In alignment with the milestones of the Demonstration, SUD treatment services provided in the Medicaid fee-for-service (FFS) delivery system will comply with the current ASAM Criteria for activities including authorizations, utilization review decisions, multi-dimensional assessments and individualized treatment plans.
The below Policy and Clinical Assumptions Grids outlines the expectations for Medicaid treatment providers in areas including admissions, interventions and treatment services, documentation, staffing and supervision.
- Residential Levels of Care for Adults (ASAM 3.1, 3.3, 3.5, 3.5PPW, 3.7, 3.7RE, 3.2WM, 3.7WM) - Updated 05/2023
- Residential Levels of Care for Adolescents (ASAM 3.5 and 3.1) - Updated 05/2023
- Residential Admission Guidance - Updated 04/2023
- Residential Flex Bed Guidance - Updated 04/2023
- Intensive Outpatient (IOP) and Partial Hospitalization (PHP) for Adults and Children (ASAM 2.1 and 2.5) - Updated 06/2023
- Ambulatory Withdrawal Management (ASAM 1-WM and 2-WM) - Updated 11/2022
- Outpatient SUD Assumptions Grid OTP - Updated 09/2023
Rates have been developed to support providers in meeting the expectations outlined in the Policy and Clinical Assumptions Grids and to meet the goals and milestones of this Demonstration.
As part of the fee-for-service rate development process for residential and ambulatory SUD treatment providers, Mercer Health & Benefits LLC presented an overview of the rate setting process including reimbursement principles, fee assumptions and development of the treatment rates and, where applicable, the room and board rates. This presentation occurred with residential providers on June 10, 2021 and with ambulatory providers on June 24, 2022. Both presentations afforded continued opportunity for feedback from the provider network.
- SUD Residential Fee-For-Service Development Overview
- Residential Staffing Example
- SUD Ambulatory Fee-For-Service Development Overview
Provider Bulletins: The Department of Social Services has issued the following guidance related to the Demonstration. Provider bulletins can also be found on the ctdssmap.com webpage.
- PB 2022-21 - Implementation of Medicaid Reimbursement for SUD Inpatient Treatment at State Operated and Private Psychiatric Hospitals Pursuant to Section 1115 Demonstration Waiver for Services Previously Excluded from Coverage by Federal Law.
- PB 2022-39 - Implementation of Medicaid and Children’s Health Insurance Program (CHIP) Reimbursement for SUD Treatment at Free-Standing Residential Treatment Facilities.
- PB 2022-86 - Reimbursement for Intermediate Substance Use Disorder (SUD) Treatment at Behavioral Health Clinics, Enhanced Care Clinics and Outpatient Drug and Alcohol Abuse.
- PB 2022-91 - Ambulatory Withdrawal Management Billing Guidelines.
- PB 2023-01 - Billing Clarification for Intermediate Substance Use Disorder (SUD) Treatment at Behavioral Health Clinics, Enhanced Care Clinics and Outpatient Drug and Alcohol Abuse.
- PB 2023-09 - Reimbursement for Intermediate Substance Use Disorder (SUD) Treatment at Outpatient Hospitals.
- PB 2023-51 - Clinical Treatment Hours for SUD IOP and PHP Programs.
State Plan Amendments (SPAs): The following approved State Plan Amendments (SPAs) have impact to or are related to the work under the Demonstration.
- SPA 22-0020 - This SPA establishes coverage and reimbursement for substance use disorder services provided in outpatient and residential settings within the rehabilitative services benefit category. For applicable levels of care, this SPA implements and is consistent with the state's approved SUD Section 1115 Demonstration waiver.
- SPA 22-0021 - This SPA updates the Alternative Benefit Plan (ABP) to implement to add coverage for substance use disorder services under the rehabilitative services benefit category for services provided in outpatient and residential settings.
- Residential Certification Scoring and Milestone Guide
- Residential Monitoring Thresholds
- Provisional Certification Guidance for NEW Residential Programs
- Ambulatory Certification Scoring and Milestone Guide
- Ambulatory Provisional Certification Thresholds
Frequently Asked Questions (FAQs) and Answers: The State has compiled questions received throughout the planning of the 1115 Demonstration Waiver along with responses that we hope assist you as we transition into implementation.
- Residential FAQs - Updated 11/2023
- Residential Flex Bed FAQs - Updated 04/2023
- Ambulatory FAQs - Updated 11/2023
- Addendum to Provider Enrollment Agreement for Psychiatric Hospitals providing inpatient SUD Services
- Acknowledgement of Deadline for Full Compliance with ASAM Guidelines for Psychiatric Hospitals providing inpatient SUD Services
- Instructions for Submission of the Acknowledgement and Addendum for Psychiatric Hospitals providing inpatient SUD Services
- Acknowledgement of Deadline for Full ASAM Certification for SUD Ambulatory and Residential Providers
- Addendum to Provider Enrollment Agreement for SUD Ambulatory and Residential Providers
- Certification and Document Upload Guide