Section He-W 513.05 - Covered Services(a) SUD treatment and recovery support services shall be covered in accordance with this section.(b) In order for the services described in this section to be covered, they shall: (1) Be delivered in accordance with appropriate guidelines that are consistent with generally accepted standards of care in the ASAM Criteria (2013), available as noted in Appendix A;(2) Include continuing care, transfer, and discharge plans that address all domains in ASAM Criteria (2013), available as noted in Appendix A, as follows: a. Plans shall include the process of transfer and discharge planning at the time of the recipient's intake to the program;b. Plans for continuing care shall include at least one of the 3 following criteria for continuing services: 1. The recipient is making progress but has not yet achieved the goals articulated in the individualized treatment plan, and continued treatment at the present level of care is assessed as necessary to permit the recipient to continue to work toward his or her treatment goals;2. The recipient is not yet making progress, but has the capacity to resolve his or her problems, is actively working toward the goals articulated in the individualized treatment plan, and continued treatment at the present level of care is assessed as necessary to permit the recipient to continue to work toward his or her treatment goals; or3. New problems have been identified that are appropriately treated at the present level of care and that requires services at a frequency and intensity that can only safely be delivered by the recipient's continued stay in the current level of care; andc. Plans for transfer or discharge planning shall include at least one of the 4 following criteria: 1. The recipient has achieved the goals articulated in the individualized treatment plan thus resolving the problem or problems that justified admission to the present level of care and continuing chronic disease management of the recipient's condition at a less intensive level of care is indicated;2. The recipient has been unable to resolve the problem or problems that justified the admission to the present level of care despite amendments to the treatment plan and has been determined to have met the maximum possible benefit from engagement in services at the current level of care, so transfer or discharge from treatment is indicated;3. The recipient has demonstrated a lack of capacity due to diagnostic or co-occurring conditions that limit his or her ability to resolve his or her problem, so treatment at a qualitatively different level of care or type of service, or discharge from treatment is indicated; or4. The recipient has experienced an intensification of his or her problem or problems or has developed a new problem or problems and can be treated effectively at a more intensive level of care;(3) Be evidence based, as demonstrated by meeting one of the following criteria: a. The service shall be included as an evidence-based mental health and substance abuse intervention on the SAMHSA Evidence-Based Practices Resource Center available at https://www.samhsa.gov/ebp-resource-center;b. The services shall be published in a peer-reviewed journal and found to have positive effects; orc. The SUD treatment and recovery support service provider shall be able to document the services' effectiveness based on the following: 1. The service is based on a theoretical perspective that has validated research; or2. The service is supported by a documented body of knowledge generated from similar or related services that indicate effectiveness;(4) When clinically appropriate, include referral to, and assistance in accessing, medication assisted SUD treatment either on site or off site;(5) Include an assessment of all recipients for risk of self-harm at all phases of treatment, such as at initial contact, during screening, intake, admission, on-going treatment services, and at discharge;(6) With the exception of peer and non-peer recovery and continuous recovery monitoring, be consistent with the "Addiction Counseling Competencies, TAP 21" (2017 revision), available as noted in Appendix A;(7) Be provided in accordance with the ASAM Level of Care service descriptions, as applicable, noted in He-W 513.11; and(8) Be provided at a length of time and frequency of care based on individual client need in accordance with ASAM Criteria (2013), available as noted in Appendix A, and not on predetermined time or frequency limits.(c) Screening, brief intervention, and referral to treatment (SBIRT) shall be a covered service when provided as follows: (1) The screening shall be provided for the purpose of identifying individuals who have an alcohol or drug use problem or who are at risk for developing one;(2) The screening shall be conducted by evaluating responses to questions as described in (3) below about the context, frequency, and amount of alcohol and other drug use;(3) The screening shall be performed using a screening instrument listed in Appendix E of "Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment, TAP 33" (2013 edition), available as noted in Appendix A;(4) SBIRT shall be provided with and billed with another medical service;(5) SBIRT shall be conducted by a provider who has been trained in the SBIRT model and is either: a. A medicaid enrolled physician or APRN;b. A medicaid enrolled physician assistant, or other practitioner under a physician's supervision; orc. A practitioner working in an outpatient SUD program as defined in He-W 513.02(q) (4) or He-W 513.02(q) (6) who is either: 1. A physician or APRN; or2. A physician assistant or other practitioner under a physician's supervision;(6) SBIRT shall be performed in the primary care practitioner's office or other health care settings not specific to the delivery of SUD treatment and recovery support services;(7) The services provided by the providers described in (5) a. above shall be billed by the medicaid enrolled practitioner; and(8) The services provided by the providers described in (5) b. above shall be billed by the supervising physician.(d) SUD screening shall be a covered service when provided as follows: (1) The screening shall be provided for the purpose of identifying individuals who have an alcohol or drug use problem or who are at risk for developing one;(2) The screening shall be conducted by evaluating responses to questions as described in (3) below about the context, frequency, and amount of alcohol and other drug use;(3) The screening shall be performed using a screening instrument listed in Appendix E of "Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment, TAP 33" (2013 edition), available as noted in Appendix A;(4) Except as allowed in (5) and (6) below, the screening shall be performed by medicaid enrolled psychotherapy providers licensed by the NH board of mental health practice, medicaid enrolled psychotherapy providers licensed by the NH board of psychology, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, medicaid enrolled outpatient SUD programs, or medicaid enrolled comprehensive SUD programs; and(5) The screening may be performed by individuals who are allowed to do such screenings under the supervision of the providers in (4) above in accordance with RSA 329-B, RSA 330-A, or RSA 330-C as follows: a. The restrictions described in He-W 513.04(c) shall not apply; andb. Such screenings shall be billed by the supervising practitioner or the outpatient or comprehensive SUD program.(e) Opioid treatment services shall be a covered service when provided as follows: (1) Opioid treatment services shall be provided by medicaid enrolled providers who meet the medical services clinic requirements in He-W 536 and are certified as an opioid treatment program in accordance with He-A 304.03;(2) Opioid treatment providers shall operate and provide services in accordance with He-A 304;(3) Opioid treatment services shall be delivered in accordance with a treatment plan;(4) Opioid treatment services shall be limited to treatment with methadone or buprenorphine;(5) Opioid treatment services shall be inclusive of the necessary components of the daily opioid treatment services, such as intake services, medication counseling, administration, medical supervision of vitals, observation afterwards, urine testing, and blood and lab work;(6) SUD treatment and recovery support services may be provided in conjunction with the opioid treatment services and may be billed separately from the opioid treatment service; and(7) Except as specified in (5) above, opioid treatment services shall be billed in accordance with He-W 536.(f) Pharmaceuticals prescribed for SUD treatment services shall be covered in accordance with He-W 570.(g) Office-based medication assisted SUD treatment shall be a covered service when provided as follows: (1) Office-based medication assisted SUD treatment via buprenorphine shall be provided by medicaid enrolled providers who: a. Have obtained a waiver in accordance with the Drug Addiction Treatment Act of 2000 (DATA 2000), Title XXXV, Section 3502 of the Children's Health Act of 2000, to treat opioid addiction with Schedule III, IV, and V narcotic medications; and(2) Office-based medication assisted SUD treatment shall be provided by medicaid enrolled providers who meet the physician requirements in He-W 531 or the advanced practice registered nurse requirements in He-W 534;(3) Office-based medication assisted SUD treatment shall be delivered in accordance with a treatment plan;(4) The writing of the prescription shall be a component of an office visit;(5) The provider shall: a. Refer the recipient to clinically appropriate SUD treatment and recovery services as described in He-W 513; andb. Coordinate care with the SUD treatment and recovery provider within or external to the office based practice;(6) Office-based medication assisted SUD shall be billed by the prescribing provider, outpatient SUD program, or comprehensive SUD program; and(7) The prescribing provider shall be listed as the rendering provider on the claim.(h) Outpatient, individual treatment consistent with Level 1, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows: (1) Outpatient, individual treatment shall be delivered in accordance with a treatment plan;(2) Outpatient, individual treatment shall be covered when provided by medicaid enrolled psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, medicaid enrolled physicians or advanced practice registered nurses (APRNs), medicaid enrolled outpatient SUD programs, or medicaid enrolled comprehensive SUD programs; and(3) Outpatient, individual treatment shall be billed by the medicaid enrolled individual or group practitioner or by the outpatient or comprehensive SUD program.(i) Group treatment consistent with Level 1, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows: (1) Group treatment shall meet the requirements in He-W 513.04(f) ;(2) Group treatment shall be delivered in accordance with a treatment plan;(3) Group treatment shall be covered when provided by medicaid enrolled psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, medicaid enrolled physicians or APRNs, medicaid enrolled outpatient SUD programs, or medicaid enrolled comprehensive SUD programs; and(4) Group treatment shall be billed by the medicaid enrolled individual or group practitioner or by the outpatient or comprehensive SUD program.(j) Family treatment consistent with Level 1, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows: (1) Family treatment shall be provided to either: b. The recipient's family members or significant others, either with or without the recipient present, if treatment is related to the recipient's SUD;(2) Family treatment shall be delivered in accordance with a treatment plan;(3) Family treatment shall be covered when provided by medicaid enrolled psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, medicaid enrolled physicians or APRNs, medicaid enrolled outpatient SUD programs, or medicaid enrolled comprehensive SUD programs; and(4) Family treatment shall be billed by the medicaid enrolled individual or group practitioner or by the outpatient or comprehensive SUD program.(k) Intensive outpatient SUD services consistent with Level 2.1, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows: (1) Intensive outpatient SUD services shall be covered when they are: a. Provided by medicaid enrolled outpatient or comprehensive SUD programs; andb. Delivered by the following practitioners: 1. Psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists; or2. MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals;(2) Intensive outpatient SUD services shall be comprised of a combination of individual and group treatment services at least 9 hours per week for recipients age 21 and over and at least 6 hours per week for recipients under age 21;(3) Group treatment shall meet the requirements in He-W 513.04(f) ;(4) Intensive outpatient SUD services shall be delivered in accordance with a treatment plan;(5) Intensive outpatient SUD services shall be comprised of a range of outpatient treatment services and other ancillary alcohol or drug treatment services to include all of the following: b. Individual, group, or family treatment;d. Activity therapies; ande. Substance use prevention education; and(6) Intensive outpatient SUD services shall be billed by the outpatient or comprehensive SUD program.(l) Partial hospitalization services consistent with Level 2.5, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows: (1) Partial hospitalization services shall be: a. Provided to recipients with moderate to severe co-occurring SUD and mental health disorders as described in DSM-5 (2013), available as noted in Appendix A;b. Provided by a medicaid enrolled outpatient or comprehensive SUD treatment program; andc. Delivered by the following practitioners: 1. For all partial hospitalization services, except medication management: (i) Psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists; or(ii) MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals; and2. For medication management services: (i) Psychiatrists licensed by the NH board of medicine; or(ii) APRNs with a psychiatric specialty;(2) Partial hospitalization shall address both disorders and be comprised of a range of outpatient treatment services and other ancillary mental health and alcohol or drug treatment services to include all of the following: b. Individual, group, or family treatment;e. Medication management, which shall include psychiatric services, including psychotropic medication management services as applicable; andf. Substance use prevention education;(3) Services shall be provided at least 20 hours per week;(4) Group sessions shall meet the requirements in He-W 513.04(f) ; and(5) Services shall be billed by the outpatient or comprehensive SUD program.(m) Rehabilitative services shall be a covered service when provided as follows: (1) Rehabilitative services shall be: a. Provided by a medicaid enrolled comprehensive SUD program;b. Delivered by the following practitioners: 1. Psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists;2. MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals;4. Advanced practice registered nurses (APRN); andc. Provided as a planned program of professionally directed evaluation, care, and treatment for the restoration of functioning for persons with SUDs;(2) Recipients who are being treated at an ASAM 3.5 level of care shall be present in the facility at least 22 hours per day; and(3) Recipients who are being treated at an ASAM 3.1 level of care shall receive at least 5 hours of clinical service per week..(n) Medically monitored outpatient withdrawal management (WM) consistent with Level 1-WM, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows: (1) Medically monitored outpatient withdrawal management services shall be provided by a medicaid enrolled outpatient or comprehensive SUD program and supervised by a licensed physician or APRN who is on the staff of, or under contract with, the outpatient or comprehensive SUD program;(2) Medically monitored outpatient withdrawal management services shall be organized and delivered by SUD treatment and mental health personnel and other health care providers who provide a planned regimen of care in the outpatient setting;(3) Personnel required in (2) above shall be: a. Psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists on the staff of, or under contract with, the outpatient or comprehensive SUD program;b. MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals on the staff of, or under contract with, the outpatient or comprehensive SUD program;c. Licensed physicians on the staff of, or under contract with, the outpatient or comprehensive SUD program; ord. Licensed APRNs on the staff of, or under contract with, the outpatient or comprehensive SUD program;(4) Medically monitored outpatient withdrawal management services shall be delivered in accordance with a treatment plan;(5) Medically monitored outpatient withdrawal management services shall be provided in regularly scheduled sessions in accordance with defined policies and procedures consistent with ASAM Criteria (2013) standards, available as noted in Appendix A;(6) Medically monitored outpatient withdrawal management services shall be provided under an integrated or collaborative service model; and(7) Medically monitored outpatient withdrawal management services shall be billed by the outpatient or comprehensive SUD program.(o) Medically monitored residential withdrawal management consistent with Level 3.7-WM, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows: (1) Medically monitored residential withdrawal management services shall be provided by a medicaid enrolled comprehensive SUD program;(2) Medically monitored residential withdrawal management services shall be organized and delivered by SUD treatment and mental health personnel and other health care providers who provide a planned regimen of care in a 24-hour live-in setting;(3) Personnel required in (2) above shall be: a. Psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists on the staff of, or under contract with, the comprehensive SUD program;b. MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals on the staff of, or under contract with, the comprehensive SUD program;c. Licensed physicians on the staff of, or under contract with, the comprehensive SUD program; ord. Licensed APRNs on the staff of, or under contract with, the comprehensive SUD program; and(4) Medically monitored residential withdrawal management services shall be billed by the comprehensive SUD program.(p) Medically managed withdrawal in an acute care setting shall be covered for recipients in accordance with the provisions of He-W 543.(q) Crisis intervention shall be a covered service when provided as follows: (1) Crisis intervention shall be covered when a recipient, family member, or significant other is facing a crisis or emergency situation and the crisis intervention is related to the recipient's SUD;(2) Crisis intervention shall be covered when provided by medicaid enrolled psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008 and Chapter Law 249:24, V, Laws of 2010, medicaid enrolled physicians or APRNs, medicaid enrolled outpatient SUD programs, or medicaid enrolled comprehensive SUD programs; and(3) Crisis intervention shall be billed by the medicaid enrolled individual or group practitioner or by the outpatient or comprehensive SUD program.(r) Peer recovery support shall be a covered service when provided as follows: (1) Peer recovery support services shall include non-clinical services delivered by peers who self-identify as having lived experience to help recipients age 12 and above and families identify and work toward strategies and goals around stabilizing and sustaining recovery and, as applicable, providing links to professional treatment and community supports;(2) Peer recovery support services shall include: a. Skill restoration therapy intended to reduce or remove barriers to achieving and maintaining recovery;b. Emergency or crisis services available by telephone;c. Assistance in accessing transportation services for individuals who lack safe transportation;d. Individual skills development and restoration to prevent continuation or recurrence of substance misuse;e. Psychoeducation interventions to support recovery;f. Development and periodic revision of a specific recovery plan based on the information collected through the assessment that shall specify the goals and actions to address the recovery goals and other services needed by the individual; andg. Working with the individual to develop and refine recovery goals;(3) Peer recovery support services shall be provided by a medicaid enrolled peer recovery program;(4) Peer recovery support services shall be delivered by a peer recovery coach who shall have: a. Completed 30 contact hours of recovery coach training approved by: 1. NH Training Institute on Addictive Disorders;2. The NH Board of Licensing for Alcohol and Other Drug Use Professionals;3. NAADAC, the Association for Addiction Professionals;4. AdCare Education Institute, Inc., of New England;5. Addiction Technology Transfer Center; or6. Connecticut Communities for Addiction Recovery (CCAR) Recovery Coach Academy (RCA);b. Completed a minimum of sixteen contact hours of training in ethics approved by any of the providers in (r) (4) a.1.-6.;c. Completed a minimum of 6 contact hours of training in suicide prevention approved by any of the providers in (r) (4) a.1.-6.; andd. Completed a minimum of 3 contact hours of training on co-occurring mental health and substance use disorders approved by any of the providers in (r) (4) a.1.-6.;(5) The individual providing the services shall be supervised by a practitioner in accordance with He-W 513.04(c) (2) who is on the staff of, or under contract with, the peer recovery program who shall have: a. Completed the training described in He-W 513.05(r) (4); andb. Completed 6 contact hours of training in the supervision of individuals delivering peer recovery support services approved by:1. NH Training Institute on Addictive Disorders;2. The NH Board of Licensing for Alcohol and Other Drug Use Professionals;3. NAADAC, the Association for Addiction Professionals;4. AdCare Education Institute, Inc., of New England;5. Addiction Technology Transfer Center; or6. Connecticut Communities for Addiction Recovery (CCAR) Recovery Coach Academy (RCA) ;(6) Peer recovery support services shall be billed by the peer recovery program; and(7) The supervising practitioner in (5) above shall be listed as the rendering provider when billing for services.(s) Recovery support services shall be a covered service when provided as follows: (1) Recovery support services shall include non-clinical group or individual services consistent with a recipient's treatment plan that help to prevent relapse and promote recovery and community integration for the individual being served;(2) Recovery support services shall include: a. Skill restoration therapy intended to reduce or remove barriers to achieving and maintaining recovery;b. Emergency and crisis services available by telephone;c. Assistance in accessing transportation services for individuals who lack safe transportation;d. Individual skills development and restoration to prevent continuation or recurrence of substance misuse;e. Psychoeducation interventions to support recovery;f. Development and periodic revision of a specific recovery plan based on the information collected through the assessment that shall specify the goals and actions to address the recovery goals and other services needed by the individual; andg. Working with the individual to develop and refine recovery goals;(3) Recovery support services shall be provided by a medicaid enrolled outpatient, comprehensive SUD treatment program, or peer recovery program;(4) Recovery support services shall be provided by a CRSW certified by the NH board of licensing for alcohol and other drug use professionals, by a LADC or MLADC licensed by the board of licensing for alcohol and other drug use professionals, or by a psychotherapist licensed by the NH board of mental health practice or the NH board of psychologists;(5) The individual providing the services shall be supervised by a practitioner in accordance with He-W 513.04(c) (2) ;(6) Recovery support shall be billed by the outpatient, comprehensive SUD program, or peer recovery program; and(7) The supervising practitioner in (5) above shall be listed as the rendering provider when billing for services.(t) Continuous recovery monitoring shall be a covered service when provided as follows: (1) Continuous recovery monitoring shall include recovery check-ups with recipients on a regular basis, evaluations of the status of the recipient's recovery, consideration of a broad array of recipient needs, and provision of active referral to community resources as applicable;(2) Continuous recovery monitoring shall be provided by a medicaid enrolled outpatient or comprehensive SUD treatment program or a peer recovery program;(3) When provided in a peer recovery program, continuous recovery monitoring shall be provided by an individual described in He-W 513.05(r) (4) above who is supervised in accordance with He-W 513.04(c) (2) above;(4) When provided in an outpatient or comprehensive SUD program, continuous recovery monitoring shall be provided by an individual described in He-W 513.05(s) (4) who is supervised in accordance with He-W 513.04(c) (2) above;(5) Continuous recovery monitoring shall be billed by the outpatient or comprehensive SUD program or peer recovery program; and(6) The supervising practitioner in (3) above shall be listed as the rendering provider when billing for services.(u) Evaluations to determine the existence and severity of the SUD and appropriate level of care for the recipient shall be a covered service when provided as follows: (1) An evaluation shall be covered when provided by a medicaid enrolled psychotherapist licensed by the NH board of mental health practice or the NH board of psychologists, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008 and Chapter Law 249:24, V, Laws of 2010, or medicaid enrolled outpatient or comprehensive SUD programs;(2) The results of the evaluation, which shall include the following, shall be maintained in the recipient's file:a. Client identified problem(s);b. Summary of data gathered;c. Diagnostic evaluation interpretive summary, including signs, symptoms, and progression of the recipient's involvement with alcohol and other drugs;d. Statement regarding provision of an HIV/AIDS screening and referrals made; ande. Documentation of the level of care recommended in accordance with ASAM Criteria (2013), available as noted in Appendix A;(3) Evaluations shall be billed by the medicaid enrolled individual or group practitioner or by the outpatient or comprehensive SUD program; and(4) Evaluations shall be completed within 3 sessions or within 3 days of client admission to services, whichever is longer.N.H. Admin. Code § He-W 513.05
#10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15
Amended byVolume XXXV Number 06, Filed February 12, 2015, Proposed by #10774, Effective 1/27/2015, Expires7/27/2015.Amended by Volume XXXV Number 36, Filed September 10, 2015, Proposed by #10922, Effective 9/1/2015, Expires9/1/2025.Amended by Volume XXXVI Number 23, Filed June 9, 2016, Proposed by #11107, Effective 7/1/2016, Expires 7/1/2026.Amended by Volume XXXVI Number 45, Filed November 10, 2016, Proposed by #12015, Effective 10/25/2016, Expires 12/25/2026.Amended by Volume XXXVII Number 15, Filed April 13, 2017, Proposed by #12157, Effective 3/10/2017, Expires 3/10/2027.Amended by Volume XXXVIII Number 50, Filed December 13, 2018, Proposed by #12681, Effective 11/27/2018, Expires 11/27/2028.