STATE LICENSURE FOR SUBSTANCE USE DISORDER COUNSELING: IMPLICATIONS FOR BILLING ELIGIBILITY

12/01/2019

STATE LICENSURE FOR SUBSTANCE USE DISORDER COUNSELING: IMPLICATIONS FOR BILLING ELIGIBILITY

Human Services Research Institute

November 2019

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ABSTRACT

The main purpose of this study was to investigate the barriers to and facilitators of licensing, credentialing, and insurance reimbursement for SUD treatment providers across the nation. The study included an environmental scan of key issues, reviews of credentialing, licensing, and reimbursement policies in the 50 states and D.C., and in-depth case studies of four states that implemented innovative strategies to incentivize their SUD workforce. This study examined licensing and credentialing requirements and billing eligibility for SUD counselors across the nation.

This brief was prepared by the Human Services Research Institute under contract #HHSP233201600015 with the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. For additional information about this subject, visit the DALTCP home page at https://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp or contact ASPE Project Officers at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, Kristina.West@hhs.gov, Judith.Dey@hhs.gov.

DISCLAIMER: The opinions and views expressed in this report are those of the authors. They do not reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. This report was completed and submitted on February 2019.


 

INTRODUCTION

The United States is experiencing a workforce shortage in the substance use disorder (SUD) treatment field, an issue that has received increasing attention by policymakers and health care professionals in recent years due to its centrality in addressing the nationwide opioid epidemic. Increased insurance coverage for SUD services has been accompanied by sweeping changes in the SUD treatment delivery environment. These changes have expanded reimbursement opportunities for providers, but in the short-term, system reforms can contribute to the SUD workforce shortage as practitioners face challenges in meeting insurance companies' and managed care organizations' (MCOs') requirements for network participation.

Increasingly, insurance plans and MCOs require a state license for joining their networks as independent providers. This study examined licensing and credentialing requirements and billing eligibility for SUD counselors across the nation. While SUD treatment is provided by professionals credentialed in a broad range of fields, including licensed professional counselors, clinical social workers, psychologists, physicians, nurses, and physician assistants, this study focused on SUD-specific counseling credentials that vary broadly from state to state.

Insurance plans, whether public or private, determine the practitioner types that can enroll in the plan's network as independent providers eligible to receive direct reimbursement. Practitioner types that are not eligible for direct reimbursement must work in a facility or program that is reimbursed on their behalf.

Licensure vs. Certification

A license is a state's grant of legal authority to practice within a designated scope of practice.[1] Certification also represents achievement of professional competency, but it can be overseen by a non-governmental board and is considered weaker than licensure in terms of title and practice protection. Title protection makes it illegal to use an SUD counseling title without an appropriate credential; practice protection establishes defined credentials without which a professional cannot legally provide SUD services.

 

FINDINGS

Licensure for SUD counseling is available in 31 states (61%), while the remaining 20 states including D.C. (39%) offer certification only (Figure 1). The study revealed wide variation across states in the educational and practice requirements for licensure and certification.

Medicaid

For Medicaid, our review identified 11 states in which an SUD counselor is eligible to enroll as an independent provider[2] (Figure 2). In 32 states, an SUD counselor is not eligible and must work in a facility/program for their services to be reimbursed. In eight states (shaded white in the map below), we could not determine billing eligibility from available documentation. All 11 states where SUD counselors have independent Medicaid billing eligibility have licensure for SUD counseling

Commercial Insurance

UnitedHealth/Optum is the nation's largest health insurer, with plans in all 50 states and D.C. Optum's website describes eligibility for independent billing status as based on geographic and specialty needs and requires a valid state license and the authority to practice independently without supervision. SUD counselors are eligible to join Optum's network as independent providers in 13 states (Figure 3), all with licensure.

 

CONCLUSIONS AND IMPLICATIONS

Insurance plans and MCOs typically require a state license for joining their networks as independent providers. This poses a barrier to network participation in the 19 states and D.C. that do not have licensure for SUD counselors. Our review shows that licensure facilitates, though by no means guarantees independent billing eligibility: Of the 31 states with licensure for SUD counseling, 14 do not allow SUD counselors to independently bill Medicaid and over half do not have a commercial Optum plan that accepts licensed SUD counselors as independent network enrollees. Lack of independent billing eligibility does not imply SUD services are not reimbursed; however, it constitutes a barrier to professionals in private practice and a deterrent to early professionals from pursing SUD counseling as opposed to other counseling fields. Although SUD services are provided by a wide range of behavioral health and medical practitioners, these other practitioner types do not necessarily have specialized education or training in SUD. Adoption of uniform minimum addiction education requirements as a condition of providing SUD counseling services, coupled with consistent pathways to independent billing status, would help address the workforce shortage by increasing the attractiveness of the field while at the same time ensuring a highly qualified workforce.

 

NOTES

  1. International Certification & Reciprocity Consortium (IC&RC). (2018). Licensure vs. Certification. Retrieved from https://www.internationalcredentialing.org/lic-cert.

  2. This analysis is based on fee-for-service Medicaid plans because they typically make reimbursement policy information publicly available.

 

FIGURE 1. State Offers Licensure for SUD Counseling
FIGURE 1, State Map. This figure is a map of the United States with the 31 states that offer licensure for SUD counseling shaded dark blue and the 20 states (including D.C.) that do not offer licensure shaded light gray. The 20 states without licensure are: Alabama, Alaska, California, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Iowa, Michigan, Mississippi, Missouri, New York, Oregon, Pennsylvania, South Carolina, Washington, West Virginia, and Wisconsin.

 

FIGURE 2. SUD Counselors are Eligible for Independent Billing Under Medicaid
FIGURE 2, State Map. This figure is a map of the United States showing which states allow an SUD counselor to enroll in the Medicaid plan as a independent provider type. In the following 11 states an SUD counselor is eligible: Arizona, Colorado, Connecticut, Kentucky, Massachusetts, New Hampshire, North Carolina, Ohio, Oklahoma, Utah, and Wyoming. In the following 8 states we could not determine SUD counselors’ edibility: Hawaii, Maine, Missouri, Nevada, North Dakota, Tennessee, Vermont, and Virginia. In the remaining 32 states (including D.C.) an SUD counselor is not eligible to enroll as independent provider type.
SOURCE: Provider manuals, fee schedules, and enrollment materials available in the public domain for states' Medicaid state plans; when eligibility was not documented we attempted to reach the state's Medicaid agency by phone and used the information if supplied; in some states, billing eligibility was inferred from documentation in billing manuals but not explicitly stated.

 

FIGURE 3. SUD Counselors are Eligible for Independent Billing under UnitedHealth/Optum Commercial Plans
FIGURE 3, State Map. This figure is a map of the United States with the 13 states in which an SUD counselor is eligible to enroll in Optum’s commercial network as an independent provider shaded dark blue, and the remaining 38 states (including D.C.) where an SUD counselor is not eligible shaded  gray. The 13 states in which a SUD counselor is eligible are: Connecticut, Delaware, Kansas, Louisiana, Maryland, Massachusetts, Montana, New Hampshire, Ohio, Oklahoma, Rhode Island, Vermont, and Wyoming.
SOURCE: Optum's Provider Express portal, accessed in July 2018 at: https://www.providerexpress.com/content/ope-provexpr/us/en/our-network.html.

 


Substance Use Disorder Providers and Insurance Reimbursement

This brief was prepared by the Human Services Research Institute under contract #HHSP233201600015 with the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. For additional information about this subject, visit the DALTCP home page at https://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp or contact ASPE Project Officers at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201, Kristina.West@hhs.gov, Judith.Dey@hhs.gov.

Reports Available

Credentialing Substance Use Disorder Counselors: The Need for Uniform Standards Issue Brief

State Licensure for Substance Use Disorder Counseling: Implications for Billing Eligibility Issue Brief

Credentialing, Licensing, and Reimbursement of the SUD Workforce: A Review of Policies and Practices Across the Nation