10 Colo. Code Regs. § 2505-10-8.746

Current through Register Vol. 47, No. 24, December 25, 2024

Section 10 CCR 2505-10-8.746 - OUTPATIENT FEE-FOR-SERVICE SUBSTANCE USE DISORDER TREATMENT

8.746.1DEFINITIONS

Community Behavioral Health Services Program means the program described at 10 CCR 2505-10 Section 8.212, by which program-enrolled Medicaid clients receive behavioral health treatment services.

Day Treatment Program means a non-residential treatment program designed for children and adolescents under the age of 21 who have an emotional, behavioral, and neurobiological, or substance use disorder diagnosis, and may be at high risk for out-of-home placement. Day Treatment Program services include family, group, and individual psychotherapy; parent-child education; skill and socialization training focused on improving functional and behavioral deficits; and intensive coordination with schools or other child service agencies.

Health First Colorado is Colorado's Medicaid Program, the free or low cost public health insurance program that provides health care coverage to low-income individuals, families, children, pregnant women, seniors, and people with disabilities. Colorado Medicaid is funded jointly by the federal and state government, and is administered by the Colorado Department of Health Care Policy and Financing.

Intensive Outpatient Psychiatric Rehabilitation Services are those that focus on maintaining and improving functional abilities for the client through a time-limited, multi-faceted approach to treatment.

Licensed Clinician means a provider who is a clinical social worker licensed pursuant to CRS 12-43-404, marriage and family therapist licensed pursuant to CRS 12-43-504, professional counselor licensed pursuant to CRS 12-43-603, addiction counselor licensed pursuant to CRS 12-43-804, or psychologist (Psy.D/Ph.D) licensed pursuant to CRS 12-43-304.

Licensed Health Practitioner means an advanced practice nurse licensed pursuant to CRS 12-38-111.5, physician/psychiatrist licensed pursuant to CRS 12-36-101, or physician assistant licensed pursuant to CRS 12-36-107.4.

Residential Treatment means a short-term residential treatment program offering 24-hour intensive residential treatment, habilitative, and rehabilitative services for up to 30 days in a highly structured, community-oriented environment.

State Fiscal Year (SFY) is July 1 - June 30.

8.746.2ELIGIBLE PROVIDERS

1. Providers eligible to render services are limited to the following:

a. Licensed Health Practitioners who are also:

i) Certified in addiction medicine by the American Society of Addiction Medicine (ASAM), the American Board of Addiction Medicine (ABAM), or the American Board of Preventive Medicine (ABPM); or

ii) Certified Addiction Counselors (CAC II or CAC III) or Licensed Addiction Counselors (LAC) by the Department of Regulatory Agencies (DORA); or

iii) National Certified Addiction Counselors II (NCAC II) or Master Addiction Counselors (MAC) by the National Association of Alcohol and Drug Abuse Counselors (NAADAC); or

iv) Certified in addiction psychiatry by the American Board of Psychiatry and Neurology certified in Addiction Psychiatry (ABPN).

b. Licensed Clinicians.

8.746.3TREATMENT PLANNING

8.746.3.A. An approved treatment plan must be in place for each client prior to the client receiving services. An initial assessment is required to establish a treatment plan. Treatment plans require approval from a licensed provider indicated in Section 8.746.2 with the authority to approve treatment plans within their scope of practice.

8.746.3.B. All rendered services must be medically necessary, as defined in Section 8.076.1.8 ., and must be detailed in the client's treatment plan and progress notes. Initial substance use disorder assessments are exempt from inclusion in the approved treatment plan.

8.746.3.C. Approved treatment plans must identify treatment goals and must explain how the proposed treatment services will achieve those stated goals.

8.746.3.D. Approved treatment plans must identify the treatment services planned for use over the course of treatment. The amount, frequency, and duration of these treatment services must be included in the approved treatment plan.

8.746.4ELIGIBLE CLIENTS

1. To be eligible for the Outpatient Fee-for-Service Substance Use Disorder Treatment benefit, client:

a. Must currently be enrolled in Colorado Medicaid; and

b. Must not be enrolled in the Community Behavioral Health Services program pursuant to 10 C.C.R. 2505-10 Section 8.212.

i) All Colorado Medicaid clients are automatically enrolled in the Community Behavioral Health Services program, unless one of the following is true:

1) Client is not eligible for enrollment in the Community Behavioral Health Services program, per 10 CCR 2505-10 Section 8.212.1.A.; or

2) Client is approved for an individual enrollment exemption, as set forth at 10 CCR 2505-10 Section 8.212.2.

8.746.5LIMITATIONS

1. Clients are not required to obtain a referral from their Primary Care Physician (PCP) or Primary Care Medical Provider (PCMP) to receive these services.

2. Clients must have a treatment plan that is approved by a licensed practitioner listed in Section 8.746.2.

3. Outpatient Fee-for-Service Substance Use Disorder Treatment services may only be rendered by providers outlined in Section 8.746.2, with an exception for certain providers of Medication Assisted Treatment described below.

4. Services are covered only when the client has been diagnosed with at least one of the following:

a. Alcohol use or induced disorder

b. Amphetamine use or induced disorder

c. Cannabis use or induced disorder

d. Cocaine use or induced disorder

e. Hallucinogen use or induced disorder

f. Inhalant use or induced disorder

g. Opioid use or induced disorder

h. Phencyclidine use or induced disorder

i. Sedative Hypnotic or Anxiolytic use or induced disorder

j. Tobacco use disorder

8.746.6COVERED SERVICES

8.746.6.A. Substance Use Disorder Assessment

1. A substance use disorder assessment is an evaluation designed to determine the most appropriate level of care based on criteria established by the American Society of Addiction Medicine (ASAM), the extent of drug or alcohol use, abuse, or dependence and related problems, and the comprehensive treatment needs of a client with a substance use disorder diagnosis.

a. Course of treatment and changes in level of care must be based on best practices as defined by the current ASAM Patient Placement Criteria.

b. Re-assessments must be spaced appropriately throughout the course of treatment to ensure the treatment plan is effectively managing the client's changing needs.

c. Each complete assessment corresponds to one unit of service.

d. An assessment may involve more than one session and may span multiple days. If the assessment spans multiple days, the final day of the assessment is reported as the date of service.

8.746.6.B. Individual and Family Therapy

1. Individual and family therapy is the planned treatment of a client's problem(s) as identified by an assessment and listed in the treatment/service plan. The intended outcome is the management and reduction, or resolution of the identified problem(s).

2. Individual and family therapy is limited to one client per session.

Individual and family therapy are billed at 15 minutes per unit.

a. A session is considered a single encounter with the client that can encompass multiple timed units.

3. Family therapy must be directly related to the client's treatment for substance use disorder or dependence.

4. Individual therapy and family therapy sessions are allowed on the same date of service.

8.746.6.C. Group Therapy

1. Group therapy refers to therapeutic substance use disorder counseling and treatment services, administered through groups of people who have similar needs, such as progression of disease, stage of recovery, and readiness for change.

2. Group therapy must include more than one patient.

3. A session of group therapy may last up to three hours and is billed in units of one hour each (e.g., a three hour group session would consist of three units).

a. A unit of service may be billed separately for each client participating in the group therapy session.

8.746.6.D. Alcohol / Drug Screening and Counseling

1. Alcohol / drug screening and counseling is the collection of urine followed by a counseling session with the client to review and discuss the results of the screening.

a. The analysis of the urine specimen (urinalysis) may only be billed by a provider with the appropriate CLIA certification for the test performed. Urinalysis is not part of the Outpatient Fee-For-Service SUD benefit.

b. Substance use disorder providers will only be reimbursed for collecting the urine specimen and providing a counseling session to review and discuss the results of the urinalysis. Claims submitted for the collection of the urine sample without the subsequent counseling of urinalysis results will not be reimbursed.

i. If the client does not return for the counseling of their urinalysis results, the collection of the sample cannot be claimed.

c. Substance use disorder counseling services to discuss and counsel the client on the test results must be provided by an eligible rendering provider, as outlined in Section 8.746.2.

d. The counseling portion of the service may be conducted during a session of individual or family therapy.

e. Multiple urine collections per date of service are not additionally reimbursed.

f. Alcohol / drug screening and counseling is limited to one unit per date of service.

i. A unit of service is the single collection and subsequent counseling session.

8.746.6.E. Targeted Case Management

1. Targeted case management refers to coordination and planning services provided with, or on behalf of, a client with a substance use disorder diagnosis.

a. The client does not need to be physically present for this service to be performed if it is done on the client's behalf.

2. Targeted case management services are limited to service planning, advocacy, and linkage to other appropriate medical services related to substance use disorder diagnosis, monitoring, and care coordination.

3. A unit of service equals one 15-minute increment of targeted case management, and consists of at least one documented contact with a client or person acting on behalf of a client, identified during the case planning process.

8.746.6.F. Social / Ambulatory Detoxification

1. Facilities licensed by the Office of Behavioral Health (OBH) to provide detoxification services are the only provider eligible to render social / ambulatory detoxification services.

2. Social / ambulatory detoxification services:

a. Include supervision, observation, and support from qualified personnel for clients exhibiting intoxication or withdrawal symptoms.

b. Are provided when there is minimal risk of severe withdrawal (including seizures and delirium tremens) and when any co-occurring mental health or medical conditions can be safely managed in an ambulatory setting.

3. A session is defined as the continuous treatment time from the first day to the last day of social/ambulatory detoxification.

a. Each session may last a maximum of three days.

Room and board is not a covered social / ambulatory detoxification service. Claims billed for room and board will not be reimbursed.

5. Social / ambulatory detoxification is divided into four distinct services-physical assessment of detoxification progress, evaluation of level of motivation, safety assessment, and provision of daily living needs-with corresponding procedure codes, which may be provided and billed on the same date of service if medically necessary, as defined in rule at 10 CCR 2505-10 Section 8.076.1.8.

8.746.6.G. Medication-Assisted Treatment (MAT)

1. Medication Assisted Treatment (MAT) is a benefit for opioid addiction that includes a medication approved by the U.S. Food and Drug Administration (FDA) for opioid addiction detoxification or maintenance treatment.

2. When methadone is administered for MAT, the reimbursement for the medication's acquisition is bundled with the reimbursement for administration and dispensing under a single billing code. When other medications are used for MAT (e.g. Suboxone), the reimbursement for the medication is billed separately from the administration and dispensing using physician administered drug billing codes.

a. Only licensed physicians, physician assistants, or nurse practitioners are eligible to administer MAT. All providers must comply with the Office of Behavioral Health's Opioid Medication Assisted Treatment program requirements set forth at 2 C.C.R. 502-1 21.320.

b. Take-home dosing is permitted in accordance with Office of Behavioral Health rules at 2 CCR 502-1 21.320.8. Therefore, one unit of MAT must be reported for each date of service the client ingests the dose of methadone.

c. If the client ingests their dose at the facility, the place of service must be reported as office. If the client ingests their dose at home, the place of service must be reported as home. Records must include documentation to substantiate claims for take-home doses.

8.746.7PRIOR AUTHORIZATION REQUIREMENTS

8.746.7.A. There are no prior authorization requirements for the Outpatient Fee-for-Service Substance Use Disorder Treatment benefit.

8.746.8NON-COVERED SERVICES

8.746.8.A. The following services are not covered under the Outpatient Fee-for-Service Substance Use Disorder Treatment benefit:

1. Day treatment program services.

2. Intensive outpatient psychiatric rehabilitation.

3. Peer advocate services.

4. Residential treatment services, with the exception of those provided in a Residential Child Care Facility, as set forth in Section 8.765.

5. Services provided by a third party that is under contract with the provider.

6. Any substance use disorder treatment service not specified as covered in Section 8.746.6.

10 CCR 2505-10-8.746