Budget Amendment ID: FY2016-S3-782

EHS 782

Chapter 258 Technical Correction

Ms. Flanagan moved that the proposed new text be amended SECTION 40. Chapter 118E of the General Laws is hereby amended by striking out section 10H, as inserted by section 19 of chapter 258 of the acts of 2014, and inserting in place thereof the following 3 sections:- Section 10I. For the purposes of this section the term “substance abuse treatment” shall 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, not covered under section 10J; and medically managed intensive inpatient services, not covered under said section 10J.

Any coverage offered by the division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall not require a member to obtain a preauthorization for substance abuse treatment if the provider is certified or licensed by the department of public health.

Section 10J. For the purposes of this section, the following terms shall, unless the context clearly requires otherwise, 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.

The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall cover the cost of medically-necessary acute treatment services and shall not require a preauthorization prior to obtaining treatment.

The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall cover the cost of medically-necessary clinical stabilization services for up to 14 days and shall not require preauthorization prior to obtaining clinical stabilization services; provided, however, that the facility shall provide to the carrier both notification of admission and the initial treatment plan within 48 hours of admission; and provided further, that utilization review procedures may be initiated on day 7.

Medical necessity shall be determined by the treating clinician, in consultation with the patient, and noted in the patient’s medical record.

Section 10K. The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall provide coverage for the administration of all Food and Drug Administration approved drugs for the treatment of opioid or alcohol dependence and shall establish billing codes and rates of payment for providers of licensed clinical stabilization services to administer such approved drugs to individuals in need of treatment.

For the purposes of this section, “clinical stabilization services” shall mean: 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.