Did you think that Medicare only covers individual therapy for older adults and people with disabilities? Think again.

You may be surprised to learn that Medicare will cover couples and family therapy – under certain conditions. This may be especially good news to the 83,635 Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) who enrolled as Medicare providers between January 1, 2024 (when they became eligible) and April, 2026.⁽¹⁾

How Medicare is LIKE private plans

LIKE private health plans that cover family and couples therapy,

• Medicare requires that one person be designated as the “Identified Patient” (IP) for the claim, notes, and treatment plan. This IP needs to have a diagnosis – and it must be more than a DSM “Z-code” as the primary or sole diagnosis
• Medicare policy states that “evaluations may include discussion with family or other sources in addition to the patient.”
• Medicare policy says “psychotherapy time may include face to face time with family members as long as the patient is present for part of the service.”
• Medicare states that other session attendees do not have to be the client’s legal relatives, but must be a member of the patient’s support system, such as a spouse, partner, significant other, or person who acts in a caregiving or support role, but this generally excludes professional caregivers.
• CPT codes are the same: 90847 for family or couples therapy with the patient present, and 90846 when the patient is not present; both are for sessions 26 minutes or more.

In fact, at times, Medicare’s coverage statements sound almost supportive of couples and family therapy

• “Family therapy is appropriate when intervention in the family interactions would be expected to improve or stabilize the patient’s emotional/behavioral disturbance.”
• “Family therapy is commonly the major treatment, especially for children and for the elderly.”
• “Where both husband and wife are covered by Medicare, such therapy may be the most effective treatment for both individuals.”

So, when WILL Medicare cover these sessions?

Here are some Medicare policy statements:

“Family psychotherapy services are covered only where the primary purpose of such psychotherapy is the treatment of the patient’s condition. Examples include:

• When there is a need to observe and correct, through psychotherapeutic techniques, the patient’s interaction with family members, and/or
• Where there is a need to assess the conflicts or impediments within the family, and assist, through psychotherapy, the family members in the management of the patient.”
• “In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder for example, the provider may contact relatives and close associates to secure background information to assist in diagnosis and treatment planning.”

But there are limits to Medicare’s generosity …

• “Family therapy will be considered medically reasonable and necessary only for treatment of the Medicare beneficiary’s mental illness and not the family member’s problems.”
• “Family psychotherapy without the patient present does not represent routine consultation with staff about the patient’s progress and treatment.” Medicare billing expert Susan Frager (psychbillingcoach.com) translates: “For example, if the clinician is working with nursing facility staff on managing the patient, or there’s a team meeting to review patient progress, that’s not billable to Medicare.”
• “Family therapy sessions with a patient whose emotional disturbance would be unaffected by changes in the patterns of family interaction … would not be considered medically reasonable and necessary.”
• ” … An emotional disturbance in a family member, which does not impact on the Medicare patient’s status, would not be covered by that patient’s Medicare benefits.”

Tips for family or couples therapy with a Medicare client

Medicare billing expert Susan Frager (psychbillingcoach.com) offers this guidance:

• If you’re providing relationship counseling and/or the chart reflects only couples issues along with an Adjustment Disorder diagnosis, your documentation may not support medical necessity, and you may fail an audit.
• Your treatment plan and interventions must focus on symptom reduction for the Identified Patient (IP). “It’s OK to include couples-based interventions, but if that’s ALL there is, this is likely to fail an audit,” says Frager.
• While Medicare does cover CPT 90846 sessions (therapy without the patient present), they might not cover treatment when ALL your visits are billed using this code.
• Be cautious about billing only family therapy codes (90847 and 90846) without providing and documenting individual sessions with the client.
• “If there’s no diagnosis in either partner and the couples counseling is strictly relationship-focused, Medicare won’t cover it, but Medicare clients can pay out of pocket,” says Frager. “You have to give them a Medicare Advance Beneficiary Notice of Noncoverage (ABN) Form.” The ABN informs clients that Medicare is expected to deny payment. “Be very clear on the ABN form why you believe the couples counseling doesn’t meet Medicare guidelines,” advises Frager. “Not giving a correctly-completed ABN in this situation could lead Medicare to order you to refund the client.”

Support is here for you

Working with couples is not only clinically challenging, but it can be difficult to navigate the added complexities in the areas of billing, documentation, and ethical practice. Check out my recorded course “Couples Therapy: Billing, Documentation, and Ethical Dilemmas.” It is guaranteed to make you rethink your policies with couples.

If you need expert consultation about Medicare billing and enrollment, contact Susan Frager for a consultation. Subscribe to her free e-newsletter here.

References:

• 1 – National Board for Certified Counselors, Inc. and Affiliates, April 29, 2026 Facebook post: https://www.facebook.com/NBCCandAffiliates/posts/we-are-excited-to-share-that-more-than-68000-mental-health-counselors-are-enroll/1527896062709667/
• Centers for Medicare and Medicaid Services, Local Coverage Determination, Psychiatry and Psychology Services, L34616, https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=34616
• Centers for Medicare and Medicaid Services, Local Coverage Determination, Psychiatry and Psychology Services, L35101, https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=35101