Telemental Health Coverage When PHE Ends

As was noted in the CSWA Announcement of March 16, 2023, “Telemental Health Coverage When PHE Ends” (https://www.clinicalsocialworkassociation.org/Announcements/13134039), there will be changes to clinical social work practice when the Public Health Emergency (PHE) ends on May 11, 2023. This paper elaborates on these additional changes which affect many more areas of practice.

HIPAA Changes

As we know, the kinds of video platforms that were allowed to conduct mental health treatment during the pandemic were relaxed. Platforms that did not meet the security requirements of HIPAA including Facetime, Skype, and others which did not provide a Business Associate Agreement (BAA), were accepted by the Office of Civil Rights (OCR) and not seen as a violation of HIPAA rules. This relaxation will change with the end of the PHE. The relaxation of providing the Good Faith Estimate (GFE) for telemental health will also be back in effect.

OCR is providing a 90-calendar day transition period for covered health care providers to come back into compliance with the HIPAA Rules with respect to their provision of telehealth. The transition period will be in effect beginning on May 12, 2023 and will expire at 11:59 p.m. on August 9, 2023. OCR will continue to exercise its enforcement discretion and will not impose penalties on covered health care providers for noncompliance with the HIPAA Rules that occurs in connection with the good faith provision of telehealth during the 90-calendar day transition period.

In other words, by August 9, 2023, all LCSWs will need to demonstrate that they are using a HIPAA compliant platform, e.g., ZoomPro, Doxy.me, and other platforms offer a BAA. OCR has not been penalizing LCSWs for the failure to give a GFE to patients who are self-pay or pro bono.  These penalties will be back in effect as of August 9 if LCSWs are found to be non-compliant.

For more information go to: https://www.hhs.gov/about/news/2023/04/11/hhs-office-for-civil-rights-announces-expiration-covid-19-public-health-emergency-hipaa-notifications-enforcement-discretion.html

Changes to Codes and Modifiers for Medicare

Medicare has added more guidance in regard to codes which will be covered and modifiers needed for coverage. In addition to psychotherapy codes, there are several new codes available to clinical social workers for Behavioral Care Management which would include care integration and other services that have not been covered until now. The code will be G0323 for Care Management Services for Behavioral Health Conditions.

The details are: 

• New for CY 2023: Describes general BHI that a clinical psychologist (CP) or clinical social worker (CSW) performs to account for monthly care integration
• A CP or CSW, serving as the focal point of care integration furnishes the mental health services
• At least 20 minutes of CP or CSW time per calendar month
• • POS of 11 should be used through the end of 2023 for telemental health

Additionally, the modifier for Medicare claims is “GT” though “95” can be used for other claims. For more details go to: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf

Medicare Advantage Changes

Medicare Advantage (MA) plans may offer continued telehealth benefits. Individuals in a Medicare Advantage plan should check with their plan about coverage for telehealth services. Remember that MA plans are commercial insurance and have their own coverage. Some MA plans may require patients to be seen in person at least once a year. After December 31, 2024, when these flexibilities expire, some MA Accountable Care Organizations (ACOs) may offer telehealth services that allow primary care doctors to care for patients without an in-person visit, no matter where they live. If your health care provider participates in an ACO, check with them to see what telehealth services may be available. In short, the coverage for MA plans may be more variable than coverage for traditional Medicare.

For more information, go to: https://www.cms.gov/files/document/what-do-i-need-know-cms-waivers-flexibilities-and-transition-forward-covid-19-public-health.pdf

Private Health Insurance and Telehealth

As is currently the case during the PHE, coverage for telehealth and other remote care services will vary by private insurance plan after the end of the PHE. When covered, private insurance may impose cost-sharing, prior authorization, or other forms of medical management on telehealth and other remote care services. For additional information on your insurer’s approach to telehealth, contact your insurer’s customer service number located on the back of your insurance card.

Summary

For more detailed information in general, go tohttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf.

The next few months will bring many changes. Let me know if you have any questions.