Below is an excellent summary of the legal protections for telehealth services, including behavioral health treatment, in all 50 states and District of Columbia (seven states do not have laws about telehealth coverage including AL, ID, PA, NC, SC, WI, WY) put together by the law firm of Foley and Lardner. The link is https://www.foley.com/-/media/files/insights/publications/2021/02/21mc30431-50state-telemed-reportmaster-02082021.pdf
The areas covered include state laws about coverage for telehealth and audio-only treatment; reimbursement requirements; how long coverage will last; the actual language of the laws in each state; and more.
Even if you think you know your state’s laws about telemental health, this is a good review and offers ways to improve telemental health laws based on what other states have done.
Let me know if you have any questions about this information.
Laura Groshong, LICSW, Director, Policy and Practice Clinical Social Work Association lwgroshong@clinicalsocialworkassociation.org
CSWA is thrilled to see President Biden’s new executive orders today which will be huge steps toward anti-racism and true equity in our country. They are:
In addition, President Biden is embedding racial equity in all Federal agencies. The President wants his team to serve as a model on diversity, including hiring, purchasing, data and access. He has called racial inequality one of the four “converging crises” facing the nation.
To hear the President’s complete remarks on his new policies go to https://www.whitehouse.gov/briefing-room/speeches-remarks/2021/01/26/remarks-by-president-biden-at-signing-of-an-executive-order-on-racial-equity/ .
CSWA is about to begin a series of six presentations on “Racism and the Clinical Process” in a virtual collaborative format on Wednesday evenings. For more information go to https://www.clinicalsocialworkassociation.org/event-4134868.
CSWA encourages all members to join us in the anti-racism effort which is finally being addressed at the Federal level.
Kendra Roberson, PhD, LCSW, President Clinical Social Work Association cswaorg.pres@clinicalsocialworkassociation.org
CSWA leadership has been trying to come to terms with the hatred unleashed by our President and his followers on January 6, the very real threat to our democracy, and the blatant racist actions that were on full display.
CSWA first reached out to our members, mindful of the traumatic impact experienced by those near the riot and desecration of the Capitol and of the secondary trauma affecting those watching on TVs, phones, and computers. The immediate message was a reminder that we must take care of ourselves, emotionally and physically. As we all know, unless we take care of ourselves, we will have difficulty continuing to treat our patients.
What the so-called “racial-reckoning” of the past summer taught us, was that unjust, unfair treatment of Black and Brown people has, tragically, always been an issue in America. The country, with its obvious privileges for White citizens, has a shaky foundation built on the premise that it is acceptable to colonize and steal Indigenous land, enslave Africans and subjugate anyone non-White, or otherwise marginalized, to second class citizenship. This foundation allowed Trump’s rhetoric and hate speech to be successful in riling a literal lynch mob to storm the Capitol. The Confederate flag, the White supremacy slogans, and the disturbingly tepid response of the Capitol police to the rioters all conveyed these ideas. As more comes to light, CSWA will continue working to learn, to educate, to advocate, and to stand with you against institutional and systemic racism and for undisputed equity.
Our actions now must be to hold the President accountable for his role in promoting the riot, in promoting racism, in promoting police and National Guard brutality in BLM protests throughout 2020, and in undermining the electoral process. Impeachment will thus create a lasting record of his unlawful behavior and prevent him from holding further federal office. CSWA encourages all members to notify their members of Congress immediately that the President be impeached for his actions.
Here is a possible way to send that message: “I am a member of the Clinical Social Work Association and a constituent. Given the President’s reckless fomenting of destructive acts on the Capitol, police and our elected officials, I believe he should be impeached.“ Email addresses and phone numbers can be found at https://www.congress.gov/members?q={%22congress%22:117}&searchResultViewType=expanded
As always, let me know when you have sent your messages.
Laura Groshong, LICSW, Director of Policy and PracticeClinical Social Work Associationlwgroshong@clinicalsocialworkassociation.org
Below is a summary of the way that the CMS Physicians’ Fee Schedule Rule will impact Medicare psychotherapy reimbursement and telemental health services for LCSWs in 2021. The final Rule was implemented at the end of December, 2020.
CPT Code Reimbursement Changes
*Group Psychotherapy, 90853, has been added to the permanent list of telemental health services.
In short,
Telemental Health Services
Telemental health videoconferencing services have been extended indefinitely which is great news. Audio only telemental health services, however, will only be covered through the Public Health Emergency, currently scheduled to end on January 20, 2021. CSWA is working with the Mental Health Liaison Group to have Congress make audio only treatment covered indefinitely as well. CMS believes that Congress must make a legislative change before audio only services can be covered. It is likely that the Public Health Emergency will again be extended past January 20th, but has not been extended yet.
In summary, the cuts were not as severe as had been planned for individual psychotherapy, but somewhat more difficult for family and group therapy and psychoanalysis. To reiterate: Stay tuned for the extension of the Public Health Emergency, which will allow the continuation of audio only treatment, but videoconferencing has been extended indefinitely.
Dear CSWA Members,
Given the chaos of the situation in Washington, DC, I wanted to let you know that CSWA is thinking of our many members who live in and around the area. It is very disturbing and frightening to watch from a distance; it would be exponentially worse to be in proximity to the destruction that has been inflicted on the heart of our democracy.
Please take care of yourselves. We hope this misery will come to a quick conclusion. On top of the pandemic, this traumatic situation will only escalate the anxiety and depression we are seeing in our practices. We must take care of ourselves so that we can take care of others. CSWA is here for you.
Kendra Roberson, LICSW, President Clinical Social Work Association kroberson@clinicalsocialworkassociation.org
Laura Groshong, LICSW, director, Policy and Practice Clinical Social Work Association lwgroshong@clinicalsocialworkassociation.org
Since The Aware Advocate article, Nine Months into the Pandemic: Practical Telemental Health for LCSWs, came out yesterday, I’ve received several questions about whether LCSWs are essential workers and when will they be eligible to get the COVID vaccines. I hope this will clarify this complicated situation.
The Centers for Disease Control and Prevention (CDC) has made recommendations about who should have access to the vaccines and in what order.
There are two Phases, but Phase 1 is divided into three parts when it comes to rolling out the vaccines:
These recommendations can be found at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html .
Note: LCSWs are considered essential workers but whether we fall in 1a, 1b, or 1c depends on where we work and the way that the state we live in is organizing the vaccinations. If we work in a hospital or skilled nursing facility it is pretty clear we would be in the 1a group. Those of us who are over 75 are clearly in the 1b group. But all the other factors that affect us make it impossible to say for sure when we you will get be eligible to be vaccinated.
I recommend that everyone google “COVID Vaccination in [your state/jurisdiction]” and find out which state agency is organizing the distribution and policies for how the vaccines will be available. It may also be prudent to contact your PCP and ask when they may be able to vaccinate you. As you know, some of the vaccines require special refrigeration and may not be storable in doctor’s offices.
Keep in mind vaccination alone may not necessarily make us immune to COVID, but it may certainly help. Keep following all guidelines for masking, staying 6 feet apart, washing hands, and not spending time in closed spaces with people you do not live with until CDC/HHS say it is safe to stop these practices. To those of you who have reservations about getting vaccinated, use your judgment and if you choose not to get the vaccine, keep following all the guidelines above.
We will get through this pandemic and are getting closer, even though we may be many months away. Happy new year to all.
Since the Affordable Care Act went into effect in 2011, there have been new forms of treatment reviews through Medicare called Comparative Billing Reports (CBRs). They are designed to identify which LCSWs are considered “outliers” in psychotherapy practice; psychologists and psychiatrists are also receiving CBRs for psychotherapy. This paper is designed to explain how CBRs are developed, what areas are being used in preparing CBRs, and offer suggestions as to how LCSWs may want to respond to them.
There are several companies, called Health Information Handlers (HIHs), which create CBRs for the 14 Medicare Administrative Contractors (MACs) in the country, including CIOX, Ability Network, Chartfast, and others. For more information see https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Information_for_Providers .
As LCSWs know, psychotherapy treatment can take several months or even years of weekly psychotherapy sessions. There can be great variation in the areas assessed by CBR companies. These include 1) how frequently a patient is seen; 2) the average number of sessions for each beneficiary; and 3) how long each session is/how much reimbursement has occurred. For LCSWs, these areas are primarily determined by the diagnoses a patient has as found in the DSM-5, and the treatment methods the LCSW uses to treat these conditions. For example, complex PTSD and complex grief can take longer to treat than adjustment disorders; cognitive behavioral therapy generally takes less time in treatment than psychodynamic psychotherapy.
To find information on the three areas noted above, the HIH preparing the CBRs reviews all psychotherapy provided by providers for a given MAC. All LCSWs are compared to all other LCSWs providing psychotherapy. Any LCSW who is in the top 10% in at least two categories, who sees at least 10 Medicare beneficiaries for psychotherapy, is sent a CBR notifying the LCSW. Additional documentation may be required to explain the reasons for the high level of service and/or reimbursement.
There are numerous evidence-based psychotherapeutic methods which treat different kinds of mental health or substance use disorders. It is safe to say that the majority of Medicare beneficiaries are senior citizens who qualify for Medicare based on age. LCSWs who understand the senior population’s emotional difficulties are likely to specialize in this kind of psychotherapeutic work and see more Medicare beneficiaries. It would be a false dichotomy to see LCSWs who see a high number of Medicare beneficiaries as outliers; this is their area of expertise and practice.
Another difficulty for LCSWs in the development of the CBRs is the comparison of all mental health conditions to all other mental health conditions. As noted above, there are numerous mental health diagnoses, some of which take longer to treat than others. Diagnoses should be “apples to apples” if these comparisons are being made.
Thus the LCSWs who are most likely to receive a CBR are those who see a large number of Medicare beneficiaries; who see these patients in long-term therapy; and who use 90837 more often than other CPT codes. Long-term psychotherapy has been shown to have multiple benefits. Some studies that have validated this point of view are:
CSWA hopes that this paper is helpful to LCSWs in understanding the CBR and responding to them.
Laura Groshong, LICSW, Director, Policy and Practice
The Aware Advocate: LCSW Reciprocity
November 2020
Laura Groshong, LICSW, CSWA Director Policy and Practice
In these difficult COVID times, the issue of being able to practice across state lines has become increasingly important. Most LCSWs* – not by choice – have become proficient in videoconferencing over the past eight months. While this has presented challenges and frustrations, the upside is that we now have the technology skills to provide psychotherapy in this format. [See the three CSWA webinars in the Members Only section on the website to review these issues.] With these skills comes the ability to practice with patients who are not close enough to meet with us in the office. Those LCSWs who have tried to make lemonade out of this development, i.e., expanding their practices online, have found that there are many barriers to practicing across state lines without a license.
This issue of The Aware Advocate, CSWA’s occasional newsletter providing a deeper dive on current matters affecting clinical social work practice will explain the current state of affairs when it comes to practicing across state lines in the time of the pandemic.
History of Reciprocity
Clinical social work licensure laws are governed by the state social work board in that state (there are four states that have governance by a state agency). These boards and agencies implement rules as to how the laws that created clinical social work licensure are implemented. Most states have rules that regulate which LCSWs may practice in each state. The Association of Social Work Boards (ASWB) serves as the organization that develops the clinical social work examination and as a ‘home base’ for social work boards but does not have oversight over them.
Until last March, most boards had some process for becoming licensed in a new state. Almost no states allowed LCSWs to practice without acquiring a license in each state, except in emergency situations (for more information see my book, Clinical Social Work Practice and Regulation: An Overview, 2009.) Some states allowed an LCSW to become licensed in another state if their license had the same or higher standards of licensure than the state in which they were licensed without going through the whole licensure process of gathering supervised experience hours; the ASWB clinical examination only needs to be taken once and is transferable to any state. Some states do require completing supervised clinical hours again, an onerous task for established clinicians.
* LCSWs is used to cover all clinical social work titles including LICSWs, LISWs, etc.
The small group of LCSWs that have chosen to become licensed in more than one state have more options for the patients that they can treat. Being licensed as an LCSW in more than one state means higher costs for being licensed in more than one state, different continuing education standards, and more complicated relationships with third party payers.
Current Clinical Social Work Policies on Reciprocity
Many of the laws and rules governing clinical social work licensure reciprocity have changed since COVID-19 has impacted our ability to see patients in person, roughly since March, 2020 when the State of Emergency was declared nationally. Beginning with Maryland, whose Governor allowed any LCSW licensed in another state to see patients in Maryland through videoconferencing without becoming an LSCW-C in Maryland, many states have relaxed the rules in place for which LCSWs can provide treatment in their state. See my article “Guide to Telemental Health Across State Lines” on 11-11-20 for more details on how to find out the current standards on reciprocity for LCSWs in each state. A good link for this information is https://www.naswil.org/post/state-by-state-guide-to-the-rules-laws-about-telehealth-services-across-state-lines. It is crucial to check these standards in the state in which you are currently licensed and the state in which a patient resides.
National Policies on Reciprocity
Another outcome of the pandemic is the increased pressure for national reciprocity for LCSWs. Psychologists have been working toward this goal with a group of states that accepts the license of a psychologist from a state which is affiliated with a group of states who agrees on licensure standards, called PSYPACT. This is a much easier task for psychologists because all psychologists licensed as psychologists have a doctorate before they become licensed and that process is standardized. NOTE: psychologists who have a terminal Master’s degree cannot become licensed as a psychologist and generally become licensed counselors.
The Master’s in Social Work is considered the terminal degree for clinical social workers, though there are several ways LCSWs continue to be trained for 2-3 years after receiving an MSW. The laws and rules governing this training varies widely from state to state and each social work board has a vested interest in the standards that they have created. Getting social work boards to agree on standards that would allow an LCSW to practice in another state is challenging. Nonetheless, CSWA in collaboration with ASWB and NASW, is hoping to find a way to do so and have been working on this goal for the past 4-5 years. There is a special urgency now because all the patients that we are seeing who we can now treat because of relaxed standards may be unable to continue their work with us, and have that work be covered by insurance, when the State of Emergency ends.
Summary
For all the reasons noted above, there are problems for licensed clinical social workers in creating a way to use our licenses across state lines. This may come about in time, but the nature of clinical social work licensing is state based and boards are reluctant to give up their right to create standards of practice for becoming licensed or for allowing reciprocity. For now, the best way to practice across state lines through telemental health is to make sure you are in compliance with the rules of your own state and those of the patient’s location. This is likely to change when the State of Emergency ends, likely within the next year.
Let me know if you have any questions at lwgroshong@clinicalsocialworkassociation.org.
I have been getting many questions about current rules for LCSWs practicing telemental health in states where they are not licensed. This used to be much simpler than it is now; pre-COVID most states did not allow an LCSW who was not licensed in the same state as the patient to practice there. These rules were determined by state Boards and there is no national policy at this time. There are some bills in Congress that would supersede state laws and rules, if they passed, about the ability to practice across state lines.
Since the pandemic began in earnest last March there have been many changes to state rules. If you wish to practice across state lines, I recommend consulting the following up-to-date guide about this topic which has been developed by the University of Pennsylvania and University of Texas which covers all mental health disciplines: https://utexas.app.box.com/s/r797qp7woupga5x65yob0ki2u7mbd84y/file/647374529609 . It is in Excel format and should be downloaded to read more easily. You should be aware of the rules in the state where your prospective client is a resident as well as knowing emergency services. Additionally, you should keep in mind that the telemental health coverage that currently exists will possibly be eliminated when the State of Emergency ends. Having a plan for how to manage the treatment around this possibility is part of good clinical practice.
Be sure you have changed your Informed Consent forms to include information about how to file complaints in your state and the state of the patient in addition to following the rules about practicing across state lines. This typically would include providing links to the social work Board of the state in which you are licensed and the social work Board where the patient is located.
Let me know if you have any questions about practicing telemental health across state lines.
Laura W. Groshong, LICSW, Director, Policy and Practice wgroshong@clinicalsocialworkassociation.org
I’ve received several questions about the HHS extension of the State of Emergency which I will answer below:
In short, coverage of telemental health and audio only treatment will now continue until January 21, 2021, for Medicare and Medicaid. The reimbursement rates will remain the same for Medicare and Medicaid during this time. Commercial insurers may follow this policy but are not required to. The responsibility to find out what coverage is for commercial insurers is our responsibility as LCSWs to check.
Let me know if you have any other questions about the State of Emergency extension at lwgroshong@clinicalsocialworkassociation.org.
Laura W. Groshong, LICSW, Director, Policy and Practice
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