Service Limitations

(A) In addition to the requirements set forth in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs, programs must adhere to the following service limitations: (1) Opioid Treatment Services. (a) Payment for oral opioid agonist and partial agonist medication is limited to one dose per member per day. Payment for providing a take home supply is limited to the amounts and frequency set forth in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. (b) Payment for opioid partial agonist medication, whether a single-agent or in combination with naloxone, is limited to one dose per member per day. Payment for a take-home supply is limited to the amounts and frequency set forth in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. (c) Payment for administering injectable opioid antagonist medication is limited to one dose per member per month. (d) Payment for administering injectable opioid partial agonist medication is limited to one dose per member per month. (e) Payment for drug screens for members receiving opioid agonist, partial agonist, and antagonist medication is limited to the amounts and frequency set forth in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. (2) Residential Rehabilitative Services – ASAM Level 3.1 Clinically Managed Low- Intensity Residential Services (RSS). The MassHealth agency will pay for the first 90 days of residential rehabilitation services per episode of care. (3) Case Consultation. (a) The MassHealth agency will pay a provider only for a case consultation that involves a personal meeting with a professional of another agency. Personal meetings may be conducted via audio-only telephonic, audio-video, or in person meetings. (b) The MassHealth agency will pay for case consultation only when written communication, and other non-reimbursable forms of communication clearly, will not suffice. Such circumstances must be documented in the member’s record. Such circumstances are limited to situations in which the program and the other party are actively involved in the treatment or management programs with the member (or family members) and where a lack of face-to-face communication would impede a coordinated treatment program. (c) The MassHealth agency will not pay for court testimony. (4) Acupuncture Withdrawal Management. (a) Each session must last at least 45 minutes and no more than 60 minutes. (b) All members seeking acupuncture withdrawal management services must be screened to ensure that acupuncture treatment is not medically contraindicated. If the screening determines that acupuncture treatment is medically contraindicated, the provider should assist the member in obtaining an alternative form of treatment. The screening may be performed by a physician assistant, an advanced practice registered nurse, or a registered nurse. The member is appropriate for acupuncture withdrawal management services if the screening determines that the member: 1. has no history of seizures, delirium tremens, or other life-threatening withdrawal symptoms; and 2. is oriented to time, place, and person. (5) Peer Recovery Coach Services and Peer Recovery Coach Services for Pregnant and Postpartum Members. The MassHealth agency pays for peer recovery coach services and peer recovery coach services for pregnant and postpartum members as rendered pursuant to 101 CMR 418.409. The MassHealth agency does not pay for peer recovery coach services or peer recovery coach services for pregnant or postpartum members that are clinical or medical in nature and outside the scope of the position. (6) Structured Outpatient Addition Program and Enhanced Structured Outpatient Addiction Program Services – ASAM 2.1. The MassHealth agency does not pay for SOAP or E-SOAP services for members who also receive group counseling in substance use disorder outpatient counseling services on the same day. (7) Telehealth. Services including the prescribing of controlled substances must be in accordance with state and federal regulations