Coverage of substance use disorder counselor services and peer support specialist services under part B of the Medicare program

(a) Coverage of Services (1) In general Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as amended by section 4251(c)(1), is amended— (A) in subparagraph (KK), by striking and at the end; (B) by inserting and at the end of subparagraph (LL); and (C) by adding at the end the following new subparagraph: (MM) substance use disorder counselor services (as defined in subsection (rrr)(1)), and peer support specialist services (as defined in subsection (rrr)(3));. (2) Definitions Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by sections 2007(b), 4221(a), and 4251(c)(2), is amended by adding at the end the following new subsection: (rrr) Substance use disorder counselor services; substance use disorder counselor; peer support specialist services; peer support specialist (1) The term substance use disorder counselor services means services performed by a substance use disorder counselor (as defined in paragraph (2)) for the diagnosis and treatment of substance use disorder and addiction that the substance use disorder counselor is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are performed, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services. (2) The term substance use disorder counselor means an individual who— (A) has performed at least 2 years of supervised substance use disorder counselor practice; (B) in the case of an individual performing services in a State that provides for licensure or certification of substance use disorder counselors or professional counselors, is licensed or certified as a substance use disorder counselor or professional counselor in such State; or (C) is a drug and alcohol counselor as described in section 40.281(a)(6) of title 49, Code of Federal Regulations. (3) The term peer support specialist services means services performed by a peer support specialist (as defined in paragraph (4)) for the well-being of individuals needing mental health support that the peer support specialist is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are performed, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services. (4) The term peer support specialist means an individual who— (A) is an individual living in recovery with mental illness, addiction, or justice system involvement; (B) has skills learned in formal training; (C) uses assets-based framing in speaking about mental health, recovery, and well-being; and (D) delivers services in behavioral health settings to promote mind-body recovery and resiliency.. (3) Provision for payment under part B Section 1832(a)(2)(B) of the Social Security Act (42 U.S.C. 1395k(a)(2)(B)) is amended by adding at the end the following new clause: (v) substance use disorder counselor services and peer support specialist services;. (4) Amount of payment Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by section 4251(c)(3), is amended— (A) by striking and before (II); and (B) by inserting before the semicolon at the end the following:, and (JJ) with respect to substance use disorder counselor services and peer support specialist services under section 1861(s)(2)(MM), the amounts paid shall be 80 percent of the lesser of the actual charge for the services or 75 percent of the amount determined for payment of a psychologist under subparagraph (L). (5) Exclusion of peer support specialist services from skilled nursing facility prospective payment system Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting peer support specialist services (as defined in section 1861(rrr)(3)), after mental health counselor services (as defined in section 1861(lll)(3)). (6) Inclusion of substance use disorder counselors as practitioners for assignment of claims Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by adding at the end the following new clauses: (ix) A substance use disorder counselor (as defined in section 1861(rrr)(2)). (x) A peer support specialist (as defined in section 1861(rrr)(4)).. (b) Coverage of Certain Mental Health Services Provided in Rural Health Clinics and Federally Qualified Health Centers Section 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by striking or by a mental health counselor (as defined in subsection (lll)(4)) and inserting by a mental health counselor (as defined in subsection (lll)(4)), by a substance use disorder counselor (as defined in subsection (rrr)(2)), or by a peer support specialist (as defined in subsection (rrr)(4)). (c) Effective Date The amendments made by this section shall apply with respect to services furnished on or after January 1, 2027.