Mental Health


Improve Medicare Beneficiaries’ Access to Clinical Social Work Services


According to the Substance Abuse and Mental Health Services Administration (SAMHSA), clinical social workers (CSWs) are the largest group of mental health services providers in the United States. There are more clinically trained social workers—over 200,000—than psychiatrists, psychologists, and psychiatric nurses combined.1 Federal law recognizes social work as one of five core mental health professions.2

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 nonphysician practitioners (such as physical therapists, physicians assistants, and occupational therapists) are reimbursed. This discrepancy deters CSWs from becoming Medicare providers, which, given the shortage of mental health providers and the growing need for mental health services, poses a barrier to Medicare beneficiaries’ health and well-being. The reimbursement for CSWs needs to be addressed and updated to the rate of 85% of the physician fee schedule.

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

Although CSWs have the expertise and knowledge to provide quality care, they are currently unable to 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 limits access to mental health care as well as continuity of 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. This can occur even if the beneficiary is moved within the same building, room, or bed.

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

Unlike psychologists and psychiatrists, CSWs are unable to bill Medicare Part B for critical health and behavior assessment and intervention (HBAI) services that help Medicare beneficiaries cope with the emotional and social concerns that arise because of a medical condition (such as a diagnosis of cancer or Alzheimer’s disease), 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.

Potential Policy Solutions

CSWs’ work is at the heart of a strengthened mental health treatment system. CSWs need to be included in Medicare Part B and be reimbursed at the same levels as other nonphysician practitioners. We urge Congress to

  • Promote payment for CSWs at the rate of 85% of the physician fee schedule to increase beneficiaries’ access to CSWs who are Medicare providers.
  • Introduce Medicare Beneficiary Mental Health Equity Act legislation to ensure Medicare beneficiaries have access to quality care provided by CSWs, including in SNFs.

1 Substance Abuse and Mental Health Services Administration. (2013). Behavioral health, United States, 2012 (HHS Publication No. SMA 13-4797).

2 Congressional Research Service. (2014). The Mental Health Workforce: A Primer.
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