TO: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc. and Health Maintenance Organizations
FROM: Daniel R. Judson, Commissioner, Division of Insurance
Monica Bharel, Commissioner, Department of Public Health
Joan Mikula, Commissioner, Department of Mental Health
DATE: July 31, 2015
RE: Access to Services to Treat Substance Use Disorders
The purpose of this Bulletin is to provide guidance regarding access to treatment for substance use disorders on and after October 1, 2015, as required by Chapter 258 of the Acts of 2014 (Chapter 258), which supplements the requirements of Chapter 80 of the Acts of 2000 and Chapter 256 of the Acts of 2008. Please refer to Division of Insurance (DOI) Bulletins 2000-10, 2002-07, 2003-11, 2009-04 and 2009-11 for additional guidance associated with coverage for and access to such services.
For the purposes of this bulletin the following terms shall have the following meanings:-
“Acute treatment services”, 24-hour medically supervised addiction treatment for adults or adolescents provided in a medically managed or medically monitored inpatient facility, as defined by the department of public health, that provides evaluation and withdrawal management and which may include biopsychosocial assessment, individual and group counseling, psychoeducational groups and discharge planning.
“Clinical stabilization services”, 24-hour clinically managed post detoxification treatment for adults or adolescents, as defined by the department of public health, usually following acute treatment services for substance abuse, which may include intensive education and counseling regarding the nature of addiction and its consequences, relapse prevention, outreach to families and significant others and aftercare planning, for individuals beginning to engage in recovery from addiction.
Access to Acute Treatment Services and Clinical Stabilization Services
Chapter 258 requires insured health plans offered under M.G.L. chapters 175, 176A, 176B, and 176G (hereinafter referred to as an insured health plan) that are issued, delivered or renewed within the commonwealth and considered creditable coverage under section 1 of chapter 111M to provide coverage for medically necessary acute treatment services and medically necessary clinical stabilization services for at least 14 consecutive days. Medical necessity is to be determined by the treating clinician in consultation with the patient.
Insured health plans shall cover and shall not require preauthorization for the 14-day period of medically necessary acute treatment and clinical stabilization services (American Society of Addiction Medicine Levels 4, 3.7 and 3.5) for an insured obtaining acute treatment services or clinical stabilization services; as long as the facility providing the noted services provides the carrier with appropriate notification of the admission within 48 hours of admission. Carriers shall not require that any facility provide notification beyond the name of the patient, information regarding the patient’s coverage with the carrier’s plan and the initial treatment plan that has been developed for the patient.
Carriers may initiate utilization review procedures on the 7th day of a patient’s stay for acute treatment services or the 7th day of a patient’s stay for clinical stabilization services, including but not limited to discussions about coordination of care and discussions of treatment plans, but a carrier may not make any utilization review decisions that impose any restriction or deny any future medically necessary acute treatment or clinical stabilization services unless a patient has received at least 14 consecutive days of acute treatment and/or clinical stabilization services. Any such decisions must follow the requirements of M.G.L. c. 176O regarding the transmission of adverse determination notifications to patients and clinicians and processes for internal and external appeals of carrier decisions.
For plans that provide or arrange for the delivery of care through a closed network of health care providers, acute treatment service and clinical stabilization services delivered by providers who are not part of an insured health plan’s closed network of providers are subject to prior authorization procedures unless the health plan’s provider network is found to be inadequate to provide access to acute treatment or clinical stabilization services for plan members.
Preauthorization Protocols for All Other Substance Use Disorder Services
Insured health plans issued, delivered or renewed within the Commonwealth, which are considered creditable coverage under section 1 of chapter 111M, shall not require a member or treating clinician to obtain a preauthorization for covered substance use disorder treatment services if the provider is certified or licensed by the Department of Public Health (DPH). Substance use disorder treatment services include early intervention services for substance use disorder treatment, outpatient services, including medically assisted therapies, intensive outpatient and partial hospitalization services, residential or inpatient services, and medically intensive inpatient services. The term provider includes facilities as well as individual practitioners certified or licensed by the DPH.
If a service is not covered by an insured health plan, a carrier should take all appropriate steps to notify relevant contracting providers and identify that a substance use disorder service is not covered within the insured health plan’s benefits.
Levels of Service
As stated above, carriers are not permitted to require preauthorization for the following types of services provided to a person with a substance use disorder when the service is covered by the insured health plan and delivered by a provider that is licensed or certified by the DPH: early intervention services for substance use disorder treatment, outpatient services, including medically assisted therapies; intensive outpatient and partial hospitalization services, residential or inpatient services, and medically managed intensive inpatient services. The following descriptions of various levels of service are provided to aid carriers in determining appropriate preauthorization protocols. This list provides guidance but is not intended to be an exhaustive list of all types of services for the treatment of substance use disorder for which carriers are prohibited from utilizing preauthorization as a method of managing utilization.
Early intervention services: American Society of Addiction Medicine (ASAM) level of care level 0.5 - services provided to a person in a variety of settings designed to identify and address problems or risk factors that appear to be related to substance use and addictive behavior. Examples of early intervention services include screening, brief intervention and referral to treatment (SBIRT), first offender driver alcohol education, and programs licensed under 105 CMR 164.200 or 105 CMR 164.211.
Outpatient services: Services provided in person to an individual with a substance use disorder in an ambulatory care setting. Outpatient services may be provided in a licensed hospital, a mental health clinic or substance abuse program licensed by the DPH, a public community mental health center, a professional office or a home-based setting. Such services are rendered by a licensed behavioral health professional acting within the scope of his or her license. Outpatient services, include, but are not limited to, the following:
Counseling: ASAM level of care level 1 - individual, group, and family treatment, which may include medication management, for persons with substance use disorders provided in an ambulatory setting. An example of counseling services includes programs licensed under 105 CMR 164.200, 105 CMR 164.221, or 105 CMR 140.801.
Day treatment: ASAM level of care level 2.1 - services based on a planned combination of diagnostic, treatment and rehabilitative approaches to a person with a substance use disorder who needs more active or intensive treatment. Day treatment programs generally require an individual to attend treatment during some portion of a day or week rather than a weekly visit. Examples of day treatment include structured outpatient addiction programs (SOAP) and programs licensed under 105 CMR 164.200 or 105 CMR 164.231.
Intensive Outpatient Programs (IOP): ASAM level of care level 2.1- multimodal, inter-disciplinary, structured behavioral health treatment provided over the course of two to three hours per day for multiple days per week in an outpatient setting. Treatment may include, but is not limited to, diagnosis, evaluation and treatment of mental health and substance use disorders. An IOP may operate in programs licensed under 105 CMR 164.200
Medically assisted therapies: ASAM level of care level 1- outpatient services provided in a variety of settings that utilize pharmacological interventions often in combination with nonpharmacological treatment services to decrease craving and relapse in order to assist persons with substance use disorders to attain and maintain abstinence from alcohol and illicit drug use. Pharmacological agents include, but are not limited to, opioid agonist medications such as methadone and buprenorphine and antagonist medications such as naltrexone. Examples of medically assisted therapy programs include Methadone treatment programs, office based opioid treatment programs, and programs licensed under 105 CMR 164.200 or 105 CMR 164.300.
Partial hospitalization: ASAM level of care level 2.5- short-term day or evening mental health programming available five to seven days per week. These services consist of therapeutically intensive acute treatment within a therapeutic milieu and include daily medication management.
Youth in-home therapy services: ASAM level of care level 1- an intensive combination of diagnostic and treatment interventions delivered in the home and community to a youth and family designed to sustain the youth in his or her home and to prevent the youth’s admission to an inpatient hospital, psychiatric residential treatment facility, or other psychiatric treatment setting. Examples of in-home therapy services include family stabilization (FST), adolescent community reinforcement approach and assertive continuing care (ACRA-ACC), and programs licensed under 105 CMR 164.200.
Residential Services: ASAM level of care level 3.1 and level 3.3- services provided to an individual with a substance use disorder in a 24-hour setting, with clinical staff and appropriately trained professional and paraprofessional staff to ensure safety for the individual, while providing active treatment and reassessment. Examples of this service include but are not limited to transitional support programs, residential rehabilitation programs commonly referred to as “recovery homes”, and programs licensed under 105 CMR 164.400, 105 CMR 164.421, 105 CMR 164.431, 105 CMR 164.450, or 105 CMR 164.441.
Inpatient Services: 24-hour services, delivered in a licensed general hospital, a psychiatric hospital or a substance use disorder facility, that provide evaluation and treatment for a substance use disorder diagnosis. Inpatient services, include, but are not limited to, the following:
Clinically managed detoxification services: ASAM level of care level 3.5, 24-hour stabilization services provided in a non-medical setting that include 24 hour per day supervision, observation and support, including at least 4 hours of nursing services each day, 7 days per week. Examples of this service include clinical stabilization services (CSS) and youth stabilization licensed under 105 CMR 164. 133(A)(1)(c).
Medically managed intensive inpatient detoxification services: ASAM level of care level 4 -24-hour withdrawal management services provided in a hospital setting that include daily medical management and primary nursing interventions. Examples of this service include acute treatment services referred to as hospital level inpatient detoxification, licensed under 105 CMR 164. 133(A)(1)(a).
Medically monitored intensive inpatient detoxification services: ASAM level of care level 3.7 - 24-hour withdrawal management services provided in a medical setting that include 24-hour, 7-day per week nursing and medical supervision. Examples of this service include acute treatment services referred to as free standing inpatient detoxification and youth stabilization, licensed under 105 CMR 164. 133(A)(1)(b).
DPH will maintain a list of those providers who have been licensed or certified by DPH on its website. Carriers should take care to monitor the DPH website to be aware of all such registered or licensed providers and the restriction from imposing any prior authorization requirements on any of the above-noted services. For any services intended to apply for more than one day, the DOI would consider it appropriate for carriers to require notification within 48 hours of the first visit or admission for services. Although the statute permits utilization review other than prior authorization, the DOI would not consider it appropriate for any carrier to retroactively deny any substance use disorder services, as defined in the statute, unless appropriate notifications are not made within 48 hours of the initial substance use disorder service or admission which leads to the provision of the substance use disorder services.
For plans that provide or arrange for the delivery of care through a closed network of health care providers, the above-mentioned services provided by providers who are not part of an insured health plan’s closed network of providers are subject to prior authorization and other utilization review procedures unless the health plan’s provider network is found to be inadequate to provide access to the above-mentioned services for plan members.
Abuse Deterrent Drug Products
Chapter 258 requires that insured health plans issued, delivered or renewed within the commonwealth provide coverage for abuse deterrent opioid drug products as identified on a formulary specified by the Drug Formulary Commission on a basis not less favorable than non-abuse deterrent opioid drug products that are covered by the insured health plan. DOI will issue guidance in the future regarding the administration of this section after the Drug Formulary Commission completes its work toward the completion of the noted formulary.
If you have any questions regarding this bulletin, please contact Kevin Beagan at 617-521-7323 or Kevin.firstname.lastname@example.org.