Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER SAT-15 June 2006 TO: Substance Abuse Treatment Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Substance Abuse Treatment Manual (Coverage of 24-Hour Post-Medical Detoxification Services for Members Aged 21 Years or Older) Due to a new state law, effective July 1, 2006, MassHealth will cover 24-hour post-medical detoxification services, defined as Level III-B and Level III-C by the Massachusetts Department of Public Health’s Bureau of Substance Abuse Services, for eligible members aged 21 years or older. This letter transmits an amendment to the substance abuse treatment regulations that reflects this change. All other conditions of 130 CMR 418.000 and 450.000 continue to apply. This letter also transmits a revised Subchapter 6 of the Substance Abuse Treatment Manual. The revisions reflect the additional coverage available for eligible members aged 21 years or older. These regulations were filed as emergency regulations, effective July 1, 2006. This transmittal letter, including the attached pages, and other publications issued by MassHealth are available on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Substance Abuse Treatment Manual Pages iv, vi, vii, 4-3, 4-4, 6-1, and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Substance Abuse Treatment Manual Page iv — transmitted by Transmittal Letter SAT-11 Pages vi, vii, 4-3, and 4-4 — transmitted by Transmittal Letter SAT-12 Pages 6-1 and 6-2 — transmitted by Transmittal Letter SAT-14 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Substance Abuse Treatment Manual Transmittal Letter SAT-15 Date 07/01/06 4. Program Regulations 418.401: Introduction 4-1 418.402: Definitions 4-1 418.403: Eligible Members 4-3 418.404: Provider Eligibility 4-4 418.405: Scope of Services 4-5 418.406: Service Limitations 4-6 418.407: InState Providers: Maximum Allowable Fees 4-7 418.408: OutofState Providers: Maximum Allowable Fees 4-7 418.409: Recordkeeping Requirements 4-8 418.410: Special Services for Pregnant Women: Scope of Services 4-8 418.411: Special Services for Pregnant Women: Service Limitations 4-10 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Substance Abuse Treatment Manual Transmittal Letter SAT-15 Date 07/01/06 6. Service Codes and Descriptions 6-1 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C1 Appendix E. Mental Health/Substance Abuse Program E-1 Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule W-1 Appendix X. Family Assistance Copayments and Deductibles X-1 Appendix Y. REVS Codes/Messages Y-1 Appendix Z. EPSDT Services Laboratory Codes Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Preface Page vii Substance Abuse Treatment Manual Transmittal Letter SAT-15 Date 07/01/06 The regulations and instructions governing provider participation in MassHealth are published in the Provider Manual Series. MassHealth publishes a separate manual for each provider type. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, administrative and billing instructions, and general information. MassHealth regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. MassHealth regulations are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For substance abuse treatment providers, those matters are covered in 130 CMR Chapter 418.000, reproduced as Subchapter 4 in the Substance Abuse Treatment Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("penandink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead MassHealth’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with MassHealth and its members. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 418.000) Page 4-3 Substance Abuse Treatment Manual Transmittal Letter SAT-15 Date 07/01/06 Nurse Practitioner — an individual licensed in accordance with M.G.L. c. 112, s. 80B, and knowledgeable in the field of substance addiction. Physician Assistant — an individual licensed in accordance with M.G.L. c. 112, s. 9G, and knowledgeable in the field of substance addiction. Pregnant Member — for purposes of these regulations, a MassHealth member qualifies for services as a pregnant member from the time her pregnancy is clinically verified until the end of the calendar month in which the 60-day postpartum period ends. Registered Nurse — an individual licensed by the Massachusetts Board of Registration in Nursing in accordance with M.G.L. c. 112, s. 74, and knowledgeable in the field of substance addiction. Substance Abuse Outpatient Counseling Service — an outpatient counseling service that is a rehabilitative treatment service for individuals and their families experiencing the dysfunctional effects of the use of substances. 418.403: Eligible Members (A) (1) MassHealth Members. The MassHealth agency pays for substance abuse treatment services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105 specifically states, for each MassHealth coverage type, which services are covered and which members are eligible to receive those services. (2) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106. (B) For information on verifying member eligibility and coverage type, see 130 CMR 450.107. (C) The MassHealth agency pays for special services for eligible pregnant members. Special services for pregnant members are subject to the requirements set forth in 130 CMR 450.124. (D) See 130 CMR 450.124 for limitations on mental health and substance abuse services provided to members enrolled with a MassHealth managed care provider. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 418.000) Page 4-4 Substance Abuse Treatment Manual Transmittal Letter SAT-15 Date 07/01/06 418.404: Provider Eligibility Payment for services described in 130 CMR 418.000 will be made only to providers of substance abuse treatment services who are participating in MassHealth on the date of service. The eligibility requirements for providers of substance abuse treatment services are as follows. (A) In State. The following requirements apply when the provider is located in Massachusetts. (1) Methadone Treatment Program. A provider who furnishes methadone detoxification and methadone maintenance services must be licensed as a methadone treatment program by the Massachusetts Department of Public Health under its regulations at 105 CMR 750.000. (2) Acute Inpatient Substance Abuse Treatment Services. A provider who furnishes acute inpatient substance abuse treatment services must be licensed or approved, or both, as a provider of acute inpatient substance abuse treatment services by the Massachusetts Department of Public Health pursuant to its regulations at 105 CMR 160.000 and 161.000. (3) Substance Abuse Outpatient Counseling Program. A provider who furnishes substance abuse outpatient counseling services must be licensed by the Massachusetts Department of Public Health to provide such services under its regulations at 105 CMR 162.000. These services include counseling services and acupuncture detoxification. (4) Special Services for Pregnant Members. A provider who furnishes intensive outpatient, day treatment, or case management services must be approved by the Massachusetts Department of Public Health to provide each of those services under its regulations at 105 CMR 162.000. A provider who furnishes enhanced acute inpatient substance abuse treatment services must be approved by the Massachusetts Department of Public Health to provide such services under its regulations at 105 CMR 160.000 and 161.000. (B) Out of State. To participate in MassHealth, an outofstate substance abuse treatment program must obtain a MassHealth provider number and meet the following criteria: Inpatient Services H0010 Alcohol and/or drug services sub-acute detoxification (residential addiction program inpatient) (Level III-B) H0010 52 Alcohol and/or drug services sub-acute detoxification (residential addiction program inpatient) (reduced services) (Level III-C) H0011 Alcohol and/or drug services acute detoxification (residential addiction program inpatient) (Level III-A) Methadone Services H0020 Alcohol and/or drug services methadone administration and/or service (provision of the drug by a licensed program) (dose only visit) H0020 TF Alcohol and/or drug services methadone administration and/or service (provision of the drug by a licensed program) (intermediate level of care) (per 30-minute unit, two units maximum per session) (individual counseling) H0020 HR Alcohol and/or drug services methadone administration and/or service (provision of the drug by a licensed program) (family/couple with client present) (per 30-minute unit, two units maximum per session) H0020 HQ Alcohol and/or drug services methadone administration and/or service (provision of the drug by a licensed program) (group setting) (per 45-minute unit, two units maximum per session required) Outpatient Services 90882 HF Environmental intervention for medical management purposes on a psychiatric patient’s behalf with agencies, employers, or institutions (substance abuse program) (case consultation) (per 30-minute unit two units maximum per session) 97810 HF Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient (substance abuse program) (I.C) (one unit maximum per session) 97811 HF each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (substance abuse program) (I.C.) (three units maximum per session) (to be used in conjunction with 97810) H0004 Behavioral health counseling and therapy, per 15 minutes (individual counseling) (four units maximum per session) H0005 Alcohol and/or drug services group counseling by a clinician (per 45-minute unit) (two units maximum) T1006 Alcohol and/or substance abuse services family/couple counseling (per 30-minute unit, two units maximum per session) Enhanced Inpatient Detoxification Services for Pregnant Members H0011 HD Alcohol and/or drug services acute detoxification (residential addiction program inpatient) (pregnant/parenting women’s program) (Level III-A) Intensive Outpatient Detoxification Services for Pregnant Members H0004 HD Behavioral health counseling and therapy, per 15 minutes (pregnant/parenting women’s program) (individual) (four units maximum per day) T1006 HD Alcohol and/or substance abuse services family/couple counseling (pregnant/parenting women’s program) (per 30-minute unit) (two units maximum per day) H0005 HD Alcohol and/or drug services group counseling by a clinician (pregnant/parenting women’s program) (per 45-minute unit) (two units maximum per day) H0006 HD Alcohol and/or drug services case management (pregnant/parenting women’s program) (per 15 minute unit) (four units maximum per day) Day Treatment Program for Pregnant Members H1005 Prenatal care, at-risk enhanced service package (includes H1001-H1004) (prenatal care, at-risk enhanced service antepartum management/care coordination/education/follow-up home visit) (individual counseling) (per one hour unit, one unit maximum per day) H1005 HQ Prenatal care, at-risk enhanced service package (includes H1001-H1004) (group setting) (prenatal care, at-risk enhanced service antepartum management/care coordination/education/follow-up home visit) (per four hour unit) (one unit maximum per day) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-1 Substance Abuse Treatment Manual Transmittal Letter SAT-15 Date 07/01/06 601 Service Codes and Descriptions Service Code Modifier Service Description Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Substance Abuse Treatment Manual Transmittal Letter SAT-15 Date 07/01/06 601 Service Codes and Descriptions (cont.) Service Code Modifier Service Description