Scope of Services

(A) The MassHealth agency pays only for services furnished by substance use disorder treatment programs, in accordance with 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs, as follows: (1) Opioid Treatment Programs. The MassHealth agency will pay for opioid treatment programs services rendered by medical, counseling, peer, and paraprofessional staff under the direction of the Medical Director and delivered in conformance with the following: (a) the administration and dispensing of FDA-approved medications for the treatment of opioid use disorders for the purposes of medically supervised withdrawal or maintenance treatment; (b) multidimensional biopsychosocial evaluation and treatment planning either performed by, or reviewed and signed off by, the clinical director or the clinical director’s independently licensed designee; (c) individual and group counseling by a clinician; (d) psychoeducation on the disease of addiction; (e) discharge planning and coordination of services; (f) for pregnant members, coordination with OB/GYN, pediatrics, and any other appropriate medical, social services providers, and state agencies; and (g) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (2) Medically Managed Inpatient Services (ASAM Level 4.0). The MassHealth agency will pay for medically managed inpatient services rendered by medical, counseling, peer, and paraprofessional staff under the direction of a physician and delivered in conformance with the following: (a) daily medical services, including medically managed withdrawal management (b) management of moderate to severe medical complexities; (c) induction onto maintenance treatment; (d) coordination with and/or referral to Medications for Addiction Treatment and Medications for Opioid Use Disorder providers; (e) multidimensional biopsychosocial evaluation and treatment planning either performed by, or reviewed and signed off by, the clinical director or the clinical director’s independently licensed designee; (f) treatment of mental health co-occurring disorders; (g) individual and group counseling; (h) psychoeducation on the disease of addiction, as clinically appropriate; (i) case management, discharge planning, and coordination of services; and (j) for pregnant members, coordination with OB/GYN, pediatrics, and any other appropriate medical, social services providers, and state agencies; and; (k) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (3) Acute Treatment Services – ASAM Level 3.7 Medically Managed Residential Treatment (ATS). The MassHealth agency will pay for acute treatment services rendered by medical, counseling, peer, and paraprofessional staff under the direction of the Medical Director, and delivered in conformance with the following: (a) medically managed withdrawal management; (b) management of mild to moderate medical complexities; (c) induction onto maintenance treatment; (d) coordination with and/or referral to Medications for Addiction Treatment and Medications for Opioid Use Disorder providers; (e) multidimensional biopsychosocial evaluation and treatment planning either performed by, or reviewed and signed off by, the clinical director or the clinical director’s independently licensed designee; (f) facilitate access to treatment of mental health co-occurring disorders either directly or through referral; (g) individual and group counseling; (h) psychoeducation on the disease of addiction; (i) case management; (j) discharge planning and coordination of services; (k) for pregnant members, coordination with OB/GYN, pediatrics, and any other appropriate medical, social services providers, and state agencies; and (l) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (4) Clinical Stabilization Services – ASAM Level 3.5 Clinically Managed High-Intensity Residential Services (CSS). The MassHealth agency will pay for clinical stabilization services rendered by medical, counseling, peer, and paraprofessional staff under the direction of the Medical Director and delivered in conformance with the following: (a) management of mild medical complexities; (b) coordination with and/or referral to Medications for Addiction Treatment and Medications for Opioid Use Disorder providers; (c) multidimensional biopsychosocial evaluation and treatment planning either performed by, or reviewed and signed off by, the clinical director or the clinical director’s independently licensed designee; (d) facilitate access to treatment of mental health co-occurring disorders either directly or through referral; (e) individual and group counseling; (f) psychoeducation on the disease of addiction; (g) case management; (h) discharge planning and coordination of services; (i) for pregnant members, provide coordination with OB/GYN, pediatrics, and any other appropriate medical and social services providers, and state agencies; and (j) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (5) Individualized Treatment Stabilization Services (ITS). The MassHealth agency will pay for Tier 1 and Tier 2 ITS services rendered by medical, counseling, peer, and paraprofessional staff under the direction of the Medical Director and delivered in conformance with the following: (a) all services listed in 130 CMR 418.409(3) and (4); (b) psychopharmacology services; (c) treatment of mental health and co-occurring disorders; (d) a minimum of six hours of clinical programming available each day, seven days a week; (e) clinical programming must include evidence-based practices such as cognitive- behavioral therapy (CBT) and acceptance and commitment therapy (ACT), as well as other targeted behavioral interventions that promote skill-building; and (f) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (6) Residential Rehabilitation Services – ASAM Level 3.1 Clinically Managed Low- Intensity Residential Services (RRS). The MassHealth agency will pay for residential rehabilitative services rendered by clinicians, case managers, counselors, and recovery support staff under the direction of a clinical director and delivered in conformance with the following: (a) a minimum of five hours of clinical programming, individual, and/or group counseling sessions per week; (b) a daily schedule of activities designed to facilitate member participation in, and transition to, the community and to promote recovery; (c) individualized case management services; (d) coordination with and/or referral to Medications for Addiction Treatment and Medications for Opioid Use Disorder providers; (e) medication management services; (f) for pregnant members, provide coordination with OB/GYN, pediatrics, and any other appropriate medical, social services providers, and state agencies; and (g) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (7) Transitional Support Services – ASAM Level 3.1 Clinically Managed Low-Intensity Residential Services (TSS). The MassHealth agency will pay for transitional support services delivered in conformance with ASAM Clinically Managed Low-Intensity Residential Services. (8) Structured Outpatient Addiction Programs – ASAM Level 2.1 (SOAP). The MassHealth agency will pay for structured outpatient addiction programs rendered by clinical and paraprofessional staff and delivered in conformance with the following: (a) SOAP services must provide specific programming that addresses the symptoms of co-occurring addiction and psychiatric disorders. (b) full therapeutic programming must be provided three to seven days a week and 3.5 hours a day, including but not limited to: 1. multidimensional biopsychosocial evaluation and treatment planning either performed by, or reviewed and signed off by, the clinical director or the clinical director’s independently licensed designee; 2. individual, group, and family counseling by a clinician; 3. treatment and recovery planning; 4. psychoeducational services; 5. case management; 6. relapse prevention education; 7. peer support and recovery-oriented services; and 8. discharge planning and coordination of services. (c) SOAP staff must provide case management upon intake and establish linkages to the member’s community to support the member through treatment and upon discharge. (d) SOAP program must coordinate with and refer members to Medications for Addiction Treatment and Medications for Opioid Use Disorder, and other behavioral health providers as necessary. (e) SOAP program must refer members to services that address social determinants of health, as indicated in the member’s assessment (e.g., food pantries, domestic violence agencies, vocational services). (9) Enhanced Structured Outpatient Addiction Program – ASAM Level 2.1 (E-SOAP). E- SOAP must also provide services to address the needs of specialty populations, including pregnant members or members who have been pregnant in the last 12 months, members experiencing or who are at risk for experiencing homelessness, and adolescents. In addition to meeting all the requirements for SOAP in 130 CMR 418.409, the MassHealth agency will pay for enhanced structured outpatient addiction programs rendered by clinical and paraprofessional staff and delivered in conformance with the following: (a) when provided to pregnant members, E-SOAP must include coordination with OB/GYN, pediatrics, and any other appropriate coordination with other medical, social services providers, and state agencies; (b) when provided to members experiencing or who are at risk of experiencing homelessness, E-SOAP must provide direct linkages to CSP-HI providers, coordination and linkages to housing resources, and any other appropriate coordination with other medical and social services providers; and (c) when provided to adolescents, E-SOAP must provide family counseling, coordination with pediatrics and family care providers, coordination with school resources including recovery high schools as appropriate, referral to and coordination with Children’s Behavioral Health Initiative (CBHI) providers, coordination with the Department of Children and Families as appropriate, and connection to or provision of evidence-based modalities. (10) Acupuncture Withdrawal Management. The MassHealth agency will pay for outpatient acupuncture withdrawal management services, which may include acupuncture treatments and motivational and supportive services. A provider may not bill separately for these components. (11) Peer Recovery Coaches. The MassHealth agency will pay for peer recovery coach services delivered in conformance with the following: (a) services must be part of the member’s overall treatment plan; (b) a wellness or recovery plan must be developed jointly with the member, as appropriate; and (c) services must assist the member in creating personally meaningful links to treatment, recovery support services, and support the member’s capacity to engage in services and supports, as needed. (12) Peer Recovery Coaches for Pregnant and Postpartum Members (PRC-PP). The MassHealth agency will pay for peer recovery coach services for pregnant and postpartum members clinically determined to be pregnant or to have been pregnant in the past 12 months, delivered in conformance with the following: (a) services must be delivered in accordance with all the underlying requirements for peer recovery coach services pursuant to 130 CMR 418.409(11); (b) services must include the adoption of an existing plan of safe care or the development of a plan of safe care in compliance with all relevant state and federal requirements, including the Child Abuse Protection and Treatment Act. The plan of safe care must be adopted or developed with the participation and consent of the member; and (c) services must support the member’s capacity to engage in medical services, including obstetric/gynecological services and pediatric services, and social services and supports that promote maternal and infant health, development, and wellness. (13) Recovery Support Navigators. The MassHealth agency will pay for recovery support navigator services delivered in conformance with the following: (a) identify existing providers and services, including collection of current individual treatment plans, medical/nursing care plans, or state agency service plans; (b) develop goals and objectives in conjunction with the member, that guide the activities of the recovery support navigator in support of current individual treatment plans, medical/nursing care plans, or state agency service plans; (c) orient the member to recovery treatment options, and community and recovery supports available to the member; and (d) assist the member with engagement in treatment services. (14) Recovery Support Navigators for Pregnant and Postpartum Members (RSN-PP). The MassHealth agency will pay for recovery support navigator services for pregnant and postpartum members clinically determined to be pregnant or to have been pregnant in the past 12 months, delivered in conformance with the following: (a) services must be delivered in accordance with all the underlying requirements for recovery support navigator services pursuant to 130 CMR 418.409(13); (b) services must include coordination with providers and supports that promote maternal and infant health, development, and wellness. Providers include both medical and social services providers, including obstetric/gynecological and pediatric providers; and (c) services must include the adoption of an existing plan of safe care or the development of a plan of safe care in compliance with all relevant state and federal requirements, including the Child Abuse Protection and Treatment Act. The plan of safe care must be adopted or developed with the participation and consent of the member. (15) Substance Use Disorder Outpatient Counseling Services – ASAM Level 1.5 Outpatient Therapy. The MassHealth agency will pay for outpatient therapy rendered by clinical staff under the direction of the Clinical Director, delivered in conformance with the following: (a) multidimensional biopsychosocial evaluation and treatment planning either performed by, or reviewed and signed off by, the clinical director or the clinical director’s independently licensed designee; (b) individual and group counseling; (c) psychoeducation on the disease of addiction; (d) discharge planning and coordination of services; and (e) for pregnant members, coordination with OB/GYN, pediatrics, and any other appropriate medical, social services providers, and state agencies. (B) The MassHealth agency pays for all medically necessary substance use disorder treatment services for EPSDT-eligible members in accordance with 130 CMR 450.140: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services: Introduction, without regard to service limitations described in 130 CMR 418.412 and with prior authorization.