4
Independent and Supervised Practice of Counselors in Other Health-Care Systems

As part of the committee’s statement of task, the Department of Defense requested that it assess the extent to which mental health counselors are authorized to practice independently under some federal programs other than TRICARE and under the Federal Employee Health Benefits Program (FEHBP). It was also asked to identify the states that had laws requiring private insurers to cover, or offer coverage of, the services of licensed mental health counselors. This chapter addresses those topics.

INDEPENDENT AND SUPERVISED PRACTICE UNDER OTHER FEDERAL PROGRAMS

The statement of task identified four federal programs for attention: Medicare, the Department of Veterans Affairs (VA) program, the Indian Health Service (IHS) program, and Head Start (HS). The text below briefly reviews their policies and those of the US Public Health Service (PHS) regarding the practice of counselors.

Medicare

Practice Under Medicare

Medicare is a federally administered health insurance program for people 65 years old or older, people under 65 years old who have speci-



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4 Independent and Supervised Practice of Counselors in Other Health-Care Systems A s part of the committee’s statement of task, the Department of Defense requested that it assess the extent to which mental health counselors are authorized to practice independently under some federal programs other than TRICARE and under the Federal Employee Health Benefits Program (FEHBP). It was also asked to identify the states that had laws requiring private insurers to cover, or offer cover- age of, the services of licensed mental health counselors. This chapter addresses those topics. INDEPENDENT AND SuPERvISED PRACTICE uNDER OTHER FEDERAL PROgRAMS The statement of task identified four federal programs for attention: Medicare, the Department of Veterans Affairs (VA) program, the Indian Health Service (IHS) program, and Head Start (HS). The text below briefly reviews their policies and those of the US Public Health Service (PHS) regarding the practice of counselors. Medicare Practice Under Medicare Medicare is a federally administered health insurance program for people 65 years old or older, people under 65 years old who have speci- 

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE fied disabilities, and people of any age who have permanent kidney failure (CMS, 2009). The program covers the cost of mental health–care visits with physicians, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician’s assistants (CMS, 2002). Those health-care professionals are recognized as independent providers of mental health services under Medicare regulations. Medicare does not recognize licensed professional counselors as independent providers, so they are not directly reimbursed through the program. Provisions in several bills that have been introduced in the House of Representatives and the Senate would have added counselors and some other mental health professionals to those eligible to provide services (CRS, 2007), but the provisions have not been enacted into law. As of October 1, 2009, bills that would grant that authority were under consideration in both chambers (HR 1693 and S 671). Medicare beneficiaries can receive services from counselors in two ways. They can visit practitioners and pay for the expense out of pocket, or the counselors can provide treatment through the Part B “incident to” clause. The latter method allows counselors to bill Medicare through physicians or psychologists. To be covered by the clause, a service must be an integral, although incidental, part of a physician’s or psychologist’s services; the counselor must work in the same facility as a physician or psychologist (as either an employee or independent contractor of the physician or psychologist or the facility); and the counselor must be under the supervision of the physician or psychologist. Supervision means that “the physician/psychologist must be present in the facility and immediately available to provide assistance and direction while the aide is performing services” (ACA, 2009a). The physician, psychologist, or facility bills Medicare for the service, and the counselor is paid as an employee or contractor of the physician, psychologist, or facility. Association Between Independent Practice Authority Under the Medicare Program and Under TRICARE The committee’s statement of task directed it to review the relation- ship, if any, between recognition of mental health professions under the Medicare program and independent practice authority for such professions under the TRICARE program. Only one non-doctoral-level mental health profession—clinical social work—has been granted inde- pendent practice authority by both TRICARE and Medicare. Clinical

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 InDEPEnDEnT AnD SUPERVISED PRACTICE oF CoUnSELoRS social workers were first granted authority under TRICARE in the FY 1983 Department of Defense Authorization Act (Public Law 97-252) and were later granted recognition under Medicare in the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239). Congress directed the authority to be granted in both circumstances. Marriage and family therapists have been granted independent practice authority only under TRICARE, through a provision of the FY 1991 Department of Defense Authorization Act (Public Law 101-510); they have not been granted recognition under Medicare. Licensed professional counselors have not been granted independent practice authority under either TRICARE or Medicare. Department of veterans Affairs VA, through programs of the Veterans Health Administration, pro- vides a comprehensive array of health-care services to about 7.9 million enrollees (VA, 2009). In December 2006, the Veterans Benefits, Health- care, and Information Technology Act was signed into law (Public Law 109-461). It established the recognition of mental health counselors as mental health–care specialists under health-care programs operated by VA. It also established the recognition of licensed marriage and family therapists as mental health–care providers. Although VA has long employed rehabilitation counselors to provide readjustment-counseling services to veterans, it did not previously recognize these professional groups. The new law allows VA to hire licensed mental health coun- selors at the same level as clinical social workers and allows counselors to apply for supervisory positions that are open to clinical social workers and marriage and family therapists. Rather than placing them in the same occupational category as other mental health professionals, the VA Under Secretary for Health approved, in February 2009, the creation of a new occupational category or categories for licensed professional counselors and marriage and family therapists to be hired by VA (ACA, 2009b). Details of those categories had not been established at the time the present report was completed. Indian Health Service IHS is an agency in the Department of Health and Human Ser- vices (HHS). It is the principal federal health-care provider and health

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE advocate for American Indians and Alaska Natives and is responsible for providing federal health services to about 1.9 million people who belong to 562 federally recognized tribes in 35 states. The goal of IHS is “to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people” (IHS, 2009c). Because this population experiences considerable disparities with regard to psychological health compared with the general population and because over one-third of the service demands in IHS facilities are related to mental health and sub- stance abuse, IHS behavioral health programs are particularly important to the population. IHS will accept a state license and the stipulated scope of practice for the license as criteria for the delivery of services in IHS facilities. In addition, individual credentialing agencies can further define and limit the scope of practice for some professionals, including advanced-practice nurses and other allied-health professionals in the federal system. Over 60% of mental health treatment and almost all substance-abuse coun- seling takes place at the tribal level (IHS, 2009a). IHS credentialing standards serve as the base guidelines for tribes, but they are able to establish additional or different standards if they choose. Regardless of the standards used, the focus is always on the scope of practice, particu- larly at the credentialing level. Behavioral health programs in IHS include community-oriented clinical and preventive services. The delivery of needed services is complex, however, and often divided among tribal, federal, state, local, and community-based providers. In addition, the availability of ser- vices varies among communities; those who live in rural areas are most adversely affected by problems of availability and lack of appropriate care. Overall, the behavioral health needs of this population are largely unmet, and adequate services are scarce and access to appropriate care difficult and expensive (IHS, 2009a). The policy of IHS is to use interdisciplinary mental health teams that comprise representatives of several mental health disciplines to pro- vide comprehensive services to the American Indian and Alaska Native population. Mental health providers identified in IHS include psychia- trists, psychologists, psychiatric nurses, psychiatric social workers, other social scientists, and mental health technicians. IHS policies stipulate that all mental health staff working in IHS facilities must meet the minimum educational requirements set forth by the Civil Service or

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 InDEPEnDEnT AnD SUPERVISED PRACTICE oF CoUnSELoRS Commissioned Corps. Mental health professionals and consultants must also be licensed in accordance with existing PHS requirements, which stipulate that all health-care providers must be licensed, certified, or registered in their disciplines (PHS-CC, 2008a). Clinical privileges are recommended for mental health technicians, mental health counselors, and psychiatric nurses and allow them to provide clinical mental health services independently of physician supervision. Licensing and credentialing standards for mental health professionals in IHS center on educational requirements, but clinical privileging standards have also been established for IHS providers on the basis of licensure, training, experience, and current competence “for all indi- viduals who are permitted by law and by a facility to provide patient care services independently in a facility whether or not they are members of the medical staff ” (IHS, 2009b). Clinical privileges are granted and maintained on the basis of demonstrated clinical competence, including an assessment of relevant findings from quality-assurance activities, peer recommendations, measured assurance that people consistently provide services within the scope of their privileges, a review of privileges at least every 2 years, and established procedures for the denial, limitation, or change in clinical privileges granted to any health-care provider. In addition to retaining their clinical privileges, mental health professionals must participate in continuing education to maintain their licensure and to continue pro- viding services in IHS facilities. Head Start HS is a national program administered by HHS that “promotes school readiness by enhancing the social and cognitive development of children through the provision of educational, health, nutritional, social and other services to enrolled children and families” (HHS, 2009). Although the program does not have a formal policy regarding the use and independent practice of licensed professional counselors, it follows the rules of the states in which mental health services are being provided. HS provides grants to local agencies that agree to follow HS regulations in implementing their programs. The grantees determine how they will use their grant funds on the basis of local needs and resources but must ensure that they meet HS regulations regarding making mental health consultation available onsite. HS program-performance standards (fed-

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE eral regulations) require that a grantee’s mental health services be sup- ported by staff or consultants who are licensed or certified mental health professionals with experience and expertise in serving young children and their families. Programs must recognize that state licensure and certification sys- tems review a professional’s training and experience and describe the scope of services that a professional is qualified to provide to children and families in the states. HS grantees are not required to provide all mental health services that a child may need but are encouraged to identify local mental health resources that can provide such services. Overall, HS does not act as a primary provider of mental health services but rather as a funder of entities that may then contract themselves out to provide services. Some other entities that may fund provision of services under specific circumstances—Medicaid, for example—may have their own policies and procedures that drive the scope of practice or billing rules. uS Public Health Service The Commissioned Corps of PHS is one of the seven uniformed services of the United States. Among its primary missions is to provide health care to underserved populations. Its officers are placed in various career fields—such as medicine, nursing, dentistry, and environmental health—depending on their training (PHS-CC, 2009a). One field, health services, includes a variety of professionals, including such clini- cal specialists as psychologists, social workers, physician assistants, and optometrists and such nonclinical specialists as hospital administrators (PHS-CC, 2008c). The Corps has a goal of expanding its active-duty strength to 6,600 officers. Some 5% of that number, or 330, are to be officers in the men- tal health functional group (PHS-CC, 2009b). As of May 15, 2007, the Corps had 108 clinical social workers and 14 clinical psychologists in its health-services field (PHS-CC, 2007). Psychiatrists and psychiatric nurses also serve in the Corps, but their numbers are not publicly avail- able (PHS-CC, 2009c). The title “licensed professional counselor” is not listed among its professional categories.

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 InDEPEnDEnT AnD SUPERVISED PRACTICE oF CoUnSELoRS INDEPENDENT AND SuPERvISED PRACTICE uNDER THE FEDERAL EMPLOYEE HEALTH BENEFITS PROgRAM Overview of the Program The FEHBP was established by law in 1959 and became active in 1960 (OPM, 2009d).1 It is administered by the Office of Personnel Management (OPM) and provides federal employees and eligible family members with a variety of privately run, government-subsidized insur- ance plans. Among the plan types are fee-for-service (FFS) plans, high- deductible health plans, and health maintenance organization (HMO) plans (OPM, 2009c). The selection of plans available to a particular employee depends both on geographic area and on the employing gov- ernment organization. Plans may not turn down employees or eligible family members because of preexisting medical conditions (OPM, 2009f ). In general, costs of the plan are split between the employee and the federal govern- ment; the government pays the smaller of 75% of the chosen plan cost or 72% of the average plan cost of all FEHBP enrollees (OPM, 2009b). Most federal employees are eligible for the FEHBP; exceptions are made for intermittent or temporary employees and employees of specific organizations, such as the Tennessee Valley Authority (OPM, 2009a). On retirement, qualified employees may continue enrollment in their current plan (OPM, 2009f ). The FEHBP offers 10 FFS benefit plans that are available nation- wide to all enrollees: the American Postal Workers Union “high,” Blue Cross and Blue Shield “standard” and “basic,” Government Employees Hospital Association “standard” and “high,” Mail Handlers “standard” and “value,” National Association of Letter Carriers “high,” and Special Agents Mutual Benefit Association “standard” and “high.” Each of those plans provides comprehensive coverage and has separate provider networks for which in-network providers have reduced costs. All plans offer international coverage (OPM, 2009f ). Four other FFS benefit plans available nationwide through the FEHBP are sponsored by employee organizations, and enrollment is strictly limited to members of the organizations: Association “high,” The FEHBP was established by Public Law 86-382. Current laws and regulations are 1 found in 5 USC Chapter 89, 5 CFR Part 890, and 48 CFR Chapter 16.

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE Foreign Service “high,” Panama Canal Area “high,” and Rural Carrier “high” (OPM, 2009f ). Finally, the FEHBP includes a set of plans that are available only to subscribers in particular states. The number of plans and the services offered vary widely among the states. For example, eligible California residents have a choice of plans available through Aetna, Blue Cross, Blue Shield, Health Net, Kaiser Foundation, PacifiCare, and UnitedHealthcare; Texas residents have access to Aetna, Firstcare, Humana, PacifiCare, and UnitedHealthcare plans; and Pennsylvania residents can choose from Aetna, Geisinger, HealthAmerica, Keystone, and University of Pittsburgh Medical Center plans (OPM, 2009g). The coverage area, including the number of states where coverage is offered, varies among plans. Altius Health Plans, for example, limits coverage to subscribers in particular sections of Utah, Idaho, and Wyoming, while Aetna Healthfund provides insurance plans in all 50 states and the District of Columbia (Table 4.1). The mental health services and providers covered by the plans differ by care organization, options purchased, and the state in which the plan was purchased. It may also vary from year to year. Program Policies Regarding Independent Practice The law governing the FEHBP lists licensed health-care providers whom plan enrollees must be free to see without physician referral or supervision (Table 4.2; 5 USC § 8902(k)(1)). HMO plans are exempted from the rule because a key feature of them is that a primary-care provider coordinates and refers specialist care (5 USC § 8902(k)(3)). Qualified clinical social workers—defined as those who have met state licensing requirements, national certification requirements in the absence of state licensing procedures, or “equivalent requirements” as determined by OPM—are among the providers whose services without physician supervision or referral must be covered (5 USC § 8901(11)). Except in states designated by OPM as underserved (Table 4.3), FEHBP plans are not explicitly required to cover licensed professional counsel- ors, although the law allows insurance plans to voluntarily cover other health professionals’ (including counselors’) services without physician supervision or referral, provided that the professionals are appropriately licensed or certified by state or federal law (5 USC § 8902(k)(1) and (2)). In underserved states, FFS, but not HMO, plans must cover all state-

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 InDEPEnDEnT AnD SUPERVISED PRACTICE oF CoUnSELoRS TABLE 4.1 Coverage of Licensed Mental Health Counselors in FEHBP Nationwide and Selected State Insurance Plans Licensed Mental FEHBP Health 2010 Federal Plan Counselors Plan Details (Provider Definitions or Insurance Plans Codes Coverage Listed Benefits) NATIONWIDE FEE-FOR-SERVICE PLANS—OPEN TO ALL Blue Cross and 10, 11 Yes Mental health or substance-abuse Blue Shield professional: a professional who is Service Benefit licensed by the state where the care is Plan provided to provide mental health or substance-abuse services within the scope of the license Benefits include professional services, including individual or group therapy, provided by licensed professional mental health practitioners and substance-abuse practitioners when acting within the scope of their licenses Government 31, 34 Yesa Benefits include individual or group Employees therapy by psychiatrists, psychologists, Hospital clinical social workers, licensed Association professional counselors, and marriage and Benefit and family therapists High Deductible Health Plans National 32 Noa Benefits include outpatient professional Association of services, including individual or Letter Carriers group therapy by such providers as psychiatrists, psychologists, and clinical social workers Mail Handlers 41, 45, Yes Benefits include outpatient professional Benefit Plan 48 services, including individual or group Value and therapy by providers approved by the Consumer managed in-network vendor; may Option include services by a licensed professional counselor or licensed marriage and family therapist continued

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 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE TABLE 4.1 Continued Licensed Mental FEHBP Health 2010 Federal Plan Counselors Plan Details (Provider Definitions or Insurance Plans Codes Coverage Listed Benefits) Special Agents 44 Yesa Benefits include outpatient professional Mutual Benefit services by such providers as Association psychiatrists, psychologists, and clinical social workers American Postal 47 Yes Benefits include professional services, Workers Union including individual or group therapy Health Plan by such providers as psychiatrists, psychologists, licensed social workers, and licensed intensive outpatient treatment centers NATIONWIDE FEE-FOR-SERVICE PLANS—OPEN ONLY TO SPECIFIC GROUPS Rural Carrier 38 Yesa Qualified clinical psychologist: a person Benefit Plan who has earned a doctoral or master’s Specific Areas clinical degree in psychology or an allied discipline and who is licensed or certified in the state where services are performed; this presumes that a licensed person has demonstrated to the satisfaction of state licensing officials that he or she, by virtue of academic and clinical experience, is qualified to provide psychological services in the state Foreign Service 40 Yes Qualified clinical psychologist: a Benefit Plan person who has earned a doctoral or Specific Areas master’s clinical degree in psychology or an allied discipline and who is licensed or certified in the state where services are performed (such as licensed professional counselors)

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 InDEPEnDEnT AnD SUPERVISED PRACTICE oF CoUnSELoRS TABLE 4.1 Continued Licensed Mental FEHBP Health 2010 Federal Plan Counselors Plan Details (Provider Definitions or Insurance Plans Codes Coverage Listed Benefits) Association 42 Yes Qualified clinical psychologist: a person Benefit Plan who has earned a doctoral or master’s Specific Areas clinical degree in psychology or an allied discipline and who is licensed or certified in the state where services are performed; this presumes that a licensed person has demonstrated to the satisfaction of state licensing officials that he or she, by virtue of academic and clinical experience, is qualified to provide psychological services in the state Panama Canal 43 Noa Benefits include outpatient services, Area Benefit Plan including individual or group therapy Specific Areas by such providers as psychiatrists, psychologists, and clinical social workers SELECTED STATE-SPECIFIC INURANCE PLANS UnitedHealthcare E9 Yesa Benefits include professional services, Insurance including individual or group therapy Company, Inc., by such providers as psychiatrists, serving AR, AZ, psychologists, and clinical social CA, CO, DC, workers FL, GA, IA, IL, KS, LA, MD, MO, MS, NC, NM, NV, OH, OK, OR, RI, TN, TX, VA, WA, WI continued

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0 MEnTAL HEALTH CoUnSELInG SERVICES UnDER TRICARE TABLE 4.1 Continued Licensed Mental FEHBP Health 2010 Federal Plan Counselors Plan Details (Provider Definitions or Insurance Plans Codes Coverage Listed Benefits) Aetna 22 Yesa Benefits include individual and group HealthFund, therapy performed by such licensed serving AK, AL, providers as psychiatrists, psychologists, AR, AZ, CA, and clinical social workers CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY Altius Health 9K Yesa Benefits include professional services, Plans, serving including individual or group therapy Utah (northern by such providers as psychiatrists, and southern psychologists, and clinical social parts of Utah), workers Idaho (Boise and eastern parts of Idaho), and Wyoming (Uinta County) Publicly available sources did not specify whether the services of licensed mental a health counselors were covered. Listed information was obtained via telephone calls to company representatives.

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 InDEPEnDEnT AnD SUPERVISED PRACTICE oF CoUnSELoRS TABLE 4.2 Licensed Health-Care Providers Whose Services Must Be Covered by FEHBP Plans Without Requiring Physician Referral or Supervisiona Clinical psychologist Nursing-school–administered clinic Optometrist Nurse practitioner or clinical specialist Nurse midwife Qualified clinical social worker This list is found under 5 USC § 8902(k)(1). HMOs are exempt from these a requirements, under 5 USC § 8902(k)(3). TABLE 4.3 States Designated as Medically Underserved by OPM for 2009a Alabama Louisiana North Dakota Arizona Mississippi South Carolina Idaho Missouri South Dakota Illinois Montana Wyoming Kentucky New Mexico a Determinations of underserved status are made annually by OPM. The definition of medically underserved is found in 6 USC § 254e. licensed medical providers although the law does not indicate whether physician supervision or referral is necessary (OPM, 2009e). Because there is no federal licensing process for mental health counselors, an FEHBP plan that wishes to recognize counselors can do so only in accordance with the laws and regulations of the states where they practice. The Foreign Service Benefit Plan, for example, is an FFS FEHBP plan that includes state-licensed professional counselors among its covered providers (AFSPA, 2009, p. 10). Being an FFS plan, it allows enrollees to visit any covered provider, including counselors, without first obtaining a referral from a physician. That particular plan, however, requires preauthorization for any mental health treatment besides medi- cation management (AFSPA, 2009, p. 48). Table 4.1 lists the federal FFS plans and a sample of state plans and shows which plans include coverage for licensed mental health counselors. State Laws, Regulations, and Policies Regarding Independent Practice States differ in their laws, regulations, and policies regarding the independent practice of counselors. An April 2009 presentation to

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162 MENTAL HEALTH COUNSELING SERVICES UNDER TRICARE the committee noted that 14 states require health plans to cover the services of licensed counselors and another six require plans to offer coverage; these are listed in Table 4.4 (Kaplan, 2009). Arkansas and Michigan laws include so-called “any-willing-provider”2 provisions that include counselors. More generally, the scope of practice and range of services allowed vary in both their details and specificity. Alabama law, for example, provides relatively general guidance, stipulating that [t]he use of specific methods, techniques, or modalities within the practice of a Licensed Professional Counselor is restricted to coun- selors appropriately trained in the use of these methods, techniques, or modalities. A licensed professional counselor or associate licensed counselor shall not attempt to diagnose, prescribe for, treat, or advise a client with reference to problems or complaints falling outside the boundaries of counseling services. (Alabama Board of Examiners in Counseling, 2003) Nebraska, in contrast, allows only persons who hold the more rigor- ous Independent Mental Health Practitioner license to perform diagno- ses. That license requires 3,000 hours of experience under supervision, “one-half of which is comprised of experience with clients diagnosed under the major mental illness or disorder category” (Nebraska Depart- ment of Health and Human Services, 2007). The illnesses and disorders are defined elsewhere as schizophrenia, major depressive disorder, bipo- lar disorder, delusional disorder, psychotic disorder, panic disorder, and obsessive-compulsive disorder (Nebraska Department of Health and Human Services Regulation and Licensure, 2004). The array of services offered is constrained in some states. For example, California, which is scheduled to begin to license counselors in 2011, does not include the assessment or treatment of couples or families in a professional clinical counselor’s scope of practice unless the counselor “has completed all of the following additional training and education, beyond the minimum training and education required for licensure” (California State Senate, Senate Bill 788, 2009). Any-willing-provider legislation requires that health plans accept any health-care 2 provider who agrees to conform to the plans’ conditions, terms, and reimbursement rates (Carroll and Ambrose, 2002).

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 InDEPEnDEnT AnD SUPERVISED PRACTICE oF CoUnSELoRS TABLE 4.4 States That Require Coverage or the Offering of Coverage of Counselors’ Services States That Require Coverage Arkansas New Hampshire Virginia Connecticut Rhode Island Washington Maryland South Dakota Wyoming Massachusetts Texas Montana Utah States That Require That Coverage Be Offered Illinois Louisiana Missouri Kansas Maine Vermont States with Any-Willing-Provider Laws Addressing Counselors Arkansas Michigan SOURCE: Adapted from Kaplan (2009). Terminology also varies. Notably, Maine licenses Professional Counselors and Clinical Professional Counselors: both are permitted to “engage in private/independent practice” (Maine Office of Licensing and Registration, 2009), but only persons holding clinical licenses may “diagnose and treat mental health disorders” (Maine Revised Statues, Title 32, Chapter 119, § 13858). All states allow counselors to practice independently at some level of licensure. Supervised practice is required for persons who hold “conditional,” “intern,” “provisional,” and like-titled licenses in the states that offer them. Those licenses are intended for persons who are beginning their professional careers and seeking to accumulate the experience needed for higher-level licenses and national certifications. Rules regarding whether counselors can perform diagnoses are more complicated. Most states explicitly include diagnosis in the scope of practice delineated in law or regulation. Three—Georgia, Idaho, and Illinois—do not use the term, and this leads to uncertainty. Maine and New Mexico permit those holding clinical licenses to perform diagnoses, Indiana prohibits counselors from making diagnoses but allows them to perform classifications according to the Diagnostic and Statistical Manual of Mental Disorders, and Nebraska permits only those hold- ing licensure as a Licensed Independent Mental Health Practitioner to perform diagnoses.

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