Increase Medicare Beneficiaries’ Access to Health and
Behavior Assessment and Intervention Services
April 2023
Issue Brief
BACKGROUND
Health and Behavior Assessment and Intervention (HBAI) services are a current benefit available to Medicare beneficiaries. HBAI services are used to identify and address the cognitive, emotional, behavioral, and social factors that are important to effective treatment or management of physical health problems that are unrelated to mental illness.
Clinical social workers (CSWs) are the largest group of mental health service providers in the United States[1] and are among the professions that can bill Medicare Part B for mental health services[2]. However, CSWs cannot currently bill Medicare for HBAI services, even though they are within their 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, recommended that federal agencies expand the scopes of practice of social workers in order 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 prevent 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.[3]
Ensuring access to qualified HBAI providers is critical to meeting the needs of the growing population of Medicare beneficiaries and reducing health care costs. More than 90% of the nation’s health care expenditures are for 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.[4] HBAI services help beneficiaries address challenges associated with these chronic illnesses, as well as with acute illnesses.
EXAMPLES
- A beneficiary with diabetes faces multiple challenges in understanding and managing the illness. HBAI services help the beneficiary identify and address emotional barriers to monitoring blood sugar levels, as well as familial resistance to changes in eating habits and lifestyle adjustments This support 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, attending medical appointments and communicating effectively with health care providers), preventing seizures (such as recognizing and avoiding triggers), and adjusting lifestyle (for instance, adjusting routine and reducing stress). 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 currently defines clinical social worker services narrowly and, in a manner, not representative of CSWs’ full scope of practice.[5]
To enhance Medicare beneficiaries’ access to HBAI services, the Social Security Act definition of “clinical social worker services” must be expanded to specifically include 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.[6]
The Improving Access to Mental Health Act includes language that would ensure CSW services explicitly include the provision of HBAI services to beneficiaries. This would both allow CSWs to be reimbursed for HBAI services under Medicare Part B and increase access to care for seniors.
LEGISLATIVE SOLUTION
The Improving Access to Mental Health Act (S. 838/H.R. 1638), introduced by Senators Debbie Stabenow (D-MI) and John Barrasso (R-WY) in the Senate and in the House by Representatives Barbara Lee (D-CA-12) and Brian Fitzpatrick (R-PA-01), expands the definition of “clinical social worker services” to include HBAI services.
Sources:
[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
[3] National 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
[4] Buttorff 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.
[5] Scope 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).
[6] Social Security Act, 42 U.S.C. § 1395x(hh)(2) (1989).