February 2025
In late 2023, the American Society of Addiction Medicine (ASAM) released the Fourth Edition, Volume 1 – Adults, the first of four planned volumes with subsequent population specific volumes targeted for release between 2026 and 2028.[1]
The ASAM Criteria are an integral part of current Ohio Department of Mental Health and Addiction Services (OhioMHAS) certification standards and Ohio Medicaid coverage and reimbursement policies. The criteria are also key components in Ohio’s implementation of its Medicaid Section 1115 Substance Use Disorder (SUD) demonstration, and specifically, Milestone 3: Use of nationally recognized, evidence-based SUD program standards to set residential treatment provider qualifications. Since the release of the Fourth Edition, the Ohio Department of Medicaid (ODM or the Department), in partnership OhioMHAS, has been engaged in a careful review of the new criteria to assess gaps and opportunities resulting from the publication of the Fourth Edition. The approach to reviewing the ASAM Criteria Fourth Edition, Volume 1 – Adults is following a uniform process for each level of care to: summarize the changes from the Third Edition; prepare a high-level overview and change description; and develop a gap analysis using ASAM Service Characteristic Categories as the framework.
As the review progresses, ODM is proposing a multi-pronged approach to gathering input on potential policy gaps and alignment opportunities as part of developing its plan to move towards The Fourth Edition. The proposed approach was initially shared with the SUD 1115 Stakeholder Advisory Committee at its June 18, 2024[2] meeting and seeks to gather input as follows:
- Cross department engagement in the initial planning and framework development, with plans to expand staff engagement as the framework takes shape.
- Engage Stakeholder Advisory Committee through presentations to the entire Committee and consider a focused workgroup approach similar to what was used with the new residential treatment provider criteria rule to gather feedback.
- Engage Health Plans in listening session forums to gather feedback.
The Department anticipates that the process to develop and gather feedback on the framework, potential policy gaps and alignment opportunities on Volume 1 – Adults will take place over the next six to nine months. Once additional volumes are released, the Department may revisit the gap analysis framework as it assesses upcoming volumes against current policies and procedures.
While the Department is undertaking this careful review, providers and managed care entities are not required to adopt or operate under The ASAM Criteria Fourth Edition. This means that the Third Edition will continue to be used in all Ohio Medicaid coverage and reimbursement policies, including but not limited to utilization management, level of care and treatment planning decisions until the Department formally adopts the Fourth Edition Criteria. OhioMHAS has several rules that reference the ASAM Criteria, sometimes generically and sometimes by edition, and these rules will need updated and aligned prior to OhioMHAS certified community mental health services or addiction services providers adopting The ASAM Criteria Fourth Edition – all volumes. Please direct inquiries about OhioMHAS rules to LicCert@mha.ohio.gov.
To assist our provider and managed care entity partners with navigating the interim period prior to adoption of The Fourth Edition Criteria, the Department has prepared the following Frequently Asked Questions to provide answers to questions that may arise during this time.
Additional Information
Additional information about Ohio Department of Medicaid behavioral health services may be accessed through the webpage, bh.medicaid.ohio.gov.
Questions
Questions pertaining to this guidance may be directed to the Ohio Department of Medicaid at: BHPolicy@medicaid.ohio.gov
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What is the process being used to review The ASAM Criteria Fourth Edition, Volume 1 - Adults?
The approach to reviewing the ASAM Criteria Fourth Edition, Volume 1 – Adults is following a uniform process for each level of care to: summarize the changes from the Third Edition; prepare a high-level overview and change description; and develop a gap analysis using ASAM Service Characteristic Categories as the framework. As the review progresses, ODM is proposing a multi-pronged approach to gathering input on potential policy gaps and alignment opportunities as part of developing its plan to move towards The Fourth Edition. The proposed approach was initially shared with the SUD 1115 Stakeholder Advisory Committee at its June 18, 2024 meeting and is available at this link: 6.18.24_SUD_1115_Waiver_Stakeholder_Advisory_Committee_Meeting_1.pdf (ohio.gov)
2. How long does ODM anticipate the review process will take?
The Department anticipates that the process to develop and gather feedback on the framework, potential policy gaps and alignment opportunities on Volume 1 – Adults will take place over the next six to nine months. Once additional volumes are released, the Department may revisit the gap analysis framework as it assesses the three remaining volumes of the Fourth Edition against current policies and procedures.
3. Does ODM have a date in mind for adopting the Fourth Edition Criteria into Ohio Medicaid coverage and reimbursement policies?
Given the extent of the changes included in the Fourth Edition, Volume 1 – Adults, the Department will not establish a timeline for implementation until it has completed the review and stakeholder engagement processes.
4. What criteria will the managed care entities use when rendering a decision on a prior authorization request?
Medicaid managed care entities will use the Third Edition Criteria when rendering a decision on a prior authorization request for SUD services until ODM formally adopts use of the Fourth Edition Criteria, Volume 1 – Adults. If a provider chooses to move towards the adoption of the Fourth Edition criteria prior to the State’s adoption, the provider must ensure that a request for PA meets the Third Edition criteria.
5. Can a provider choose to move towards The Fourth Edition Criteria, Volume 1 – Adults before it is required?
Providers should be familiarizing themselves and their staff with The ASAM Criteria, Fourth Edition – Adults, including attending or participating in applicable trainings. Currently, OhioMHAS rules reference the ASAM Criteria in multiple places; the discharge summary rule (OAC 5122-27-05), the addiction treatment level of care rule (OAC 5122-27-07), the residential and withdrawal management rule (OAC 5122-29-09), and the general licensure requirements for opioid treatment programs rule (OAC 5122-40-04). The first two rules generically refer to the ASAM criteria while the last two rules refer specifically to the 3rd Edition. OhioMHAS is recommending OhioMHAS certified addiction treatment and mental health services providers as well as licensed opioid treatment programs continue to use the 3rd Edition of ASAM until all OhioMHAS rules and regulations are updated. Please direct additional inquiries about OhioMHAS rules to LicCert@mha.ohio.gov.
If a provider chooses to move towards The Fourth Edition Criteria, Volume 1 - Adults before required to do so by the Department, the provider is still responsible to maintain compliance with all current OhioMHAS rules.
6. What does it mean for providers that currently offer an ASAM 3.2-WM, 3.7-WM or 3.3 level of care? How much time will be allotted for providers to make changes in order to meet the Fourth Edition Criteria, Volume 1 – Adults levels of care?
Providers currently offering ASAM levels of care 3.2-WM, 3.7-WM or 3.3 may continue to provide services in accordance with current Ohio Medicaid coverage and reimbursement policies and OhioMHAS certification standards until the Department adopts the Fourth Edition, Volume 1 – Adults. However, providers operating units at the Third Edition levels of care are encouraged to begin exploring transition to the Fourth Edition, Volume 1 – Adults while the gap analysis framework and stakeholder feedback processes are underway. A transition timeline has not yet been established by the Department.
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