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CT Third Party (Vendorship) Requirements for Social Workers

Third party payment law in Connecticut, also referred to as Vendorship, requires health insurers to reimburse eligible social workers for diagnosis and treatment for mental or nervous conditions, when the policy comes under the state law. Generally speaking, reimbursement is restricted to licensed clinical social workers, however LMSW’s may be eligible to bill insurance in certain settings (described below).

ELIGIBLE SOCIAL WORKERS BY STATE STATUTE:

  1. Licensed clinical social workers (LCSW) who have passed the clinical examination of the Association of Social Work Boards and have completed at least 2000 hours of post-master’s social work experience in: a non-profit agency qualifying as a tax-exempt organization under Section 501 (c) of the  Internal Revenue Code of 1986 or any other subsequent corresponding internal revenue code of the United States; in a municipal, state or federal agency; or in an institution licensed by the Department of Health Services. At this time practically all insurers simply seek the LCSW regardless of whether the above noted 2000 hours have been met or not.
  2. Licensed clinical social workers that were certified by the State of Connecticut as a Certified Independent Social Worker (CISW) prior to October 1, 1990 (the 2000 hours and examination requirements in #1 do not apply to this group).
  3. A LMSW providing services in a child guidance clinic under the supervision of a licensed clinical social worker, physician, licensed psychologist, licensed marital & family therapist, licensed professional counselor or an APRN.
  4. A MSW providing outpatient services in a non-profit community mental health center as defined by the department of mental health or in a non-profit licensed adult psychiatric clinic operated by an accredited hospital, under the supervision of a licensed clinical social worker, physician, licensed psychologist, licensed marital & family therapist, licensed professional counselor or an APRN.
  5. A LMSW in private practice as long as the LMSW is under professional clinical supervision (see eligible supervisors in #3 & #4), may be reimbursed under the provision of service too. The LMSW must check with each insurer as to provider status eligibility.

MEDICARE AND MEDICAID

Medicare will only accept LCSWs as providers. Medicaid will accept LCSWs in agency settings where Medicaid is accepted and LMSWs are eligible providers in certain agency settings where clinical supervision is provided. Medicaid will also accept LCSWs in private practice settings. LMSWs working in an existing private practice under professional clinical supervision are Medicaid eligible providers in accordance with DSS policy https://www.ctdssmap.com/CTPortal/Information/Get-Download-File?Filename=pb22_67.pdf&URI=Bulletins/pb22_67.pdf

INSURANCE POLICIES THAT COME UNDER THE LAW AND EXCEPTIONS

All group and individual health insurance policies written in Connecticut come under the third party payment statute. However, individual policies (those covering an individual vs. an individual who is part of a group policy) may not have mental health benefits included. Additionally, the following EXCEPTIONS exist that exempt at least 50% of all policies.

  • If the group policy is through an employer that is self-insured than the policy is exempt from state insurance mandates including social work vendorship. It is important to note that the employer may contract with an insurance company to administer their policy, so the key here is to determine who is the employer. Many large employers and even some mid-size employers are self-insuring. This does not mean that they will not accept social workers as providers; it means they do not have to accept social workers.
  • Group policies written out-of-state where less than 50% of the employees on the policy are in Connecticut.
  • Individual policies written out-of-state.

MANAGED CARE

Managed care organizations can deny access to their provider panels even if you are eligible under the vendorship law. Individual’s seeking to become a provider for any given managed care panel must contact the provider relations unit of the managed care company to apply for provider status. In some cases, managed care organizations may authorize the individual provider for specific patients but not accept the provider on their panel.

This information is for general use and may not apply in all circumstances.