Medicare Reimbursement

Improving Access to Mental Health Act (S. 782/H.R. 1533)

Download the 2019 Medicare Reimbursement Issue Brief


Background


Across the country, millions of Medicare beneficiaries experience significant health and mental health challenges. 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. 

Clinical social workers (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.1 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. CSWs are currently able to bill Medicare Part B for the diagnosis and treatment of mental illness. However, they are not able to bill Medicare Part B for psychosocial services provided in skilled nursing facilities (SNFs) or for Health and Behavior Assessment and Intervention (HBAI) services, even though they are within CSWs’ scope of practice.

The National Academies of Sciences, Engineering, and Medicine in its September 2019 Consensus Study, Integrating Social Care Into the Delivery of Health Care, recommends that federal agencies expand the scopes of practice of social workers in order to build the workforce to address the social (e.g. 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 prevent and treatment of acute and chronic illnesses. The study also calls for the adequate payment of social workers to ensure a sufficient social care workforce.2

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 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.


Overview of Provisions


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.

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

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


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