Under the
HealthChoice Substance Abuse Initiative (SAII), HealthChoice enrollees
are able to self-refer to substance abuse treatment providers that are
not part of their Managed Care Organization (MCO) provider network.
Providers who do not have contracts with an individual’s MCO or
Behavioral Health Organization (BHO) may be reimbursed for services to
these individuals. The SAII, implemented January 1, 2001, expands
the limited option for self-referral for a comprehensive substance abuse
assessment. This document explains the SAII procedures, contains
links to the necessary SAII documents.
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Before the SAII: Comprehensive Substance Abuse Assessment.
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Since 1999,
HealthChoice enrollees could self-refer for a comprehensive
substance abuse assessment if the following conditions
are met:
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The
recipient is not in substance abuse treatment. |
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The
recipient has not received a self-referred comprehensive
substance abuse assessment that calendar year. |
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The
assessment provider is an ADAA-certified substance abuse
treatment provider who is qualified to conduct the assessment
using the required tools: |
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Addiction
Severity Index (ASI) for enrollees aged 20 or older
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Problem
Oriented Screening Instrument for Teenagers (POSIT) for
enrollees under age 20 |
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American
Society of Addictions Medicine Patient Placement Criteria for
the Treatment of Substance-Related Disorders to determine
appropriate level and intensity of care treatment.
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MCOs or their
BHOs will reimburse any ADAA-certified provider $50 for an
assessment which meets the conditions described above. The provider
does not have to be a Medicaid enrolled provider to bill the MCO for
this service.
While
HealthChoice enrollees are now able to self-refer for
treatment rather than just for assessment, the limitation of
one-self referral for assessment is still in force and providers
should be aware of its provisions.
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The main components of the SAII are: |
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Self-Referral according to a
protocol and other documents that explain responsibilities,
provides a reimbursement schedule, and lists contact numbers.
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Prompt Payment. |
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Expansion of Networks. |
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I. |
Self Referral Process: To Increase Access to Substance
Abuse Treatment and to Minimize Disagreements between Providers and
MCOs/BHOs |
Under
the SAII, HealthChoice enrollees may self-refer for substance abuse
treatment. The purpose of the Initiative is to increase access to
substance abuse treatment and to minimize disagreements between
treatment providers and Managed Care Organizations (MCOs) and Behavioral
Health Organizations (BHOs). Key features of the self-referral under
the SAII are:
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1.
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A
HealthChoice enrollee can self refer for substance abuse treatment
to any appropriate, willing substance abuse treatment provider.
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The
provider need not be part of the enrollee’s MCO/BHO network. |
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A provider is not required to accept
the enrollee as a patient or a client, but does have a
professional obligation to refer the individual to the appropriate
provider. |
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2. Agreed-upon reimbursement. |
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Substance abuse treatment providers, MCOs, BHOs, and State staff
developed a detailed SAII protocol that lays out the rules that
treatment providers, MCOs, and BHOs will follow. |
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The protocol includes preauthorized
units of service, the notification process for each treatment
modality, and other important information. When a HealthChoice
enrollee presents, the provider should identify the ASAM level
of care and follow the provisions for the appropriate treatment
modality. |
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Familiarity with the protocol, including the guidelines and
footnotes, is crucial.
Providers not following these procedures could be denied
authorization and/or payment. An MCO or BHO that does not
follow the procedures could be obligated to pay for services it
might not otherwise have authorized. |
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The
protocol for ICF-A Continued Care Authorizations is found in a
separate document.
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Providers, MCO/BHO, and
DHMH staff developed five forms to streamline communications between
providers and all MCO/BHOs. These forms satisfy the requirement
for a treatment plan for the Office of Health Care Quality. These
forms are on the HealthChoice web site. They are:
MCOs/BHOs will promptly
pay clean bills submitted by providers within 30 days. If they do not
pay providers within 30 days, MCOs/BHOs are penalized and have to pay
interest to the provider. Network providers will be reimbursed at the
rate specified by the contract. In the absence of a contract, that is,
for non-network providers, reimbursement consists of the Medicaid
fee-for-service rate.
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III. Expansion of
Networks |
As a result of the
Initiative, MCOs/BHOs are more willing to contract with appropriate
providers, which greatly enhances patient access. Appropriate providers
include DHMH certified addictions programs or independent practitioners
for whom substance abuse treatment is within the scope of their practice
according to the Health Occupations Act. See
Core
Elements in Contracting and Credentialing.
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HealthChoice Substance Abuse Workgroup |
The HealthChoice
Substance Abuse Workgroup meets every the second Thursday of the month
to resolve SAII issues and give MCOs, BHOs,
providers, and State representatives an opportunity to share information
on emerging issues. It meets from 1:00-3:00, generally at a
substance abuse treatment facility or an MCO office.
All are welcome. For information, contact
Mike Franch at
franchm@dhmh.state.md.us.
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