Current through all regulations passed and filed through September 16, 2024
(A)
For the purpose
of medicaid reimbursement, substance use disorder treatment services shall be
defined by and shall be provided according to the American society of addiction
medicine also known as the ASAM treatment criteria for addictive, substance
related and co-occurring conditions for admission, continued stay, discharge,
or referral to each level of care (LOC).
(B)
Medicaid will
reimburse for the services provided under the following ASAM levels of
care:
(1)
LOC
1: outpatient services. LOC 1 services are designed to treat the recipient's
level of clinical severity and function. These services may be delivered in a
variety of settings. Addiction, mental health, or general health care treatment
personnel provide professionally directed screening, evaluation, treatment, and
ongoing recovery and disease management services. Such services are provided in
regularly scheduled sessions and follow a defined set of policies and
procedures or medical protocols. Service provision is limited to less than nine
hours per week for adults and less than six hours per week for
adolescents.
(2)
LOC 2: intensive outpatient/partial hospitalization
including LOC 2 withdrawal management (WM). LOC 2 services are capable of
meeting the complex needs of people with addiction and co-occurring conditions.
They can be rendered during the day, before or after work or school, in the
evening, and/or on weekends.
(3)
LOC 3:
residential services/inpatient services including LOC 3 WM. These services are
co-occurring capable, co-occurring enhanced, and complexity capable in nature
and provided by addiction treatment, mental health and general medical
personnel in a twenty four hour treatment setting. Services are provided in
Ohio department of mental health and addiction services certified permanent
facilities which are staffed twenty four hours a day. The following services
are included in the residential treatment service and will not be reimbursed
separately:
(a)
Ongoing assessments and diagnostic
evaluations.
(b)
Crisis intervention.
(c)
Individual,
group, family psychotherapy and counseling.
(d)
Case
management.
(e)
Substance use disorder peer recovery
services.
(f)
Urine drug screens.
(g)
Medical
services.
(4)
The following services are considered non-covered for
individuals in residential treatment:
(a)
Therapeutic
behavioral services.
(b)
Psychosocial rehabilitation.
(c)
Community
psychiatric supportive treatment.
(d)
Mental health day
treatment.
(e)
Assertive community treatment.
(f)
Intensive home
based treatment.
(C)
Individuals in
residential treatment may receive medically necessary services from
practitioners who are not affiliated with the residential treatment program.
Examples include, but are not limited to, psychiatry, medication assisted
treatment, or other medical treatment that is outside the scope of the
residential level of care as defined by the American society of addiction
medicine. Medicaid will reimburse providers of these services outside the per
diem rate paid to residential treatment programs. All treatment services,
regardless of whether they are rendered by the residential treatment program or
unaffiliated billing practitioners or agencies must be documented in the
client's treatment plan maintained by the residential treatment
provider.
(D)
The entity providing a residential service must ensure
that the medicaid recipient has access to the appropriate practitioner for
receipt of clinical services as stated in the ASAM treatment
criteria.
(E)
Eligible practitioners of substance use disorder
treatment services must meet all applicable requirements stated in rule
5160-27-01 of the Administrative
Code. Qualified mental health specialists are not eligible to be a residential
treatment team practitioner.
(F)
Limitations.
(1)
Residential levels of care are mutually exclusive,
therefore a patient can only receive services through one level of care at a
time.
(2)
Prior authorization is required for LOC 2.5 (partial
hospitalization) which requires a minimum of twenty hours of services per week.
If, after the first four consecutive weeks of treatment, the amount of services
provided is less than twenty hours, the prior authorization will be rescinded
but services may still be reimbursed at a lower level of care not to exceed
19.9 hours per week.
(3)
Prior authorization is required for LOC 3 residential
treatment according to the following:
(a)
Up to thirty
consecutive days without prior authorization per medicaid enrollee for the
first and second admission in a calendar year. If the stay continues beyond the
thirty days of the first or second stay, prior authorization is required to
support the medical necessity of the continued stay. If medical necessity is
not substantiated and approved by the ODM designated entity, only the initial
thirty consecutive days will be reimbursed.
(b)
Third and
subsequent admissions during the same calendar year must be prior authorized
from the first day of admission.
(G)
The patient's
medical record must substantiate the medical necessity of services performed.
Providers shall adhere to documentation requirements set forth in rules
5160-1-27 and
5160-8-05 of the Administrative
Code.
