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LPC and LMFT Providers Must Enroll in Medicare Effective March 1, 2024

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Medicare has recognized licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs) as provider types that can bill Medicare Part B and be reimbursed for approved services in accordance with Medicare reimbursement rates as of January 1, 2024.

Effective March 1, 2024, LMFT and LPC providers must enroll in Medicare or obtain a pediatric practice exemption. An exemption can be indicated in the Program Specific questions within the Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment and Management System (PEMS) national provider identifier (NPI) record. If a pediatric-based LMFT or LPC is enrolling in Texas Medicaid as part of a Medicare-enrolled group, then the LMFT or LPC must also be enrolled in Medicare. In addition, claims for dates of service beginning January 1, 2024, will require that a provider have a Medicare number on file with Texas Medicaid and bill Medicare first, or Texas Medicaid will deny the claims.

Under the Program Specific Questions section of the Program and Service Participation Details page, PEMS has been updated to include the question "Are you using a Medicare certification number for this location?" If a provider answers Yes, they will be required to enter the Medicare number and effective date. If they answer No, they will be required to submit a Medicare Waiver Request that is subject to review for approval.

New Medicaid Providers

Newly enrolling LMFT and LPC providers and those with any pending PEMS enrollment applications (New, Revalidation, Reenrollment, and Existing) submitted before March 1, 2024, will be required to respond to the Enrolling with Medicare question and provide their Medicare information under the Program Specifics Questions section of the Program and Service Participation Details page within PEMS or submit a Medicare Waiver Request.

Existing Medicaid Providers

Existing LMFT and LPC Texas Medicaid providers that provide services to dually eligible clients will be required to respond to the Enrolling with Medicare question during their revalidation period or submit a Medicare Waiver Request. The Medicare question can be found under the Program Specifics Questions section of the Program and Service Participation Details page within PEMS. LMFTs and LPCs must provide their Medicare information through an Existing Enrollment to continue providing services to dually eligible clients.

Note: Claims for dates of service on or after January 1, 2024, that are billed directly to Texas Medicaid for clients covered by Medicare will be denied. These claims must be billed to Medicare first.

For more information, call the TMHP Contact Center at 800-925-9126.