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

November 13, 2021

Good news from CMS. Yesterday CMS announced the first group of many rules regarding the Physician Fee Schedule, which CSWA, and many of you, our members, commented on in August. Our voices made a difference. CMS will extend coverage of telemental health and audio only psychotherapy indefinitely. This was a major goal of ours and CSWA is delighted.

Now we need more clarity on eliminating the need to see patients in person every six months and the payment schedule for LCSWs in 2022. CSWA will continue to provide information on these issues as it is available.

Here is the statement issued by CMS (key statements in yellow outline). For the original document, go to cmslists@subscriptions.cms.hhs.gov:

Expanding Use of Telehealth and Other Telecommunications Technologies for Behavioral Health Care

The final rule makes significant strides in expanding access to behavioral health care – especially for traditionally underserved communities – by harnessing telehealth and other telecommunications technologies. In line with legislation enacted last year, CMS is eliminating geographic barriers and allowing patients in their homes to access telehealth services for diagnosis, evaluation, and treatment of mental health disorders.

“The COVID-19 pandemic has highlighted the gaps in our current health care system and the need for new solutions to bring treatments to patients, wherever they are,” said Brooks-LaSure. “This is especially true for people who need behavioral health services, and the improvements we are enacting will give people greater access to telehealth and other care delivery options.”

CMS is bringing care directly into patients’ homes by providing certain mental and behavioral health services via audio-only telephone calls. This means counseling and therapy services, including treatment of substance use disorders and services provided through Opioid Treatment Programs, will be more readily available to individuals, especially in areas with poor broadband infrastructure.

In addition, for the first time outside of the COVID-19 public health emergency (PHE), Medicare will pay for mental health visits furnished by Rural Health Clinics and Federally Qualified Health Centers via telecommunications technology, including audio-only telephone calls, expanding access for rural and other vulnerable populations.

Thanks again to everyone who contributed to this effort. Let me know if you have any questions.

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

October 4-5, 2021

By Laura Groshong, LICSW, Director, Policy and Practice

The first in-person meeting of the Social Work Compact Technical Assistance Group (TAG) took place in the Hall of States in Washington, DC. Kendra Roberson, PhD, LCSW, CSWA President, and I were the representatives from CSWA. The development of a social work interstate Compact is sponsored by the Department of Defense and the Council of State Governments, a non-partisan agency which has many projects that work to facilitate interstate cooperation. What began as a way for military spouses to take a social work license to another state when a spouse was redeployed will become inclusive of all licensed clinical social workers. For more information on CSG go to https://Compacts.csg.org/Compacts/

Home State

Compacts require that the home state for an LCSW be the state of residence, not the state of practice. Currently, if an LCSW wants to have licensure in a state separate from their state of residence, they must become licensed in that state. Under the Compact, if a clinical social worker is licensed in a home state that is a member of the Compact, the LCSW will be eligible to apply to practice in other states that also are in the Compact.

Work of the TAG

The TAG will now meet every three weeks to:

Next Steps

TAG will develop the following:

All the above should be ready for the Document Drafting Team by February, 2022. TAG will meet every three weeks until Compact language is completed. I will continue to send updates on the progress of the Compact.

September 24, 2021

The Council of State Governments (CSG) is partnering with the Department of Defense (DoD) and a coalition of organizations, including the Clinical Social Work Association (CSWA), to develop new interstate compacts for the social work profession. These compacts will create agreements among participant states to reduce the barriers to license portability and employment. Participants will learn about the aspirations for the project; the function of interstate compacts and the development process; and the need for license portability in the social work profession.

Bios:

Dan Logsdon: Dan is the Director of the CSG National Center for Interstate Compacts where he provides technical support and consulting regarding the development and enactment of interstate compacts. In recent years Dan has worked with a number of professional associations to develop new interstate compacts for occupational licensing portability including the American Occupational Therapy Association, American Counseling Association, and American Speech-Language-Hearing Association.

Matt Shafer: Matt is a program manager in the CSG Center of Innovation where he manages a portfolio of grant funded projects including the cooperative agreement with the Department of Defense to create new interstate compacts for occupational licensing portability. Matt also managed two Department of Labor grants focused on state occupational licensing policy and has extensive experience developing and building consensus on policy options for state leaders.

Keith Buckhout: Keith is a research associate in the CSG Center of Innovation and is primarily responsible for supporting the DoD Interstate Compacts project. Keith came to CSG after several years of working with licensure issues in state government in Kentucky.

Learning Objectives:

1. Learn the goals of the compact and the timeline for its implementation

2. Learn the benefits of a compact for working across state lines

3. Understand the ways that the Council on State Governments and Department of Defense are involved with CSWA in this project

CEs: No

September 6, 2021

No matter what one’s position about abortion might be, the Texas abortion law, SB 8, that became operational on September 1st must necessarily raise grave concerns. This law, prohibiting abortions as early as six weeks after conception, not only denies women in Texas their constitutional right to health care, but criminalizes the participation of anyone who “aids and abets” a woman seeking an abortion. (To read the full text of SB 8, go to https://capitol.texas.gov/tlodocs/87R/billtext/html/SB00008E.htm)

SB 8 poses an immediate threat to Texas LCSWs. Using the consulting room to help clients work through the often traumatic decision to abort may now be seen as “aiding and abetting” in Texas. Texas law is indirectly telling us that LCSWs can no longer provide a compassionate safe place for our patients to discuss difficult choices when an unwanted pregnancy occurs (no exceptions for rape or incest) without risking a $10,000 fine and attorney’s fees.

Limiting what can be talked about in the therapy session undermines our ethical standards and the confidentiality we guarantee, but there is another element of this new law that is even more chilling: enforcement of this new law is placed in the hands of private citizens, incentivizing a ‘bounty-hunter’ approach designed to intimidate. Further, a spouse or family member who perceives an LCSW as supporting an abortion could report the clinician to authorities.

Purposely drafted to make it difficult to challenge in court, SB 8 carries the stench of Jim Crow, disproportionately impacting people of color, people with low-income, and other historically marginalized communities. Nonetheless, legislatures in several other states are already drafting copycat legislation.

The disappointing refusal of the US Supreme Court in a 5-4 decision to consider the Texas law - with vigorous dissent from Chief Justice Roberts and Justices Sotomayor, Kagan, and Breyer - leaves the law in place for now. However, some of the organizations actively fighting this blatantly unconstitutional law include the Lilith Fund, Whole Woman's Health Alliance, Inc., Texas Equal Access Fund, Jane's Due Process, Clinic Access Support Network, Support Your Sistah at the Afiya Center, West Fund, Fund Texas Choice, Frontera Fund, and The Bridge Collective, and the ACLU. New challenges have already been filed.

CSWA supports all efforts to stop Texas from interfering in the work of clinical social workers, and will be working with our Texan colleagues who are clearly at risk if they treat women seeking abortions. We are gathering information about the protection that may be available through malpractice insurance and other potential resources, if indeed other states follow the Texas lead. We urge members to consider signing the petition prepared by Texas social worker Dr Monica Faulkner, PhD, LMSW, at https://www.change.org/StandWithSocialWorkers, and to pay close attention to what is happening in your local state legislatures.

August 27, 2021

As you know, each August CMS puts out changes to the rules that govern the Physician Fee Schedule (PFS). These changes affect our practices and CSWA sends comments on the rules, which go into effect the following year.

Below please find the comments which CSWA has sent on the PFS 2022, a 1747-page document. CSWA chose three areas for comment, Mental Health Disparities, Telemental Health Coverage, and Telemental Health Parity in reimbursement. CSWA encourages all members to send their individual comments on any or all of these areas. CMS is asking that members not send a standard message. Use any of the language in the CSWA comments for your own comments. Send them by September 13, 2021, to https://www.federalregister.gov/documents/2021/07/23/2021-14973/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part.

As always, let me know when you have sent your comments and send a copy. Thanks for your help.

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

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August 27, 2021

Centers for Medicare and Medicaid Services, Department of Health and Human Services

RE: Comment on Physician Fee Schedule 2022

https://www.federalregister.gov/documents/2021/07/23/2021-14973/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part

The Clinical Social Work Association (CSWA) is pleased to have the opportunity to submit comments on the proposed Physician Fee Schedule for 2022 (PFS2022). We also want to take this opportunity to thank CMS for covering mental health treatment provided through videoconferencing and audio-only delivery during this Public Health Emergency (PHE).

We will be commenting on three major areas of the bill which are of particular interest to Licensed Clinical Social Workers (LCSWs). These areas are 1) addressing mental health disparities; 2) telemental health continuation after the Public Health Emergency; and 3) reimbursement parity between in-person mental health treatment and telemental health treatment.

Mental Health Disparities

The disparities between mental health access, treatment, and outcomes for white populations as compared to Black, Indigenous, and People of Color (BIPOC), have been well-documented and it is past time to address the root causes. CSWA is pleased to see the request in the PFS2022 for comment on p. 434: “Solicit comments on addressing health disparities and promoting health equity.”

Health disparities are costly: approximately 30% of direct medical costs for African Americans, Hispanics and Asian Americans are excess costs due to these health inequities, and the economy loses an estimated $309 billion per year due to the direct and indirect costs of disparities. (Nov. 2012, Henry J Kaiser Family Foundation)

A major root cause driving these inequities lies in Social Determinants of Health (SDOH). According to the peer reviewed journal,

Health Affairs, disparities “may be rooted in differences in insurance coverage, inequalities in access to good providers, or discrimination by health professionals in the clinical encounter. Disparities may be the result of years of institutional racism, lack of trust due to years of broken promises, cultural traditions, and more.” (Health Affairs, 2008, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.27.2.393)

When it comes to mental health treatment, whites are more likely to receive psychotherapy and medication on an out-patient basis, whereas BIPOC citizens are more likely to be referred to in-patient treatment for the same conditions

(Health Affairs, 2015, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.27.2.393)

Yet, the rates of depression are lower in Blacks (24.6%) and Hispanics (19.6%) than in whites (34.7%). Correspondingly, depression in African Americans and Hispanics tends to be more persistent, likely due at least in part to difficulties accessing effective and affordable out-patient care.

Further, since untreated mental health issues tend to exacerbate physical health issues, treatment costs related to physical health tend to rise as well. Simultaneously, outcomes become less hopeful, and may come to include disability, addiction, homelessness, and incarceration - again disproportionately affecting BIPOC communities.

Indeed, the prison population has become the largest group of people with diagnosable mental health disorders, between 45-60% (When Did Prisons Become Acceptable Mental Health Facilities?, Stanford Law School, 2017.) Lack of critical mental health care during incarceration has been persistent, as are the difficulties accessing mental health care through Medicaid upon release. Here, then, is another example of the SDOH role in exacerbating disparities, especially given the excessively high numbers of brown and Black people incarcerated in the US.

CSWA would be happy to provide additional data on how SDOH factors are connected to mental health disparities and need to be addressed.

Telemental Health Coverage

When the Public Health Emergency was implemented in March, 2020, most LCSWs began providing psychotherapy through virtual telemental health (videoconferencing) and audio-only (telephone). The decision by CMS to cover these new delivery systems during the PHE has been crucial to the wellbeing of Medicare beneficiaries living in areas without local mental health services or accessible transportation to more remote care. Previously unable to obtain in-person psychotherapy, they finally have the needed treatment because of the new delivery systems. It is unrealistic to expect them to begin treatment in person when the PHE ends unless SDOH transportation and other barriers to access are addressed.

CSWA therefore recommends that all three forms of treatment delivery be approved and reimbursed at the rate being paid for in-person treatment. LCSWs who provide services through videoconferencing and audio-only are working as hard, if not harder, than when they see patients in person. Further, even the requirement that patients being treated via videoconferencing and audio-only must be seen in person every six months is highly problematic; certainly it would be a huge barrier to seeing patients who can ONLY access treatment through virtual means.

The elderly - the main group of Medicare beneficiaries - are chronically underserved when it comes to mental health treatment. Not all Medicare beneficiaries have access to Rural Health Centers and Federally Qualified Health Centers; many had the opportunity to establish virtual psychotherapy relationships with independent LCSWs as a result of the PHE. However, the biannual in-person requirement has created a barrier to virtual treatment. If it is not eliminated, these beneficiaries may well find themselves back among the “chronically underserved”.

Telemental Health Parity

As noted in the Proposed Rule, “the estimated cost impact of this proposal is unclear, the proposed requirement that a modifier be appended to the claim to identify that the service was furnished via audio-only communication technology would allow us to closely monitor utilization and address any potential concerns regarding overutilization through future rulemaking” (p.1198). This comment applies to videoconferencing as well.

In fact, LCSWs and other mental health clinicians have been involved in an in vivo application of these two delivery systems throughout the pandemic. We ask that this data be collected and analyzed to see how much these services are being utilized and how their use affects cost offsets of medical conditions before CMS moves forward on plans to limit or eliminate them.

CSWA recommends that all three forms of treatment delivery be approved until CMS completes such a study, and that all three be reimbursed at the rate being paid for in-person treatment. LCSWs providing mental health treatment through videoconferencing and audio-only means are working just as hard, if not harder, providing professional clinical treatment virtually as when they provide services in person.

LCSWs have been long been called the backbone of psychotherapy services, and with more than 250,000 licensees, LCSWs are the largest mental health provider group in the country. However, as you know, LCSWs are reimbursed by Medicare at 25% less than psychologists for providing the same services, with the exact same CPT psychotherapy codes. LCSWs have equivalent clinical training, experience, client overall satisfaction, and provide long-term relief of emotional problems. The reimbursement disparity for LCSWs has not gone unnoticed and the number of LCSW Medicare providers has continually dropped. Lowering reimbursement for telemental health services would likely result in even fewer LCSW Medicare providers.

CSWA hopes that these comments are helpful developing the Proposed Rule and would be happy to discuss them with you further.

Sincerely,

- Kendra C. Roberson, PhD, LCSW, CSWA President

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

August 6, 2021

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

Though we are in the dog days of summer, there are many things going on that affect our clinical practices. CSWA is pleased to offer information on the following four topics that are currently affecting us: (1) ways to determine what the COVID risk is in your area are by county; (2) a template for writing letters that confirm medical necessity when insurers question the validity of our treatment; (3) an update on the Physician Fee Schedule which will affect our reimbursement in 2022; and a (4) a member survey to determine where people stand on the decision to return to in-office practice and additional topics to gauge ways to better support members.

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COVID Issues

The rise in COVID-19 cases due to the new Delta variant and others is cause for concern. But in this case, as in much of the pandemic, all concerns are not created equal. To understand the risk we face on the personal and professional level, it is necessary to get information that is specific to our location. The CDC has just created a new data base that provides the current level of infection for every county in the country. The COVID Data Tracker is updated daily and can be found at https://covid.cdc.gov/covid-data-tracker/#county-view CSWA suggests that whether you live in an area that is a hot spot for infection or one with low levels of infection, it is prudent to continue to wear masks and maintain social distance of 6 feet in public indoor areas.

The topic of whether to return to seeing patients in person is also on the minds of LCSWs. Please see the two hour webinar I recorded on July 22 to get detailed information on how to make your own decision about what is best for you. You can find it at https://www.clinicalsocialworkassociation.org/CSWA-Webinars#ToBe in the Members Only section.

To give members an overview of the way others are viewing returning to the office, CSWA is asking all members to take the short anonymous Survey to gather this information:

Please click here to complete the survey.

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Medical Necessity

More and more often, LCSWs are receiving letters questioning the “medical necessity” of our treatment. To address these often baseless conclusions, CSWA has developed the response template which you may use to explain the validity of your treatment decisions. Click here for the MEDICAL NECESSITY LETTER [Template].

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Physician Fee Schedule

As happens every August, the Center for Medicare and Medicaid Services (CMS) has issued potential changes to the rules that govern all medical practice which includes clinical social work practice. The CSWA Government Relations Committee is developing comments on this year’s PFS and will send them to members before the August 23 deadline for review.

Thanks for your support of CSWA and have a great summer!