December 4, 2020

There are now 25 new ICD-10 codes for substance use disorders (SUD) which all LCSWs who work with patients diagnosed with these disorders should know.

They are:

Be sure to use these codes in addition to the mental health disorder codes that we commonly use for anxiety, depression and other conditions.

HEADS UP for the Physician Fee Schedule! We have been waiting for this rule since last summer. It should be coming out any day now. I plan to answer any questions you have about it at the online Town Hall next Thursday, December 10, 2020, at 5 pm EST. Register at the CSWA website. Hope to see you then.

November 15, 2020

By Laura Groshong, LICSW, CSWA Director of 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.

November 11, 2020

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, CSWA Director of Policy and Practice

November 3, 2020

I am delighted to inform you that the Federal Court which made the ruling in Wit v. United Behavioral Health in March of 2019 has issued further remedies for the implementation of this ruling today. This ruling was consolidated with Alexander et al. v. United Behavioral Health, another case which found UBH in violation of mental health parity laws nationally and in California. The court explained in the 99-page document the need for the following steps:

1. a 10-year injunction requiring UBH to exclusively apply medical necessity criteria developed by non-profit clinical specialty associations;

2. appointment of a special master;

3. training of UBH in the proper use of court-ordered medical necessity criteria; and

4. reprocessing of nearly 67,000 mental health and substance use disorder benefit claims denied during the class period.

The remedies only apply to self-insured plans that fall under the Employee Retirement Income Security Act of 1974 (ERISA). It does not apply to government employees or commercial insurance plans.

Nonetheless, this implementation of the Wit ruling is as a major success for fully implementing mental health parity for the 50,000 ERISA enrollees in California and serves as a guide for laws in other states which have not fully implemented mental health parity laws.

October 28, 2020

CSWA is happy to report that the Texas State Board of Social Work Examiners has voted today to overturn the rule change that was enacted last week to allow LCSWs to refuse to see clients on the basis of disability, sexual orientation or gender identity. For a more complete report go to the Texas Tribune article at https://www.texastribune.org/2020/10/27/texas-social-workers-lgbtq-disabilities-discrimination/.

Many thanks go to CSWA Board member Kathy Rider, LCSW, a longtime advocate for clinical social work in Texas who was a major contributor to the effort to overturn the unethical rule.

October 25, 2020

You may have been hearing about a new rule that is called “Open Notes” which begins on November 2, 2020. It allows patients to have extended access to their Medical Record.

While it is technically true that patients have increased access to their electronic clinical records as of November 2, it should not be much of a change for the way we as LCSWs practice with one exception (see below). Open Notes was part of the Interoperability section of the CURES Act last spring which says:

Blease C, Walker J, DesRoches CM, et al. Annals of Internal Medicine. October 13, 2020. doi: 10.7326/M20-5370

On 2 November 2020, new federal rules will implement the bipartisan 21st Century Cures Act that, in part, “. . . promotes patient access to their electronic health information, supports provider needs, advances innovation, and addresses industry-wide information blocking practices.” The rules forbid health care organizations, information technology vendors, and others from restricting patients’ access to their electronic health care data, or “information blocking.” Although the Health Insurance Portability and Accountability Act gave patients the legal right to review their medical records, the new ruling goes further by giving them the right to access their electronic health records rapidly and conveniently via secure online portals. Providers must share not only test results, medication lists, and referral information but also the notes written by clinicians. Over the past decade, this practice innovation—known as “open notes”— has spread widely, and today more than 50 million patients in the United States are offered access to their clinical notes." https://www.opennotes.org/research/new-u-s-law-mandates-access-to-clinical-notes-implications-for-patients-and-clinicians/

I believe that Open Notes is primarily for other kinds of medical services, not psychotherapy. The only exception may be if we are not making notes in the interoperable medical record. There may come a time when other providers or patients complain about it and we will need to make “open notes” in an interoperable record, but that is not the case now unless you are paneled in a plan that requires you make notes in an interoperable record.

Remember that Psychotherapy Notes can be a separate file from the Medical Record which is for our use only, most commonly what we call process recordings, and are not shared with anyone else. There is certain information which cannot be kept out of the Medical Record by being put in Psychotherapy Notes; see the CSWA website for more information.

We know that it is a clinical issue if the patient wants to see what we have written about them and it happens fairly rarely. We also know that it is a best practice whether we are keeping notes for our own Medical Record or an interoperable one, to keep notes brief and connected to the treatment goals established for a given patient. If we stick to these practices, Open Notes should not pose a problem for clinical social workers.

Please let me know if you have any questions.

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

October 23, 2020

CSWA is concerned about a change in the Texas State Board of Social Work Examiners’ rules which allows LCSWs to refuse to provide services to clients on the basis of disability, sexual orientation or gender identity. This change was made to make non-discrimination rules consistent with existing Texas statutes. Governor Greg Abbott proposed the change to LCSW rules. See the article on this issue in the Texas Tribune at https://www.texastribune.org/2020/10/14/texas-social-workers-rule-discrimination-lgbt-disabilities/#:~:text=New%20Texas%20rule%20lets%20social,conform%20with%20existing%20state%20law.

This change is completely at odds with the ethics and values of clinical social work. This kind of attack on our profession should be fought as strongly as possible whenever it occurs. The fact that the Texas State Board of Social Work Examiners and the Texas Behavioral Health Executive Council, which oversees behavioral health boards, accepted the proposed rule without objection (on advice of counsel) is even more concerning than the fact that it was proposed in the first place.

CSWA will be filing a complaint with the Texas Social Work Board and the Governor’s office as well as signing on to a Declaration from the Hogg Foundation for Mental Health, an organization that opposes discrimination in all forms. To see the Declaration go to https://hogg.utexas.edu/who-we-are/racism-declaration?utm_content=82b8b13291ac3a2233b0e8193b1bb908&utm_campaign=Healthy%20Mind%20Project%20RFP&utm_source=Robly.com&utm_medium=email.

If this can happen in Texas, it can happen anywhere so we wanted to make all members aware of this situation. CSWA encourages all members to oppose any laws and rules that threaten our values and the rights of all clients to our services.

October 8, 2020

I’ve received several questions about the HHS extension of the State of Emergency which I will answer below:

1. Does the HHS State of Emergency affect reimbursement for telemental health or audio only treatment? No, this only applies to the coverage in some form of telemental health and audio only therapy by Medicare and Medicaid, which is determined by CMS. Reimbursement rates are the same as for in-person sessions.

2. Does the HHS State of Emergency extension affect coverage and reimbursement by commercial insurers? The commercial insurers, e.g., Optum, Aetna, BlueCross/BlueShield, Cigna, etc., will develop their own policies about telemental health/audio only coverage. Many have followed the direction that CMS takes so far. Reimbursement is more varied. Some states have required insurers that cover telemental health and audio only treatment to reimburse at the same level as in-person treatment. Check with your Insurance Commissioner or Social Work Board.

3. Does the HHS State of Emergency extension affect the ability to provide treatment across state lines without being licensed in the state of the client? The extension does not address the ability to treat clients in states where the LCSW is not licensed. Some states have allowed LCSWs to get a temporary license, some allow temporary reciprocity if an LCSW is licensed in another state. There are a couple bills in Congress that would make this national policy if they are passed. For now, it is the responsibility of the individual LCSW to find out what the policy about treating clients in states where they are not licensed in that state, as well as in the state where they ARE licensed.

4. What will happen when the State of Emergency ends to coverage of telemental health and audio only treatment? That is currently unknown but unless there is a permanent requirement that telemental health and audio only treatment be covered as in-person treatment is, it is likely that insurers will only cover in-person treatment.

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, CSWA Director of Policy and Practice

October 6, 2020

A new extension of the State of Emergency has been signed by Alex Azar. This extends coverage of telemental health services and audio only services until January 20, 2021. Click here for the Memo.

Let me know if you have questions at lwgroshong@clinicalsocialworkassociation.org.

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

October 28, 2020

Please visit the CSWA Position Papers page to view a Position Paper on Mental Health.