N.J. Admin. Code § 10:66-2.3

Current through Register Vol. 56, No. 9, May 6, 2024

Section 10:66-2.3 - Substance use disorder treatment services

(a) Substance use disorder treatment services provided in independent clinics include: substance use disorder outpatient rehabilitative services; substance use disorder intensive outpatient (IOP) services; substance use disorder partial care services; non-hospital based withdrawal management services; ambulatory outpatient withdrawal management services; short-term residential services; and opioid treatment and maintenance services, in accordance with N.J.A.C. 10:161A and 10:161B.

1. Medicaid and NJ FamilyCare fee-for-service beneficiaries shall be eligible for substance use disorder treatment facility services only if those services:

i. Are prescribed by a physician or an advanced practice nurse (APN) as described in (c) through (i) below;

ii. Meet the Federal financial participation requirements under Title XIX of the Social Security Act ( 42 U.S.C. § 1396 );

iii. Are included in the facility's Medicaid or NJ FamilyCare fee-for-service approval letter; and

iv. Are licensed by the State of New Jersey Department of Human Services as per N.J.A.C. 10:161A for residential services, N.J.A.C. 10:161B for outpatient, and/or N.J.A.C. 10:161B-11 for opioid treatment services, as applicable.

(b) Medicaid and NJ FamilyCare fee-for-service beneficiaries shall receive a minimum of one counseling session per week during the first three months after initiation of treatment, and at least one counseling session every two weeks thereafter until discharged. See N.J.A.C. 8:43A-26.5.

(c) Substance use disorder outpatient rehabilitative services is a set of treatment activities designed to help the client achieve changes in his or her alcohol or other drug using behaviors. Outpatient rehabilitative services approximate ASAM Level of Care 1 and 2 and the services shall include: intake and assessment by appropriately licensed staff; and individual counseling, group counseling, and/or family counseling. See N.J.A.C. 10:161B for program standards including documentation, staffing, and licensing requirements. Services are provided in regularly scheduled sessions of fewer than nine contact hours per week in a licensed substance use disorder treatment facility.

1. Multiple services may be provided on the same date of service, but no more than one of the same service type.

2. Outpatient rehabilitative services shall not be billed on the same date of service as IOP services.

3. A physician visit may be provided and billed on the same date of service as any outpatient rehabilitative service.

4. Opioid treatment can be provided with outpatient services as per N.J.A.C. 10:161B-11.

5. In accordance with N.J.A.C. 10:161B-8.1, the intake assessment shall include obtaining health related information from the client and recording the information in the client's record. If there is an indication for medical treatment or screening, the staff person shall coordinate referral for services. Resolution of health related problems shall be included as part of the comprehensive treatment plan and all referrals or treatment, and shall be documented in the client chart.

(d) Substance use disorder IOP services are bundled rehabilitative services designed to help clients change alcohol or drug use and related behaviors while receiving treatment in a licensed substance use disorder facility. This service consists of nine to 12 hours of service per week that are delivered at a minimum of three hours per day, for a minimum of three days per week. This level of care approximates ASAM level 2.1. Services shall include: individual counseling; group substance use disorder counseling; other group counseling; and family counseling. Services are provided as listed in N.J.A.C. 10:161B-11. IOP services cannot be combined with individual outpatient rehabilitative services or partial care services.

1. In accordance with N.J.A.C. 10:161B-8.1, the intake assessment shall include obtaining health related information from the client and recording the information in the client's record. If there is an indication for medical treatment or screening, the staff person shall coordinate referral for services. Resolution of health related problems shall be included as part of the comprehensive treatment plan and all referrals or treatment, and shall be documented in the client chart.

(e) Substance Use Disorder-Partial Care Services is a bundled service program that provides a broad range of clinically intensive treatment services in a structured environment for a minimum of 20 hours per week, up to five days per week at a licensed substance use disorder treatment facility. Services shall be delivered for no less than four hours per day. This level of care approximates ASAM level 2.5. Services shall include: individual counseling; group substance use disorder counseling; group counseling; family counseling; and lab services. Services are provided as described in N.J.A.C. 10:161B. Services are billed in units of one hour per day, with a maximum of five hours per day, not to exceed 25 units per week. Substance use disorder partial care services may be provided along with opioid treatment but cannot be provided concurrently with intensive outpatient services.

1. In accordance with N.J.A.C. 10:161B-7.1, a partial care program shall have written protocols to ensure ready access to psychiatric and medical services if needed.

2. In accordance with N.J.A.C. 10:161B-8.1, the intake assessment shall include obtaining health related information from the client and recording the information in the client's record. If there is an indication for medical treatment or screening, the staff person shall coordinate referral for services. Resolution of health related problems shall be included as part of the comprehensive treatment plan and all referrals or treatment, and shall be documented in the client chart.

(f) Non-hospital based withdrawal management rehabilitative services are provided in residential rehabilitative substance use disorder treatment facilities designed primarily to provide short-term care, which has been prescribed by a physician and conducted under medical supervision, to treat a client's physical symptoms caused by addiction according to medical protocols appropriate to each specific type of addiction. This level provides care to clients whose withdrawal signs and symptoms are sufficiently severe to require 23-hour medical monitoring care but can be monitored outside of an inpatient hospital setting. All other licensing requirements for medical services must be followed. This service generally approximates ASAM level 3.7D. Services are provided as listed in N.J.A.C. 10:161A.

(g) Ambulatory outpatient withdrawal management services shall be provided by substance use disorder treatment programs that have been approved by DMHAS to provide outpatient withdrawal management, including opioid treatment programs providing short-term, meaning less than 30 days, opiate withdrawal management using methadone and/or other approved medications. Programs shall accept and provide withdrawal management services only to clients who meet the ASAM Criteria, Level 1-D or 2-D. All programs must comply with N.J.A.C. 10:161B-12.

(h) Short-term residential services is rehabilitative treatment at a facility in which treatment is designed primarily to address specific addiction and living skills problems through a prescribed 23-hour per day activity regimen on a short-term basis. Short-term residential services shall provide a minimum of seven hours of structured programs provided on a billable day. Structured activities shall include a minimum of 12 hours per week of services including, but not limited to, individual counseling, group counseling, and family therapy. Service admission is recommended by a physician or a licensed practitioner within his or her scope of practice. This service approximates ASAM level 3.7 treatment services. Services are provided as listed in N.J.A.C. 10:161A.

(i) Opioid treatment and maintenance service programs dispense opioid agonist treatment medication, including methadone or other approved medications, along with a comprehensive range of medical and rehabilitative services, to the individual to alleviate the adverse medical, psychological, or physical effects related to opiate addiction. These services must be determined to be medically necessary by a licensed clinician and provided in compliance with State rules. This term encompasses: opioid withdrawal management, short-term withdrawal management, long-term withdrawal management, initial maintenance treatment, interim maintenance treatment, and comprehensive maintenance treatment. Opioid treatment programs providing withdrawal management that is less than 30 days shall comply with the provisions in N.J.A.C. 10:161B-12. Licensed opioid treatment programs shall comply with the standards set forth in N.J.A.C. 10:161B-11, including maintaining certification as an opioid treatment program with the Federal Substance Abuse and Mental Health Services Administration (SAMHSA) and complying with all regulations enforced by the Drug Enforcement Administration (DEA), as referenced in N.J.A.C. 10:161B-11.

1. Effective for claims with dates of service on or after July 1, 2016, Medication Assisted Treatment (MAT) delivered by an Opioid Treatment Program (OTP) shall be billed with a bundled weekly rate. A bundled weekly rate applies to Methadone and non-Methadone opioid treatment services including, but not limited to, buprenorphine/buprenorphine-naloxone. The bundled weekly rate includes coverage for medication dispensing, drug costs, individual or group counseling sessions, a case management session, and medication monitoring related to MAT. The bundled rate does not include transportation, intensive outpatient services, or an intake or psychiatric evaluation. The same bundled weekly rate applies to Phase I-VI consumers.

2. The weekly bundled services billing rate shall begin the date of admission for seven days. Minimum billing requirements must be in accordance with provided services outlined in N.J.A.C. 10:161B-11.8 and comply with DMHAS Annex A contracts provided to Opioid Treatment Providers upon approval as providers. If a replacement copy of the annex is needed, one can be obtained by sending a request to:

Division of Mental Health and Addiction Services

222 South Warren St.

PO Box 700

Trenton, NJ 08625-0700

N.J. Admin. Code § 10:66-2.3

Amended by 49 N.J.R. 1405(a), effective 6/5/2017