[Congressional Record Volume 145, Number 55 (Wednesday, April 21, 1999)]
[Senate]
[Pages S4032-S4033]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Ms. MIKULSKI (for herself, Mrs. Murray, Mr. Inouye, Mr. Wyden, 
        Mr. Johnson, Mr. Hollings, Mr. Reid, and Mr. Bingaman):
  S. 847. A bill to amend title XVIII of the Social Security Act to 
exclude clinical social worker services from coverage under the 
medicare skilled nursing facility prospective payment system; to the 
Committee on Finance.


                medicare social work equity act of 1999

  Ms. MIKULSKI. Mr. President, I rise today to introduce the Medicare 
Social Work Equity Act of 1999. I am proud to sponsor this legislation 
which will amend section 4432 in the Balanced Budget Act of 1997 which 
prevents social workers from directly billing Medicare for mental 
health services provided in skilled nursing facilities (SNF's). This 
bill will also ensure that clinical social workers (CSW's) can receive 
Medicare reimbursement for mental health services they provide in 
skilled nursing facilities. I am honored to be joined by my good 
friends Senators Murray, Inouye, Hollings, Wyden, Johnson, Reid, and 
Bingaman who care equally about correcting these inequities for social 
workers and about ensuring quality mental health services for nursing 
home residents.
  The Balanced Budget Act of 1997 (BBA) changed the payment method for 
skilled nursing facility care. Before BBA, reimbursement was made after 
services had been delivered for the reasonable costs incurred. However 
this ``cost-based system'' was blamed for inordinate growth in Medicare 
spending at skilled nursing facilities.
  The Balanced Budget Act of 1997 phased in a prospective payment 
system for skilled nursing facilities that was fully implemented on 
January 1, 1999, for Medicare part A services. Payments for part B 
services for skilled nursing facility residents are to be consolidated. 
This means that the provider of the services must bill the facility 
instead of directly billing Medicare. The consolidated billing 
provision has been delayed indefinitely by the Health Care Financing 
Administration (HCFA) while it addresses Year 2000 (Y2K) compliance 
issues.
  However, Congress was careful to not include psychologists and 
psychiatrists in this consolidated billing provision. Social workers 
were included, I think by mistake. Clinical social workers are the 
primary providers of mental health services to residents of nursing 
homes, particularly in underserved urban and rural areas. CSW's are 
also the most cost effective mental health providers.

  This legislation is important for three reasons: First, I am 
concerned that section 4432 inadvertently reduces mental health 
services to nursing home residents. Second, I believe that the 
consolidated billing requirement will result in a shift from using 
social workers to other mental health professionals who are reimbursed 
at a higher cost to Medicare. Finally, I am concerned that clinical 
social workers will lose their jobs in nursing homes or will be 
inadequately reimbursed.
  In addition, this bill ensures that clinical social workers can 
receive Medicare reimbursement for mental health services they provide 
in skilled nursing facilities. An April 1998, HCFA rule would have 
effectively eliminated Medicare reimbursement for clinical social 
worker services provided to residents of SNF's, whether or not their 
stay was being paid by Medicare, Medicaid, or a private payer. It would 
have deemed all mental health services provided to nursing home 
residents ``required'' services, not distinguishing between the mental 
health diagnosis and treatment services provided by CSW's and the 
required medically-related social services provided at the SNF.
  Facilities would likely bring in a psychiatrist or psychologist (if 
available) because services provided by them could still be billed 
separately This would affect seniors in many rural and underserved 
areas where CSW's are often the only available mental health provider 
and have developed relationships over time with these SNF patients. 
HCFA delayed this rule for two years. However, clarification is needed 
in the law to ensure that CSW's can be reimbursed by Medicare for the 
mental health services they provide to inpatients in SNF's. This bill 
makes that necessary change.
  I like this bill because it will correct inequities for America's 
social workers, it will assure quality of care for nursing home 
residents, and will assure cost efficiency for Medicare. This bill is 
strongly supported by the National Association of Social Workers, 
Clinical Social Work Federation, American Psychological Association, 
American Group Psychotherapy Association, Bazelon Center for Mental 
Health Law, National Mental Health Association, National Council for 
Community Behavioral Health Care, National Association of Protection 
and Advocacy Systems, Anxiety Disorders Association of America, and the 
Mental Health and Aging Network of the American Society on Aging. I now 
look forward to the Senate's support of this important legislation.

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