Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 30 - Medical Providers-Fee for Service
Subchapter 5 - Individual Providers and Specialties
Part 6 - INPATIENT PSYCHIATRIC AND SUBSTANCE USE DISORDER SERVICES
Section 317:30-5-95.46 - Residential substance use disorder (SUD) - Covered services and medical necessity criteria
Universal Citation: OK Admin Code 317:30-5-95.46
Current through Vol. 42, No. 1, September 16, 2024
(a) In order for the services described in this Section to be covered, individuals shall:
(1) Be diagnosed with an SUD as described in
the most recent edition of the DSM; and
(2) Meet residential level of care as
determined through completion of the designated ASAM placement tool as required
by the Oklahoma Department of Mental Health and Substance Abuse Services
(ODMHSAS).
(3) For additional
medical necessity criteria, refer to the ODMHSAS Prior Authorization Manual
available at www.odmhsas.org/arc.htm.
(b) Coverage includes the following services:
(1)
Clinically managed low intensity
residential services (ASAM Level 3.1).
(A)
Halfway house services -
Individuals age thirteen (13) to seventeen (17).
(i)
Service description. This
service places a major emphasis on continuing SUD care and community ancillary
services in an environment supporting continued abstinence. The facility shall
have scheduled services to assess and address the individual needs of each
member. Services include individual, family, and/or group therapy, individual
and/or group rehabilitation services, care management, crisis intervention, and
for members age sixteen (16) and older, community recovery support services.
Group therapy is limited to a total of six (6) individuals. Rehabilitation
services shall not exceed a staffing ratio of eight (8) individuals to one (1)
qualified provider.
(ii)
Staffing requirements. A licensed physician must be available by
telephone twenty-four (24) hours a day, seven (7) days a week. A minimum of two
(2) direct care and/or clinical staff must be on-site and awake twenty-four
(24) hours a day, seven (7) days a week. Staffing ratios shall not exceed those
specified in OAC
340:110-3-153.2. All staff who
provide treatment services shall meet qualifications in accordance with the
Oklahoma Medicaid State Plan and OAC 450:18.
(iii)
Treatment hours. A minimum
of six (6) treatment hours per week shall be provided. A week begins on Sunday
and ends on Saturday.
(B)
Halfway house services -
Individuals age eighteen (18) to sixty-four (64).
(i)
Service description. This
service places a major emphasis on continuing SUD care and community ancillary
services in an environment supporting continued abstinence. The facility shall
have scheduled services to assess and address the individual needs of each
member. Services include individual, family, and/or group therapy, individual
and/or group rehabilitation services, care management, crisis intervention, and
community recovery support services. Group therapy is limited to a total of
eight (8) individuals. Rehabilitation services shall not exceed a staffing
ratio of fourteen (14) individuals to one (1) qualified provider.
(ii)
Staffing requirements. A
licensed physician must be available by telephone twenty-four (24) hours a day,
seven (7) days a week. Additional clinical and/or direct care staff must be
on-site and awake twenty-four (24) hours a day, seven (7) days a week. All
staff who provide treatment services shall meet qualifications in accordance
with the Oklahoma Medicaid State Plan and OAC 450:18.
(iii)
Treatment hours. A minimum
of six (6) treatment hours per week shall be provided. A week begins on Sunday
and ends on Saturday.
(C)
Halfway house services - Individuals with minor dependent children or
women who are pregnant.
(i)
Service description. This service provides a planned regimen of
twenty-four (24) hours, seven (7) days a week, supervised living arrangements,
to include professionally directed evaluation, care, and treatment. The
facility shall have scheduled services to assess and address the individual
needs of each member. Services include individual, family, and/or group
therapy, individual and/or group rehabilitation services, care management,
crisis intervention, and community recovery support services. Group therapy is
limited to a total of eight (8) individuals for adults a total of six (6)
individuals for children. Rehabilitation services shall not exceed a staffing
ratio of fourteen (14) individuals to one (1) qualified provider for adults and
eight (8) individuals to one (1) qualified provider for children.
(ii)
Staffing requirements. A
licensed physician must be available by telephone twenty-four (24) hours a day,
seven (7) days a week. Additional clinical and/or direct care staff must be
on-site twenty-four (24) hours a day, seven (7) days a week. All staff who
provide treatment services shall meet qualifications in accordance with the
Oklahoma Medicaid State Plan and OAC 450:18.
(iii)
Treatment services for dependent
children. Services are available to the child when provided to address
the impacts related to the parent's addiction, including, but not limited to,
individual and family therapy. Compliance with separate provider
qualifications, in accordance with OAC
317:30-5-240.2, is required for
other treatment services provided to dependent children by the residential SUD
provider. Provision of such treatment services shall be provided in accordance
with OAC 317:30-5, Part 21.
(iv)
Treatment hours. A minimum of six (6) treatment hours per week
shall be provided to the individual with minor dependent children and women who
are pregnant. A week begins on Sunday and ends on Saturday. Dependent children
shall be provided treatment services in accordance with the child's service
plan if services are provided by the residential SUD
provider.
(2)
Clinically managed, population specific, high intensity residential
services (ASAM Level 3.3). This service includes residential treatment
for adults with co-occurring disorders.
(A)
Service description. This service provides a planned regimen of
twenty-four (24) hours, seven / (7) days a week, structured evaluation, care,
and treatment. Daily treatment service shall be provided to assess and address
individual needs of the member. Services include individual, family, and group
therapy, individual and/or group rehabilitation services, crisis intervention,
care management, and community recovery support services. Psychiatric and/or
psychological and/or mental health evaluations shall be completed on all
members. In addition to the requirements in OAC
317:30-5-95.47, the service plan
shall address the member's mental health needs and medications. The member's
medications shall be re-assessed a minimum of once every thirty (30) days and
monitoring of medications shall be provided. Group therapy is limited to a
total of eight (8) individuals. Rehabilitation services shall not exceed a
staffing ratio of fourteen (14) individuals to one (1) qualified provider.
Treatment services must address both mental health and SUD needs as identified
in the service plan.
(B)
Staffing requirements. A licensed psychiatrist must be available
by telephone twenty-four (24) hours a day, seven (7) days a week. Additional
staff must be on-site twenty-four (24) hours a day, seven (7) days a week. All
staff who provide treatment services shall meet qualifications in accordance
with the Oklahoma Medicaid State Plan and OAC 450:18.
(C)
Treatment hours. A weekly
minimum of twenty-four (24) service hours shall be provided, which shall
include a minimum of one (1) hour of individual, group, or family therapy and a
minimum of seven (7) hours of individual or group rehabilitation services. A
week begins on Sunday and ends on Saturday. A maximum of seven (7) hours per
week of community (peer) recovery support services may count toward the weekly
required treatment hours.
(3)
Clinically managed medium and high
intensity (ASAM Level 3.5).
(A)
Residential treatment, medium intensity - individuals age thirteen (13)
to seventeen (17).
(i)
Service
description. This service provides a planned regimen of twenty-four (24)
hours / seven (7) day a week, professionally directed evaluation, care, and
treatment. A multidisciplinary team approach shall be utilized in providing
daily treatment services to assess and address the individual needs of each
member, including individual, family, and/or group therapy, individual and/or
group rehabilitation services, care management, crisis intervention, and, for
members age sixteen (16) or older, community recovery support services. Group
therapy is limited to a total of six (6) individuals. Rehabilitation services
shall not exceed a staffing ratio of eight (8) individuals to one (1) qualified
provider.
(ii)
Staffing
requirements. A licensed physician must be available by telephone
twenty-four (24) hours a day, seven (7) days a week. A minimum of two (2)
direct care and/or clinical staff must be on-site and awake twenty-four (24)
hours a day, seven (7) days a week. Staffing ratios shall not exceed those
specified in OAC
340:110-3-153.2. All staff who
provide treatment services shall meet qualifications in accordance with the
Oklahoma Medicaid State Plan and OAC 450:18.
(iii)
Treatment hours. A weekly
minimum of fifteen (15) treatment hours for members attending academic training
and twenty-four (24) treatment hours for members not attending academic
training shall be provided. Weekly treatment hours shall include a minimum of
one (1) hour of individual, family and/or group therapy and a minimum of seven
(7) hours of individual or group rehabilitation services. A maximum of seven
(7) hours per week of community (peer) recovery support services may count
toward the weekly required treatment hours. A week begins on Sunday and ends on
Saturday.
(B)
Residential treatment, high intensity - adults.
(i)
Service description. This
service provides a planned regimen of twenty-four (24) hours / seven (7) day a
week, professionally directed evaluation, care, and treatment. Daily treatment
service shall be provided to assess and address individual needs of each
member. Services include individual, family, and/or group therapy, individual
and/or group rehabilitation services, crisis intervention, care management, and
community recovery support services. Group therapy is limited to a total of
eight (8) individuals. Rehabilitation services shall not exceed a staffing
ratio of fourteen (14) individuals to one (1) qualified provider.
(ii)
Staffing requirements. A
licensed physician must be available by telephone twenty-four (24) hours a day,
seven (7) days a week. Additional clinical and/or direct care staff must be
on-site twenty-four (24) hours a day, seven (7) days a week. All staff who
provide treatment services shall meet qualifications in accordance with the
Oklahoma Medicaid State Plan and OAC 450:18.
(iii)
Treatment hours. A weekly
minimum of twenty-four (24) service hours shall be provided, which shall
include a minimum of one (1) hour of individual, family, and/or group therapy
and a minimum of seven (7) hours of individual or group rehabilitation
services. A maximum of seven (7) hours per week of community (peer) recovery
support services may count toward the weekly required treatment hours. A week
begins on Sunday and ends on Saturday.
(C)
Intensive residential treatment,
high intensity - adults.
(i)
Service description. This service provides a planned regimen of
twenty-four (24) hours / seven (7) day a week, professionally directed
evaluation, care, and treatment. Daily treatment service shall be provided to
assess and address individual needs of each member. Services include
individual, family, and/or group therapy, individual and/or group
rehabilitation services, crisis intervention, care management, and community
recovery support services. Group therapy is limited to a total of eight (8)
individuals. Rehabilitation services shall not exceed a staffing ratio of
fourteen (14) individuals to one (1) qualified provider.
(ii)
Staffing requirements. A
licensed psychiatrist must be available by telephone twenty-four (24) hours a
day, seven (7) days a week. Additional clinical and/or direct care staff must
be on-site twenty-four (24) hours a day, seven (7) days a week. All staff who
provide treatment services shall meet qualifications in accordance with the
Oklahoma Medicaid State Plan and OAC 450:18.
(iii)
Treatment hours. A weekly
minimum of thirty-seven (37) service hours shall be provided, which shall
include a minimum of four (4) hours of individual, family, and/or group therapy
and a minimum of seven (7) hours of individual or group rehabilitation
services. A maximum of eleven (11) hours per week of community (peer) recovery
support services may count toward the weekly required treatment hours. A week
begins on Sunday and ends on Saturday.
(D)
Intensive residential treatment,
high intensity - individuals age thirteen (13) to seventeen (17).
(i)
Service description. This
service provides a planned regimen of twenty-four (24) hours / seven (7) day a
week, professionally directed evaluation, care, and treatment. Daily treatment
service shall be provided to assess and address individual needs of each
member. Services include individual, family, and/or therapy, individual and/or
group rehabilitation services, crisis intervention, care management, and, for
members age sixteen (16) or older, community recovery support services. Group
therapy is limited to a total of six (6) individuals. Rehabilitation services
shall not exceed a staffing ratio of eight (8) individuals to one (1) qualified
provider.
(ii)
Staffing
requirements. A licensed psychiatrist must be available by telephone
twenty-four (24) hours a day, seven (7) days a week. Additional clinical and/or
direct care staff must be on-site twenty-four (24) hours a day, seven (7) days
a week. Staffing ratios shall not exceed those specified in OAC
340:110-3-153.2. All staff who
provide treatment services shall meet qualifications in accordance with the
Oklahoma Medicaid State Plan and OAC 450:18.
(iii)
Treatment hours. A weekly
minimum of thirty-seven (37) service hours shall be provided, which shall
include a minimum of four (4) hours of individual, family, or group therapy and
a minimum of seven (7) hours of individual or group rehabilitation services. A
maximum of eleven (11) hours per week of community (peer) recovery support
services may count toward the weekly required treatment hours. A week begins on
Sunday and ends on Saturday.
(E)
Residential treatment for
individuals with minor dependent children and women who are pregnant.
(i)
Service description. This
service provides a planned regimen of twenty-four (24) hours / seven (7) day a
week, professionally directed evaluation, care, and treatment. The facility
shall provide SUD treatment services to assess and address individual needs of
each member. Services include individual, family, and/or group therapy,
individual and/or group rehabilitation services, crisis intervention, care
management, and community recovery support services. Group therapy is limited
to a total of eight (8) individuals for adults a total of six (6) individuals
for children. Rehabilitation services shall not exceed a staffing ratio of
fourteen (14) individuals to one (1) qualified provider for adults and eight
(8) individuals to one (1) qualified provider for children.
(ii)
Staffing requirements. A
licensed physician must be available by telephone twenty-four (24) hours a day,
seven (7) days a week. Additional staff must be on-site twenty-four (24) hours
a day, seven (7) days a week. All staff who provide treatment services shall
meet qualifications in accordance with the Oklahoma Medicaid State Plan and OAC
450:18.
(iii)
Treatment
services for dependent children. Services are available to the child
when provided to address the impacts related to the parent's addiction,
including but not limited to individual and family therapy. Compliance with
separate provider qualifications, in accordance with OAC
317:30-5-240.2, is required for
other treatment services provided to dependent children by the residential SUD
provider. Provision of such treatment services shall be provided in accordance
with OAC 317:30-5, Part 21.
(iv)
Treatment hours. A minimum of twenty-four (24) service hours shall
be provided to the individual with minor dependent children and women who are
pregnant. Treatment hours shall include a minimum of one (1) hour of
individual, family, and/or group therapy and a minimum of seven (7) hours of
individual or group rehabilitation services. A maximum of seven (7) hours per
week of community (peer) recovery support services may count toward the weekly
required treatment hours. A week begins on Sunday and ends on Saturday.
Dependent children shall be provided treatment services in accordance with the
child's service plan if services are provided by the residential SUD
provider.
(F)
Intensive residential treatment for individuals with dependent children
and women who are pregnant.
(i)
Service description. This service provides a planned regimen of
twenty-four (24) hours / seven (7) day a week, professionally directed
evaluation, care, and treatment. The facility shall provide SUD treatment
services to assess and address individual needs of each member. Services
include individual, family, and/or group therapy, individual and/or group
rehabilitation services, crisis intervention, care management, and community
recovery support services. Group therapy is limited to a total of eight (8)
individuals for adults a total of six (6) individuals for children.
Rehabilitation services shall not exceed a staffing ratio of fourteen (14)
individuals to one (1) qualified provider for adults and eight (8) individuals
to one (1) qualified provider for children.
(ii)
Staffing requirements. A
licensed psychiatrist must be available by telephone twenty-four (24) hours a
day, seven (7) days a week. Additional clinical and/or direct care staff must
be on-site twenty-four (24) hours a day, seven (7) days a week. All staff who
provide treatment services shall meet qualifications in accordance with the
Oklahoma Medicaid State Plan and OAC 450:18.
(iii)
Treatment services for dependent
children. Services are available to the child when provided to address
the impacts related to the parent's addiction, including but not limited to
individual and family therapy. Compliance with separate provider
qualifications, in accordance with OAC
317:30-5-240.2, is required for
other treatment services provided to dependent children by the residential SUD
provider. Provision of such treatment services shall be provided in accordance
with OAC 317:30-5, Part 21.
(iv)
Treatment hours. A weekly minimum of thirty-five (35) service
hours shall be provided to the individual with minor dependent children and
women who are pregnant. Treatment hours shall include a minimum of four (4)
hours of individual, family, and/or group therapy and a minimum of seven (7)
hours of individual and/or group rehabilitation services. A maximum of eleven
(11) hours per week of community (peer) recovery support services may count
toward the weekly required treatment hours. A week begins on Sunday and ends on
Saturday. Dependent children shall be provided treatment services in accordance
with the child's service plan if services are provided by the residential SUD
provider.
(4)
Medically monitored high intensity withdrawal management (ASAM Level
3.7).
(A)
Medically supervised
withdrawal management - individuals age thirteen (13) to seventeen (17).
(i)
Service description and
requirements. This service is provided under the direction of a licensed
physician and a licensed registered nurse supervisor, for members who are
withdrawing or are intoxicated from alcohol or other drugs. Members shall be
assessed as currently experiencing no apparent medical or neurological symptoms
that would require hospitalization. Daily SUD withdrawal management treatment
services shall be provided, which include, but are not limited to, taking of
vital signs (temperature, pulse, respiration rate, blood pressure),
documentation of fluid and food intake a minimum of one (1) time every six (6)
hours or more often as indicated by the member's condition. Medications shall
be prescribed if needed during withdrawal management. The medications are to
include those needed for physical health issues and mental impairment if
acquired during the withdrawal process.
(ii)
Staffing requirements. A
licensed physician providing supervision of withdrawal management must be
available on site or on call twenty-four (24) hours a day, seven (7) days a
week. A licensed nurse must provide twenty-four (24) hours a day, seven (7)
days a week monitoring and statutorily approved personnel administer
medication. A minimum of two (2) medical and/or clinical/direct care staff must
be on-site and awake twenty-four (24) hours a day, seven (7) days a week.
Staffing ratios shall not exceed those specified in OAC
340:110-3-153.2.
(B)
Medically supervised withdrawal
management - adults.
(i)
Service
description and requirements. This service is provided under the
direction of a licensed physician and a licensed registered nurse supervisor,
for members who are withdrawing or are intoxicated from alcohol or other drugs.
Members shall be assessed as currently experiencing no apparent medical or
neurological symptoms that would require hospitalization. Daily SUD withdrawal
management treatment services shall be provided, which include, but are not
limited to, taking of vital signs (temperature, pulse, respiration rate, blood
pressure), documentation of fluid and food intake a minimum of one (1) time
every six (6) hours or more often as indicated by the member's condition.
Medications prescribed if needed during withdrawal management. The medications
are to include those needed for physical health issues and mental impairment if
acquired during the withdrawal process.
(ii)
Staffing requirements. A
licensed physician providing supervision of withdrawal management must be
available on site or on call twenty-four (24) hours a day, seven (7) days a
week. A licensed nurse must provide twenty-four (24) hours a day, seven (7)
days a week monitoring and statutorily approved personnel administer
medication.
Disclaimer: These regulations may not be the most recent version. Oklahoma may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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