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Medical Policy

Policy Num:      10.002.007
Policy Name:    Social Work Services
Policy ID           [10.002.007]  [Ar / L / M+ / P-]  [0.00.00]

Last Review:    November 26, 2024
Next Review:   Policy Archived
 

Related Policies: None

Social Work Services

Summary

A Social worker is a person trained to help people manage, prevent or cope with everyday problems. They are employed in a variety of settings, mostly child welfare and human services, schools, or healtcare agencies providers. A bachelor's or master's degree is required in all settings, and it should be accredited by the Council on Social Work Education. A license is required to practice, and others requirements may apply depending on the state. 

A Clinical Social Worker requires a master's degree, supervised clinical experience, and a license from the Council of Social Workers Professionals of Puerto Rico.

Objective

This policy objective is to establish the authorized services to be provided by the Clinical Social Worker under Triple S, Inc., and Puerto Rico state law 249 of 2010. 

Policy Guidelines

The clinical social worker may charge Triple-S for services authorized by law for clinical management (diagnosis and treatment) of mental illness. A direct invoice can be made if they are outpatient services offered as a member of a multidisciplinary mental health team or under the supervision of the psychiatrist. In the case of a mental health care facility, the latter may charge for the service of the clinical social worker by mutual agreement. In hospitalized patients, these services are included in the "per diem". The services offered by this professional will be charged according to the rate established by Triple-S. The clinical social worker will not charge for the consultation service provided to other health care professionals.

Benefit Application

BlueCard/National Account Issues

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

According to Law 163 of August 13, 2024 - “Law for the Protection, Security, Integration, Well-being and Comprehensive Development of People with Autism Spectrum Disorders”, medical plans are obliged to offer coverage for all health interventions scientifically validated as effective for Autism Spectrum Disorders and may not establish limitations regarding age, limit of benefit, or number of visits to a medical services professional, once medical necessity has been established by a licensed physician.

Background

Mental Health

Mental health disorders, also known as mental illnesses or mental health conditions, are medical conditions that affect a person's thinking, feeling, behavior, or mood. There are many different types of mental health disorders, including: 

• Anxiety disorders: Excessive fear and worry 
• Depression: Depressed mood, loss of interest in activities, and other symptoms 
• Bipolar disorder: Alternating depressive episodes with manic symptoms 
• Schizophrenia: Significant impairments in perception and changes in behavior 
• Obsessive-compulsive disorder (OCD): A type of anxiety disorder 
• Post-traumatic stress disorder (PTSD): A type of mental disorder 
• Attention-deficit/hyperactivity disorder (ADHD): A type of mental disorder 
• Eating disorders: A type of mental disorder 
• Personality disorders: A type of mental disorder 
• Factitious disorders: A condition where someone intentionally creates physical or emotional symptoms to appear sick or in need of help 
• Sexual and gender disorders: Disorders that affect sexual desire, performance, and behavior 

Mental health disorders can affect anyone, regardless of age, gender, race, ethnicity, or other factors. In the United States, about 1 in 5 adults and adolescents live with a mental health disorder. This conditions are treatable, and there are many treatments available to help people manage them. 

Social Workers

Social workers help people and communities deal with challenges in their lives. They can help with a variety of situations, including: 

• Crisis situations: Responding to child abuse, mental health emergencies, or other crises 
• Life changes: Helping people adjust to changes like divorce, illness, or unemployment 
• Community resources: Researching and advocating for community resources like childcare, food stamps, and healthcare 
• Social problems: Helping clients with social problems like substance abuse, inadequate housing, or unemployment 
• Domestic conflicts: Assisting families with serious domestic conflicts, including child or spousal abuse 

Social workers can also work at a broader level to help community organizations and policymakers improve social programs, services, and conditions. This is sometimes called macro social work.  

Social workers practice in many different settings and may specialize in serving a specific population. They listen to and support people, empowering them to improve their lives. They also protect people from harm when necessary. 

Rationale

Clinical Social Workers

A clinical social worker is a mental health professional who assesses, diagnoses, treats, and prevents behavioral and mental health conditions. They also create care plans, monitor clients' progress, and collaborate with other healthcare professionals. 

Clinical social workers differ from other social workers in that only they can provide counseling treatments. All social workers can connect clients with resources and offer guidance, but clinical social workers focus on helping individuals function best in their external environment. 

Population Reference No. 1 

Text

Suplemental Information

CMS Manual System Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 170 states the following:

170 - Clinical Social Worker (CSW) Services (Rev. 1, 10-01-03) B3-2152

A.    Clinical Social Worker Defined

Section 1861(hh) of the Act defines a “clinical social worker” as an individual who:

• Possesses a master’s or doctor’s degree in social work;

• Has performed at least two years of supervised clinical social work; and

• Is licensed or certified as a clinical social worker by the State in which the services are performed; or

• In the case of an individual in a State that does not provide for licensure or certification, has completed at least 2 years or 3,000 hours of post master’s degree supervised clinical social work practice under the supervision of a master’s level social worker in an appropriate setting such as a hospital, SNF, or clinic.

B.    Clinical Social Worker Services Defined

Section 1861(hh)(2) of the Act defines “clinical social worker services” as those services that the CSW is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed for the diagnosis and treatment of mental illnesses. Services furnished to an inpatient of a hospital or an inpatient of a SNF that the SNF is required to provide as a requirement for participation are not included. The services that are covered are those that are otherwise covered if furnished by a physician or as incident to a physician’s professional service.

C.   Covered Services

Coverage is limited to the services a CSW is legally authorized to perform in accordance with State law (or State regulatory mechanism established by State law). The services of a CSW may be covered under Part B if they are:

• The type of services that are otherwise covered if furnished by a physician, or as incident to a physician’s service. (See §30 for a description of physicians’ services and §70 of Pub 100-1, the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, for the definition of a physician.);

• Performed by a person who meets the definition of a CSW (See subsection A.); and

• Not otherwise excluded from coverage

References

1. https://www.socialworkers.org/Practice/Clinical-Social-Work#:~:text=Clinical%20social%20work%20is%20a,emotional%2C%20and%20other%20behavioral%20disturbances.
2. https://www.indeed.com/career-advice/careers/what-does-a-clinical-social-worker-do#:~:text=Clinical%20social%20workers%20develop%20treatment,collaborating%20with%20other%20healthcare%20experts.
3. https://www.socialworklicensure.org/articles/clinical-vs-direct-services-social-work/#:~:text=The%20main%20difference%20between%20clinical,workers%20can%20provide%20counseling%20treatments.
4. https://www.bu.edu/ssw/choosing-a-major-clinical-or-macro/#:~:text=In%20clinical%20social%20work%2C%20you,help%20them%20live%20better%20lives.
5. https://www.bls.gov/ooh/community-and-social-service/social-workers.htm#:~:text=Social%20workers%20typically%20do%20the,to%20as%20macro%20social%20work.
6. https://www.socialworkers.org/News/Facts/Social-Workers#:~:text=Who%20are%20social%20workers?,working%20in%20a%20specific%20setting.
7. https://socialwork.buffalo.edu/admissions/is-social-work-right-career-for-me/what-is-social-work.html#:~:text=Social%20work%20is%20a%20profession,%2C%20families%2C%20groups%20and%20societies.
8. https://www.socialworkengland.org.uk/about/about-social-work/#:~:text=A%20social%20worker's%20role%20is,people%20at%20any%20one%20time.
9. https://www.who.int/news-room/fact-sheets/detail/mental-disorders
10. https://medlineplus.gov/mentaldisorders.html#:~:text=What%20are%20some%20types%20of,Psychotic%20disorders%2C%20including%20schizophrenia
11. https://my.clevelandclinic.org/health/diseases/22295-mental-health-disorders#:~:text=Anyone%20of%20any%20age%2C%20sex,people%20ages%2015%20to%2034.
12. https://www.nami.org/about-mental-illness/mental-health-conditions/
13. https://www.nimh.nih.gov/health/topics
14. https://www.webmd.com/mental-health/mental-health-types-illness#:~:text=Factitious%20disorders:%20Factitious%20disorders%20are,of%20sexual%20and%20gender%20disorders.
15. https://www.psychiatry.org/patients-families/what-is-mental-illness#:~:text=Mental%20health%20is%20a%20component,the%20severity%20of%20its%20impact.
16. https://www.cms.gov/medicare/prevention/prevntiongeninfo/downloads/bp102c15.pdf

Codes

Policy History