Medicare Reimbursement

Improve Medicare Beneficiaries’ Access to Clinical Social Work Services


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Background


Clinical social workers 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

Clinical social workers 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 clinical social workers for the diagnosis and treatment of mental illness. Clinical social workers 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 Clinical Social Workers


Access to Adequate Reimbursement Rates for Clinical Social Workers:
Clinical social workers are one of three mental health professions that provide psychotherapy services for Medicare beneficiaries. Medicare reimburses clinical social workers 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 clinical social workers from becoming Medicare providers and also makes it difficult to retain clinical social workers as Medicare providers, thereby decreasing Medicare beneficiaries’ access to mental health services. Thus, the reimbursement for clinical social workers 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 Skilled Nursing Facility (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, clinical social workers cannot be reimbursed as independent Medicare Part B providers for mental health services delivered to beneficiaries receiving 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 clinical social worker 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 clinical social worker 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, clinical social workers 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. Clinical social workers 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 clinical social workers’ scope of practice under state licensure laws.

Leglative Solution: Support the Improvinig Access to Mental Health Act, S. 2613/H.R. 1290


Clinical social workers’ work is at the heart of a strengthened mental health treatment system. NASW urges Representatives and Senators to cosponsor and support the Improving Access to Mental Health Act (S. 2613/ H.R. 1290). This bipartisan legislation in the Senate, introduced by Senators Debbie Stabenow (D-MI) and John Barrasso (R-WY) along with the companion House bill introduced by Representative Barbara Lee (D-CA-13), enhances Medicare beneficiaries’ access to mental health services in three ways:

  • Ensures beneficiaries’ access to clinical social workers by increasing the Medicare reimbursement rate for clinical social workers to 85% of the physician fee schedule rate.
  • Ensures SNF residents’ access to clinical social workers by excluding clinical social work services from SNF consolidated billing.
  • Ensures beneficiaries’ access to HBAI services provided by clinical social workers..

References


1. Heisler, E.J., & Bagalman, E. (2015). The mental health workforce: A primer, Congressional Research Service

Issue: Enable Medicare Beneficiaries’ Access to Health and Behavior Assessment and Intervention Services from Clinical Social Workers

Improving Access to Mental Health Act of 2015 (S. 2173/H.R. 3712) FAQ