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The 191st General Court of the Commonwealth of Massachusetts

Section 4II: Coverage for medically necessary acute treatment or clinical stabilization services

Section 4II. 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.

Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary acute treatment services and medically necessary clinical stabilization services for up to a total of 14 days and shall not require preauthorization prior to obtaining acute treatment services or clinical stabilization services; provided that the facility shall provide the carrier both notification of admission and the initial treatment plan within 48 hours of admission; provided further, that utilization review procedures may be initiated on day 7; provided further, any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for, without preauthorization, a substance abuse evaluation ordered pursuant to section 511/2 of chapter 111.

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