While addiction often goes undetected and untreated 
among older adults, aging and disability makes the 
body more vulnerable to the effects of alcohol and 
drugs, further exacerbating other age-related health 
problems. Medicare coverage for addiction treatment 
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of the elderly needs to recognize these special 
vulnerabilities. 
(8) The disabled are another population receiv-
ing inadequate mental health care through medicare. 
According to the Centers for Medicare & Medicaid 
Services, medicare is the primary health care cov-
erage for the 5,000,000 nonelderly, disabled people 
on Social Security Disability Insurance. Up to 40 
percent of these individuals have a diagnosis of men-
tal illness. 
(9) The current medicare benefit structure dis-
criminates against the millions of Americans who 
suffer from mental illness and maintains an out-
dated bias toward institutionally based service deliv-
ery. According to the report of the Surgeon General 
on mental health for 1999, intensive outpatient serv-
ices, such as psychiatric rehabilitation and assertive 
community treatment, represent state-of-the-art 
mental health services. These evidence-based com-
munity support services help people with psychiatric 
disabilities improve their ability to function in the 
community and reduce hospitalization rates by 30 to 
60 percent, even for people with the most severe 
mental illnesses. 
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TITLE I—ESTABLISHING PARITY 
FOR MENTAL HEALTH SERVICES 
SEC. 101. ELIMINATION OF LIFETIME LIMIT ON INPATIENT 
MENTAL HEALTH SERVICES. 
(a) IN GENERAL.—Section 1812 of the Social Secu-
rity Act (42 U.S.C. 1395d) is amended— 
(1) in subsection (b)— 
(A) in paragraph (1), by adding ‘‘or’’ at 
the end; 
(B) in paragraph (2), by striking ‘‘; or’’ at 
the end and inserting a period; and 
(C) by striking paragraph (3); and 
(2) by striking subsection (c). 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply to items and services furnished 
on or after January 1, 2006. 
SEC. 102. PARITY IN TREATMENT FOR OUTPATIENT MEN-
TAL HEALTH SERVICES. 
(a) IN GENERAL.—Section 1833 of the Social Secu-
rity Act (42 U.S.C. 1395l) is amended by striking sub-
section (c). 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply to items and services furnished 
on or after January 1, 2006. 
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TITLE 
II—EXPANDING 
COV-
ERAGE 
OF 
COMMUNITY- 
BASED 
MENTAL 
HEALTH 
SERVICES 
SEC. 201. COVERAGE OF INTENSIVE RESIDENTIAL SERV-
ICES. 
(a) COVERAGE UNDER PART A.—Section 1812(a) of 
the Social Security Act (42 U.S.C. 1395d(a)) is amend-
ed— 
(1) in paragraph (4), by striking ‘‘and’’ at the 
end; 
(2) in paragraph (5), by striking the period at 
the end and inserting ‘‘; and’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(6) intensive residential services (as defined in 
section 1861(bbb)) furnished to an individual for up 
to 120 days during any calendar year, except that 
such services may be furnished to the individual for 
additional days (not to exceed 20 days) during the 
year if necessary for the individual to complete a 
course of treatment.’’. 
(b) SERVICES DESCRIBED.—Section 1861 of the So-
cial Security Act (42 U.S.C. 1395x) is amended by adding 
at the end the following new subsection:
‘‘Intensive Residential Services 
‘‘(bbb)(1) Subject to paragraphs (3) and (4), the 
term ‘intensive residential services’ means a program of 
residential services (described in paragraph (2)) that is— 
‘‘(A) prescribed by a physician for an individual 
entitled to, or enrolled for, benefits under part A 
who is under the care of the physician; and 
‘‘(B) furnished under the supervision of a phy-
sician pursuant to an individualized, written plan of 
treatment established and periodically reviewed by a 
physician (in consultation with appropriate staff par-
ticipating in such services), which plan sets forth— 
‘‘(i) the individual’s diagnosis, 
‘‘(ii) the type, amount, frequency, and du-
ration of the items and services provided under 
the plan, and 
‘‘(iii) the goals for treatment under the 
plan. 
In the case of such an individual who is receiving qualified 
psychologist services (as defined in subsection (ii)), the in-
dividual may be under the care of the clinical psychologist 
with respect to such services under this subsection to the 
extent permitted under State law. 
‘‘(2) The program of residential services described in 
this paragraph is a nonhospital-based community residen-
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tial program that furnishes acute mental health services 
or substance abuse services, or both, on a 24-hour basis. 
Such services shall include treatment planning and devel-
opment, medication management, case management, crisis 
intervention, individual therapy, group therapy, and de-
toxification services. Such services shall be furnished in 
any of the following facilities: 
‘‘(A) Crisis residential programs or mental ill-
ness residential treatment programs. 
‘‘(B) Therapeutic family or group treatment 
homes. 
‘‘(C) Residential detoxification centers. 
‘‘(D) Residential centers for substance abuse 
treatment. 
‘‘(3) No service may be treated as an intensive resi-
dential service under paragraph (1) unless the facility at 
which the service is provided— 
‘‘(A) is legally authorized to provide such serv-
ice under the law of the State (or under a State reg-
ulatory mechanism provided by State law) in which 
the facility is located or meets such certification re-
quirements that the Secretary may impose; and 
‘‘(B) meets such other requirements as the Sec-
retary may impose to assure the quality of the inten-
sive residential services provided. 
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‘‘(4) No service may be treated as an intensive resi-
dential service under paragraph (1) unless the service is 
furnished in accordance with standards established by the 
Secretary for the management of such services.’’. 
(c) AMOUNT OF PAYMENT.—Section 1814 of the So-
cial Security Act (42 U.S.C. 1395f) is amended— 
(1) in subsection (b), in the matter preceding 
paragraph (1), by inserting ‘‘other than intensive 
residential services,’’ after ‘‘hospice care,’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘Payment for Intensive Residential Services 
‘‘(m)(1) The amount of payment under this part for 
intensive residential services under section 1812(a)(6) 
shall be equal to an amount specified under a prospective 
payment system established by the Secretary, taking into 
account the prospective payment system established for 
psychiatric hospitals pursuant to section 124 of the Medi-
care, Medicaid, and SCHIP Balanced Budget Refinement 
Act of 1999 (113 Stat. 1501A–332), as enacted into law 
by section 1000(a)(6) of Public Law 106–113. 
‘‘(2) Prior to the date on which the Secretary imple-
ments the prospective payment system established under 
paragraph (1), the amount of payment under this part for 
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such intensive residential services is the reasonable costs 
of providing such services.’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply to items and services furnished on 
or after January 1, 2006. 
SEC. 202. COVERAGE OF INTENSIVE OUTPATIENT SERV-
ICES. 
(a) COVERAGE.—Section 1832(a)(2) of the Social Se-
curity Act (42 U.S.C. 1395k(a)(2)) is amended— 
(1) in subparagraph (I), by striking ‘‘and’’ at 
the end; 
(2) in subparagraph (J), by striking the period 
at the end and inserting ‘‘; and’’; and 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(K) intensive outpatient services (as de-
scribed in section 1861(ccc)).’’. 
(b) SERVICES DESCRIBED.—Section 1861 of the So-
cial Security Act (42 U.S.C. 1395x), as amended by sec-
tion 201(b), is amended by adding at the end the following 
new subsection: 
‘‘Intensive Outpatient Services 
‘‘(ccc)(1) The term ‘intensive outpatient services’ 
means the items and services described in paragraph (2) 
prescribed by a physician and provided within the context 
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described in paragraph (3) under the supervision of a phy-
sician (or, to the extent permitted under the law of the 
State in which the services are furnished, a non-physician 
mental health professional) pursuant to an individualized, 
written plan of treatment that is established by a physi-
cian and periodically reviewed by a physician or, to the 
extent permitted under the laws of the State in which the 
services are furnished, a non-physician mental health pro-
fessional (in consultation with appropriate staff partici-
pating in such services), which plan sets forth the patient’s 
diagnosis, the type, amount, frequency, and duration of 
the items and services provided under the plan, and the 
goals for treatment under the plan. 
‘‘(2)(A) The items and services described in this 
paragraph are the items and services described in sub-
paragraph (B) that are reasonable and necessary for the 
diagnosis or treatment of the individual’s condition, rea-
sonably expected to improve or maintain the individual’s 
condition and functional level and to prevent relapse or 
hospitalization, and furnished pursuant to such guidelines 
relating to frequency and duration of services as the Sec-
retary shall by regulation establish (taking into account 
accepted norms of clinical practice). 
‘‘(B) For purposes of subparagraph (A), the items 
and services described in this paragraph are as follows: 
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‘‘(i) Psychiatric rehabilitation. 
‘‘(ii) Assertive community treatment. 
‘‘(iii) Intensive case management. 
‘‘(iv) Day treatment for individuals under 21 
years of age. 
‘‘(v) Ambulatory detoxification. 
‘‘(vi) Such other items and services as the Sec-
retary may provide (but in no event to include meals 
and transportation). 
‘‘(3) The context described in this paragraph for the 
provision of intensive outpatient services is as follows: 
‘‘(A) Such services are furnished in a facility, 
home, or community setting. 
‘‘(B) Such services are furnished— 
‘‘(i) to assist the individual to compensate 
for, or eliminate, functional deficits and inter-
personal and environmental barriers created by 
the disability; and 
‘‘(ii) to restore skills to the individual for 
independent living, socialization, and effective 
life management. 
‘‘(C) Such services are furnished by an indi-
vidual or entity that— 
‘‘(i) is legally authorized to furnish such 
services under State law (or the State regu-
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latory mechanism provided by State law) or 
meets such certification requirements that the 
Secretary may impose; and 
‘‘(ii) meets such other requirements as the 
Secretary may impose to assure the quality of 
the intensive outpatient services provided.’’. 
(c) PAYMENT.— 
(1) IN
GENERAL.—With respect to intensive 
outpatient 
services 
(as 
defined 
in 
section 
1861(ccc)(1) of the Social Security Act (as added by 
subsection (b)) furnished under the medicare pro-
gram, the amount of payment under such Act for 
such services shall be 80 percent of— 
(A) during 2006 and 2007, the reasonable 
costs of furnishing such services; and 
(B) on or after January 1, 2008, the 
amount of payment established for such serv-
ices under the prospective payment system es-
tablished by the Secretary under paragraph (2) 
for such services. 
(2) ESTABLISHMENT OF PPS.— 
(A) IN GENERAL.—With respect to inten-
sive outpatient services (as defined in section 
1861(ccc)(1)) of the Social Security Act (as 
added by subsection (b)) furnished under the 
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medicare program on or after January 1, 2008, 
the Secretary of Health and Human Services 
(in this paragraph referred to as the ‘‘Sec-
retary’’) shall establish a prospective payment 
system for payment for such services. Such sys-
tem shall include an adequate patient classifica-
tion system that reflects the differences in pa-
tient resource use and costs and shall provide 
for an annual update to the rates of payment 
established under the system. 
(B) ADJUSTMENTS.—In establishing the 
system under subparagraph (A), the Secretary 
shall provide for adjustments in the prospective 
payment amount for variations in wage and 
wage-related costs, case mix, and such other 
factors as the Secretary determines appropriate. 
(C) COLLECTION OF DATA AND EVALUA-
TION.—In developing the system described in 
subparagraph (A), the Secretary may require 
providers of services under the medicare pro-
gram to submit such information to the Sec-
retary as the Secretary may require to develop 
the system, including the most recently avail-
able data. 
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(D) REPORTS
TO
CONGRESS.—Not later 
than October 1 of each of 2006 and 2007, the 
Secretary shall submit to Congress a report on 
the progress of the Secretary in establishing the 
prospective payment system under this para-
graph. 
(d) 
CONFORMING
AMENDMENTS.—(1) 
Section 
1835(a)(2) of the Social Security Act (42 U.S.C. 
1395n(a)(2)) is amended— 
(A) in subparagraph (E), by striking ‘‘and’’ at 
the end; 
(B) in subparagraph (F), by striking the period 
at the end and inserting ‘‘; and’’; and 
(C) by inserting after subparagraph (F) the fol-
lowing new subparagraph: 
‘‘(G) in the case of intensive outpatient 
services, (i) that those services are reasonably 
expected to improve or maintain the individual’s 
condition and functional level and to prevent re-
lapse or hospitalization, (ii) an individualized, 
written plan for furnishing such services has 
been established by a physician and is reviewed 
periodically by a physician or, to the extent per-
mitted under the laws of the State in which the 
services are furnished, a non-physician mental 
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health professional, and (iii) such services are 
or were furnished while the individual is or was 
under the care of a physician or, to the extent 
permitted under the law of the State in which 
the services are furnished, a non-physician men-
tal health professional.’’. 
(2) Section 1861(s)(2)(B) of the Social Security Act 
(42 U.S.C. 1395x(s)(2)(B)) is amended by inserting ‘‘and 
intensive outpatient services’’ after ‘‘partial hospitalization 
services’’. 
(3) Section 1861(ff)(1) of the Social Security Act (42 
U.S.C. 1395x(ff)(1)) is amended— 
(A) by inserting ‘‘or, to the extent permitted 
under the law of the State in which the services are 
furnished, a non-physician mental health profes-
sional,’’ after ‘‘under the supervision of a physician’’ 
and after ‘‘periodically reviewed by a physician’’; and 
(B) by striking ‘‘physician’s’’ and inserting ‘‘pa-
tient’s’’. 
(4) Section 1861(cc) of the Social Security Act (42 
U.S.C. 1395x(cc)) is amended— 
(A) in paragraph (1), in the matter preceding 
subparagraph (A), by striking ‘‘physician—’’ and in-
serting ‘‘physician or, to the extent permitted under 
the law of the State in which the services are fur-
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nished, a non-physician mental health professional— 
’’; and 
(B) in paragraph (2)(E), by inserting before 
the semicolon at the end the following: ‘‘, except that 
a patient receiving social and psychological services 
under paragraph (1)(D) may be under the care of 
a non-physician mental health professional with re-
spect to such services to the extent permitted under 
the law of the State in which the services are fur-
nished’’. 
(e) EFFECTIVE DATE.—The amendments made by 
this section shall apply to items and services furnished on 
or after January 1, 2006. 
TITLE 
III—IMPROVING 
BENE-
FICIARY ACCESS TO MEDI-
CARE-COVERED SERVICES 
SEC. 301. EXCLUDING CLINICAL SOCIAL WORKER SERVICES 
FROM COVERAGE UNDER THE MEDICARE 
SKILLED NURSING FACILITY PROSPECTIVE 
PAYMENT SYSTEM AND CONSOLIDATED PAY-
MENT. 
(a) IN GENERAL.—Section 1888(e)(2)(A)(ii) of the 
Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is 
amended by inserting ‘‘clinical social worker services,’’ 
after ‘‘qualified psychologist services,’’. 
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(b) 
CONFORMING
AMENDMENT.—Section 
1861(hh)(2) of the Social Security Act (42 U.S.C. 
1395x(hh)(2)) is amended by striking ‘‘and other than 
services furnished to an inpatient of a skilled nursing facil-
ity which the facility is required to provide as a require-
ment for participation’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to items and services furnished on 
or after January 1, 2006. 
SEC. 302. COVERAGE OF MARRIAGE AND FAMILY THERA-
PIST SERVICES. 
(a) COVERAGE OF SERVICES.—Section 1861(s)(2) of 
the Social Security Act (42 U.S.C. 1395x(s)(2)) is amend-
ed— 
(1) in subparagraph (Y), by striking ‘‘and’’ at 
the end; 
(2) in subparagraph (Z), by adding ‘‘and’’ at 
the end; and 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(AA) marriage and family therapist services 
(as defined in subsection (ddd));’’. 
(b) DEFINITION.—Section 1861 of the Social Secu-
rity Act (42 U.S.C. 1395x), as amended by sections 
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201(b) and 202(b), is amended by adding at the end the 
following new subsection: 
‘‘Marriage and Family Therapist Services 
‘‘(ddd)(1) The term ‘marriage and family therapist 
services’ means services performed by a marriage and 
family therapist (as defined in paragraph (2)) for the diag-
nosis and treatment of mental illnesses, which the mar-
riage and family therapist is legally authorized to perform 
under State law (or the State regulatory mechanism pro-
vided by State law) of the State in which such services 
are performed, provided such services are covered under 
this title, as would otherwise be covered if furnished by 
a physician or as incident to a physician’s professional 
service, but only if no facility or other provider charges 
or is paid any amounts with respect to the furnishing of 
such services. 
‘‘(2) The term ‘marriage and family therapist’ means 
an individual who— 
‘‘(A) possesses a master’s or doctoral degree 
which qualifies for licensure or certification as a 
marriage and family therapist pursuant to State 
law; 
‘‘(B) after obtaining such degree has performed 
at least 2 years of clinical supervised experience in 
marriage and family therapy; and 
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‘‘(C) is licensed or certified as a marriage and 
family therapist in the State in which marriage and 
family therapist services are performed.’’. 
(c) PROVISION FOR PAYMENT UNDER PART B.—Sec-
tion 1832(a)(2)(B) of the Social Security Act (42 U.S.C. 
1395k(a)(2)(B)) is amended by adding at the end the fol-
lowing new clause: 
‘‘(v) marriage and family therapist 
services;’’. 
(d) AMOUNT OF PAYMENT.— 
(1) IN GENERAL.—Section 1833(a)(1) of the 
Social Security Act (42 U.S.C. 1395l(a)(1)) is 
amended— 
(A) by striking ‘‘and’’ before ‘‘(V)’’; and 
(B) by inserting before the semicolon at 
the end the following: ‘‘, and (W) with respect 
to marriage and family therapist services under 
section 1861(s)(2)(AA), the amounts paid shall 
be 80 percent of the lesser of (i) the actual 
charge for the services or (ii) 75 percent of the 
amount determined for payment of a psycholo-
gist under subparagraph (L)’’. 
(2) DEVELOPMENT
OF
CRITERIA
WITH
RE-
SPECT TO CONSULTATION WITH A PHYSICIAN.—The 
Secretary of Health and Human Services shall, tak-
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ing into consideration concerns for patient confiden-
tiality, develop criteria with respect to payment for 
marriage and family therapist services for which 
payment may be made directly to the marriage and 
family therapist under part B of title XVIII of the 
Social Security Act (42 U.S.C. 1395j et seq.) under 
which such a therapist must agree to consult with a 
patient’s attending or primary care physician in ac-
cordance with such criteria. 
(e) EXCLUSION OF MARRIAGE AND FAMILY THERA-
PIST SERVICES FROM SKILLED NURSING FACILITY PRO-
SPECTIVE PAYMENT SYSTEM.—Section 1888(e)(2)(A)(ii) 
of the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)), 
as amended in section 301(a), is amended by inserting 
‘‘marriage and family therapist services (as defined in sub-
section (ddd)(1)),’’ after ‘‘clinical social worker services,’’. 
(f) COVERAGE OF MARRIAGE AND FAMILY THERA-
PIST SERVICES PROVIDED IN RURAL HEALTH CLINICS 
AND FEDERALLY QUALIFIED HEALTH CENTERS.—Sec-
tion 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 
1395x(aa)(1)(B)) is amended by striking ‘‘or by a clinical 
social worker (as defined in subsection (hh)(1)),,’’ and in-
serting ‘‘, by a clinical social worker (as defined in sub-
section (hh)(1)), or by a marriage and family therapist 
(as defined in subsection (ddd)(2)),’’. 
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(g) INCLUSION OF MARRIAGE AND FAMILY THERA-
PISTS
AS
PRACTITIONERS
FOR
ASSIGNMENT
OF 
CLAIMS.—Section 1842(b)(18)(C) of the Social Security 
Act (42 U.S.C. 1395u(b)(18)(C)) is amended by adding 
at the end the following new clause: 
‘‘(vii) A marriage and family therapist (as de-
fined in section 1861(ddd)(2)).’’. 
(h) EFFECTIVE DATE.—The amendments made by 
this section shall apply to items and services furnished on 
or after January 1, 2006. 
SEC. 303. COVERAGE OF MENTAL HEALTH COUNSELOR 
SERVICES. 
(a) COVERAGE OF SERVICES.—Section 1861(s)(2) of 
the Social Security Act (42 U.S.C. 1395x(s)(2)), as 
amended in section 302(a), is amended— 
(1) in subparagraph (Z), by striking ‘‘and’’ at 
the end; 
(2) in subparagraph (AA), by inserting ‘‘and’’ 
at the end; and 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(BB) mental health counselor services (as 
defined in subsection (eee)(2));’’. 
(b) DEFINITION.—Section 1861 of the Social Secu-
rity Act (42 U.S.C. 1395x), as amended by sections 
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201(b), 202(b), and 302(b), is amended by adding at the 
end the following new subsection: 
‘‘Mental Health Counselor; Mental Health Counselor 
Services 
‘‘(eee)(1) The term ‘mental health counselor’ means 
an individual who— 
‘‘(A) possesses a master’s or doctor’s degree in 
mental health counseling or a related field; 
‘‘(B) after obtaining such a degree has per-
formed at least 2 years of supervised mental health 
counselor practice; and 
‘‘(C) is licensed or certified as a mental health 
counselor or professional counselor by the State in 
which the services are performed. 
‘‘(2) The term ‘mental health counselor services’ 
means services performed by a mental health counselor (as 
defined in paragraph (1)) for the diagnosis and treatment 
of mental illnesses which the mental health counselor is 
legally authorized to perform under State law (or the 
State regulatory mechanism provided by the State law) of 
the State in which such services are performed, provided 
such services are covered under this title, as would other-
wise be covered if furnished by a physician or as incident 
to a physician’s professional service, but only if no facility 
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or other provider charges or is paid any amounts with re-
spect to the furnishing of such services.’’. 
(c) PAYMENT.— 
(1) IN GENERAL.—Section 1833(a)(1) of the 
Social Security Act (42 U.S.C. 1395l(a)(1)), as 
amended by section 302(d), is amended— 
(A) by striking ‘‘and’’ before ‘‘(W)’’; and 
(B) by inserting before the semicolon at 
the end the following: ‘‘, and (X) with respect 
to mental health counselor services under sec-
tion 1861(s)(2)(BB), the amounts paid shall be 
80 percent of the lesser of (i) the actual charge 
for the services or (ii) 75 percent of the amount 
determined for payment of a psychologist under 
subparagraph (L)’’. 
(2) DEVELOPMENT
OF
CRITERIA
WITH
RE-
SPECT TO CONSULTATION WITH A PHYSICIAN.—The 
Secretary of Health and Human Services shall, tak-
ing into consideration concerns for patient confiden-
tiality, develop criteria with respect to payment for 
mental health counselor services for which payment 
may be made directly to the mental health counselor 
under part B of title XVIII of the Social Security 
Act (42 U.S.C. 1395j et seq.) under which such a 
counselor must agree to consult with a patient’s at-
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tending or primary care physician in accordance 
with such criteria. 
(d) EXCLUSION OF MENTAL HEALTH COUNSELOR 
SERVICES FROM SKILLED NURSING FACILITY PROSPEC-
TIVE PAYMENT SYSTEM.—Section 1888(e)(2)(A)(ii) of 
the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)), 
as amended by sections 301(a) and 302(e), is amended 
by inserting ‘‘mental health counselor services (as defined 
in section 1861(eee)(2)),’’ after ‘‘marriage and family 
therapist services (as defined in subsection (ddd)(1)),’’. 
(e) COVERAGE
OF MENTAL HEALTH COUNSELOR 
SERVICES PROVIDED IN RURAL HEALTH CLINICS AND 
FEDERALLY
QUALIFIED
HEALTH
CENTERS.—Section 
1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 
1395x(aa)(1)(B)), as amended by section 302(f), is 
amended— 
(1) by striking ‘‘or by a marriage’’ and insert-
ing ‘‘by a marriage’’; and 
(2) by inserting ‘‘or a mental health counselor 
(as defined in subsection (eee)(1)),’’ after ‘‘marriage 
and family therapist (as defined in subsection 
(ddd)(2)),’’. 
(f) INCLUSION OF MENTAL HEALTH COUNSELORS AS 
PRACTITIONERS FOR ASSIGNMENT OF CLAIMS.—Section 
1842(b)(18)(C) of the Social Security Act (42 U.S.C. 
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1395u(b)(18)(C)), as amended by section 302(g), is 
amended by adding at the end the following new clause: 
‘‘(viii) A mental health counselor (as defined in 
section 1861(eee)(1)).’’. 
(g) EFFECTIVE DATE.—The amendments made by 
this section shall apply to items and services furnished on 
or after January 1, 2006. 
SEC. 304. STUDY OF COVERAGE CRITERIA FOR ALZ-
HEIMER’S DISEASE AND RELATED MENTAL 
ILLNESSES. 
(a) STUDY.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the 
‘‘Secretary’’) shall conduct a study to determine 
whether the criteria for coverage of any therapy 
service (including occupational therapy services and 
physical therapy services) or any outpatient mental 
health care service under the medicare program 
under title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.) unduly restricts the access of 
any medicare beneficiary who has been diagnosed 
with Alzheimer’s disease or a related mental illness 
to such a service because the coverage criteria re-
quires the medicare beneficiary to display continuing 
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clinical improvement to continue to receive the serv-
ice. 
(2) DETERMINATION OF NEW COVERAGE CRI-
TERIA.—If the Secretary determines that the cov-
erage criteria described in paragraph (1) unduly re-
stricts the access of any medicare beneficiary to the 
services described in such paragraph, the Secretary 
shall identify alternative coverage criteria that would 
permit a medicare beneficiary who has been diag-
nosed with Alzheimer’s disease or a related mental 
illness to receive coverage for health care services 
under the medicare program that are designed to 
control symptoms, maintain functional capabilities, 
reduce or deter deterioration, and prevent or reduce 
hospitalization of the beneficiary. 
(b) REPORT.—Not later than 1 year after the date 
of enactment of this Act, the Secretary shall submit to 
the committees of jurisdiction of Congress a report on the 
study conducted under subsection (a) together with such 
recommendations for legislative and administrative action 
as the Secretary determines appropriate. 
Æ 
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