Increase Medicare Beneficiaries’ Access to Health Behavior Assessment and Intervention Services

Medicare Access

September 2025

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Background

Medicare beneficiaries living with physical health conditions often benefit from Health Behavior Assessment and Intervention (HBAI) services. HBAI services identify and address the cognitive, emotional, behavioral, and social factors that are important to effective treatment or management of physical health conditions that are unrelated to mental illness.

Clinical social workers (CSWs) are one of the largest groups of mental health service providers in the United Statesⁱ and are among the professions that can bill Medicare Part B for mental health services.ⁱⁱ The Centers for Medicare & Medicaid Services (CMS) permitted CSWs to bill Medicare for services associated with certain HBAI codes as part of its Calendar Year (CY) 2024 Medicare Physician Fee Schedule (PFS) Final Rule.

Modifying the statutory definition of CSW services to include all HBAI services for Medicare beneficiaries will both codify the changes CMS made in the CY 2024 PFS Final Rule and ensure beneficiary access to the complete set of HBAI services provided by CSWs.

Social work practice embraces whole person care, which aligns with HBAI services. CSWs training, principles, and scope of practice equip them to provide services associated with HBAI codes, such as conducting biopsychosocial assessments and family interventions.

Expanding access to qualified HBAI service providers is critical both to meeting the needs of the growing population of Medicare beneficiaries and to reducing health care costs. More than 90% of the nation’s health care expenditures are for treatment of chronic illnesses, such as heart disease, diabetes, and cancer. Millions of Medicare beneficiaries live with chronic illness, and most live with two or more chronic conditions.ⁱⁱⁱ HBAI services help beneficiaries address challenges associated with these chronic illnesses, as well as with acute illnesses.

Furthermore, expanding Medicare beneficiaries’ access to HBAI services provided by CSWs is consistent with recommendations of the National Academies of Sciences, Engineering, and Medicine. In its 2019 consensus study Integrating Social Care into the Delivery of Health Care, the National Academies recommended that federal agencies expand the scopes of practice of social workers to build the workforce to address the social (that is, non-medical) factors that play a key role in health outcomes. These factors, also called the social determinants of health, include stable housing, reliable transportation and economic security. There is consistent and compelling evidence that addressing the social factors in health is critical in improving prevention and treatment of acute and chronic illnesses. The study also called for the adequate payment of social workers to ensure a sufficient social care workforce.^iv

Examples

• A beneficiary with diabetes faces multiple challenges in understanding and managing the illness. HBAI services help the beneficiary identify and address not only emotional barriers to monitoring blood sugar levels, but also familial resistance to the beneficiary’s need for changes in eating habits and lifestyle. This support of HBAI services can prevent stroke or amputation and the substantial health care costs associated with complications from diabetes.
• A beneficiary with a recent epilepsy diagnosis faces social and emotional barriers to managing treatment. For example, the beneficiary has difficulty attending medical appointments and communicating effectively with health care providers; recognizing and avoiding factors that can trigger seizures; and incorporating lifestyle changes, such as stress reduction and adjustment of daily routine. HBAI services, which include psychoeducation, help the beneficiary identify and address these barriers.

Solution: Expand Definition of "Clinical Social Worker Services" in the Social Security Act

For purposes of independent reimbursement under Medicare Part B, the Social Security Act defines “clinical social worker services” narrowly, in a manner not representative of CSWs’ full scope of practice.^v Expanding this definition to include HBAI services would enhance Medicare beneficiaries’ access to HBAI services.

The current Medicare statute—Section 1861(hh)(2) of the Social Security Act—reads:

The term “clinical social worker services” means services performed by a clinical social worker for the diagnosis and treatment of mental illness . . . which the clinical social worker is legally authorized to perform under state law in which such services are performed as would otherwise be covered if furnished by a physician or an incident to a physician’s professional service.^vi

The Expanding Seniors Access to Mental Health Services Act amends this definition to include HBAI services. Enactment of this change would allow CSWs to be reimbursed for HBAI services under Medicare Part B, thereby increasing access to care for older adults and people with disabilities.

Legislative Solution

The Expanding Seniors Access to Mental Health Services Act (S. 1797/H.R. 3808), introduced by Senators John Barrasso (R-WY) and Chris Coons (D-DE) in the Senate and in the House by Representatives Brian Fitzpatrick (R-PA-01) and Paul Tonko (D-NY-20), expands the definition of “clinical social worker services” to include HBAI services.

ⁱHeisler, E. J. (2018, April). The mental health workforce: A primer (Congressional Research Service report R43255). Retrieved from https://fas.org/sgp/crs/misc/R43255.pdf
ⁱⁱCenters for Medicare & Medicaid Services. (n.d.). Mental health care: Outpatient. Retrieved from www.medicare.gov/coverage/mental-health-care-outpatient
ⁱⁱⁱButtorff C, Ruder T, Bauman M. Multiple Chronic Conditions in the United States. Santa Monica, CA: Rand Corp.; 2017. Center for Medicare & Medicaid Services. National Health Expenditure Data for 2016.
^ivNational Academies of Science, Engineering and Medicine. (2019, September). Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Retrieved from http://nationalacademies.org/hmd/Reports/2019/integrating-social-care-into-the-delivery-of-health-care
^vScope of Medicare Benefits and Application of the Outpatient Mental Health Treatment Limitation to Clinical Psychologist and Clinical Social Worker Services Rule, 42 C.F.R. § 410.73 (1998).
^viSocial Security Act, 42 U.S.C. § 1395x(hh)(2) (1989).