March 1, 2022

President Biden’s State of the Union address tonight will have a major focus on the need for more mental health funding and services. A few of the areas he will discuss are:

To see a complete summary of what the President will discuss regarding mental health go to: https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/01/fact-sheet-president-biden-to-announce-strategy-to-address-our-national-mental-health-crisis-as-part-of-unity-agenda-in-his-first-state-of-the-union/

CSWA will provide a message to send to Congress, who will have to approve the funding and policy measures regarding mental health, on the issues that most affect clinical social workers following the State of the Union speech.

February 1, 2022

As you have no doubt heard, the Public Health Emergency (PHE) will end on May 11, 2023. Continued coverage for telemental health treatment may depend on the insurance your patient holds when the PHE ends. Here is what we know currently.

Federal Government

CMS, which oversees Medicare and Medicare Advantage, has already announced that these programs will cover telemental health through December 31, 2024. CMS is reviewing the use of telemental health treatment and will make a decision, along with DHHS, about the future of expanded telemental health coverage after the end of 2024.

Some members of Congress are wanting to end the PHE immediately. The Senate and the President will not agree to this, so it is extremely unlikely that this will happen. Regardless, it will not affect the coverage of telemental health by Medicare and Medicare Advantage at this time.

Medicaid

All 50 states and DC expanded coverage and/or access to telehealth services in Medicaid during the PHE. When the PHE ends, coverage for telehealth services may be tied to federal and/or state PHEs. Most states have made, or plan to make, some Medicaid telehealth flexibilities permanent.

Commercial Insurers

It is likely that some commercial insurers will no longer cover telemental health after May 11, 2023. I have heard that LCSWs have been told that telemental health will no longer be covered by commercial insurers NOW. Those companies should be reported to your Insurance Commissioner. As long as the PHE is in effect, telemental health should be covered.

Communication about commercial insurance has been spotty, so have patients check with their insurers. Some states, but not all, are putting laws into effect that will require commercial insurers to cover telemental health treatment.

Free Vaccines and COVID-19 Tests

Separate from the coverage of telemental health, the end of the PHE creates changes about who may receive free vaccines and COVID-19 test kits. A good summary of the changes that are coming has been put together by Kaiser Family Foundation at https://www.kff.org/coronavirus-covid-19/issue-brief/what-happens-when-covid-19-emergency-declarations-end-implications-for-coverage-costs-and-access/#coverage-costs-and-payment.

The Possible Impact on LCSWs

Many of us have converted our practices to exclusively provide telemental health and some us no longer have physical offices. The end of the PHE may require us to reconsider these decisions if telemental health does not continue in the way that we have been using it.

There is a lot of uncertainty at the moment, and CSWA will do our best to give you timely and accurate information about the situation.

January 26, 2022

I hope everyone is feeling well informed about the Good Faith Estimate rule, part of the No Surprises Act, which went into effect on January 1. There have been several webinars on this topic and one was listed on the CSWA website in the Members Only Section.

CSWA is working on two fronts to get LCSWs exempted from the GFE. One is a letter we co-wrote with the Psychotherapy Action Network (attached). The other is a campaign to let members of Congress know about the fact that LCSWs in private practice do not need to be part of the GFE; we already do everything that it requires and there are vanishingly low numbers of LCSWs who have had actionable complaints filed against them for surprise billing.

Please send your members of Congress at www.Congress.gov the following message: “I am a constituent and a member of the Clinical Social Work Association. The No Surprises Act requires me as a Licensed Clinical Social Worker to give my patients a Good Faith Estimate. I am in private practice and have patients pay me directly. The GFE interferes with the mental health treatment process (detailed in the attached letter). Please exempt LCSWs from the Good Faith Estimate requirements.”

NSA Letter to CMS (fin.) - 1-25-22.pdf

As always let me know when you have sent your messages.

- Laura Groshong, LICSW, CSWA Director of Policy and Practice

January 20, 2022

In the rush to figure out the Good Faith Estimate, another important issue has been on the back burner.

As you know, the No Surprises Act also had a provision that we see every patient at least once every 12 months. This was extended from the previous rule which required this provision every 6 months.

With recent guidance from CMS, it is now clear that this requirement will go into effect after the end of the Public Health Emergency (PHE). That is not likely to be before the end of 2022 at the earliest.

CSWA is hoping to work with many other mental health groups to eliminate this rule. We will keep you posted.

December 20, 2021

By Laura Groshong, LICSW, CSWA Director of Policy and Practice

There are a number of issues that are affecting LCSW practices in the waning days of 2021, particularly in the area of Medicare (which we know affects commercial insurance heavily). These issues are: 1) giving patients a “Good Faith Estimate” of what the treatment we provide will cost; 2) elimination of 2022 cuts to Medicare reimbursement; 3) telemental health coverage; and 4) DCEs. Discussion of each of these follows.

Good Faith Estimates

This rule requires us to give a “good faith estimate” (GFE) to a patient of what our services will cost and how long they may last. While this policy is part of most of our informed consent forms, signed by the patient already, it is prudent to review what the GFE is more formally requesting we include in our information to the patient. The main difference about past practices and the GFE is that it applies to private pay patients as well as insured patients and uninsured patients.

Medicare Cuts Stopped

LCSWs can take a deep breath as Congress has acted to prevent the trio of Medicare payment cuts that were set to take effect at the beginning of 2022—a 3.75% cut due to scheduled changes in the Medicare Physician Fee Schedule (“PFS”), a 2% cut for Medicare sequestration, and a 4% Statutory Pay-As-You-Go Act (“PAYGO”). These Act cuts would have slashed Medicare payments by nearly 10% during a tumultuous time for healthcare. Instead, The Protecting Medicare and American Farmers from Sequester Cuts Act (S. 610) was approved by the U.S. House of Representatives on December 7 and passed the U.S. Senate on December 9, 2021. The bill has been sent to President Biden’s desk for his signature.

The Protecting Medicare and American Farmers from Sequester Cuts Act includes:

This is the second year that a last-minute change stopped a substantial reimbursement cut for LCSWs. CSWA will be encouraging CMS and Congress to stop these attempts to balance the Medicare budget on the backs of clinicians moving forward.

Telemental Health Coverage

As you know, CMS issued a new rule last month to expand telemental health and audio only psychotherapy through 2023. You also know we are still unable to practice across state lines unless we are licensed in the state where the patient resides and/or there is still increased reciprocity in the state where the patient resides. CSWA is still working with Department of Defense and the Council of State Governments to create a “Compact” that will make it much easier to work across state lines; it should be ready to begin implementing in early 2023.

The requirement that LCSWs see patients in person every 6 months has been extended to every 12 months. This is still a hardship for some patients and LCSWs who have given up a physical office. CSWA will be working to eliminate this requirement.

Medicare Direct Contracting Entity

Over the past decade, over 50 models of delivering health care through Medicare have been explored, with the goals of lowering costs for dual-eligibles; eliminating access to care, based on economic disparities; and, moving away from a fee for service (FFS) payment model. The last goal has an impact on LCSWs in private practice who have used the FFS model for some time.

A new model has been emerging called the Medicare Direct Contracting Entity (MDCE). It is similar to the Accountable Care Organizations that have been in use for the past five years but is run by commercial for-profit agencies. CMS has started to ‘assign’ beneficiaries who are in traditional Medicare to MDCE plans without consent. There is concern that this could lead to the privatization of Medicare which would have the same difficulties that commercial insurance for-profit plans have, i.e., the focus on profit leads to diminished health care services.

Surgeon General Report on Youth Mental Health

U.S. Surgeon General Vivek Murthy, MD, released an advisory statement on December 7 to highlight the urgent need to address the nation’s youth mental health crisis, “Protecting Youth Mental Health” (PDF, 1.01MB). This excellent document outlines the COVID-19 pandemic’s harm to the mental health of America’s youth and families, as well as the mental health challenges that had accumulated before the pandemic began. CSWA is delighted to see the Surgeon General paying attention to this increasingly difficult situation.

CSWA wishes you a happy and healthy holiday season!

December 14, 2021

I want to call your attention to a new rule from CMS that will go into effect on January 1, 2022. This rule requires us to give a “good faith estimate” (GFE) to a patient of what our services will cost and how long they may last. While this policy is part of most of our informed consent forms, signed by the patient already, it is prudent to review what the GFE is more formally requesting we include in our information to the patient about the course of their treatment. The main difference about past practices and the GFE is that it applies to private pay patients as well as uninsured patients.

There is a CMS template for providing this information which can be found at good faith estimate (PDF, 130KB). However, this 8-page document is more applicable to hospital stays and procedures. It may be more helpful for LCSWs to make sure they have the following information in their informed consent or verbally transmitted and documented.

Here is a list of what belongs in the GFE (which can also be part of an informed consent or disclosure statement) for private practitioners:

This information can be transmitted orally but should be given to the patient as soon as possible. For ongoing patients, there should be a new informed consent or GTE statement provided with the information above. CSWA will provide a template for this shortly.

December 4, 2021

There have been several requests for language to send members of Congress regarding the Medicare requirement that all patients be seen in-person at least once every 12 months. This would put patients and LCSWs at risk and CSWA is strongly opposed to this requirement.

There is a possibility that this requirement would only go into effect after the public health emergency ends. CSWA still opposes any in-person requirement, as it could have a disorienting effect on the treatment. There is no medical necessity for seeing a patient in person occasionally unless the treatment would be better served by in-person clinical work; seeing a patient once a year in-person would hardly be beneficial to the patient.

With these concerns in mind, CSWA offers the following suggested language for members to send their members of Congress (at www.congress.gov) to explain the problems with this requirement:

“I am a constituent and a member of the Clinical Social Work Association. The over 270,000 licensed clinical social workers (LCSWs) are the largest group of mental health providers in the country and provide mental health services to Medicare beneficiaries.

I am writing because Section 123 of the 2022 Physician Fee Schedule has a requirement that LCSWs must see patients at least once a year in-person. The only way I can safely see my patients currently is virtually, as I have been since the pandemic began in March 2020. This has worked well for most of my patients. It would be a hardship for me to maintain an office for a once-a-year meeting, and an intrusion into the virtual treatment for my patients.

This requirement should be eliminated so that I can continue to provide services to the over 50% of our citizens suffering from emotional distress. Please oppose this requirement so that I can continue to help all those suffering from PTSD, anxiety, depression, and other difficulties in these perilous times.”

Feel free to use your own words. As always, let me know when you have sent your messages.

- Laura Groshong, LICSW, CSWA Director of Policy and Practice

November 30, 2021

As we continue our pandemic journey, changes to the use of telemental health continue to develop. Two significant ones from CMS have come out this month, one on Place of Service (POS) codes and one on in-person visits required for telemental health treatment.

Place of Service Codes

POS codes are being divided by 1. telemental health provided outside the patient’s home and 2. telemental health provided in the patient’s home. POS 02, which previously covered both categories, should only be used as of January 1, 2022, for telemental health psychotherapy provided outside the patient’s home. POS 10, a new code, should be used as of January 1, 2022, for telemental health psychotherapy provided in the patient’s home. The complete descriptions are as follows:

1. POS 02: Telehealth Provided Other than in Patient’s Home Descriptor: The location where health services and health-related services are provided or received through telecommunication technology. The patient is not located in their home when receiving health services or health-related services through telecommunication technology.

2. POS 10: Telehealth Provided in Patient’s Home Descriptor: The location where health services and health-related services are provided or received through telecommunication technology. The patient is located in their home when receiving health services or health-related services through telecommunication technology.

Links for more information can be found at https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set. These changes may be adopted by commercial insurance; check with each carrier directly.

Required In-Person Visits with Medicare Patients

I have been tracking this difficult rule for the past year for the Clinical Social Work Association. It is unclear to me how it is going to be enforced. The most recent iteration came out earlier this month.

The rule was amended in the recent 2022 Physician Fee Schedule as follows:

“Section 123 of the CAA removed the geographic restrictions and added the home of the beneficiary as a permissible originating site for telehealth services furnished for the purposes of diagnosis, evaluation, or treatment of a mental health disorder. Section 123 requires for these services that there must be an in-person, non-telehealth service with the physician or practitioner within six months prior to the initial telehealth service and requires the Secretary to establish a frequency for subsequent in-person visits. We are implementing these statutory amendments, and finalizing that an in-person, non-telehealth visit must be furnished at least every 12 months for these services, that exceptions to the in-person visit requirement may be made based on beneficiary circumstances (with the reason documented in the patient’s medical record), and that more frequent visits are also allowed under our policy, as driven by clinical needs on a case-by-case basis.”

The whole rule can be found at https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-schedule-final-rule.

The "beneficiary circumstances" seem to offer a way to avoid seeing patients in person but this will need to be clarified by HHS. In any case, the time period has been extended from 6 months to 12 months for in-person meetings.

As for how to fight this rule, CSWA is working on a two-pronged approach. We encourage all mental health associations to oppose it through letters to HHS and CMS. All individual clinicians can oppose it by writing to our senators and representative about the chilling effect this rule will have on telemental health treatment, especially in this pandemic when emotional distress is high and meeting in person may be dangerous.

This will be a long-term fight in my view and there is no alternative to holding the government's feet to the fire.

- Laura W. Groshong, LICSW, CSWA Director of Policy and Practice

November 12, 2021

Next Tuesday the Senate Finance Committee will have a hearing on funding for mental health and substance use programs. While this does not affect Medicare reimbursement or private insurance rates directly, increased funding will be helpful in those areas.

Please read the attached statement which CSWA developed with other mental health groups. We will keep you posted on the outcome of the hearing.

November 4, 2021

The announcement from CMS on rules for telemental health raised some questions which I will answer below:

1. Does the new rule mean that LCSWs are able to freely use telemental health to see patients in states where we are not licensed? No. That is what CSWA is working on through the Compact. All state restrictions about licensure still apply. Check with the state social work Board if you wish to see a patient who resides in a state in which you are not licensed. A few states still have relaxed reciprocity standards, but others are ending their willingness to extend the ability to practice without licensure.

2. Does this mean that private insurers will also agree to coverage of telemental health and audio only psychotherapy? No. Private insurers often follow Medicare rules, but there is no guarantee. There appeared to be some changes in the way that private insurers were going to cover telemental health before the rule was announced. The rule may affect those changes and others going forward. Check with individual insurers or have patients check.

3. Does the state in which the patient resides in general still dictate the necessity of being licensed in their state to treat the patient? In general, yes. Check with the state social work Board where the patient resides as noted in #1.

4. Do you think the change in the CMS administration led to this positive outcome? There is no way of knowing for sure, but it is possible.

5. Will this rule cover Medicaid as well as Medicare? All Medicaid decisions will be made by states, though this may encourage some states to cover telemental health in Medicaid.

6. Will LCSWs still be required to see patients in person every six months as previously required? No, this requirement has now been changed to every 12 months. CSWA will be working to eliminate this requirement as we did to eliminate the six month rule.

One correction: the coverage of telemental health and audio only treatment will now be allowed until the end of 2023. Another decision will be made about further coverage at that time.

- Laura W. Groshong, LICSW, CSWA Director of Policy and Practice