At the start of the COVID-19 pandemic in January 2020, the Secretary of the U.S. Department of Health and Human Services first declared a 90-day public health emergency (PHE). The PHE declaration allowed flexibility in health care funding and regulations to respond to the pandemic. Since January 2020, the PHE has been renewed 11 times and is currently in effect through mid-January 2023.

When the COVID-19 PHE ends, which is expected in 2023, state agencies will begin the “unwinding” of continuous Medicaid and Children’s Health Insurance Program (CHIP) by going through the redetermination process for all enrollees. Up to 15 million people may be at risk of losing health insurance coverage.

End of the Public Health Emergency (PHE)

The exact end date of the PHE is not known at this time. The PHE was renewed in October 2022 and remains in effect until at least January 11, 2023. The Biden-Harris administration has committed to providing a 60-day notice to states before the PHE will expire. No notice was given in November 2022, so it is assumed that the PHE will continue beyond mid-January 2023. If the PHE is renewed again in January 2023, it will continue until mid-April 2023. 

During the PHE, Medicaid and CHIP enrollees will continue to maintain coverage and cannot be disenrolled.This is a critical time for social workers to help individuals and families anticipate the redetermination process that will happen in the months ahead. This blog is intended to provide an overview of unwinding and strategies to reduce coverage losses.

What is Unwinding?

Unwinding refers to the return to normal operations for Medicaid and CHIP agencies after the COVID-19 PHE ends. In 2020, Congress passed the Families First Coronavirus Response Act that provided states enhanced funding for Medicaid and CHIP and required states to adopt continuous coverage for individuals and families through the end of the PHE. Individuals were not disenrolled from Medicaid, even if their income and eligibility status changed. As a result, over the past three years Medicaid and CHIP programs have grown significantly to 90 million enrollees in July 2022 as compared to 71.2 million in December 2019, according to the Kaiser Family Foundation.

When the PHE ends, states will begin conducting redeterminations again and will disenroll those who are no longer eligible. Individuals and families with income above the Medicaid threshold may be eligible to gain coverage on the Health Insurance Marketplace.

Unwinding Concerns

A concern of advocates, including NASW, is that individuals and families will lose coverage because of lack of communication with recipients to verify income. State agencies will be in contact with enrollees to confirm continued eligibility.

However, state agencies may have outdated contact information such as mailing and email addresses and phone numbers for recipients. These communication barriers may lead to loss of health care coverage for families that continue to meet eligibility requirements.

The Centers for Medicare and Medicaid Services (CMS) and advocacy organizations are providing guidance on ways to prepare individuals with Medicaid for the upcoming redetermination process. Each state has written an “unwinding operational plan” with its strategy for conducting redeterminations. The Georgetown University Center for Children and Families has developed a 50-State Unwinding Tracker for information on each state plan.  

NASW urges states to make unwinding plans public so that advocates can identify gaps, and CMS is encouraging states to seek input from stakeholders.

NASW and advocates strongly encourage states agencies to use multiple means of outreach to contact households for information, including mail, text, and email. NASW supports the expanded use of “ex parte” renewals (also known as automated renewals) when state agencies use available electronic data sources to verify eligibility (such as SNAP information). This practice can support continuity of health insurance coverage and streamline the redetermination process. State agencies are also partnering with other health insurance plans, health providers, and local organizations to conduct outreach to individuals who may be at risk of losing coverage. 

Social Work Advocacy

Social workers are important stakeholders who help individuals maintain their Medicaid and CHIP coverage– or facilitate a smooth transition to another health insurance program. Social workers, and the organizations in which they work, help individuals and families who receive Medicaid and CHIP to contact state agencies proactively to verify or update their contact information. Social workers also encourage clients to be on the lookout for mail, emails and phone calls that may alert them to the need to provide information. Many states are already conducting campaigns to ask recipients to be in contact with Medicaid and CHIP agencies to update their information. Organizations can amplify these campaign messages in their offices and on social media platforms.

If individuals no longer qualify for Medicaid or CHIP because their income has increased, they may be able to get health coverage through an employer or the healthcare marketplace. Social workers help individuals navigate through this transition.

Social workers can be vocal in responding to state unwinding plans and highlighting areas for improvement. They recommend strategies for effective outreach and communication with hard-to-reach populations. Medicaid and CHIP agencies benefit from the insights and experience that social workers have in engaging underserved individuals and families.

NASW will continue to monitor resources that are helpful for advocacy at the state level and provide additional guidance on how social workers can support individuals and communities as the PHE ends.

Update, January 18, 2023:

With the passage of the Consolidated Appropriations Act, 2023 (also known as the omnibus appropriations bill), Medicaid unwinding is no longer determined by the end of the COVID-19 Public Health Emergency (PHE). The Consolidated Appropriations Act, 2023, passed in December 2022, keeps the Medicaid continuous enrollment provision in effect through March 31, 2023, and Medicaid disenrollments can begin on April 1, 2023. States have up to one year to initiate renewals. Detailed information can be found in the CMCS Bulletin from January 5, 2023, Key Dates Related to the Medicaid Continuous Enrollment Condition Provisions in the Consolidated Appropriations Act, 2023. On January 11, 2023, the COVID-19 Public Health Emergency was renewed and will be in effect until mid-April 2023.

Unwinding Resources

• Medicaid Unwinding and Returning to Regular Operations after COVID-19
• Medicaid and CHIP Continuous Enrollment Unwinding – Toolkit- English
• Medicaid and CHIP Continuous Enrollment Unwinding – Toolkit- Spanish
• Kaiser Family Foundation – 10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Requirement
• Families USA – Not a Moment to Lose: Critical Changes States Should Implement to Prevent Medicaid Coverage Losses
• Office of the Assistant Secretary for Planning and Evaluation Issue Brief Unwinding the Medicaid Continuous Enrollment Provision: Projected Enrollment Effects and Policy Approaches
• Georgetown University Center for Children and Families 50-State Unwinding Tracker
• Urban Institute Fact Sheet – Most Adults in Medicaid-Enrolled Families Are Unaware of Medicaid Renewals Resuming in the Future
• CMS- Ex Parte Renewal: Strategies to Maximize Automation, Increase Renewal Rates, and Support Unwinding Efforts

Examples of State Outreach Material

• Arkansas – Update Arkansas Graphics
• Arizona – AHCCCS Preparing for the End of COVID-19: Return to Normal Renewals  
• California – Medi-Cal Ambassador Resources
• Kansas – KanCare Promotional Videos in Spanish by El Centro, Inc.
• Montana – Cover Montana Medicaid & HMK Continuous Coverage Unwinding: Communications Toolkit
• Virginia – FAMIS Promotional Material
• Washington – Apple Health End of the PHE Communications Toolkit

The Centers for Medicare and Medicaid Services (CMS)  is seeking feedback from clinical social workers and other providers about how they should provide estimates for costs of services for patients who use their insurance to pay for health and mental health services.  Your feedback would be helpful in providing information to CMS who may create a proposed rule for preparing national standards in this area.

The request for feedback is related to the No Surprise Act (NSA), which protects patients from large, surprise healthcare bills. Clinical social workers (CSWs) are currently required to give Good Faith Estimates (GFEs) to patients who are uninsured and patients who have insurance but do not plan to use it.

Read “No Surprises Act Regulations 2022”

A future rule may add to the Good Faith Estimate requirements for patients who intend to use their insurance to cover their care.  CMS is proposing that the CSW will need to notify the patient’s health plan of their estimated charges.

The health plan would then send the patient an Advanced Explanation of Benefits based on the CSW’s estimate.

The request for information will help CMS propose detailed steps for sending GFEs from CSWs and other providers to the patient’s health plan.  There are a series of questions available for response.  You may respond to one or more of the questions.  Examples include:

• What privacy concerns does the transfer of AEOB and GFE data raise?
• What burdens or barriers would be encountered by small, rural, or other providers, facilities, plans, insurers, and carriers in complying with industry-wide standards for the exchange of information?
• Would it alleviate burden to allow CSWs and other providers, for purposes of verifying coverage, to rely on a patient’s representation regarding whether the patient is enrolled in a health plan?

A list of additional questions is available at Request for Information: Advanced Explanation of Benefits and Good Faith Estimate for Covered Individuals.  The deadline for submitting feedback to CMS is November 15, 2022.

NASW will be submitting comments and requesting an exemption from the proposed requirement that clinical social workers issue GFEs to insurers, and advocating for less burdens.

NASW members may forward questions to Clinical.Practice@socialworkers.org

A blog post written by NASW Senior Practice Associate Denise Johnson, CMS Creates Additional Place of Service Code for Telehealth, clarifies what POS codes clinical social workers should use when providing telehealth services.  Johnson points out that POS codes are used on health insurance claim forms to indicate where patient services are rendered. CMS revised the description for POS codes 02 and 10 for telehealth.

NASW members can log in and read the full article in NASW Social Work Advocates magazine.

The proposed rule also looks to solicit comments from stakeholders on ways to identify and improve access to high value, potentially underutilized services by Medicare beneficiaries. Such services include but are not limited to preventative services, behavioral health integration services, and chronic care management. The following provides key takeaways for clinical social workers:

Telehealth

CMS is proposing several policy changes to Medicare telehealth services.  This includes extending coverage for telehealth services that have been temporarily authorized during the COVID-19 public health emergency (PHE). The proposed rule would also implement policies under the Consolidated Appropriations Act of 2022 (P.L. 117-103), which would allow for the continuation of certain flexibilities until 151 days after the end of the PHE.

This would extend the waiver of the geographic location requirement, delay the in-person requirement for mental health services, and continue to allow the use of audio-only and audio-video technology. CMS is proposing telehealth claims use the appropriate place of service (POS) indicator on the claim, in lieu of the modifier “95,” after 151 days following the end of the PHE.  Beginning January 2023, services provided using audio-only communications technology would use modifier 93.

Behavioral Health

In an effort to meet growing mental health needs, CMS is proposing to develop a new code (GBHI1) for behavioral health integration services performed by clinical social workers (CSWs) or clinical psychologists. This code would account for the monthly integration care where mental health is the focal point with the psychiatric diagnostic evaluation code 90791 serving as the initiating visit. Services can be billed “incident to” under general supervision, during the same month as transitional care services and chronic care management providing all requirements are met.

CMS proposes to make an exception to the direct supervision requirement under the “incident to” regulation.  Behavioral health services would be provided under the general supervision of a physician or non-physician practitioner (NPP) instead of under direct supervision when these services are provided by auxiliary personnel incident to the services of a physician or NPP.

Lastly, CMS is soliciting comments on whether present payment policies sufficiently cover intensive outpatient mental health services, to include services for substance use disorders and indirect costs for mental health services in non-facility settings.

Chronic Pain Management Services

CMS proposes to revise the definition of chronic pain as persistent or recurrent pain lasting longer than three months.  Beneficiaries who are newly diagnosed, as well as those who were previously diagnosed with chronic pain would both be eligible.

Two new HCPCS (GYYY1 and GYYY2) codes have been also created for chronic pain management and treatment services. The proposed codes would include a monthly bundle of services.

Opioid Treatment Programs (OTPs)

CMS proposes a payment increase for the non-drug component of bundled services. The base rate for individual therapy would be increase from 30 to 45 minutes.

CMS seeks to clarify that services delivered via OTP mobile units will be considered for reimbursement under Medicare OTP bundled payment codes and/or add-on codes and would be treated as though they were provided at the OTP’s physical location. CMS notes that the prohibition on billing OTP services for the same beneficiary more than once within a contiguous seven-day period would apply regardless of location.

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

CMS is proposing to implement policies under the Consolidated Appropriations Act of 2022 which includes delaying the in-person requirements for mental health visits furnished by RHCs and FQHCs through telecommunication technology under Medicare until the 152nd day after the COVID-19 PHE ends.

The agency is also proposing to add the new chronic pain management and behavioral health integration services to the RHC and FQHC (HCPCS G0511). the payment rate for HCPCS code G0511 would continue to be the average of the national non-facility PFS payment rates for the RHC and FQHC care management and general behavioral health CPT codes and PCM CPT codes.

Per the request of interested parties, CMS clarifies that 12-consecutive months of cost report data should be used to establish a specified provider-based RHC’s payment limit per visit. They believe the report accurately reflects the costs of providing RHC services and will establish a more accurate base to update payment limits moving forward.

Read NASW comments on the proposed rule.

Prepared by Denise Johnson, LCSW-C, NASW Senior Practice Associate for Clinical Social Work

Following a recent update from the Center for Medicare, and Medicaid Services (CMS), NASW has received multiple inquiries regarding telehealth place of service codes (POS) for Medicare, Medicaid, and private health insurance companies. The purpose of this blog is to clarify what POS codes clinical social workers should use when providing telehealth services.

POS codes are used on health insurance claim forms to indicate where patient services are rendered. CMS revised the description for POS codes 02 and 10 for telehealth. The current descriptors are:

• 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. Patient is not located in their home when receiving health services or health related services through telecommunication technology.
• 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. Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.

For some health insurance companies, the code changes became effective on January 1, 2022, while Medicare implemented the changes on April 1, 2022. Since the policies around the use of these codes may vary, clinical social workers should consult with each health insurance company with whom they are credentialed for specific guidance on the usage of POS codes. The Place of Service Code Set can also be found on the CMS website.

Prepared by Denise Johnson, LCSW-C, Senior Practice Associate, Clinical Social Work

Getty Images

Posted April 22, 2022

On April 6, 2022, the National Academies of Sciences, Engineering, and Medicine (NASEM) released a report entitled The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. The report represents the culmination of 18 months of work by a study committee that included NASW Social Work Pioneer^® and Wisconsin Chapter member Colleen Galambos. Study sponsors included the Commonwealth Fund and the John A Hartford Foundation.

The report includes several recommendations supportive of social work, including the recommendation that every nursing home—regardless of size—employ a full-time social worker with a minimum of a bachelor’s degree in social work from a program accredited by the Council on Social Work Education [CSWE] and a year of supervised social work experience in a health care setting (including field placements and internships) working directly with individuals to address behavioral and psychosocial care. (NASEM report, p. 511; recommendations, p. 3, item 2b)

The report also indicates the preference for a master’s degree in social work from a CSWE-accredited program for anyone serving as a director of social services in a nursing home.

Other report recommendations include the need for (a) federally funded research to inform staffing ratios for social workers and other disciplines, (b) clinical social workers to provide mental health services to nursing home residents and to receive Medicare reimbursement for those services, and (c) data collection regarding the training, expertise, and staffing patterns of social workers and other disciplines.

NASW applauds these recommendations and thanks the study committee for its work. During the coming months, association staff will read and analyze other report recommendations—including those not focused on the social work profession—and engage in the following activities:

• development of an NASW Practice Perspective to educate members about the report in greater depth
• submission of comments to the Centers for Medicare & Medicaid Services in response to its Request for Information on Revising the Requirements for Long-Term Care Facilities to Establish Mandatory Minimum Staffing Levels
• collaboration with social workers, other disciplines, and like-minded organizations to advocate for implementation of various report recommendations.

Chris Herman, MSW, LICSW (she/her)

Senior Practice Associate–Aging, NASW national office

The Centers for Medicare and Medicaid Services (CMS) has released clarifying information about Part 2 of the No Surprise Act, Good Faith Estimates (GFEs). The frequently asked questions (FAQs) answer many of the questions that social workers asked when the No Surprise Act was implemented in January 2022. Part 2 focuses on services provided to the uninsured or self-pay patients who receive services provided by clinical social workers in independent practice.  Social workers employed as salaried employees in hospitals, nursing homes, primary care, and other health settings should contact their administration for information regarding the use of  GFEs in their setting.

In January 2022, NASW posted FAQs on GFEs for social workers. The document prompted additional questions from social workers some of which have now been clarified in the questions and answers below.  This is a reminder that the GFEs are only completed for patients who are uninsured or self-pay.

If a diagnostic code has not been determined at the time of scheduling, what code should the social worker use on the GFE?
In the absence of a diagnostic code, the expected charge and service code for the service should be furnished.  An example of a service code would be a Current Procedural Terminology (CPT) code.

Where is the GFE maintained?
The GFE is part of the patient’s medical record and must be maintained in the same manner as a patient’s medical record. See the HIPAA Privacy Rule, https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

Are social workers required to provide a GFE for expected charges for future visits in the initial visit?
A social worker is not required to include a GFE for future services in an initial visit, however, following an initial visit, upon scheduling of additional services, a social worker must provide a new GFE that includes expected charges for the services expected to be furnished.  In addition, a social worker may, but is not required to, issue a single GFE for recurring  services.

Does a GFE need to be provided for each instance of a recurring service?
In circumstances where a social worker expects to furnish recurring services, such as psychotherapy services, a social worker may issue a GFE for those recurring services, rather than a GFE for each instance.

• A GFE issued for recurring services must be written in clear and simple language the expected scope of the recurring services, including time frames, frequency, and total number of recurring services.  The scope of such GFE must not exceed 12 months.  If additional recurrences of such recurring services are beyond 12 months, a new GFE must be provided if the social worker expects changes to the scope of a GFE such as expected changes in services, frequency, recurrences, and duration.
• A new GFE must also be issued to a patient no later than 1 business day before the services are scheduled to be furnished. The social worker must also communicate these changes to the patient upon delivery of a new GFE to help the patient understand what was changed between the initial GFE and the new GFE.

How does a social worker address situations where unforeseen items or services that were not scheduled in advance are furnished during a visit?
Charges for services that could not have been reasonably expected do not require a GFE. A GFE provided to a patient must include an itemized list of services that are reasonably expected to be furnished during the known period of care.

Is a social worker required to provide a GFE to patients upon scheduling same-day or walk-in services?
The requirement to provide a GFE to a patient is not triggered upon scheduling a service if the service is being scheduled less than 3 business days before the date the service is expected to be furnished.

In situations where the social worker does not provide a patient with a GFE when scheduling a service because they had health insurance, but upon arrival, it is discovered that the patient is now uninsured or self-pay. Should the social worker provide a GFE to the patient prior to providing service, even if it means rescheduling the service for a later date?
No. When a patient schedules an appointment, the social worker must inquire if the patient is uninsured or self-pay. If the patient is uninsured or self-pay at that time, the social worker must provide a GFE. In situations where a social worker has previously determined that a patient has insurance and becomes aware that a patient is uninsured or self-pay less  than three business days in advance of the scheduled service, nothing in the GFE regulations requires that the social worker provide a GFE to the patient or reschedule an appointment to allow for the provision of a GFE.

For more information, read “FAQs About Consolidated Appropriations Act, 2021 Implementation”

Social workers should also review their state regulations for guidance regarding state-specific requirements for GFEs. NASW will keep its members informed as new information becomes available regarding the usage of GFEs.

Prepared by Mirean Coleman, MSW, LICSW, CT, Clinical Manager

Alert: Information in this blog post was updated on January 5, 2022

NASW will continue to monitor policy developments pertaining to surprise billing and update members as new information is made available. See January 5, 2022 update.

Application to Clinical Social Work Services

December 21, 2021

Under a new federal rule to protect consumers from surprise health care bills, clinical social workers and other health care provider types must, effective January 1, 2022, provide a good faith estimate of expected charges.

Under a new federal rule to protect consumers from surprise health care bills, clinical social workers (CSW) and other health care provider types must, effective January 1, 2022, provide a good faith estimate (GFE) of expected charges that may be billed for items and services to individuals who are uninsured (e.g., not enrolled in any health plan or coverage) or who are self-pay (e.g., not seeking to file a claim with their plan or coverage). The GFE must be provided both orally and in writing, upon request or at the time of scheduling health care items and services, and within specific timeframes.

The rule applies to both current and future patients who are uninsured or self-pay. However, GFEs do not need to be provided to patients who are enrolled in federal health insurance plans (e.g., Medicare, Medicaid, TRICARE, Indian Health Service or the Veterans Affairs health system).

Providing a GFE to patients is not new to CSWs who, as part of best clinical practice, routinely discuss services and fees before or during the initial interview with new patients.

Federal Rule Background and Definitions

On October 7, 2021, an interim final rule was issued by the U.S. Department of Health and Human Services and several other federal agencies, the Requirements Related to Surprise Billing; Part II.

Below are definitions of a several key terms in the rule as they apply to CSWs:

“Convening provider” or facility: That who receives the initial request for a good faith estimate and who is responsible for scheduling the primary item/service in question.

“Expected charge” for an item or service:

• the cash pay rate or rate established by a provider for an uninsured (or self-pay) patient, reflecting any discounts for such individuals; or
• the amount the provider would expect to charge if the provider intended to bill a health care plan directly for such item or service.

“Items and services”:  All encounters, procedures, medical tests provided or assessed in connection with the provision of health care. Services related to mental health substance use disorders are specifically included.

“Provider”: Any health care provider who is acting within the scope of the provider’s license or certification under applicable state law. CSWs meet that definition.

Compliance Steps

To comply with the new federal rule, CSWs should take the following steps:

• Ask patients if they have any health insurance coverage and ascertain if they are uninsured or self-pay. If a patient is insured, make a copy of the insurance card for your files and ask the patient if they plan to submit a claim for the services they will receive.
• Inform all uninsured and self-pay patients of their right to a GFE. Written notice must be provided in clear language that the individual can understand in an accessible format, prominently displayed in the office and on the provider/facility’s website and must be easily searchable from a public search engine. Written notices should account for any vision, hearing or language limitations, including individuals with limited English proficiency or other literacy needs. It may be provided on paper or electronically, depending on the individual’s preference. The written notice should also state that information will be orally provided when the service is scheduled or when the patient asks about costs, and available in accessible formats, in the language(s) spoken by the patient.

• Provide all uninsured or self-pay patients with a GFE. This must include:
  • Patient name and date of birth.
  • a clear description of each item/service with diagnosis codes, expected service codes and expected charges associated with each listed item or service (and date of service if scheduled).
  • an itemized list of items/services reasonably expected to be furnished in conjunction with the primary item/service grouped by provider/facility along with the NPI/TIN and location of each.
  • provider’s name, National Provider Identification (NPI) number, and Tax Identification Number (TIN) and office (s) where the items or services are expected to be furnished.
  • a disclaimer that the GFE is only an estimate of items/services reasonably expected to be furnished at the time and final items, services or charges may differ. (For recurring services, see “GFEs for Recurring Services”, below).
  • a disclaimer that additional recommended items or services may be part of the course of care but are not reflected in the GFE along with a separate list of items/services that require separate scheduling and for which separate GFEs would need to be requested.
  • a disclaimer informing the patient of their right to initiate the patient-provider dispute resolution (PPDR) process if the actual billed charges are substantially greater than the estimated charges along with instructions of where to find more information and written assurance that initiating such process will not adversely affect the quality of services rendered. (See “Disputes”, below).
  • a disclaimer that the estimate is not a contract and does not require the individual to obtain the items or services from any of the providers or facilities identified.
• Explain the GFE to the patient over the phone or in-person if the patient requests it, and follow-up with a paper or electronic GFE.

• Document the GFE in the clinical record.

CSWs who are employed by group practices and other types of health care facilities should contact their compliance officers for guidance.

Timeframes

Information regarding scheduled items and services must be furnished within one (1) business day of scheduling an item or service to be provided in three (3) business days; and within three (3) business days of scheduling an item or service to be provided in at least 10 business days. A new GFE must be provided, within the specified timeframes if the patient reschedules the requested item or service. If any information provided in the estimate changes, a new GFE must be provided no later than 1 business day before the scheduled care. Also, if there is a change in the expected provider less than one business day before the scheduled care, the replacement provider must accept the original GFE as their expected charges.

GFEs for Recurring Services

If you expect to provide a recurring service to the uninsured or self-pay patient, you may submit a single GFE to that patient for those services, so long as the GFE includes, in a clear and understandable manner, the “expected scope of the recurring primary items or services (such as timeframes, frequency, and total number of recurring items or services)”.  The GFE can only include recurring services that are expected to be provided within the next 12 months. For additional recurrences beyond 12 months, the provider must provide a new GFE and communicate any changes between the initial and the new estimates.

For example, if you have a patient whom you expect will need continuing services throughout the year, the GFE could say: “I expect that my care of you will require continued weekly therapy sessions continuing through the end of the year, at $X per session for a total of 50 weeks, accounting for vacations and holidays for an estimated total of AMOUNT.”

If the future course of treatment is less certain, the GFE could say: “Depending on the progress we make this year, I expect that you will need 10–20 more sessions this year. At $X per session the estimated total cost would be AMOUNT.”

Templates and Resources

Find Centers for Medicare and Medicaid Services (CMS) resources, including templates that can be used to prepare good faith estimates and model language for informing patients of their rights to GFE.

Enforcement

GFEs are considered part of a patient’s medical record and must be maintained in the same manner. Accordingly, convening providers/facilities must be able to provide a copy of any estimates within the last six (6) years. Providers will not be considered non-compliant if they act in good faith and with reasonable due diligence and correct any inaccuracies as soon as practicable. HHS will exercise enforcement discretion in scenarios where convening providers and facilities are relying on the accuracy of expected charges for items or services for which they do not bill from co-providers or co-facilities, provided that they did not know or reasonably should have known, that the information was incomplete or inaccurate, and that they attempt to correct any inaccuracies as soon as possible. Providers/facilities who experience others’ failures to comply with these requirements may file a complaint for enforcement investigation.

Disputes

Although the information provided in the GFE is only an estimate, and the actual items, services, or charges may differ from what is included in it, uninsured or self-pay individuals may challenge a bill from a provider through a new patient-provider dispute resolution (PPDR) process if the billed charges substantially exceed the expected charges in the GFE. “Substantially exceeds” means an amount that is at least $400 more than the expected charges listed on the GFE.

Future Action

The federal government will also soon issue regulations requiring CSWs and other health providers to provide GFEs to commercial or government insurers when the patient has insurance and plans to use it.

NASW will continue to monitor policy developments pertaining to surprise billing and update members as new information is made available.

Disclaimer:  Legal and regulatory issues are complex and highly fact-specific and state-specific. They require legal expertise that cannot be provided in this article. The information in this alert does not constitute and should not be relied upon as legal advice and should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions.

December 2021

On November 2, 2021, the Centers for Medicare and Medicaid Services (CMS) released the CY 2022 Medicare Physician Fee Schedule (PFS) final rule. The 2400+-page rule includes updates to policies and payments that are pertinent to clinical social workers (CSWs) and other Medicare providers. NASW submitted comments on September 13, 2021 to CMS on the proposed rule.  A  number of NASW’s recommendations are reflected in the final rule. The final rule goes into effect on January 1, 2022. Below is a summary of the provisions and their implications for CSWs.

NASW will continue to monitor Medicare regulation and inform members of any further updates from CMS clarifying the CY 2022 final rule provisions. NASW also continues to undertake vigorous advocacy with CMS on behalf of CSWs and their clients, including efforts to increase the CSW reimbursement rate.

Reimbursement

The final rule called for 3.75 percent reimbursement cuts to Medicare providers, including CSWs. An intense advocacy effort fueled by NASW members and other professional organizations has earned a win: Congress has passed legislation that offsets most of the proposed cuts and delays additional reductions that were looming due to sequestration and other budget requirements. Without congressional action, CSWs and other provider types were facing the 3.75 cut plus additional across-the-board reductions totaling an additional 6 percent. This included a 2 percent sequestration cut which has now been delayed until April 2022, when a 1 percent sequestration will be imposed until June 30, 2022, with the required 2 percent cut returning in July and remaining until the sequestration system expires in 2031. The legislation approved by the Congress also delays implementation of a 4 percent deficit control cut until 2023.

Telehealth

Before the public health emergency (PHE), Medicare telehealth coverage was limited.

The PHE brought a steep decline in the use of in-person services creating significant concerns about health equity and access to care. As a result, CMS temporarily expanded telehealth coverage under the PFS.  This included the removal of geographic restrictions, as well as the addition of covered services and coverage of services provided via both smartphones and audio-only devices.  The final rule continues many of these flexibilities.

Telehealth Services List: CMS will continue the use of the temporary services added to the list through December 31, 2023. During this time, CMS will continue to evaluate the effectiveness of these services for permanent inclusion. A current list of codes can be found here

Geographic Restrictions 

The removal of the geographic restrictions continues, allowing the beneficiary’s home as an originating site for telehealth services for the purposes of evaluation, diagnosis, and treatment of a mental health disorder. The definition of “home” has also been expanded to include temporary lodging, such as hotels and homeless shelters as well as locations a short distance from the beneficiary’s home.

In-Person Requirement

CMS is requiring that an in-person, non-telehealth service be furnished by a practitioner at least once within six (6) months before each telehealth service furnished for the evaluation, diagnosis, or treatment of a mental health disorder (other than for treatment of a diagnosed substance use disorder or co-occurring mental health disorder). The in-person non-telehealth service requirements apply only to telehealth services furnished to a patient in a home originating site. A 12 month in-person visit is required thereafter.  Exceptions to the in-person visit is based on the beneficiary’s circumstance which must be documented in the clinical record. Payment will not be made to a telehealth service unless the above conditions are met.

In a provider group setting, the in-person requirement may be met by another provider of the same specialty in the same group if the provider rendering the telehealth service is not available. CMS plans to provide additional guidance on the in-person requirement.

In its public comment letter on the proposed rule, NASW urged CMS to remove the in-person requirement entirely. NASW is continuing to advocate for its removal.

Audio-Only Communication

The definition of interactive telecommunications system for telehealth services has been revised to include audio-only communications technology for the treatment of mental health and substance use disorders.  The use of audio-only services is permissible when CSWs have the capability of using two-way, audio/video communications, but the beneficiary is not capable of, or does not agree to, using two-way, audio/video technology. CSWs must document the rationale for audio-only services in the patient’s record and use the appropriate claim modifier which clarifies the service performed.

CMS also finalized a requirement for the use of a new modifier for services performed using audio-only communications. NASW is delighted that audio-only has been continued beyond the PHE, as it has advocated vigorously for it to be made permanent.

Opioid Treatment Programs (OTP)

OTPs are able to deliver counseling and therapy services via audio-only interaction (e.g.. telephone calls) following the PHE in instances where the beneficiary does not consent to or have the capability to use two-way audio/video interaction. CSWs will be required to use the appropriate service-level modifier and document the rationale for audio-only use in the patient’s record.

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

CMS now allows RHCs and FQHCs conduct mental health visits using real-time telecommunication technology, such as video conferencing or a smartphone. It also allows the use of audio-only services when the beneficiary does not consent to or has the capability of using video technology.

CMS has indicated the in-person, non-telehealth visit requirement must be provided at least every 12 months for these services. More visits are permitted under CMS policy, based on clinical need.  Exceptions to the in-person requirement may be granted depending on the beneficiary’s circumstances. In this instance, CSWs should document the reason in the patient’s record.

RHCs and FQHCs will be able to bill for Transitional Care Management (TCM) and other care management services provided for the same beneficiary during the same service period, given all billing code requirements are met.

Tribal FQHC Payments

CMS is soliciting comments, per the request of American Indian and Alaska Native communities to revise its Medicare regulations to allow all Indian Health Service (IHS) and tribally operated outpatient facilities/clinics eligible for payment at the Medicare outpatient per visit. CMS has also been asked to consider flexibilities pertaining to cost reporting requirement for these facilities.

Quality Payment Program (QPP)

The Merit-Based Incentive Payment System (MIPS) is a component of Medicare’s Quality Payment Program.  It is a value-based payment program that promotes the delivery of high-value care by Medicare providers through payment incentives.  Beginning January 1, 2022, CSWs will be one of 15 eligible Medicare providers to perform and submit quality measures in their practice as an individual, a group practice, or virtual group.   Additional information about QPP is available at Clinical Social Work Quality Payment Program

NASW will continue to monitor CMS policies for any future changes and advocate for members as needed. Questions about the final rule may be emailed to Mirean Coleman at mcoleman.nasw@socialworkers.org 

Two adults are interacting with an older person. The older person is lying in bed. All three are wearing face masks.

The COVID-19 pandemic has had a profound impact on nursing home residents, families, and staff. Limitations on visits from family (as defined by each resident), other personal guests, and even certain service providers (such as hospice personnel and long-term care ombudsmen) have drastically exacerbated loneliness and social isolation among residents.

Recognizing the physical and emotional toll of these visitation restrictions, the Centers for Medicare & Medicaid Services (CMS) recently updated its guidance to nursing homes regarding visitation during COVID-19. As of the date the guidance was released (November 12, 2021), residents may receive visitors of their choice at any time of day, indoors or outdoors, even during COVID-19 outbreaks. Infection prevention practices, as detailed by CMS in the updated guidance, remain critical.

Resources

Updated guidance from CMS (November 12, 2021)

Recording of CMS National Nursing Home Stakeholder Call on COVID-19 (November 23, 2021)

Summary of the guidance from the National Consumer Voice for Quality Long-Term Care (November 2021)

Consumer Voice Webinar recording and slides regarding the guidance (November 18, 2021)

Consumer Voice podcast regarding the guidance (December 10, 2021)

Summary of CMS stakeholder call by LeadingAge, association representing nonprofit nursing homes and other aging services providers (November 23, 2021)

Chris Herman, MSW, LICSW

Senior Practice Associate–Aging, NASW national office