Frequently Asked Questions for the Expanding Seniors Access to Mental Health Services Act
Medicare Access
July 2025
Download the Frequently Asked Questions for the Expanding Seniors Access to Mental Health Services Act (S.1797/H.R. 3808)
The Expanding Seniors Access to Mental Health Services Act (S.1797/H.R. 3808), introduced in the Senate by Senators John Barrasso (R-WY) and Chris Coons (D-DE) and in the House by Representatives Brian Fitzpatrick (R-PA-01) and Paul Tonko (D-NY-20), improves Medicare beneficiaries’ access to health and mental health services provided by clinical social workers (CSWs) by:
- enabling beneficiaries residing in Skilled Nursing Facilities (SNFs) to obtain mental health services from CSWs under Medicare Part B; and
- updating the definition of “clinical social worker services” to include Health and Behavior Assessment and Intervention (HBAI) Services that CSWs are licensed to perform.
Skilled Nursing Facility Services
- Q: What is the difference between a SNF and a nursing home?
A: Although the terms “SNF” and “nursing home” are often used interchangeably, they are not identical. SNFs usually provide short-term care, often for rehabilitation after a hospital stay. Available SNF services include physical therapy (PT), occupational therapy (OT), and speech–language pathology (SLP) services; assistance with activities of daily living (ADLs), such as bathing and dressing, may also be provided. Nursing home services, which are often provided on a long-term basis, always include at least some ADLs and may include OT, PT, and SLP.
For Medicare beneficiaries, SNF services are reimbursed by Medicare Part A. In contrast, nursing home services tend to be paid out of pocket, through Medicaid, or through commercial long-term care insurance.
- Q: How many Medicare beneficiaries do SNFs serve?
A: In 2023, about 14,500 SNFs furnished about 1.6 million Medicare-covered stays to 1.2 million fee-for-service (FFS) beneficiaries.1
- Q: Why do SNF residents need outpatient mental health services from CSWs?
A: Some Medicare beneficiaries enter SNFs with pre-existing mental health conditions, such as depression or anxiety. Others develop such conditions during their stay. In either situation, mental health services are an important component of beneficiaries’ health care.
When beneficiaries are in SNFs, Medicare Part B covers outpatient mental
health services, that is, psychotherapy services provided by a licensed, independent mental health provider who is not on the SNF staff. However, Medicare Part B does not cover outpatient mental health services to SNF residents when those services are provided by CSWs, even though beneficiaries can obtain Medicare coverage for psychotherapy services from a CSW in settings such as nursing homes, assisted living residences, or outpatient offices.
- Q: Why can’t independent CSWs receive Medicare Part B reimbursement for mental health services provided to SNF residents?
A: The Balanced Budget Act (BBA) of 1997 mandated that payment for almost all services provided to Medicare beneficiaries during a SNF stay be included in a bundled prospective payment made through Medicare Part A. Thus, each SNF must bill the bundled services to the Part A Medicare Administrative Contractor in a consolidated bill. Medically related social services, which are provided by CSWs or other SNF staff, were included in this prospective payment system (PPS). When the BBA of 1997 was implemented, services provided by psychiatrists and psychologists were excluded from consolidated billing because psychiatry and psychology services were not included in the SNF PPS. However, CMS did not distinguish medically related social services provided by CSWs and discretionary psychotherapy services provided to residents with specialized needs. Thus, CSW services were not excluded from consolidated billing. Consequently, independent CSWs cannot seek reimbursement from Medicare Part B for psychotherapy services provided in a SNF. This inconsistency creates a barrier to mental health services for Medicare beneficiaries—a disparity that has grown even greater since the addition of licensed professional counselors (LPCs) and marriage and family therapists (MFTs) to the Medicare program with the same SNF billing privileges as psychiatrists and psychologists.
- Q: Can CSWs who provide Medicare Part B–reimbursed psychotherapy services to a Medicare beneficiary outside a SNF continue to provide those services under Part B when the beneficiary transfers to a SNF?
A: No. CSWs are not able to receive reimbursement from Medicare when a beneficiary transfers to a SNF. This barrier disrupts continuity of care for the beneficiary.
- Q: How does the Expanding Seniors Access to Mental Health Services Act assist Medicare beneficiaries receiving SNF services obtain access to psychotherapy services provided by independent CSWs?
A: S. 1797/H.R. 3808 excludes CSW services from SNF consolidated billing, thereby recognizing the qualitative difference between medically related social services provided by SNF staff to all residents and psychotherapy services provided by independent CSWs to residents on a discretionary basis. This change would bring about parity in beneficiaries’ access to psychotherapy services in SNFs.
Health and Behavior Assessment and Intervention (HBAI) Services
- Q: What are HBAI services?
A: HBAI services are cognitive, behavioral, social, and psychophysiological procedures designed to improve a beneficiary’s physical health and well-being. The services are provided to beneficiaries who present with an established physical illness or symptoms (such as a diagnosis of cancer or an exacerbation of multiple sclerosis) and do not have a diagnosed mental illness.
- Q: Social workers have been providing HBAI services in health care settings for several decades. What barrier does the Expanding Seniors Access to Mental Health Services Act address with respect to these services?
A: Because the Medicare definition of CSW services is restricted to the diagnosis and treatment of mental illness, beneficiaries have historically been unable to receive these vital services when provided by CSWs. In its 2024 Medicare Physician Fee Schedule (PFS) final rule, the Centers for Medicare and Medicaid Services (CMS) recognized the need for increased access to these services when the agency permitted CSWs to bill certain HBAI codes (namely, 96158, 96159, 96164, 96165, 96167, and 96168). Yet, this regulatory change is subject to amendment by any given administration. Moreover, CSWs remain unable to receive direct Medicare reimbursement for HBAI services associated with four codes: 96160, 96161, 96170, and 96171. Modifying the statutory definition of CSW services to include all HBAI services will both codify the changes CMS made in the 2024 PFS final rule and expand beneficiary access to the complete set of HBAI services provided by CSWs.
Specific Populations
- Q: How does S. 1797/H.R. 3808 help Medicare beneficiaries living with Alzheimer’s Disease or related dementias (ADRD)?
A: Regardless of setting, Medicare coverage of psychotherapy is based on the beneficiary’s cognitive ability to engage in therapy. Psychotherapy could be indicated to treat a beneficiary with adjustment disorder related to a new diagnosis of Alzheimer’s Disease, for example, for depression, anxiety, or other mental health conditions that may co-occur with ADRD. Depending on the CSW’s assessment (which includes the beneficiary’s goals), HBAI codes could be used for adjustment to a new diagnosis of dementia or to diagnosis or exacerbation of an unrelated medical condition, such as congestive heart failure. Thus, S.1797/H.R. 3808 will increase access to psychotherapy services in SNFs and to HBAI services for beneficiaries living with ADRD.
- Q: How does S. 1797/H.R. 3808 help Medicare beneficiaries who live with substance use disorders (SUDs) or substance misuse?
A: CSWs play an integral role in assessment and treatment of SUDs and substance misuse, and many have the state-specific credentials required to obtain third-party reimbursement for these services. Thus, S. 1797/H.R. 3808 will enhance Medicare beneficiaries’ access to treatment for substance misuse or SUDs.
1 Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Chapter 6. Skilled nursing facilities services. (2025, March). Retrieved from www.medpac.gov/document/march-2025-report-to-the-congress-medicare-payment-policy/