PRIMARY CARE 101: A GLOSSARY FOR PREVENTION PRACTITIONERS | 1

Primary Care 101: A Glossary for Substance Misuse

Prevention Professionals

Over the past two decades, the health care landscape has experienced 

numerous and rapid changes, including new laws, diseases, behaviors, 

research findings, technologies, and funding mechanisms. These changes 

have resulted in growing recognition of the value of prevention, including 

substance misuse prevention, for improving health outcomes and reducing 

costs. They have also opened the door to new opportunities for primary

health care and prevention to work together in more deliberate and 

coordinated ways.

This glossary is designed to facilitate collaboration across prevention and primary care, 

specifically, by defining key terms and concepts familiar to primary care providers that may not 

be known to prevention professionals. Specifically, it describes:

• Legislation that Influences Health Care

• Payers that Fund Health Care

• Organizations that Provide Health Care

• Payment Systems that Reimburse Providers

• Trade Associations that Represent Health Care Professionals

FEDERAL LEGISLATION

Understanding the effects of legislation on primary care can help prevention practitioners 

capitalize on these opportunities to strengthen the scope and reach of prevention services. For 

example, the Affordable Care Act includes many potential funding avenues for substance misuse

screenings and referrals. This section describes federal legislation that has altered insurance 

Understanding the Basics
PRIMARY CARE 101: A GLOSSARY FOR PREVENTION PRACTITIONERS | 2

coverage, service delivery, benefits packages, and the availability of other health care resources

for millions of Americans in recent decades.

• 2008: Mental Health Parity and Addiction Equity Act (MHPAEA). Also known as 

“parity,” MHPAEA imposed a conditional behavioral coverage requirement on certain 

insurers. While MHPAEA does not require insurers to offer behavioral health coverage, 

those who provide it must do so at the same level of coverage they provide for general 

health care services. For instance, applicable plans must cover depression screenings at

parity with cancer screenings.

• 2010: Affordable Care Act (ACA). The ACA was originally passed to expand health 

insurance coverage, reduce the growing cost of health care, and improve the quality of 

health care services. It expanded coverage by offering subsidies for certain individuals to

purchase private insurance and allowing states to expand their Medicaid programs. As a 

result, uninsured individuals decreased from 46.5 million in 2010 to 27.5 million by 2021. 

The law also encouraged integration of care and sought to improve the quality of health 

coverage through Essential Health Benefits:

• Essential Health Benefits (EHBs). These are a set of 10 health benefit categories 

that certain insurers must provide. One of the 10 is “mental health and substance 

use disorder services, including behavioral health treatment” as well as 

“preventive and wellness services.” The EHBs present an opportunity to secure 

coverage for numerous substance misuse prevention services. For example, by 

2019, 87% of people with employer-sponsored health insurance were enrolled in 

plans required to cover EHBs. The EHBs were designed to synergize with 

MHPAEA’s provisions to expand access to behavioral health coverage.

• 2018: Substance Use Disorder Prevention that Promotes Opioid Recovery and 

Treatment for Patients and Communities Act (SUPPORT). The SUPPORT Act dedicated 

federal funding to a wide array of new initiatives and reforms to advance overdose 

prevention, education, and treatment programs. It required state Medicaid programs to 

cover medications for opioid use disorder (MOUD) and eliminated geographic restrictions 

on Medicare coverage of behavioral telehealth services. It also funded primary care 

provider training on improving care coordination for people with co-occurring substance 

use and physical health problems.

• 2020: Coronavirus Aid, Relief and Economic Security Act (CARES). The CARES Act was a 

temporary emergency stimulus bill crafted in response to the emergence of the COVID-
PRIMARY CARE 101: A GLOSSARY FOR PREVENTION PRACTITIONERS | 3

19 pandemic. The CARES Act also significantly expanded access to telehealth services

(including behavioral telehealth services) through federally qualified health centers, rural 

health clinics, and Medicare coverage.

• 2022: Inflation Reduction Act (IRA). The Inflation Reduction Act aimed to reduce the 

federal deficit to fight inflation. It created a three-year extension of ACA subsidies 

designed to lower (or eliminate) health care premiums for millions of Americans. These 

subsidies continued the ACA’s goal of expanding coverage and creating new 

opportunities for accessing behavioral health services. It also allowed Medicare to 

negotiate drug prices for certain drugs and put a $2,000 cap on out-of-pocket costs for 

prescription drugs (including those used to treat behavioral health disorders).

PAYERS

When collaborating with primary care, it is important to understand how your partners are 

funded. Whether, how, and to what extent prevention services can be funded are likely to drive 

their service delivery decisions. Payers are the entities that fund health care services. They

dictate where individuals can receive health care and the types of services they can receive. In 

many cases, health care providers will make service delivery decisions based on payers’ policies.

• Children’s Health Insurance Program (CHIP). CHIP provides free or low-cost health 

insurance coverage for children through age 18 in low-income families who earn too 

much to qualify for Medicaid (see below). Each state uses federal funds to subsidize CHIP,

but qualification and benefit rules and coverage types vary. Although CHIP is not a part of 

Medicaid, it works closely with state Medicaid programs, and states may choose to use 

funds from CHIP to expand their Medicaid program to include children through age 18,

establish a standalone children’s health insurance program, or some combination of 

both.

• Medicaid. State Medicaid programs offer health coverage to low-income Americans, 

including adults, children, pregnant women, and individuals with disabilities. States 

administer their own Medicaid programs, but Medicaid is jointly funded with the federal 

government. As a result, while every state has a Medicaid program, each Medicaid 

program is unique. The federal government sets basic Medicaid requirements, but states

have wide latitude to provide more benefits or serve more people than the federally 

mandated minimum.
PRIMARY CARE 101: A GLOSSARY FOR PREVENTION PRACTITIONERS | 4

• Medicare. Medicare is the country’s

federally funded health care program for

older adults. Because it is so large, 

Medicare is the focus of myriad 

integration and cost-saving initiatives, 

often as part of major health care 

legislation (see Federal Legislation, 

above). Medicare provides coverage for 

inpatient and outpatient behavioral 

health treatment services. It also covers 

and promotes a wide range of 

preventive and screening services, 

including tobacco cessation counseling. 

Additionally, it covers yearly wellness 

visits, which provide an opportunity for 

substance misusescreenings and other 

prevention services.

• Private Insurance. Refers to any 

insurance not provided by the 

government. Private insurance can be 

provided by an employer or purchased 

directly by the consumer. Under the 

ACA, many more individuals have

obtained private insurance. This 

presents new opportunities to expand 

coverage for prevention screenings and 

early interventions. However, even with 

legislative requirements such as EHBs 

and parity, implementing coverage 

changes can be a slow and difficult 

process. Insurers’ relationships with 

providers will be heavily influenced by 

existing reimbursement systems.

• TRICARE. TRICARE is the government-managed health care system for military personnel, 

including active-duty service members and retirees, their families, and dependent 

Additional Payment Mechanisms

In addition to knowing the payers themselves, 

it is helpful to know about the mechanisms 

that can influence payment decisions. Two 

important examples are:

• Medicaid Waivers/Medicaid State Plan 

Amendments (SPAs). Medicaid waivers 

or SPAs are mechanisms states can use 

to modify their Medicaid programs. 

Modifications can include 

adding/changing coverage or adjusting 

payment methodologies. They can also 

exempt states from certain federal 

requirements if the exemption would 

further advance health care outcomes. 

The federal government must approve 

proposed changes, and states must 

guarantee that they will continue to 

meet federal coverage requirements 

and not increase federal costs. States 

seeking to expand substance misuse 

prevention coverage beyond federal 

requirements may be able to use these 

mechanisms.

• Payer of Last Resort. This applies to 

certain payers that only pay for services 

after all other potential payers have 

paid for the services they cover. The 

term most often refers to government 

health care programs. Medicare and 

Medicaid are both payers of last resort.
PRIMARY CARE 101: A GLOSSARY FOR PREVENTION PRACTITIONERS | 5

survivors. The program allows enrollees to select from several different plans and 

payment systems that allow them to see any primary care organization that accepts 

TRICARE. As a result, many enrollees see health care providers outside of the Defense 

Health Agency or the Veterans Health Administration. This presents opportunities for

civilian providers to improve behavioral health outcomes among military personnel, 

veterans, and their families.

PRIMARY CARE ORGANIZATIONS AND RELATED TERMS

Primary care describes a patient’s source of regular health care, and primary care providers are 

often a patient’s first contact with the health care system. Primary care may include health 

promotion, disease prevention, health maintenance, counseling, patient education, diagnosis, 

and treatment. Primary care practices are typically owned by either hospital groups or individual 

physicians.

• Hospital-owned primary care practices are owned by hospitals or hospital groups rather 

than by the individuals who comprise the practice. Because these networks are often 

quite large, collaborating with hospital-owned practices may allow prevention 

professionals to reach many more individuals than through physician-owned practices. 

However, physicians in hospital-owned groups will have less authority to add new 

services, necessitating partnerships with the owner hospitals.

• Physician-owned primary care practices are defined as one or more physicians who 

provide primary care out of one or more offices and own their own practice. These 

practices often include other medical professionals (e.g., nurses, nurse practitioners, 

physician’s assistants). Physician-owned practices have discretion over the services they

offer and the payers they accept.

Regardless of ownership structure, primary care organizations can take many different forms

that influence how they interact with consumers, health insurers, and other health care 

providers—including organizations providing prevention services. Understanding the different 

types of primary care organizations can help prevention professionals decide where to direct 

their collaborative efforts.

• Accountable Care Organizations (ACOs). These are collaborative organizations that 

comprise numerous health care providers (e.g., doctors and hospitals) and one or more 

payers to coordinate care for their shared patients. ACOs are designed to better 

coordinate and improve care—while also reducing costs—and their members agree to be 
PRIMARY CARE 101: A GLOSSARY FOR PREVENTION PRACTITIONERS | 6

accountable for the quality, cost, and overall care of their patients. ACOs were originally 

limited to Medicare; however, there are now Medicaid and private insurer ACOs as well. 

ACOs often emphasize preventive services as a way to improve patient outcomes and 

reduce costs. As a result, ACOs are likely to value substance misuse prevention 

partnerships and services that can help prevent more costly treatment.

• Charitable (Free) Clinics. These are non-profit health care organizations that provide a 

range of free health care services (including but not limited to primary care) to those who 

are uninsured, underinsured, or have limited access to health care. Many community 

health centers (see below) that charge a sliding scale fee are still considered charitable 

clinics if they provide care regardless of a patient’s ability to pay.

• Community Health Centers (CHCs). This general term refers to community-based 

outpatient clinics that provide primary and preventive care in their communities. Many

CHCs play a significant role in providing health care to uninsured individuals by accepting 

patients regardless of ability to pay.

• Coordinated or Integrated Care. Together, these concepts refer to multiple health care 

professionals or organizations with different specialties working together to treat their 

shared patients. Some experts distinguish between care provided in a single location by 

multiple professionals in multiple disciplines (integrated care) and care provided by 

professionals or providers that are working together but not at a single location 

(coordinated care). The term “integrated care” may also refer to integrating behavioral

health and primary care or integrating specialty services and primary care.

• Employee Wellness Programs. Also known as workplace health programs, these 

programsseek to improve employees’ health outcomes by promoting healthy behaviors 

within an organization. Among other tools, wellness programs can provide health 

education, weight management, and medical screenings. Though wellness programs do 

not offer primary care, they are a potential partner for substance misuse prevention 

(particularly for screenings) because of their focus on preventive care and long-term

health.

• Federally Qualified Health Centers (FQHCs). FQHCs are CHCs (see above) that meet 

certain federal criteria, including serving an underserved or vulnerable population and 

offering a sliding fee scale. FQHCs receive designated federal grants and enhanced 

Medicare and Medicaid reimbursements. FQHCs are a significant source of services for 
PRIMARY CARE 101: A GLOSSARY FOR PREVENTION PRACTITIONERS | 7

substance use treatment and may be interested in expanding the substance use arm of 

their preventive services.

• Federally Qualified Health Center Look-Alikes (FQLA). These are community-based 

primary and preventive care provider organizations that meet all federal FQHC

administrative and clinical requirements but do not receive federal FQHC funding.

• Integrated Delivery Systems (IDS). Also commonly known as integrated delivery 

networks or provider-sponsored health plans, an IDS is a comprehensive network of 

health care services where the provider also operates a health insurance plan. An IDS 

health insurance plan is unique in that IDS patients are restricted to seeing providers at 

facilities operated by the IDS. An IDS offers a network of inpatient and outpatient care 

services, including hospitals, primary care, surgery centers, and more. 

• Nurse-Managed Health Centers (NMHCs). These health centers provide primary care 

and disease prevention services to patients with limited access to health care. NMHCs 

are often affiliated with universities, nursing schools, or CHCs in communities with high 

uninsurance rates. NMHCs are managed by Advanced Practice Registered Nurses and 

often staffed by an interdisciplinary team of health care providers (e.g., physicians, 

therapists, and social workers) to provide wraparound physical and behavioral health 

care. 

• Patient-Centered Medical Homes (PCMHs). This is a care coordination model that puts 

patients at the center of a highly personalized treatment plan, with a team of providers 

working together to provide services. PCMHs require either a single practice with both 

primary and specialty care providers or a primary care practice with care coordination 

agreements with specialty providers. PCMH providers collaborate to provide broader 

access to services, comprehensive care management, and patient engagement in health 

care services. This model allows for early identification of behavioral health needs as part 

of a patient’s overall treatment plan.

PAYMENT SYSTEMS AND RELATED TERMS 

When partnering with primary care providers, it is important to understand not only the payer(s) 

and provider(s) but also the payment/reimbursement structures through which they interact, as 

these may influence if or how a provider is willing to implement new prevention initiatives. Most 

providers see patients from multiple payers and each of these payers compensates the provider 
PRIMARY CARE 101: A GLOSSARY FOR PREVENTION PRACTITIONERS | 8

through its own payment structure. Understanding how providers get paid can help you develop 

innovative ways to fund primary care collaborations.

• Direct Primary Care. In a direct primary care model (sometimes known as “membership 

medicine” or “concierge medicine”), patients pay a primary care physician or practice a 

fixed monthly or annual fee for highly personalized, comprehensive care. Typically, 

insurers are not involved and providers bill patients directly for services rendered.

• Fee for Service (FFS). This is the most “basic” health care payment model. In an FFS

structure, providers receive payments for each service delivered. When operating under 

FFS, providers have a straightforward financial incentive to implement new substance 

misuse prevention initiatives (e.g., screenings). However, that financial incentive only 

exists if the applicable payer covers those services. Note that a provider operating under 

FFS for one patient may operate under a different payment structure for another patient 

(e.g., if the patients have different insurance plans). In addition, many payers are 

attempting to phase out simple FFS models in favor of other payment mechanisms that 

are more likely to reduce costs.

• Managed Care. This broad term refers to several related strategies designed toreduce 

costs and improve the quality of health care. Managed care strategies can include (but 

are not limited to): contracting with a select set of health care providers, offering 

incentives for providers or patients to choose less costly care (e.g., by changing their 

reimbursement systems), reviewing the medical necessity of specific services, and 

intensive management of high-cost patients. Examples of managed care systems include 

health maintenance organizations, preferred provider organizations, and point of service 

plans.

• Provider Network. In certain managed care systems (see above), the provider network is 

the group of organizations (e.g., physician groups, hospitals) that agree to accept prenegotiated payments for a set of enrollees from one specific payer. For example, “innetwork” providers accept their patients’ insurance payments because they are part of 

the managed care system. In contrast, “out-of-network” providers do not have preexisting agreements with the payer, and so require patients to pay for care through other

means.

• Value-Based Purchasing (VBP). Counter to traditional fee for service models (see above), 

value-based purchasing (also known as pay-for-performance) refers to a set of related 

strategies that link some portion of a health care provider’s compensation directly to 
PRIMARY CARE 101: A GLOSSARY FOR PREVENTION PRACTITIONERS | 9

patient outcomes (e.g., payments based on lowering patients’ blood pressure). VBP 

programs may also penalize providers for poor outcomes. Providers within VBP programs 

may have a financial incentive to implement new prevention initiatives to avoid 

penalization for poor patient outcomes related to substance misuse. Alternative Payment 

Models (APMs) are the mechanism by which VBP strategies are implemented. Some 

examples include:

o Capitated Payments. Under this APM, health care providers receive a lump sum 

payment for each patient for a set period (e.g., one year). Providers must cover all 

patient costs during that time and may keep any remaining funds as profit. Providers 

using capitated payments may be resistant to new prevention services that were not

considered as part of their capitated payment. However, they may also recognize 

prevention as a way to achieve long-term savings (e.g., by preventing a more costly 

substance use disorder through preventive screenings).

o Bundled Payments. Also known as episode-of-care payments, under this APM, health 

care providers receive a single payment for all services that a patient receives for an 

acute or chronic health condition within a set period of time. As with capitated 

payments, providers using bundled payments may resist new prevention services that 

were not considered part of their bundled payment; however, they may also favor 

those services to achieve long-termsavings.

TRADE ASSOCIATIONS

Health care trade associations represent different types of health care professionals and 

organizations. Though trade associations have a diverse set of purposes and are generally 

national in scope, they offer an avenue through which substance misuse prevention can 

establish partnerships that “filter down” to the association’s members. Many national 

associations also have state, regional, or metropolitan associations or chapters that present 

opportunities for local collaboration with substance misuse prevention.

• American Academy of Family Physicians (AAFP). The AAFP represents family physicians 

with the goal of improving health care through advocacy, practice enhancement, and

education.

• American College of Physicians (ACP). The ACP represents internal medicine specialists 

(i.e., physicians who provide primary care for adults) in enhancing quality and effective 
PRIMARY CARE 101: A GLOSSARY FOR PREVENTION PRACTITIONERS | 10

health care through improving clinical knowledge, providing continuing medical 

education, and supporting advocacy initiatives. 

• American Hospital Association (AHA). The AHA is the largest trade association for 

hospitals and health care networks in the United States. It supports research, provides 

technical assistance, develops standards, promotes advocacy, and lobbies for its 

members. It also publishes multiple journals and newsletters. The AHA is organized by 

region, with each region (and some states) represented by a single executive.

• American Medical Association (AMA). The AMA is the largest physician and medical 

student trade association in the United States. It supports research, provides education, 

conducts advocacy and lobbying activities, and develops standards. The AMA also 

publishes the Journal of the American Medical Association, a weekly medical journal.

• Continuing Medical Education (CME). Many states require physicians and other medical 

professionals to attend ongoing professional development in order to maintain their 

professional licensure. CMEs help to ensure that medical professionals maintain their 

knowledge and skills, including learning about new research or practices. Several sources 

offer CMEs, including many trade associations. Professionals working to prevent 

substance use and misuse may consider working with partners to develop CMEs specific 

to substance use prevention or screening.

• Federation of State Medical Boards (FSMB). The FSMB supports state medical boards 

licensing and regulating primary care physicians and other medical professionals. It

provides exam and credentialing services, medical professional query services, CME (see 

above), and advocacy efforts to improve the safety and well-being of patients.

• National Association of Community Health Centers (NACHC). The NACHC works with a 

network of state health centers and primary care organizations to advocate for health 

centers and their clients, educate the public about health centers, train and provide 

technical assistance to health center staff, and foster alliances with partners to facilitate 

the delivery of primary care in under-resourced communities. States and regions have 

their own NACHC affiliates, including primary care associations and associations of 

community health centers.

SPTAC@edc.org | samhsa.gov/SPTAC