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Jan 09, 2017

One of the Most Important Questions about Veteran Mental Health is Who’s Paying the Bill?

There are several challenges regarding veteran mental health, and the combination of them can often make the task of accessing mental health services impossible for veterans. There is, of course, the stigma attached to seeking mental health services. There is also the need for counselors and therapists to be culturally competent, both because they need to be aware of what their client is going through, but also so that the veteran is able to connect with and trust their mental health provider.

An additional challenge: who’s going to pay for it. I am personally of the opinion that veterans should not have to pay for their own mental health counseling. I recognize that there is debate about this: the client should have some buy-in through co-pays and no-show fees, without having some skin in the game it is easier for the veteran to not show up for a scheduled appointment, and I understand all of that. From my perspective, however, veterans have paid for it, through their service and their experiences. I do have some flexibility, of course; the current TRICARE co-pay for outpatient mental health counseling is $12. If a veteran is not willing to pay a $12 co-pay for something that can benefit them, then a conversation about commitment probably has to happen.

I work with veterans involved in the criminal justice system. Once a veteran has plead guilty to a charge, we have a contract with the local probation department to be paid for the services we provide. Once a veteran is in the program, we can provide weekly individual and group counseling, and more if needed. My problem with this is, why does a veteran have to first commit a crime, and then plead guilty to that crime in order to have full access to services? Wouldn’t it be better if the veteran were to receive treatment first, in order to avoid involvement in the courts?

There are several attempts to solve these challenges. Masters level mental health counselors are now eligible to participate in the Department of Veterans Affairs Choice program, after a change that happened in December of 2014 and a contract change in the spring of 2015.  Originally, Licensed Professional Counselors (LPCs) and Licensed Marriage and Family Therapists (LMFTs) were excluded from participating in the program because the original guidance required that all Choice providers be eligible to participate in Medicare.

This is the crux of the challenge: unfortunately, mental health professionals with licensure of LPCs and LMFTs are currently prohibited from being reimbursed under Medicare. As it stands, the only Masters-level mental health counselors eligible for reimbursement are Licensed Clinical Social Workers (LCSW), even though LPCs and LMFTs are recognized at the state level to be able to perform the same services.

The fact that LPCs are ineligible for reimbursement under Medicare is significant for several reasons. Federal agencies such as the Department of Defense and the Department of Veterans Affairs often require that mental health practitioners be required to be eligible for Medicare reimbursement, regardless of state licensure. By allowing LPCs to be included in this category, the overwhelming need for mental health professionals in these two agencies can be addressed.

Another challenge is that I often see veterans who are medically retired and have both Medicare and TRICARE. TRICARE requires that other health insurance be billed before TRICARE is billed; therefore, a veteran seeking services at our agency, who was medically retired due to a service-connected disability, is essentially barred from receiving services because the majority of our clinicians are not eligible to be reimbursed by Medicare.  

This is a challenge that many of the professional organizations that represent mental health counselors have been trying to overcome for many years. There have been changes, and significant ones, over the past five years. The problem remains, however, that there are veterans in need who are not receiving services because of their lack of ability to pay. Each of us, individually, has the ability to reach out to their local lawmakers and have a conversation about what changes need to be made to impact veteran mental health in our country.

Get involved in advocacy efforts. If you are a mental health professional, reach out to your professional representative organization and work with their advocacy branch. If you are a veteran, or support one, reach out to your local lawmaker or their veteran services liaison, and ask to have a discussion about what changes need to be made in order to reduce this particular barrier to mental health services. Change happens when enough of the population cares enough about a subject to be vocal about it, and this is certainly a change that absolutely needs to happen. 

Duane K. L. France is a combat veteran of Iraq and Afghanistan as well as a counselor working with veterans in Colorado. He is passionate about helping veterans achieve stability and wellness, as well as raising awareness about veteran mental health. Want to join in the conversation? Read more of his insights at 



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