clinical social work association

[This document clarifies the ways that LCSWs work with Medicare beneficiaries. ]

Opt-in and Opt-out

Medicare opt-in and opt-out status for LCSWs has been a source of confusion.  Previously, CSWA had been informed that all LCSWs needed to opt-in or opt-out of Medicare.  This was an error.  There is no requirement to opt-in as a Medicare provider if an LCSW chooses not to work with Medicare beneficiaries.  LCSWS must opt-in if they wish to be paid through Medicare.

LCSWs must, however, opt-out if they want to work with Medicare beneficiaries who pay the LCSW privately.  This requires a signed contract with each beneficiary the LCSW treats that confirms neither the LCSW or the beneficiary will submit any claims to Medicare for the psychotherapy services that provided.  CSWA has a template which can be used for this purpose and an opt-out letter as well which should both be sent to your regional Medicare Administrative Center (MAC) if you choose to opt-out.  A beneficiary may have a private contract with an LCSW while maintaining Medicare coverage with other providers if they so choose.

A good Medicare summary document can be found at  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1311.pdf

CSWA has templates for private contracts with Medicare enrollees and to opt-out of Medicare in the Members Only section of the CSWA website (www.clinicalsocialworkassociation.org) .

Assignment

If an LCSW decides to opt-in, the LCSW accepts “assignment” of all Medicare cases who seek treatment.  If an LCSW chooses to refer a beneficiary who seeks treatment, a referral and reason for the referral should be documented. The Medicare terminology for this category is participating (“par”).  There is another category for other providers, non-participating (“non-par”) which does not apply to LCSWs. 

Another form of assignment is “incident to” the services of physicians, psychologists, nurse-practitioners, or physician assistants.

Medicare Mental Health Care (outpatient)

Here is a summary of what Medicare currently covers taken from https://www.medicare.gov/coverage/outpatient-mental-health-care.html

Medicare Part B (Medical Insurance)covers mental health services and visits with these types of health professionals: 

• Psychiatrist or other doctor
• Clinical psychologist
• Clinical social worker
• Clinical nurse specialist
• Nurse practitioner
• Physician assistant

Medicare only covers these visits, often called counseling or therapy, when they’re provided by a health care provider who accepts ">assignment[all LCSWs.]

Part B covers outpatient mental health services, including services that are usually provided outside a hospital (like in a clinic, doctor’s office, or therapist’s office) and services provided in a hospital’s outpatient department. Part B also covers outpatient mental health services for treatment of inappropriate alcohol and drug use. Part B helps pay for these covered outpatient services:

• One depression screening per year. The screening must be done in a primary care doctor’s office or primary care clinic that can provide follow-up treatment and referrals.
• Individual and group psychotherapy with doctors or certain other licensed professionals allowed by the state where beneficiary gets the services [includes all LCSWs.]
• Family counseling, if the main purpose is to help with individual beneficiary treatment.
• Psychiatric evaluation.
• Medication management.
• Diagnostic tests.
• A yearly “Wellness” visit. This is a good time to talk to a doctor or other mental health care provider about changes in the beneficiary’s mental health so they can evaluate changes from year to year.

All people with Part B are covered.

Costs in Original Medicare

• You pay nothing for your yearly depression screening if your doctor or health care provider accepts assignment [includes all LCSWs.]
• 20% of the Medicare-approved amount for visits to a doctor or other ">health care provider to diagnose or treat your condition. The Part B ">deductible applies.
• If you get your services in a hospital outpatient clinic or hospital outpatient department, you may have to pay an additional copayment or ">coinsurance amount to the hospital. This amount will vary depending on the service provided, but will be between 20-40% of the Medicare-approved amount.

Telehealth Services

• Medicare pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via telehealth.  This includes certain mental health services (e.g., individual psychotherapy and pharmacologic management, behavior assessment and intervention, psychiatric diagnostic interview exam, annual depression screening, psychoanalysis, family psychotherapy) as well as a number of specific behavioral health and substance abuse disorder services (e.g., smoking cessation services, alcohol and/or substance abuse structured assessment and intervention services, annual alcohol misuse screening, brief face-to-face behavioral counseling for alcohol misuse)
  
• To be eligible for telehealth services, the originating site (location of the beneficiary) must be in a rural health professional shortage area (HPSA) located either outside a metropolitan statistical area (MSA) or in a rural census tract; or a county outside of a MSA.
  

LCSWs have concerns about non-mental health clinicians being allowed to provide psychotherapy or make mental health diagnostic assessments, which CMS allows. CSWA continues to work with CMS on the problems with untrained mental health clinicians providing these services.

Summary

LCSWs do not need to opt-in or opt-out of Medicare.  If an LCSW wishes to be paid through Medicare, the LCSW must opt-in as a Medicare provider. All LCSWs are expected to accept assignment of any Medicare beneficiary who needs mental health treatment unless there is a reason that the beneficiary needs to be referred.  If an LCSW wishes to be paid privately, the LCSW needs to opt-out of Medicare and have each beneficiary sign a contract agreeing to refrain from submitting any claims to Medicare for the LCSW’s services.    Telemental health services continue to be limited to rural areas with a shortage of mental health clinicians.

Laura Groshong, LICSW, CSWA Director, Policy and Practice
Clinical Social Work Association
The National Voice of Clinical Social Work
Strengthening IDENTITY | Preserving INTEGRITY | Advocating PARITY