Who Can Provide Substance Use Services?  

As substance use and addiction continue to be critical public health concerns, healthcare providers play a pivotal role in delivering much-needed services to individuals struggling with substance use disorders (SUD). For those navigating the complex world of healthcare services, it’s important to understand which professionals can provide substance use services and how these services are reimbursed by Medicare. This long read will break down the key roles and services involved in substance use care, payment structures, and the importance of addressing health equity within this field. 

Providers Eligible to Offer Substance Use Services 

Substance use services can be provided by a variety of healthcare professionals, each bringing a unique skill set to the table. Here is a comprehensive look at the different types of Medicare Part B providers who are authorized to offer these services: 

• Physicians (MDs or DOs): Medical doctors or doctors of osteopathy can provide a wide range of services, including diagnosis, treatment planning, and prescribing medications for SUD. 

• Clinical Psychologists (CPs): Licensed psychologists can offer psychological assessments, therapy, and counseling to those struggling with substance use. 

• Clinical Social Workers (CSWs): Social workers provide essential mental health counseling and can assist patients with navigating social services and resources to support their recovery. 

• Certified Alcohol and Drug Counselors: These specialized counselors work directly with individuals struggling with substance use, providing assessments, counseling, and support in managing their recovery. 

• Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs): Advanced practice nurses who can diagnose and treat substance use disorders, as well as prescribe medications as part of a treatment plan. 

• Physician Assistants (PAs): PAs can offer substance use counseling, prescribe medications, and help with ongoing management of a patient’s treatment plan. 

• Certified Nurse-Midwives (CNMs): In addition to maternity care, CNMs are trained to provide substance use counseling and treatment for women, particularly during pregnancy. 

• Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs): These professionals provide therapeutic services that are vital for addressing the relational and emotional aspects of substance use disorders. 

Auxiliary Personnel and “Incident To” Services 

In addition to the primary providers listed above, some physicians and non-physician practitioners (NPPs) have the ability to delegate certain substance use services to auxiliary personnel under what is known as “incident to” billing. This means that services provided by trained staff members (such as nurses or medical assistants) can be billed under the supervising provider’s Medicare account, as long as the services are incidental to the provider’s care. 

Medicare Advantage (MA) Plans and Behavioral Health 

For patients enrolled in Medicare Advantage (MA) plans, CMS has introduced a new facility-specialty provider category known as “Outpatient Behavioral Health.” This category consolidates various behavioral health providers under one umbrella, simplifying the process for beneficiaries to access the care they need. 

How Providers Are Paid for Substance Use Services 

Medicare Part B offers different payment structures depending on the type of provider offering substance use services: 

• Physicians and Clinical Psychologists (CPs): Services provided by physicians and CPs are reimbursed at 100% under the Medicare Physician Fee Schedule (PFS). 

• Clinical Social Workers (CSWs), Marriage and Family Therapists (MFTs), and Mental Health Counselors (MHCs): These providers are reimbursed at 80% of the lesser of the actual charge or 75% of what a CP is reimbursed under the Medicare PFS. 

• Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs): These providers are reimbursed at 80% of the lesser of the actual charge or 85% of what a physician is paid under the Medicare PFS. 

• Certified Nurse-Midwives (CNMs): CNMs receive 80% of the lesser of the actual charge or 100% of what a physician is paid under the Medicare PFS. 

Health Equity and Substance Use Services 

Substance use and addiction disproportionately affect minority and underserved communities. By ensuring that these groups have access to high-quality care, providers can help address health disparities and advance health equity. The CMS Office of Minority Health provides several resources to support providers in this effort, including: 

• Health Equity Technical Assistance Program: A program designed to offer guidance and support for healthcare organizations seeking to improve health equity in their practices. 

• Disparities Impact Statement: A tool to help providers assess and address health disparities within their patient populations. 

Key Services for Substance Use Disorders 

Medicare Part B covers several specific services related to substance use disorders, each designed to help prevent and treat various forms of addiction. 

Alcohol Misuse Screenings 

Part B covers alcohol misuse screenings for adults who use alcohol but do not meet the criteria for alcohol dependence. Providers can offer up to four brief, face-to-face counseling sessions per year, as long as the patient is competent and alert during the sessions. 

To conduct effective counseling, providers can use the U.S. Preventive Services Task Force’s (USPSTF) 5 A’s Behavioral Counseling Framework: 

• Assess: Screen for alcohol misuse and determine any related health risks. 

• Advise: Provide clear, personalized advice about the risks of continued alcohol use. 

• Agree: Collaboratively set treatment goals with the patient. 

• Assist: Help the patient acquire the skills and support needed to change their behavior. 

• Arrange: Schedule follow-up visits to monitor progress and adjust the treatment plan as needed. 

Tobacco Use Counseling 

Medicare covers up to eight smoking cessation counseling sessions per year. Providers can choose between intermediate and intensive counseling strategies to help patients quit. Eligible patients include anyone who uses tobacco products, regardless of whether they show signs of tobacco-related disease. 

Opioid Use Disorder (OUD) Screenings 

Part B also covers opioid use disorder (OUD) screenings during annual wellness visits or preventive physical exams. If a provider diagnoses a patient with OUD, Medicare covers a range of treatment options, including: 

• Medication management: Physicians and NPPs can manage medications like buprenorphine and naltrexone to support recovery. 

• Office-based SUD treatment: Providers can offer a monthly bundle of services, including care coordination, psychotherapy, and substance use counseling, all billed under one code. 

For more intensive treatment, providers can refer patients to opioid treatment programs (OTPs), which offer medication-assisted treatment (MAT) with FDA-approved medications like methadone and buprenorphine. 

Behavioral Health Integration Services 

Medicare covers Behavioral Health Integration (BHI) services for patients with behavioral health disorders stemming from substance use. BHI services are critical for patients who need a coordinated approach to managing both their mental health and substance use issues. 

Screening, Brief Intervention, and Referral to Treatment (SBIRT) 

SBIRT is a comprehensive approach to intervening before patients develop more severe substance use problems. The three components of SBIRT include: 

1. Screening: Identifying patients with risky substance use behaviors. 

2. Brief Intervention: Providing motivational counseling to encourage behavior change. 

3. Referral to Treatment: Directing patients who need more intensive care to specialized treatment programs. 

SBIRT services are a vital tool for preventing the progression of substance use disorders and ensuring that patients receive the help they need before their condition worsens. 

Substance use services are essential for addressing the growing problem of addiction in the United States, and Medicare Part B provides coverage for a variety of healthcare professionals to offer these services. By understanding the roles different providers play and how services are reimbursed, you can better navigate the complex world of substance use treatment.