Sponsors (3)
The bill expands and clarifies Medicare coverage for clinical social worker behavioral‑health services—improving access and billing clarity for beneficiaries and providers—while raising program costs and creating short‑term implementation and utilization risks.
Medicare beneficiaries in skilled nursing facilities (SNFs) and hospital inpatients will have increased access to reimbursable clinical social worker behavioral‑health and psychosocial services because the SNF exclusion is removed and those services can be provided outside the SNF per‑diem cap.
Medicare beneficiaries in SNFs and hospitals gain clearer Medicare coverage for clinical social worker services for mental illness and health/behavioral assessment starting Jan 1, 2026, reducing uncertainty about eligibility for these services.
Hospitals, SNFs, and other providers get clearer billing guidance because the bill explicitly lists HCPCS codes, likely lowering administrative ambiguity and reducing claim denials and disputes.
Taxpayers and Medicare beneficiaries could face higher program costs because expanding billable clinical social worker services is likely to increase Medicare spending.
Medicare beneficiaries may receive more billed behavioral‑health services without guaranteed improvements in outcomes, increasing utilization but not necessarily patient benefit.
Hospitals, SNFs, and state payers could face transitional billing complexity and reimbursement disputes during implementation through 2026 if guidance or systems are incomplete.
Based on analysis of 2 sections of legislative text.
Removes clinical social worker services from SNF per‑diem limits and expands Medicare Part A coverage to include mental health diagnosis/treatment and health/behavior services by clinical social workers.
Official title: Amend title XVIII of the Social Security Act to improve access to mental health services under the Medicare program.
Introduced May 15, 2025 by John A. Barrasso · Last progress May 15, 2025
The bill changes Medicare rules to treat clinical social worker services differently: it removes clinical social worker services from the per‑diem payment limits under the SNF prospective payment system and expands the definition of covered clinical social worker services under Medicare Part A to explicitly include diagnosis and treatment of mental illness and health/behavior assessment and intervention (with certain HCPCS codes). The changes apply to items and services furnished on or after January 1, 2026. The effect is to allow greater Medicare payment recognition for clinical social worker services provided to beneficiaries (including those in SNFs) for mental health and related behavioral services, potentially improving access to mental health care for older adults under Medicare.