Rehabilitative Services Policy

Substance Abuse Treatment Services

Introduction

Counseling Services
Counseling Services refers to those services provided to Medicaid (MA) recipients for the purpose of evaluation, treatment and rehabilitation of problems directly related to substance abuse. Counseling services may be provided in residential (halfway houses and therapeutic communities) and outpatient treatment settings and are reimbursable only when provided in accordance with a treatment plan approved by a program clinical director. Counseling services include individual and group therapy and necessary counseling provided to Medicaid  eligible family members and Medicaid eligible significant others as documented in the client’s plan of care.

Methadone Maintenance Services
Methadone Maintenance Services are provided for the purpose of treating MA recipients with opiate dependency. Methadone maintenance services will be provided in outpatient treatment settings and are reimbursable only when provided in accordance with a treatment plan approved by a program clinical director.

Residential Treatment Program
The Residential Treatment Program is a 24 hour supervised treatment program that is designed to provide the necessary support and address the substance abuse treatment needs of MA recipients with substance abuse problems. Covered services include detoxification, rehabilitation, mental health, childcare, and care coordination services when provided by qualified staff. Qualified staff must provide these services in accordance with a written plan of care. Such plans of care, or initial assessments of the need for services, must be recommended by a physician or other licensed practitioner of the healing arts.

Covered Services

Substance abuse treatment services are covered for both categorically and medically needy MA recipients.

The following table lists all covered services for Substance Abuse treatment and counseling. The table shows the procedure code, service description, if the service requires prior authorization (Y-yes or N-no).

Procedure CodeDescriptionPA

H2036Alcohol and/or other drug treatment program, per diemN

H0001Alcohol and/or drug assessment, 60-90 minutesN

H0004Substance abuse counseling and therapy; per 15 minutesN

H0005Alcohol and/or drug services; group counseling by a clinicianN

H0020Alcohol and/or drug services; methadone administration and/or service (1 unit per week)N

H0001 UDAlcohol and/or drug assessment; 60-90 minutes; residential settingN

H0004 UDSubstance abuse counseling and therapy per 15 minutes; residential settingN

H0005 UDAlcohol and/or drug services; group counseling by a clinician; residential settingN

Prior Authorizations

Prior authorization (PA) is required for the following services:

  • Outpatient and day treatment services in excess of the allowed 30 sessions per calendar year.
  • Intensive outpatient services in excess of the allowed 60 sessions per calendar year.
  • Short-term residential center services in excess of the allowed 60 sessions per calendar year.
  • Long term residential services in excess of the allowed 75 sessions per calendar year
  • All services provided to DCYF recipients require PA through DCYF.

Limitations

The following limitations apply to all providers providing substance abuse treatment services to MA recipients:

  • The primary diagnosis must be substance abuse
  • Outpatient and day treatment services cannot exceed 3 sessions per week, 1 session per day maximum.
  • Intensive outpatient and day treatment services provided in sessions lasting 2 or more hours cannot exceed 3 sessions per day, 3 or more days per week.
  • Short Term Residential services provided in a residential setting may not exceed 30 days of treatment, 3 sessions per day
  • Long Term Residential services provided in a residential setting for more than 30 days may not exceed 3 sessions per day.
  • Methadone Maintenance services are limited to 1 session per week.

Provider Participation

All services are limited to facilities licensed by and under contract with the Rhode Island Department of Health (RIDOH).

All participating providers must be in receipt of the annual continuation grant funds from the Rhode Island Department of Health (RIDOH).

Patient Liability

There is no recipient co-pay or patient liability for substance abuse treatment services.