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Medicare Reimbursement

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Improve Medicare Beneficiaries’ Access to Clinical Social Work Services

Background

Clinical social workers (CSWs) are the largest group of mental health services providers in the United States and are recognized by federal law as one of five core mental health professions.1

CSWs have a graduate degree (master’s or doctorate) in social work, two years of postgraduate supervised experience in a clinical setting, and a clinical license in their state of practice. Third-party payers, including Medicare, reimburse CSWs for the diagnosis and treatment of mental illness. CSWs use a holistic approach in providing mental health and other services to Medicare beneficiaries, focusing on biological, psychological, and social factors.

Medicare Restrictions And Reimbursement Issues For CSWS

Access to Adequate Reimbursement Rates for CSWs:

CSWs are one of three mental health professions that provide psychotherapy services for Medicare beneficiaries. Medicare reimburses CSWs at only 75% of the rate reimbursed to psychiatrists and psychologists. This rate is even lower than the 85% other non-physician practitioners (such as physical therapists, physicians assistants, and occupational therapists) are reimbursed. This discrepancy deters CSWs from becoming Medicare providers and also makes it difficult to retain CSWs as Medicare providers, thereby decreasing Medicare beneficiaries’ access to mental health services. Thus, the reimbursement for CSWs needs to be updated to the rate of 85% of the physician fee schedule.

Access to Mental Health Services for Residents of Skilled Nursing Facilities:

When SNF consolidated billing was implemented, psychiatrists’ and psychologists’ services were excluded from the Prospective Payment System (PPS), but clinical social worker services were not excluded. Thus, CSWs cannot be reimbursed as independent Medicare Part B providers for mental health services delivered to beneficiaries receiving skilled nursing facility (SNF) services under Medicare Part A. This restriction limits continuity of mental health care for Medicare beneficiaries who transfer from a setting where they receive mental health services from a CSW to a SNF, where they cannot receive such services from their provider of choice. Such care transitions can occur even if the beneficiary is moved within the same building and even if a beneficiary remains in the same bed. The reimbursement restriction also impedes access to mental health care for beneficiaries who are not receiving mental health services from a CSW prior to SNF admission, but for whom a mental health need is identified during the SNF stay.

Access to Services That Help Medicare Beneficiaries Cope with Medical Conditions:

Unlike psychologists, CSWs are unable to bill Medicare Part B for critical Health and Behavior Assessment and Intervention (HBAI) services that help Medicare beneficiaries with the emotional and psychosocial concerns that arise because of a medical condition (such as a diagnosis of cancer or congestive heart failure), and which are unrelated to a mental health condition. CSWs should have access to use the HBAI Current Procedural Terminology (CPT) codes and should be reimbursed by Medicare for services that benefit Medicare beneficiaries and that fall within CSWs’ scope of practice under state licensure laws.
Learn more about HBAI codes.

LEGISLATIVE SOLUTION: SUPPORT THE IMPROVING ACCESS TO MENTAL HEALTH ACT OF 2017, H.R. 1290

CSWs’ work is at the heart of a strengthened mental health treatment system. NASW urges Representatives to cosponsor and support the Improving Access to Mental Health Act of 2017 (H.R. 1290). This legislation, introduced by Representative Barbara Lee, enhances Medicare beneficiaries’ access to mental health services in three ways:

  • ensures beneficiaries’ access to CSWs by increasing the Medicare reimbursement rate for CSWs to 85% of the physician fee schedule rate
  • ensures SNF residents’ access to CSWs by excluding CSW services from SNF consolidated billing
  • ensures beneficiaries’ access to Health and Behavior Assessment and Intervention (HBAI) services provided by CSWs.
Frequently Asked Questions

1 Heisler, E.J., & Bagalman, E. (2015). The mental health workforce: A primer. Retrieved from Congressional Research Service website:http://fas.org/sgp/crs/misc/R43255.pdf

For more information contact:

Dina Kastner, MSS, MLSP
dkastner.nasw@socialworkers.org
202.336.8218


http://www.socialworkers.org/advocacy/issues/medicare_reimbursement.asp
7/24/2017
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