Current through Vol. 42, No. 1, September 16, 2024
(a)
Definitions. The following words and terms, when used in this
section, shall have the following meaning, unless the context clearly indicates
otherwise:
(1)
"Medication-assisted
treatment (MAT)" means an evidence-based practice approved by the Food
and Drug Administration (FDA) to treat opioid use disorder, including methadone
and all biological products licensed under federal law for such purpose. MAT
also includes the provision of counseling and behavioral therapy.
(2)
"Office-based opioid treatment
(OBOT)" means a fully contracted SoonerCare provider that renders MAT
services in OBOT settings. OBOT providers must have capacity to provide all
drugs approved by the FDA for the treatment of opioid use disorder, directly or
by referral, including for maintenance, detoxification, overdose reversal, and
relapse prevention, and appropriate counseling and other appropriate ancillary
services.
(3)
"Opioid
treatment program (OTP)" means a program or provider:
(A) Registered under federal law;
(B) Certified by the Substance Abuse and
Mental Health Services Administration (SAMHSA);
(C) Certified by ODMHSAS, unless deemed an
exempted entity as defined by federal law;
(D) Registered by the Drug Enforcement Agency
(DEA);
(E) Registered by the
Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD); and
(F) Engaged in opioid treatment of
individuals by use of an opioid agonist treatment medication, including
methadone.
(4)
"Opioid use disorder (OUD)" means a cluster of cognitive,
behavioral, and physiological symptoms in which the individual continues use of
opioids despite significant opioid-induced problems.
(5)
"Phase I" means the first
ninety (90) days of treatment.
(6)
"Phase II" means the second ninety (90) days of
treatment.
(7)
"Phase
III" means the third ninety (90) days of treatment.
(8)
"Phase IV" means the last
ninety (90) days of the first year of treatment.
(9)
"Phase V" means the phase of
treatment for members who have been receiving continuous treatment for more
than one (1) year.
(10)
"Phase VI" means the phase of treatment for members who have been
receiving continuous treatment for more than two (2) years.
(b)
Coverage. The SoonerCare
program provides coverage of medically necessary MAT services in OTPs,
including but not limited to, methadone treatment, to eligible individuals with
OUD. An OTP must have the capacity to provide the full range of services
included in the definition of MAT and must document both medication dosing and
supporting behavioral health services, including but not limited to,
individual, family and group therapy and rehabilitation services. MAT services
and/or medications may also be provided in OBOT settings per OAC
317:30-5-9(b)(16).
(c)
OTP requirements. Every OTP
provider shall:
(1) Have a current contract
with the OHCA as an OTP provider;
(2) Hold a certification as an OTP from
ODMHSAS, unless deemed an exempted entity as defined by federal law;
(3) Hold a certification from the Substance
Abuse and Mental Health Services Administration (SAMHSA);
(4) Be appropriately accredited by a
SAMHSA-approved accreditation organization;
(5) Be registered with the DEA and the OBNDD;
and
(6) Meet all state and federal
opioid treatment standards, including all requirements within OAC
450:70.
(d)
Individual OTP providers. OTP providers include a:
(1) MAT provider who is a physician,
physician's assistant (PA), or advanced practice registered nurse (APRN) who
may prescribe, dispense, and administer medications in accordance with state
and federal law and the Oklahoma Medicaid State Plan.
(2) OTP behavioral health services
practitioner who is a practitioner that meets the qualifications in OAC
317:30-5-240.3, except for family
support and training providers, qualified behavioral therapy aide providers,
multi-systemic therapy providers, and case manager I providers, for the
provision of outpatient behavioral health services.
(e)
Intake and assessment. OTPs
shall conduct intake and assessment procedures in accordance with OAC
450:70-3-5 through OAC
450:70-3-7.
(f)
Service phases. In
accordance with OAC
450:70-6-17.2 through OAC
450:70-6-17.8, the OTP shall have
structured phases of treatment and rehabilitation to support member progress
and to establish requirements regarding member attendance and service
participation. The OTP shall utilize ASAM criteria to determine the appropriate
level of care during each phase of treatment. Treatment requirements for each
phase shall include, but not limited to, the following:
(1) During phase I, the member shall
participate in a minimum of four (4) treatment sessions per month. Available
services shall include, but not be limited to, therapy, rehabilitation, case
management, and peer recovery support services.
(2) During phase II, the member shall
participate in at least two (2) treatment sessions per month. Available
services shall include, but not be limited to, therapy, rehabilitation, case
management, and peer recovery support services.
(3) During phase III, phase IV and phase V,
the member shall participate in at least one (1) treatment session per month.
Available services shall include, but not be limited to, therapy,
rehabilitation, case management, and peer recovery support services.
(4) During phase VI, the LBHP, licensure
candidate or certified alcohol and drug counselor (CADC) determines the
frequency of therapy or rehabilitation service sessions with input from the
member.
(5) If an OTP is providing
MAT medications to members receiving residential substance use disorder
services, the required minimum services for the OTP may be delivered by the
residential substance use disorder provider. The OTP provider shall document
the provision of these services and the provider delivering such services in
the member's service plan.
(g)
Service plans. In accordance
with OAC 450:70-3-8, a service plan shall
be completed for each member upon completion of the admission evaluation. The
service plan shall be based on the patient's presenting problems or diagnosis,
intake assessment, biopsychosocial assessment, and expectations of their
recovery.
(1)
Service plan
development. Service plans shall be completed by an LBHP or licensure
candidate. Service plans, including updates, must include dated signatures of
the person served [if age fourteen (14) or older], the parent/guardian (if
required by law), and the LBHP or licensure candidate. If a minor is eligible
to self-consent to treatment pursuant to state law, a parent/guardian signature
is not required. Service plans completed by a licensure candidate must be
co-signed and dated by a fully-licensed LBHP. Signatures must be obtained after
the service plan is completed.
(2)
Service plan content. Service plans shall address, but not limited
to, the following:
(A) Presenting problems or
diagnosis;
(B) Strengths, needs,
abilities, and preferences of the member;
(C) Goals for treatment with specific,
measurable, attainable, realistic and time-limited;
(D) Type and frequency of services to be
provided;
(E) Dated signature of
primary service provider;
(F)
Description of member's involvement in, and responses to, the service plan and
his or her signature and date;
(G)
Individualized discharge criteria or maintenance;
(H) Projected length of treatment;
(I) Measurable long and short term treatment
goals;
(J) Primary and supportive
services to be utilized with the patient;
(K) Type and frequency of therapeutic
activities in which patient will participate;
(L) Documentation of the member's
participation in the development of the plan; and
(M) Staff who will be responsible for the
member's treatment.
(3)
Service plan updates. Service plan updates shall be completed by
an LBHP or licensure candidate. Service updates completed by a licensure
candidate must be co-signed and dated by a fully-licensed LBHP. Service plan
review and updates shall occur no less than every six (6) months and shall
occur more frequently if required based upon the service phase or certain
circumstances:
(A) Change in goals and
objectives based upon member's documented progress, or identification of any
new problem(s);
(B) Change in
primary therapist or rehabilitation service provider assignment;
(C) Change in frequency and types of services
provided;
(D) Critical incident
reports; and/or
(E) Sentinel
events.
(4)
Service
plan timeframes. Service plans shall be completed by the fourth visit
after admission.
(h)
Progress notes. Progress notes shall be completed in accordance
with OAC 317:30-5-248(3).
(i)
Discharge planning. All
members shall be assessed for biopsychosocial appropriateness of discharge from
each level of care using ASAM criteria that includes a list of symptoms for all
six (6) dimensions and each of the levels of care, to determine a clinically
appropriate placement in the least restrictive level of care. This organized
process involves a professional determination by an LBHP or licensure candidate
for appropriate placement to a specific level of care based on the following
symptoms and situations:
(1) Acute
intoxication and/or withdrawal potential;
(2) Biomedical conditions and
complications;
(3) Emotional,
behavioral or cognitive conditions and complications;
(4) Readiness to change;
(5) Relapse, continued use or continued
problem potential; and
(6)
Recovery/living environment.
(j)
Service exclusions. The
following services are excluded from coverage:
(1) Components that are not provided to or
exclusively for the treatment of the eligible individual;
(2) Services or components of services of
which the basic nature is to supplant housekeeping or basic services for the
convenience of a person receiving covered services;
(3) Telephone calls or other electronic
contacts (not inclusive of telehealth);
(4) Field trips, social, or physical exercise
activity groups;
(k)
Reimbursement. To be eligible for payment, OTPs shall:
(1) Have an approved provider agreement on
file with the OHCA. Through this agreement, the OTP assures that they are in
compliance with all applicable federal and state Medicaid law and regulations,
including, but not limited to, OHCA administrative rules, ODMHSAS
administrative rules, and the Oklahoma Medicaid State Plan.
(2) Obtain prior authorization for applicable
drugs and services by the OHCA or its designated agent before the service is
rendered by an eligible provider. Without prior authorization for applicable
drugs and services, payment is not authorized.
(3) Record the National Drug Code (NDC)
number for each drug used in every encounter at the time of billing.
(4) Be reimbursed pursuant to the methodology
described in the Oklahoma Medicaid State Plan.
