Medicare Reimbursement

Improve Medicare Beneficiaries’ Access to Clinical Social Work Services

Download the 2019 Medicare Reimbursement Issue Brief


BACKGROUND

Across the country, millions of Medicare beneficiaries experience significant health and mental health challenges that clinical social workers (CSWs) are uniquely qualified to address. The beneficiary population is rapidly increasing in size, changing demographically, and coping with issues such as functional limitations, multiple chronic conditions, social isolation, economic insecurity, and ageism. Our health care system must be able to meet beneficiaries’ health and mental health needs. CSWs also are essential in meeting the needs of beneficiaries who have psychosocial concerns arising from medical diagnoses (such as depression or anxiety arising from a cancer diagnosis).1

CSWs are the largest group of mental health service providers in the United States and are among the professions that can bill Medicare Part B for mental health services.2 They 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 or jurisdiction of practice. They use a holistic approach in providing services, focusing on biological, psychological, and social factors. Third-party payers, including Medicare, reimburse them for the diagnosis and treatment of mental illness.

ACCESS TO CLINICAL SOCIAL WORK SERVICES FOR MEDICARE BENEFICIARIES

Increase Medicare Beneficiaries’ Access to Mental Health Services in Skilled Nursing Facilities (SNFs): Mental health concerns, such as depression and anxiety, are common among SNF residents, and SNFs frequently address these concerns by arranging for services from an independent mental health provider. However, beneficiaries who receive SNF services under Medicare Part A cannot simultaneously receive services from an independent CSW under Part B. This limits the pool of practitioners who can serve SNF residents, which is problematic given the high incidence of mental health conditions among SNF residents, and the high ratio of 120 residents to every medical social worker (who may not actually have received a social work degree). This access barrier exists because when SNF consolidated billing was implemented, psychiatrists’ and psychologists’ services were excluded from the Prospective Payment System, but CSW services were not. Medicare beneficiaries who transfer from a setting in which they receive mental health services from an independent CSW under Medicare Part B to a SNF, where they cannot receive such services, experience a disruption in care. Such care transitions can occur even if the beneficiary is moved within the same building or remains in the same bed. The reimbursement restriction also limits the pool of Medicare providers available to meet newly identified mental health needs of beneficiaries during a SNF stay. Correcting this will enhance beneficiaries’ access to mental health services in SNFs.

Increase Medicare Beneficiaries’ Access to Health and Behavior Assessment and Intervention (HBAI) Services: HBAI services help Medicare beneficiaries with emotional and psychosocial concerns that arise because of a medical condition (such as a diagnosis of cancer or an exacerbation of multiple sclerosis) and are unrelated to a mental health condition. Although beneficiaries can access Medicare Part B–reimbursed HBAI services from psychologists and psychiatrists, they cannot access them from independent CSWs. This access barrier exists because Medicare Part B reimbursement for independent CSW services is restricted to the diagnosis and treatment of mental illness. Expanding this definition to include HBAI services will remove the access barrier for beneficiaries.

Increase Medicare Reimbursement for Independent Clinical Social Workers: CSWs are among the few mental health professions that provide psychotherapy services for Medicare beneficiaries. Medicare reimburses CSWs at only 75% of the physician fee schedule. Psychiatrists and psychologists are reimbursed 100% of the fee schedule. The CSW rate is even lower than the 85% rate at which other non-physician practitioners (such as occupational therapists) are reimbursed. Mitigating this reimbursement inequity by increasing CSWs’ rates to 85% of the physician fee schedule will increase recruitment and retention of CSWs in the Medicare workforce, thereby expanding provider options for beneficiaries.

LEGISLATIVE SOLUTION: SUPPORT THE IMPROVING ACCESS TO MENTAL HEALTH ACT, S. 782/H.R. 1533

NASW urges Members of Congress to cosponsor and advance the Improving Access to Mental Health Act (S. 782/H.R. 1533). This legislation was introduced in a bipartisan manner by Senators Debbie Stabenow, MSW (D-MI), and John Barrasso, MD (R-WY), and has a companion House bill introduced by Representative Barbara Lee, MSW (D-CA-13). The legislation enhances Medicare beneficiaries’ access to the valuable services of independent CSWs in two scenarios:

» While residing in SNFs, even if they are accessing Medicare Part A

» While experiencing a psychosocial concern arising due to a medical condition

The Improving Access to Mental Health Act also increases the Medicare reimbursement rate for CSWs from 75% to 85% of the physician fee schedule, thereby mitigating reimbursement inequity.

1 Heisler, 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
2 Centers for Medicare & Medicaid Services. (n.d.). Mental health care: Outpatient. Retrieved from www.medicare.gov/coverage/mental-health-care-outpatient

For more information contact: Dina Kastner, MSS, MLSP dkastner.nasw@socialworkers.org » 202.336.8218


Access Frequently Asked Questions on the Improving Access to Mental Health Act