Section 1115 Waiver Update e-Memo

Alaska Department of Health sent this bulletin at 05/17/2019 02:46 PM AKDT

Good afternoon,

 

As most of you know, the Division of Behavioral Health has received Centers for Medicare & Medicaid Services (CMS) approval of the substance use component of the 1115 Behavioral Health Demonstration application.  CMS’s approval of the 1115(a) substance use component demonstration marks the beginning of the behavioral health systems redesign for the State of Alaska.  Implementation of a statewide systems redesign will begin July 1, 2019 for all providers in Phase I regions, and those preapproved additional providers in other regions. 

 

The 1115 serves as the vehicle to redesign, build and expand the treatment infrastructure necessary to improve the outcomes of Alaskans suffering from serious mental illness, severe emotional disturbance, substance use disorder and/or co-occurring substance use and mental illness.  Under the demonstration, new approved Medicaid covered services for substance use disorder treatment have been established to address the complex behavioral health needs of Alaskans suffering from addiction.  The use of applicable 1115 service codes will be required for all providers facilitating substance use disorder treatment as they phase in, and some services will be removed from coverable services as phase in rolls out. 

 

Proposed Services as identified in, Center for Medicare & Medicaid Special Terms and Conditions & Alaska 1115 Substance Use Disorder Waiver Implementation Plan:

 

    • Residential Treatment for Individuals with Substance Use Disorder (SUD)

    Treatment services delivered to residents of an institutional care setting, including facilities that meet the definition of an institution for mental diseases (IMD), are provided to Alaska Medicaid recipients with a SUD diagnosis when determined to be medically necessary and in accordance with an individualized service plan.  i. Residential treatment services are provided in an Alaska Department of Health and Social Services (DHSS) licensed facility that has been enrolled as a Medicaid provider and assessed/designated/certified by DHSS as delivering care consistent with ASAM or other nationally recognized, SUD-specific program standards for residential treatment facilities.  ii. Residential treatment services can be provided in settings of any size.  iii. Room and board costs are not considered allowable costs for residential treatment service providers unless they qualify as inpatient facilities under section 1905(a) of the Act.

      • Component services include: i. Clinically-directed therapeutic treatment to facilitate recovery skills, relapse prevention, and emotional coping strategies ii. Addiction pharmacotherapy and drug screening iii. Motivational enhancement and engagement strategies iv. Counseling and clinical monitoring v. Withdrawal management and related treatment designed to alleviate acute emotional, behavioral, cognitive, or biomedical distress resulting from, or occurring with, an individual’s use of alcohol and other drugs vi. Regular monitoring of the individual's medication adherence vii. Counseling services involving the beneficiary’s family and significant others to advance the beneficiary’s treatment goals, when (1) the counseling with the family member and significant others is for the direct benefit of the beneficiary, (2) the counseling is not aimed at addressing treatment needs of the beneficiary’s family or significant others, and (3) the beneficiary is present except when it is clinically appropriate for the beneficiary to be absent in order to advance the beneficiary’s treatment goals; and vii. Education on benefits of medication assisted treatment and referral to treatment as necessary

     

    • Opioid Treatment Services (OTS) for Persons Experiencing an Opioid Use Disorder (OUD)

    Physician-supervised daily or several times weekly opioid agonist, partial agonist and antagonist medication and counseling services including SUD care coordination services as appropriate provided in either an Opioid Treatment Program (OTP) or Office-Based Opioid Setting (OBOT) provided to maintain multidimensional stability for those with severe opioid use disorder in accordance with an individualized treatment plan determined by a licensed physician or licensed prescriber and approved and authorized according to state requirements.

     

    • Intensive Outpatient Services

    Intensive outpatient includes structured programming services provided to beneficiaries (a minimum of nine hours with a maximum of 19 hours a week for adults, and a minimum of six hours with a maximum of 19 hours a week for adolescents) when determined to be medically necessary and in accordance with an individualized treatment plan. Treatment is focused on major lifestyle, attitudinal, and behavior issues which impair the individual’s ability to cope with major life tasks without use of substances. 

      • Component Services include: i. Individualized, person-centered assessment and clinically-directed treatment. ii. Cognitive, behavioral, and other substance use disorder-focused therapies, reflecting a variety of treatment approaches, provided to the individual on an individual, group, and/ or family basis iii. Appropriate drug screening iv. Psychoeducation Services v. Medication Services vi. Crisis Intervention Services 

     

    • Partial Hospitalization Services (PHP)

    PHP services will be specifically designed for the diagnosis or active treatment of a SUD when there is a reasonable expectation for improvement or when it is necessary to maintain the person’s functional level and prevent relapse or inpatient hospitalization. Services within the PHP are more clinically intense than IOP and, in addition to addressing major lifestyle, attitudinal, & behavior issues which impair the individual’s ability to cope with major life tasks without the addictive use of alcohol and/or other drugs, have the capacity to treat individuals with substantial medical and psychiatric problems.

      • Component Services include: i. Individualized, person-centered assessment and clinically-directed treatment ii. Cognitive, behavioral, and other substance use disorder-focused therapies, reflecting a variety of treatment approaches, provided to the individual on an individual, group, and/ or family basis iii. Appropriate drug screening iv. Psychoeducation Services v. Medication Services vi. Crisis Intervention Services vii. viii. Occupational and recreational therapy services as appropriate

     

    • Medically Monitored Intensive Inpatient Services

    These are services provided during a 24-hour professionally directed evaluation, observation, medical monitoring, and addiction treatment in an inpatient setting (hospital-based).   

      • Component Services include: i. Individualized, person-centered assessment and medically directed & managed treatment ii. Addiction pharmacotherapy and medication services iii. Appropriate drug screening iv. Cognitive behavioral and other substance-use disorder-focused therapies, reflecting a variety of treatment approaches, provided to the individual on an individual, group, or family basis v. Daily medical and nursing services vi. Counseling and clinical/medical monitoring vii. Daily treatment services focused on managing the individual’s acute symptoms viii. Psychoeducation services 

     

    • Ambulatory Withdrawal Management Services.  These are outpatient services that may be delivered in an office setting, a health care facility, an addiction treatment facility, or a patient’s home for individuals at mild withdrawal risk and with a high commitment to withdrawal management process. Services delivered by physicians and nurses require training in managing intoxication and withdrawal states and clinical staff knowledgeable about the biopsychosocial dimensions of SUDs. Physicians are available via telephone or in- person for consultation; physician and emergency services consultation are available 24/7.
      • Component Services include: i. Individualized, person-centered Assessment ii. Physician and/or Nurse Monitoring iii. Management of Signs & Symptoms of Intoxication & Withdrawal iv. Medication Services v. Psychoeducation Services vi. Non-Pharmacological Clinical Support Services vii. Referral for Counseling Services

     

    • Clinically Managed Residential Withdrawal Management

    These are services provided in a residential treatment setting that include supervision, observation, and support for individuals who are intoxicated or experiencing withdrawal and require 24-hour structure and support but do not require the medical and nursing care specified for medically monitored/managed inpatient withdrawal management services. 

      • Component Services include: i. Individualized, person-centered Assessment ii. Physician and/or Nurse Monitoring iii. Management of Signs & Symptoms of Intoxication & Withdrawal Medication Services iv. Patient Education Services v. Non-Pharmacological Clinical Support Services vi. Referral for Counseling Services

     

    • Medically Monitored Inpatient Withdrawal Management Services

    Services will consist of severe withdrawal and needs 24-hour nursing care and physician visits as necessary. This service is necessary because the patient is unlikely to complete withdrawal management without medical and nursing monitoring.

      • Component Services include: i. Individualized, person-centered assessment and medically monitored treatment ii. Addiction pharmacotherapy and medication services iii. Appropriate drug screening iv. Cognitive behavioral and other substance-use disorder-focused therapies, reflecting a variety of treatment approaches, provided to the individual on an individual, group, or family basis v. Daily medical and nursing services and monitoring vi. Management of signs and symptoms of intoxication and withdrawal vii. Counseling and clinical/medical monitoring viii. Daily treatment services focused on managing the individual’s acute symptoms ix. Psychoeducation services

     

    • Medically Managed Intensive Inpatient Withdrawal Management Services

    Services are for severe, unstable withdrawal needs. This can include 24-hour nursing care and daily physician visits to modify withdrawal management regimen and manage medical instability.

      • Component Services include: i. Individualized, person-centered assessment and medically directed & managed treatment. ii. Addiction pharmacotherapy and medication services.  iii. Appropriate drug screening. iv. Cognitive behavioral and other substance-use disorder-focused therapies, reflecting a variety of treatment approaches, provided to the individual on an individual, group, or family basis. v. Daily medical and nursing services. vi. Management of signs and symptoms of intoxication and withdrawal. vii. Counseling and clinical/medical monitoring. viii. Daily treatment services focused on managing the individual’s acute symptoms ix. Patient Education services

     

  • Community Recovery Support Services


    These are services designed to help people overcome personal and environmental obstacles to recovery, assist the newly recovering person into the recovery community, and serve as a personal guide and mentor toward the achievements of goals.  Services are provided as counseling and wraparound support to prevent relapse and to promote recovery.

    Proposed Service Codes:

    • H2021 V1-Community Recovery Support Services
    • H0015 V1-Intensive Outpatient Program ASAM 2.1
    • H0035V1-SUD Partial Hospitalization ASAM 2.5
    • H0014 V1-Ambulatory Withdrawal Management w/ Extended On-Site Monitoring ASAM 2-WM
    • H0010 V1 -Clinically Managed Residential Withdrawal Management
    • H0010 V1-Medically Monitored Inpatient Withdrawal Management
    • H0011 V1-Medically Managed Intensive Inpatient Withdrawal Management ASAM 4-WM
    • H009 V1-Medically Managed  Intensive Inpatient Services
    • H009 V1-Medically Monitored  Intensive Inpatient Services
    • H0047 V1-SUD Care Coordination
    • T1007 V1-Treatment Plan Development / Revision
    • H0023 V1-Intensive Case Management

In line with CMS requirements providers facilitating substance use disorder services on or after July 1, 2019 will be required to utilize service codes initiated under the 1115.  Explicitly, Alaska specific screening tool; Client Status Review; Comprehensive Community Support Services; Recipient Support; and Behavioral Rehabilitation Services will be replaced by the proposed codes noted above.  This change represents a significant first step in a statewide systems redesign and as such we understand many providers are excited about the option to participate as an early adopter.  However, please know there is no opt-out option.  If a provider elects to phase in outside of their region they may not later request to opt out.  The use of applicable 1115 service codes will be required for all providers, grantees and non-grantees, facilitating substance use disorder treatment as they phase in. 

Please take this opportunity review the services and proposed codes with all relevant staff.

Please email any questions to: HSS DBH MPASS Unit mpassunit@alaska.gov

Additional information about the 1115 Behavioral Health Medicaid Waiver is available
at: http://dhss.alaska.gov/HealthyAlaska/Pages/PublicComment/1115waiverComment.aspx

Thank you,

Farina Brown

Deputy Director, Division of Behavioral Health
Alaska Department of Health and Social Services