Substance Use Disorder Providers and Insurance Reimbursement

A growing gap for services

There’s an urgent need to make appropriate treatment for substance use disorders more widely available in the US: According to SAMHSA’s 2015 National Survey on Drug Use and Health, 21.7 million people aged 12 or older needed treatment for substance use disorder (SUD) in the past year, but only 14% received treatment, and only 8.1% received that treatment at a specialty facility. And given the opioid epidemic, that gap has likely grown.

Examining system barriers to treatment

An individual’s situation and lifestyle may influence whether they seek treatment, but characteristics of the healthcare system itself can also affect whether people seek and obtain treatment. Obstacles to treatment can include complex eligibility and admission criteria, the absence of appropriate services for certain cultural groups, and a lack of available treatment providers.

Financial support for services can be another major barrier. Although insurance coverage for treatment has become more widespread in recent years, SUD treatment providers have historically relied on grant funding more than on insurance reimbursement. Changing that requires a different set of policies and procedures. And treatment providers will need assistance to navigate the requirements and processes for joining insurance provider networks—including credentialing, billing, and more—especially at a time when treatment and recovery systems are overwhelmed by demand.

Scanning for best practices

Across the nation, state Medicaid agencies, their managed care organizations, and commercial insurers have developed a range of policies, programs, and reimbursement strategies to address the need for services, including those related to:

• Eligibility
• Benefits and services
• Provider qualifications
• Financing (rates, premiums, and value-based purchasing)

We examined this variation to uncover standout practices that are helping to expand access to providers and treatment. In addition to examining existing literature, we gathered data from all 50 states and D.C. regarding their licensing and credentialing requirements for providers and insurance reimbursement policies for Medicaid and Medicare, as well as commercial insurers’ policies. We also interviewed national experts in the field for additional insights on barriers to treatment access and innovative strategies to address them. 

Findings

We found the following factors to be key barriers to entering the SUD counseling field:

• Variability across (and in some cases, within) states in career ladders and certification/licensing requirements;
• Low education requirements for qualification, lack of education programs focusing on SUD treatment;
• Unavailability of licensure in 20 states;
• Lack of pathways to independent practice;
• Lack of insurance coverage for SUD services; and
• Low reimbursement rates compared to other behavioral health professions.

Facilitators to address these barriers include:

• National and state-level collaboration and consensus-building efforts among multiple credentialing boards;
• State-level centralized training, technical assistance, and information dissemination efforts for SUD professionals;
• Establishment of state-regulated scopes of practice, licensing, and educational standards in collaboration with institutions of higher education;
• Loan repayment programs with incentives for obtaining post-graduate degrees; and
• Medicaid waivers to redesign states’ behavioral health systems including expansion of coverage for SUD services, rate parity between SUD and other behavioral health services, and service system integration.

We also presented these findings at the AcademyHealth Annual Research Meeting in June 2019. View the presentation.