Current through Reg. 49, No. 38; September 20, 2024
(a)
Subject to the specifications, conditions, limitations, and requirements
established by the Health and Human Services Commission (HHSC) or its designee,
substance use disorder treatment services are those services provided by a
provider or facility licensed by the HHSC to provide substance use disorder
treatment services.
(b) Substance
use disorder has the definition assigned in the most current American
Psychiatric Association's Diagnostic and Statistical Manual of Mental
Disorders.
(c) Covered outpatient
substance use disorder treatment services include:
(1) assessment;
(2) outpatient group and individual
counseling;
(3) medication assisted
treatment; and
(4) outpatient
withdrawal management.
(d) Covered outpatient substance use disorder
treatment services are limited as follows.
(1) One assessment per episode of care, which
must be performed at the start of each new episode of care.
(2) A maximum of 135 sessions per person, per
calendar year for outpatient group counseling services. Additional services
beyond this limit may be considered with documentation of the supporting
medical necessity for continued treatment services. Using their best judgement,
a provider determines the length of time that constitutes a group session
depending on the group members, the focus of the session, and other relevant
variables.
(3) A maximum of 26
hours per person, per calendar year of outpatient individual counseling
services. Additional services beyond this limit may be considered with
documentation of the supporting medical necessity for continued treatment
services.
(4) Medication assisted
treatment duration is determined on an individual basis, based on the person's
unique needs and treatment goals. Medication assisted treatment is the use of
Food and Drug Administration-approved medications in combination with
psychosocial treatment to treat substance use disorders, particularly alcohol
and opioid use disorders, in compliance with 42 Code of Federal Regulations
Part 8. Medication Assisted Treatment for Opioid Use Disorders, and applicable
state rules.
(5) Outpatient
withdrawal management is limited to an appropriate duration of service based on
medical necessity and level of intoxication for a maximum of 21 days per
episode of care. There are no limits on the number of episodes of
care.
(e) Covered
residential substance use disorder treatment services include:
(1) residential withdrawal management;
and
(2) residential
treatment.
(f) Covered
residential substance use disorder treatment services are billed on an
outpatient claim form and are limited as follows.
(1) Residential withdrawal management is
limited to an appropriate duration of service based on medical necessity and
level of intoxication for a maximum of 21 days per episode of care. There are
no limits on the number of episodes of care.
(2) Residential treatment is limited to an
appropriate duration of service based on medical necessity and severity of
substance use disorder for a maximum of 35 days per episode of care and no more
than two episodes of care per rolling six month period, and four episodes per
rolling 12 month period. Additional episodes within the six-month or 12-month
time frame may be considered with documentation of medical necessity.
