Identification of Psychosocial Needs
  • Medicare law generally proscribes fee-for-service (FFS) reimbursement for “screening,“ but screening still occurs in FFS and Medicare Advantage plans in several ways
  • Medicare FFS also provides full coverage for health and behavior assessment
Coverage and reimbursement vary by state, but generally:
  • Some screening covered for children under age 21 through the Medicaid Early Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit
  • Coverage of Health and Behavior Current Procedural Terminology (CPT) codes varies by state
Care Planning; Linking of Patients with Psychosocial Services; Coordination of Psychosocial and Biomedical Care; Follow-up
  • Some reimbursement is provided as part of FFS payments for medical Evaluation and Management (E/M) services, and payments for some E/M services increased in 2007
  • Medicare Advantage plans’ more flexible reimbursement also allows for these services
  • Multiple demonstration projects are ongoing to test models of care coordination
  • Medicaid payments are generally low, but states’ Primary Care Case Management (PCCM) programs offer some financial support, as do state Medicaid agency contracts with managed care plans; as of 2005, 25 states offered PCCM services with some limits
  • Most states also offer “targeted case management” to certain beneficiaries to enable access to and coordination of necessary medical, social, and educational care and other service needs (CMS, 2005a)


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