(a) Substance use disorder services, as
defined in this section, provided to a Medi-Cal beneficiary, shall be covered
by the Medi-Cal program when determined medically necessary in accordance with
Section
51303. Services shall be
prescribed by a physician, and are subject to utilization controls, as set
forth in Section
51159.
(b) For the purposes of this Section, the
following definitions and requirements shall apply:
(1) "Admission to treatment date" means the
date of the first face-to-face treatment service, as described in Subsection
(d), rendered by the provider to the beneficiary.
(2) "Beneficiary" has the same meaning as in
Section
51000.2.
(3) "Calendar Week" means the seven (7) day
period from Sunday through Saturday.
(4) "Collateral services" means face-to-face
sessions with therapists or counselors and significant persons in the life of a
beneficiary, focusing on the treatment needs of the beneficiary in terms of
supporting the achievement of the beneficiary's treatment goals. Significant
persons are individuals that have a personal, not official or professional,
relationship with the beneficiary.
(5) "Counselor" means any of the following:
(A) A "Certified AOD Counselor," as defined
in Section
13005(a)(2) of
Title 9, CCR.
(B) A "Registrant,"
as defined in Section
13005(a)(8) of
Title 9, CCR.
(6)
"County" means the department authorized by the county board of supervisors to
administer alcohol and substance use disorder programs, including Drug Medi-Cal
substance use disorder services.
(7) "Crisis intervention" means a
face-to-face contact between a therapist or counselor and a beneficiary in
crisis. Services shall focus on alleviating crisis problems. "Crisis" means an
actual relapse or an unforeseen event or circumstance which presents to the
beneficiary an imminent threat of relapse. Crisis intervention services shall
be limited to stabilization of the beneficiary's emergency situation.
(8) "Day care habilitative services" means
outpatient counseling and rehabilitation services provided at least three (3)
hours per day, three (3) days per week to persons with substance use disorder
diagnoses, who are pregnant or postpartum, and/or to Early and Periodic
Screening Diagnosis, and Treatment (EPSDT)-eligible beneficiaries, as otherwise
authorized in this Chapter.
(9)
"Department" means the State of California Department of Health Care Services
which is authorized to administer Drug Medi-Cal substance use disorder
services. Whenever the Department contracts for Drug Medi-Cal substance use
disorder services directly with a provider, the Department shall also assume
the role and responsibilities assigned to the county under this
section.
(10) "Face-to-face" means
occurring in person, at a certified facility. Telephone contacts, home visits,
and hospital visits shall not be considered face-to-face.
(11) "Group counseling" means face-to-face
contacts in which one or more therapists or counselors treat two or more
clients at the same time, focusing on the needs of the individuals served.
Group counseling shall be conducted in a confidential setting, so that
individuals not participating in the group cannot hear the comments of the
group participants, therapist or counselor. A beneficiary that is 17 years of
age or younger shall not participate in group counseling with any participants
who are 18 years of age or older. However, a beneficiary who is 17 years of age
or younger may participate in group counseling with participants who are 18
years of age or older when the counseling is at a provider's certified school
site.
(A) For outpatient drug free treatment
services and narcotic treatment programs, group counseling shall be conducted
with no less than four and no more than ten clients at the same time, only one
of whom needs to be a Medi-Cal beneficiary.
(B) For day care habilitative services, group
counseling shall be conducted with no less than two and no more than twelve
clients at the same time, only one of whom needs to be a Medi-Cal
beneficiary.
(12)
"Individual counseling" means face-to-face contacts between a beneficiary and a
therapist or counselor. Individual counseling shall be conducted in a
confidential setting, so that individuals not participating in the counseling
session cannot hear the comments of the beneficiary, therapist or
counselor.
(13) "Intake" means the
process of admitting a beneficiary into a substance use disorder treatment
program. Intake includes the evaluation or analysis of the cause or nature of
mental, emotional, psychological, behavioral, and substance use disorders; the
diagnosis of substance use disorders utilizing the Diagnostic and Statistical
Manual of Mental Disorders Third Edition-Revised or Fourth Edition, published
by the American Psychiatric Association; and the assessment of treatment needs
to provide medically necessary treatment services by a physician. Intake may
include a physical examination and laboratory testing (e.g., body specimen
screening) necessary for substance use disorder treatment and evaluation
conducted by staff lawfully authorized to provide such services and/or order
laboratory testing within the scope of their practice or licensure.
(14) "Medical psychotherapy" means a type of
counseling service that has the same meaning as defined in Section
10345 of Title 9, CCR.
(15) "Medication Services" means the
prescription or administration of medication related to substance use disorder
treatment services, or the assessment of the side effects or results of that
medication conducted by staff lawfully authorized to provide such services
and/or order laboratory testing within the scope of their practice or
licensure.
(16) "Naltrexone
treatment services" means an outpatient treatment service directed at serving
detoxified opiate addicts who have substance use disorder diagnosis by using
the drug Naltrexone, which blocks the euphoric effects of opiates and helps
prevent relapse to opiate addiction.
(17) "Narcotic treatment program" means an
outpatient service using methadone and/or levoalphacetylmethadol (LAAM),
directed at stabilization and rehabilitation of persons who are opiate addicted
and have a substance use disorder diagnoses. For the purposes of this section,
"narcotic treatment program" does not include detoxification
treatment.
(18) "Outpatient drug
free treatment services" means an outpatient service directed at stabilizing
and rehabilitating persons with substance use disorder diagnoses.
(19) "Perinatal certified substance use
disorder program" means a Medi-Cal certified program which provides substance
use disorder services, as specified in Subsection (c)(4), to pregnant and
postpartum women with substance use disorder diagnoses.
(20) "Perinatal residential substance use
disorder services program" means a non-institutional, non-medical, residential
program which provides rehabilitation services to pregnant and postpartum women
with substance use disorder diagnoses. Each beneficiary shall live on the
premises and shall be supported in her efforts to restore, maintain, and apply
interpersonal and independent living skills and access community support
systems. Programs shall provide a range of activities and services for pregnant
and postpartum women. Supervision and treatment services shall be available day
and night, seven days a week.
(21)
"Physician" means a person licensed as a physician by the Medical Board of
California or the Osteopathic Medical Board of California.
(22) "Postpartum" means within the
eligibility period specified in Section
50260.
(23) "Postservice postpayment utilization
review" has the same meaning as Section
51159(c).
(24) "Provider" means the entity certified
pursuant to Section
51200 to provide Drug Medi-Cal
substance use disorder services to eligible beneficiaries at its certified
location(s).
(25) "Relapse" means a
single instance of a beneficiary's substance use or a beneficiary's return to a
pattern of substance use.
(26)
"Relapse trigger" means an event, circumstance, place or person that puts a
beneficiary at risk of relapse.
(27) "Substance use disorder diagnoses" are
those set forth in the Diagnostic and Statistical Manual of Mental Disorders
Third Edition-Revised or Fourth Edition, published by the American Psychiatric
Association.
(28) "Substance Use
Disorder Medical Director" has the same meaning as in Section
51000.24.4.
(A) For outpatient drug free, day care
habilitative, perinatal residential and naltrexone treatment services programs
the following shall apply:
(i) The substance
use disorder medical director's responsibilities shall at a minimum include all
of the following:
(a) Ensure that medical care
provided by physicians, registered nurse practitioners, and physician
assistants meets the applicable standard of care.
(b) Ensure that physicians do not delegate
their duties to nonphysician personnel.
(c) Develop and implement medical policies
and standards for the provider.
(d)
Ensure that physicians, registered nurse practitioners, and physician
assistants follow the provider's medical policies and standards.
(e) Ensure that the medical decisions made by
physicians are not influenced by fiscal considerations.
(f) Ensure that provider's physicians are
adequately trained to perform diagnosis of substance use disorders for
beneficiaries, determine the medical necessity of treatment for beneficiaries
and perform other physician duties, as outlined in this
section.
(ii) The
substance use disorder medical director may delegate his/her responsibilities
to a physician consistent with the provider's medical policies and standards;
however the substance use disorder medical director shall remain responsible
for ensuring all delegated duties are properly performed.
(iii) A substance use disorder medical
director shall receive a minimum of five (5) hours of continuing medical
education in addiction medicine each year.
(B) For narcotic treatment programs, a
substance use disorder medical director shall meet the requirements specified
in Section
10110 of Title 9,
CCR.
(29) "Support plan"
means a list of individuals and/or organizations that can provide support and
assistance to a beneficiary to maintain sobriety.
(30) "Therapist" means any of the following:
(A) A psychologist licensed by the California
Board of Psychology.
(B) A clinical
social worker or marriage and family therapist licensed by the California Board
of Behavioral Sciences.
(C) An
intern registered with the California Board of Psychology or the California
Board of Behavioral Sciences.
(D) A
physician.
(31) "Unit of
service" means:
(A) For outpatient drug free,
day care habilitative, perinatal residential, and Naltrexone treatment
services, a face-to-face contact on a calendar day.
(B) For narcotic treatment program services,
a calendar month of treatment services provided pursuant to this section and
Chapter 4 commencing with Section
10000 of Title 9,
CCR.
(c) Drug
Medi-Cal substance use disorder services for pregnant and postpartum women:
(1) Any of the substance use disorder
services listed in Subsection (d) shall be reimbursed at enhanced perinatal
rates pursuant to Section
51516.1(a)(3)
only when delivered by providers who have been certified pursuant to Section
51200 to provide perinatal
Medi-Cal services to pregnant and postpartum women.
(2) Only pregnant and postpartum women are
eligible to receive residential substance use disorder services.
(3) Perinatal services shall address
treatment and recovery issues specific to pregnant and postpartum women, such
as relationships, sexual and physical abuse, and development of parenting
skills.
(4) Perinatal services
shall include:
(A) Mother/child habilitative
and rehabilitative services (i.e., development of parenting skills, training in
child development, which may include the provision of cooperative child care
pursuant to Health and Safety Code Section
1596.792);
(B) Service access (i.e., provision of or
arrangement for transportation to and from medically necessary
treatment);
(C) Education to reduce
harmful effects of alcohol and drugs on the mother and fetus or the mother and
infant; and
(D) Coordination of
ancillary services (i.e., assistance in accessing and completing dental
services, social services, community services, educational/vocational training
and other services which are medically necessary to prevent risk to fetus or
infant).
(d)
Drug Medi-Cal substance use disorder services shall include all of the
following:
(1) Narcotic treatment program
services, utilizing methadone and/or levoalphacetylmethadol (LAAM) as narcotic
replacement drugs, including intake, treatment planning, medical direction,
body specimen screening, physician and nursing services related to substance
use, medical psychotherapy, individual and/or group counseling, admission
physical examinations and laboratory tests, medication services, and the
provision of methadone and/or LAAM, as prescribed by a physician to alleviate
the symptoms of withdrawal from opiates, rendered in accordance with the
requirements set forth in Chapter 4 commencing with Section
10000 of Title 9, CCR.
(2) Outpatient drug free treatment services
including admission physical examinations, intake, medical direction,
medication services, body specimen screens, treatment and discharge planning,
crisis intervention, collateral services, group counseling, and individual
counseling, provided by staff that are lawfully authorized to provide,
prescribe and/or order these services within the scope of their practice or
licensure, subject to all of the following:
(A) Group counseling sessions shall focus on
short-term personal, family, job/school, and other problems and their
relationship to substance use or a return to substance use. Services shall be
provided by appointment. Each beneficiary shall receive at least two group
counseling sessions per month.
(B)
Individual counseling shall be limited to intake, crisis intervention,
collateral services, and treatment and discharge planning.
(3) Day care habilitative services including
intake, admission physical examinations, medical direction, treatment planning,
individual and group counseling, body specimen screens, medication services,
collateral services, and crisis intervention, provided by staff that are
lawfully authorized to provide, prescribe and/or order these services within
the scope of their practice or licensure. Day care habilitative services shall
be provided only to pregnant and postpartum women and/or to EPSDT-eligible
beneficiaries as otherwise authorized in this Chapter. The service shall
consist of regularly assigned, structured, and supervised treatment.
(4) Perinatal residential substance use
disorder services including intake, admission physical examinations and
laboratory tests, medical direction, treatment planning, individual and group
counseling services, parenting education, body specimen screens, medication
services, collateral services, and crisis intervention services, provided by
staff that are lawfully authorized to provide and/or order these services
within the scope of their practice or licensure.
(A) Perinatal residential substance use
disorder services shall be provided in a residential facility licensed by the
Department pursuant to Chapter 5 (commencing with Section
10500), Division 4, Title 9,
CCR.
(B) Perinatal residential
substance use disorder services shall be reimbursed through the Medi-Cal
program only when provided in a facility with a treatment capacity of 16 beds
or less, not including beds occupied by children of residents [In accordance
with 42 CFR Section
435.1009, Medicaid reimbursement is not
allowed for individuals in facilities with a treatment capacity of more than 16
beds].
(C) Room and board shall not
be reimbursable through the Medi-Cal program.
(5) Naltrexone treatment services including
intake, admission physical examinations, treatment planning, provision of
medication services, medical direction, physician and nursing services related
to substance use, body specimen screens, individual and group counseling,
collateral services, and crisis intervention services, provided by staff that
are lawfully authorized to provide, prescribe and/or order these services
within the scope of their practice or licensure. Naltrexone treatment services
shall only be provided to a beneficiary who meets all of the following
conditions:
(A) Has a confirmed, documented
history of opiate addiction.
(B) Is
at least (18) years of age.
(C) Is
opiate free.
(D) Is not
pregnant.
(e)
The Department shall do all of the following:
(1) Provide administrative and fiscal
oversight, monitoring, and auditing for the provision of statewide Drug
Medi-Cal substance use disorder services.
(2) Ensure that utilization review is
maintained through on-site postservice postpayment utilization
review.
(3) Demand recovery of
payment in accordance with the provisions of Subsection
(m).
(f) The county shall
do all of the following:
(1) Implement and
maintain a system of fiscal disbursement and controls over the Drug Medi-Cal
substance use disorder services rendered by providers delivering services
within its jurisdiction pursuant to an executed provider agreement.
(2) Monitor to ensure that billing for
reimbursement is within the rates established for services.
(3) Process claims for
reimbursement.
(g) In
addition to the requirements of Section
51476 and the regulations set
forth in this chapter, the provider shall:
(1)
Establish, maintain, and update as necessary, an individual patient record for
each beneficiary admitted to treatment and receiving services. Each
beneficiary's individual patient record shall include documentation of personal
information as specified in Paragraph (A) and beneficiary treatment episode
information as specified in Paragraph (B) below.
(A) Documentation of personal information
shall include all of the following:
(i)
Information specifying the beneficiary's identifier (i.e., name,
number).
(ii) Date of beneficiary's
birth, the beneficiary's sex, race and/or ethnic background, beneficiary's
address and telephone number, beneficiary's next of kin or emergency
contact.
(iii) For pregnant and
postpartum women, medical documentation that substantiates the beneficiary's
pregnancy and the last day of pregnancy.
(B) Documentation of treatment episode
information shall include documentation of all activities, services, sessions,
and assessments, as specified in Subsections (b), (c), (d) and (h), including
but not limited to all of the following:
(i)
Intake and admission data, including, if applicable, a physical
examination.
(ii) Treatment
plans.
(iii) Compliance with
Subsection (h)(4).
(iv) Progress
notes.
(v) Continuing services
justifications.
(vi) Laboratory
test orders and results.
(vii)
Referrals.
(viii) Counseling
notes.
(ix) Discharge
plan.
(x) Discharge
summary.
(xi) Compliance with the
multiple billing requirements specified in Section
51490.1(b).
(xii) Any other information relating to the
treatment services rendered to the beneficiary.
(xiii) Evidence of compliance with
requirements for the specific treatment service as described in Subsection
(d).
(2)
Establish and maintain a sign-in sheet for every group counseling session,
which shall include all of the following:
(A)
The typed or legibly printed name and signature of the therapist(s) and/or
counselor(s) conducting the counseling session. By signing the sign-in sheet
the therapist(s) and/or counselor(s) certify that the sign-in sheet is accurate
and complete.
(B) The date of the
counseling session.
(C) The topic
of the counseling session.
(D) The
start and end time of the counseling session.
(E) A typed or legibly printed list of the
participants' names and the signature of each participant that attended the
counseling session. The participants shall sign the sign-in sheet at the start
of or during the counseling session.
(3) Provide services.
(4) Submit claims for reimbursement and
maintain documentation specified in Section
51008.5 supporting good cause
claims where the good cause results from provider-related
delays.
(h) For a
provider to receive reimbursement for Drug Medi-Cal substance use disorder
services, those services shall be provided by or under the direction of a
physician and all of the following requirements shall apply:
(1) Admission criteria and procedures.
(A) For outpatient drug free, Naltrexone
treatment, day care habilitative, and perinatal residential treatment services
each of the following requirements shall be met:
(i) The provider shall develop and document
procedures for the admission of beneficiaries to treatment; and
(ii) The provider shall complete a personal,
medical, and substance use history for each beneficiary upon admission to
treatment.
(iii) The physician
shall review each beneficiary's personal, medical and substance use history
within thirty (30) calendar days of the beneficiary's admission to treatment
date.
(iv) Physical examination
requirements
(a) If a beneficiary had a
physical examination within the twelve (12) month period prior to the
beneficiary's admission to treatment date, the physician shall review
documentation of the beneficiary's most recent physical examination within
thirty (30) calendar days of the beneficiary's admission to treatment date. If
a provider is unable to obtain documentation of a beneficiary's most recent
physical examination, the provider shall describe the efforts made to obtain
this documentation in the beneficiary's individual patient record.
(b) As an alternative to complying with
Paragraph (a) or in addition to complying with Paragraph (a) above, the
physician, a registered nurse practitioner or a physician's assistant, may
perform a physical examination of the beneficiary within thirty (30) calendar
days of the beneficiary's admission to treatment date.
(c) If the physician has not reviewed the
documentation of the beneficiary's physical examination as provided for in
Paragraph (a) or the provider does not perform a physical examination of the
beneficiary as provided for in Paragraph (b), then the provider shall include
in the beneficiary's initial and updated treatment plans the goal of obtaining
a physical examination, until this goal has been met.
(v) Diagnosis Requirements
(a) The physician shall evaluate each
beneficiary to diagnose whether the beneficiary has a substance use disorder,
within thirty (30) calendar days of the beneficiary's admission to treatment
date. The diagnosis shall be based on the applicable diagnostic code from the
Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised or
Fourth Edition, published by the American Psychiatric Association. The
physician shall document the basis for the diagnosis in the beneficiary's
individual patient record.
(b) As
an alternative to complying with Paragraph (a) above, the therapist, physician
assistant, or nurse practitioner, acting within the scope of their respective
practice, shall evaluate each beneficiary to diagnose whether the beneficiary
has a substance use disorder, within thirty (30) calendar days of the
beneficiary's admission to treatment date. The diagnosis shall be based on the
applicable diagnostic code from the Diagnostic and Statistical Manual of Mental
Disorders Third Edition -- Revised or Fourth Edition, published by the American
Psychiatric Association. The individual who performs the diagnosis shall
document the basis for the diagnosis in the beneficiary's individual patient
record. The physician shall document approval of each beneficiary's diagnosis
that is performed by a therapist, physician assistant or nurse practitioner by
signing and dating the beneficiary's treatment plan.
(vi) The physician shall determine whether
substance use disorder services are medically necessary, consistent with
Section
51303 within thirty (30) calendar
days of each beneficiary's admission to treatment date.
(B) In addition to the requirements of
Subsection (h)(1)(A), for Naltrexone treatment services, for each beneficiary,
all of the following shall apply:
(i) The
provider shall confirm that the beneficiary meets all of the following
conditions:
(a) Has a documented history of
opiate addiction.
(b) Is at least
eighteen (18) years of age.
(c) Has
been opiate free for a period of time to be determined by a physician based on
the physician's clinical judgment. The provider shall administer a body
specimen test to confirm the opiate free status of the beneficiary.
(d) Is not pregnant and is discharged from
the treatment if she becomes pregnant.
(ii) The physician shall certify the
beneficiary's fitness for treatment based upon the beneficiary's physical
examination, medical history, and laboratory results; and
(iii) The physician shall advise the
beneficiary of the overdose risk should the beneficiary return to opiate use
while taking Naltrexone and the ineffectiveness of opiate pain relievers while
on Naltrexone.
(C) For
narcotic treatment programs, the provider shall adhere to the admission
criteria specified in Section
10270, Title 9,
CCR.
(2) Treatment plan
for each beneficiary.
(A) For each
beneficiary admitted to outpatient drug free, day care habilitative, perinatal
residential, and Naltrexone treatment services the provider shall prepare an
individualized written initial treatment plan, based upon the information
obtained in the intake and assessment process. The provider shall attempt to
engage the beneficiary to meaningfully participate in the preparation of the
initial treatment plan and updated treatment plans.
(i) The initial treatment plan and updated
treatment plans shall include all of the following:
(a) A statement of problems to be
addressed.
(b) Goals to be reached
which address each problem.
(c)
Action steps which will be taken by the provider, and/or beneficiary to
accomplish identified goals.
(d)
Target dates for the accomplishment of action steps and goals.
(e) A description of the services, including
the type of counseling, to be provided and the frequency thereof.
(f) The assignment of a primary therapist or
counselor.
(g) The beneficiary's
diagnosis as required by Subsection (h)(1)(A)(v).
(h) If a beneficiary has not had a physical
examination within the twelve month period prior to the beneficiary's admission
to treatment date, a goal that the beneficiary have a physical
examination.
(i) If documentation
of a beneficiary's physical examination, which was performed during the prior
twelve months, indicates a beneficiary has a significant medical illness, a
goal that the beneficiary obtain appropriate treatment for the
illness.
(ii) The provider
shall ensure that the initial treatment plan meets all of the following
requirements:
(a) The therapist or counselor
shall complete, type or legibly print their name, and sign and date the initial
treatment plan within thirty (30) calendar days of the admission to treatment
date.
(b) The beneficiary shall
review, approve, type or legibly print their name, sign and date the initial
treatment plan, indicating whether the beneficiary participated in preparation
of the plan, within (30) calendar days of the admission to treatment date. If
the beneficiary refuses to sign the treatment plan, the provider shall document
the reason for refusal and the provider's strategy to engage the beneficiary to
participate in treatment.
(c) The
physician shall review the initial treatment plan to determine whether the
services are medically necessary. This determination shall be consistent with
Section
51303. If the physician determines
the services in the initial treatment plan are medically necessary, the
physician shall type or legibly print their name, and sign and date the
treatment plan within fifteen (15) calendar days of signature by the therapist
or counselor.
(iii) The
provider shall ensure that the treatment plan is reviewed and updated as
described below:
(a) The therapist or
counselor shall complete, type or legibly print their name, sign and date the
updated treatment plan no later than ninety (90) calendar days after signing
the initial treatment plan, and no later than every ninety (90) calendar days
thereafter, or when a change in problem identification or focus of treatment
occurs, whichever comes first.
(b)
The beneficiary shall review, approve, type or legibly print their name and,
sign and date the updated treatment plan, indicating whether the beneficiary
participated in preparation of the plan, within thirty (30) calendar days of
signature by the therapist or counselor. If the beneficiary refuses to sign the
updated treatment plan, the provider shall document the reason for refusal and
the provider's strategy to engage the beneficiary to participate in
treatment.
(c) The physician shall
review each updated treatment plan to determine whether the services are
medically necessary. This determination shall be consistent with section
51303. If the physician determines
the services in the updated treatment plan are medically necessary, the
physician shall type or legibly print their name and, sign and date the updated
treatment plan, within fifteen (15) calendar days of signature by the therapist
or counselor. If the physician has not prescribed medication, a psychologist
licensed by the State of California Board of Psychology may review for medical
necessity, type or legibly print their name and sign and date an updated
treatment plan.
(B) For narcotic treatment programs,
providers shall complete initial and updated treatment plans in accordance with
the requirements specified in Section
10305, Title 9,
CCR.
(3) Progress notes
shall be legible and completed as follows:
(A)
For outpatient drug free or Naltrexone treatment services, for each individual
and group counseling session, the therapist or counselor who conducted that
counseling session shall record a progress note for each beneficiary who
participated in the counseling session; and type or legibly print their name,
and sign and date the progress note within seven (7) calendar days of the
counseling session. Progress notes are individual narrative summaries and shall
include all of the following:
(i) The topic
of the session.
(ii) A description
of the beneficiary's progress on the treatment plan problems, goals, action
steps, objectives, and/or referrals.
(iii) Information on the beneficiary's
attendance, including the date, start and end times of each individual and
group counseling session.
(B) For day care habilitative and perinatal
residential treatment services, the therapist or counselor shall record at a
minimum one (1) progress note, per calendar week, for each beneficiary
participating in structured activities including counseling sessions. The
therapist or counselor shall type or legibly print their name, and sign and
date progress notes within the following calendar week. Progress notes are
individual narrative summaries and shall include all of the following:
(i) A description of the beneficiary's
progress on the treatment plan problems, goals, action steps, objectives,
and/or referrals.
(ii) A record of
the beneficiary's attendance at each counseling session including the date,
start and end times and topic of the counseling session.
(C) For narcotic treatment programs, the
therapist or counselor shall record progress notes in accordance with the
requirements of Section
10345, Title 9,
CCR.
(4) Minimum provider
and beneficiary contact.
(A) For outpatient
drug free, day care habilitative, perinatal residential, or Naltrexone
treatment services, a beneficiary shall be provided a minimum of two (2)
counseling sessions per thirty (30) day period except when the physician
determines that either of the following apply:
(i) Fewer beneficiary contacts are clinically
appropriate.
(ii) The beneficiary
is progressing toward treatment plan goals.
(B) Narcotic treatment program providers
shall provide counseling in accordance with Section
10345, Title 9, CCR. A beneficiary
shall receive a minimum of fifty (50) minutes of counseling per calendar month.
Waivers of this requirement shall be in accordance with Section
10345, Title 9,
CCR.
(5) Continuing
services shall be justified as shown below:
(A) For outpatient drug free, day care
habilitative, perinatal residential, and Naltrexone treatment services:
(i) For each beneficiary, no sooner than five
(5) months and no later than six (6) months after the beneficiary's admission
to treatment date or the date of completion of the most recent justification
for continuing services, the therapist or counselor shall review the
beneficiary's progress and eligibility to continue to receive treatment
services, and recommend whether the beneficiary should or should not continue
to receive treatment services.
(ii)
For each beneficiary, no sooner than five (5) months and no later than six (6)
months after the beneficiary's admission to treatment date or the date of
completion of the most recent justification for continuing services, the
physician shall determine whether continued services are medically necessary,
consistent with Section
51303. The determination of
medical necessity shall be documented by the physician in the beneficiary's
individual patient record and shall include documentation that all of the
following have been considered:
(a) The
beneficiary's personal, medical and substance use history.
(b) Documentation of the beneficiary's most
recent physical examination.
(c)
The beneficiary's progress notes and treatment plan goals.
(d) The therapist or counselor's
recommendation pursuant to Paragraph (i) above.
(e) The beneficiary's
prognosis.
(iii) If the
physician determines that continuing treatment services for the beneficiary is
not medically necessary, the provider shall discharge the beneficiary from
treatment.
(B) For
narcotic treatment program services, the review to determine continuing need
for services shall be performed in accordance with Section
10410, Title 9,
CCR.
(6) Discharge of a
beneficiary from treatment may occur on a voluntary or involuntary basis. In
addition to the requirements of this subsection, an involuntary discharge is
subject to the requirements set forth in Subsection (p).
(A) A therapist or counselor shall complete a
discharge plan for each beneficiary, except for a beneficiary with whom the
provider loses contact.
(i) The discharge
plan shall include, but not be limited to, all of the following:
(a) A description of each of the
beneficiary's relapse triggers and a plan to assist the beneficiary to avoid
relapse when confronted with each trigger.
(b) A support plan.
(ii) The discharge plan shall be prepared
within thirty (30) calendar days prior to the date of the last face-to-face
treatment with the beneficiary.
(iii) During the therapist or counselor's
last face-to-face treatment with the beneficiary, the therapist or counselor
and the beneficiary shall type or legibly print their names, sign and date the
discharge plan. A copy of the discharge plan shall be provided to the
beneficiary.
(B) The
provider shall complete a discharge summary, for any beneficiary with whom the
provider lost contact, in accordance with all of the following requirements:
(i) For outpatient drug free, day care
habilitative, perinatal residential, and Naltrexone treatment services, the
provider shall complete the discharge summary within thirty (30) calendar days
of the date of the provider's last face-to-face treatment contact with the
beneficiary. The discharge summary shall include all of the following:
(a) The duration of the beneficiary's
treatment as determined by the dates of admission to and discharge from
treatment.
(b) The reason for
discharge.
(c) A narrative summary
of the treatment episode.
(d) The
beneficiary's prognosis.
(ii) For narcotic treatment program services,
the discharge summary shall meet the requirements of Section
10415, Title 9,
CCR.
(7) Except
where share of cost, as defined in Section
50090, is applicable, providers
shall accept proof of eligibility for Drug Medi-Cal as payment in full for
treatment services rendered. Providers shall not charge fees to a beneficiary
for access to Drug Medi-Cal substance use disorder services or for admission to
a Drug Medi-Cal treatment slot.
(i) For each beneficiary, providers shall
maintain all of the documentation in the beneficiary's individual patient
record established pursuant to Subsection (g)(1) for a minimum of three (3)
years from the date of the last face-to-face contact between the beneficiary
and the provider. In addition providers shall maintain documentation that the
beneficiary met the requirements for good cause specified in Section
51008.5, where the good cause
results from beneficiary-related delays, for a minimum of three (3) years from
the date of the last face-to-face contact. If an audit takes place during the
three year period, the providers shall maintain records until the audit is
completed.
(j) Reimbursement for
Drug Medi-Cal Substance Use Disorder Services.
(1) The Department shall not reimburse a
provider for services not rendered or received by a beneficiary.
(2) In order to receive and retain
reimbursement for services provided to a beneficiary, the provider shall comply
with the requirements listed in Subsection (i).
(3) When a beneficiary receives services from
more than one provider, the Department shall reimburse only one provider for a
single unit of service provided at a single certified location on a calendar
day.
(4) For outpatient drug free,
day care habilitative, and Naltrexone treatment services, the Department may
reimburse the provider for an additional unit of service on a calendar day
under either of the circumstances listed below. The additional unit of service
shall be reimbursed pursuant to Section
51490.1(b) and
shall be documented in the individual patient record as a separate unit of
service in accordance with Subsection (h)(3).
(A) Outpatient drug free and Naltrexone for
crisis intervention or collateral services; or
(B) Day care habilitative for crisis
intervention.
(5) The
Department shall reimburse a narcotic treatment program for services based on
Section
51516.1. If the beneficiary
receives less than a full month of services, the Department shall prorate
reimbursement to the daily rate per beneficiary, based on the annual rate per
beneficiary and a 365-day year pursuant to Section
14021.51(g)
of the Welfare and Institutions Code.
(k) The Department shall conduct a
postservice postpayment utilization review of Drug Medi-Cal substance use
disorder services. The review shall do all of the following:
(1) Verify that the documentation
requirements of Subsection (i) are met.
(2) Verify that each beneficiary meets the
admission criteria, including the use of an appropriate Diagnostic and
Statistical Manual of Mental Disorders Third Edition-Revised or Fourth Edition,
published by the American Psychiatric Association diagnostic code, and medical
necessity for services is established pursuant to Subsection
(h)(1)(A)(vi).
(3) Verify that a
treatment plan exists for each beneficiary and that the provider rendered
services claimed for reimbursement in accordance with the requirements set
forth in Subsection (h).
(4)
Establish the basis for recovery of payments in accordance with Subsection
(m).
(l) The Department
shall base its postservice postpayment utilization review findings and the
amount of provider overpayments on a sampling of beneficiary and other provider
records. These records shall be provided while Department personnel are on the
provider's premises conducting the postservice postpayment utilization review
for that site. In determining provider compliance or the amount of provider
overpayments, the Department shall not consider records provided after
Department personnel have left the provider's premises.
(m) In addition to the provisions of Section
51458.1(a), the
Department shall recover overpayments to providers for any of the following
reasons:
(1) For all providers who:
(A) Claimed reimbursement for a service not
rendered.
(B) Claimed reimbursement
for a service at an uncertified location.
(C) Failed to meet the requirements of
Subsections (b), (c), (d), (g), (h), and (i).
(D) Used erroneous, incorrect, or fraudulent
good cause codes and procedures specified in Sections
51008 and
51008.5.
(E) Used erroneous, incorrect, or fraudulent
multiple billing codes and certification processes specified in Section
51490.1(b).
(2) For outpatient drug free, day care
habilitative, perinatal residential, and Naltrexone treatment services if the
provider received reimbursement in excess of the limits set forth in Section
51516.1(a).
(3) For narcotic treatment programs, because
the provider failed to meet any of the following:
(A) The admission criteria time frames
specified in Section
10270, Title 9, CCR.
(B) The time frames for treatment plan
completion and for review specified in Section
10305, Title 9, CCR.
(C) The continuing treatment time frames
specified in Section
10410, Title 9,
CCR.
(4) For all
providers who received reimbursement for an ineligible narcotic treatment
program individual or group counseling session. For purposes of this
subsection, "ineligible narcotic treatment program individual or group
counseling session" means any of the following:
(A) The counseling session does not meet the
minimum requirements set forth in Section
10345, Title 9, CCR;
(B) The counseling session is not the type
specified in the treatment plan required by Section
10305, Title 9, CCR; or
(C) The frequency of counseling exceeds that
specified in the treatment plan required by Section
10305, Title 9,
CCR.
(5) For all
providers who received reimbursement for an ineligible individual counseling
session. For purposes of this subsection "ineligible individual counseling
session" means an individual counseling session which does not meet the
requirements specified in Subsection (b)(12) and, for outpatient drug free
treatment services as specified in Subsection (d)(2)(B).
(6) For all providers who received
reimbursement for an ineligible group counseling session. For purposes of this
subsection, "ineligible group counseling session" means a group counseling
session which does not meet the requirements specified in Subsection (b)(11)
and, for outpatient drug free treatment services as specified in Subsection
(d)(2)(A).
(7) For all providers
who received reimbursement for an ineligible day care habilitativeunit of
service. For purposes of this subsection, "ineligible day care habilitative
unit of service" means a unit of service that was less than three hours of
service on the calendar day billed or provided to a non-pregnant,
non-postpartum or non-EPSDT eligible beneficiary.
(n) The Department shall utilize the
procedures contained in Section
51458.2 to determine the amount of
the demand for recovery of payment.
(o) Provider noncompliance with other
requirements set forth in this section shall be noted as programmatic
deficiencies. The Department shall issue a report to the provider documenting
any demand for recovery of payment and/or programmatic deficiencies and the
provider shall submit a corrective action plan within sixty (60) calendar days
of the date of the report. The plan shall do all of the following:
(1) Address each demand for recovery of
payment and/or programmatic deficiency.
(2) Provide a specific description of how the
deficiency shall be corrected.
(3)
Specify the date of implementation of the corrective
action.
(p) Providers
shall inform each beneficiary of the right to a fair hearing related to denial,
involuntary discharge, or reduction in Drug Medi-Cal substance use disorder
services as it relates to their eligibility or benefits, pursuant to Section
50951.
(1) Providers shall advise the beneficiary in
writing at least ten (10) calendar days prior to the effective date of the
intended action to terminate or reduce services. The written notice shall
include all of the following:
(A) A statement
of the action the provider intends to take.
(B) The reason for the intended
action.
(C) A citation of the
specific regulation(s) supporting the intended action.
(D) An explanation of the beneficiary's right
to a fair hearing for the purpose of appealing the intended action.
(E) An explanation that the beneficiary may
request a fair hearing by submitting a written request to:
DEPARTMENT OF SOCIAL SERVICES
STATE HEARINGS DIVISION
P.O. BOX 944243, MS 9-17-37
SACRAMENTO, CA 94244-2430
1 (800) 952-5253
TDD 1(800) 952-8349
(F) An explanation that the provider shall
continue treatment services pending a fair hearing decision only if the
beneficiary appeals in writing to the Department of Social Services for a
hearing within ten (10) calendar days of the mailing or personal delivery of
the notice of intended action.
(2) All fair hearings shall be conducted in
accordance with Section
50953.
(q) County and Provider Administrative
Appeals
A provider and/or county may appeal Drug Medi-Cal
dispositions concerning demands for recovery of payment and/or programmatic
deficiencies of specific claims.
(1)
Requests for first-level appeals, grievances, and complaints will be managed as
follows:
(A) The provider and/or county shall
initiate action by submitting a letter to:
DIVISION CHIEF
SUBSTANCE USE DISORDERS PREVENTION, TREATMENT, AND
RECOVERY
SERVICES DIVISION
DEPARTMENT OF HEALTH CARE SERVICES
PO BOX 997413, MS-2621
SACRAMENTO, CA 95899-7413
(i) The provider and/or county shall submit
the letter on the official stationery of the provider and/or county and it
shall be signed by an authorized representative of the provider and/or
county.
(ii) The letter shall
identify the specific claim(s) involved and describe the disputed (in)action
regarding the claim.
(B)
The letter shall be submitted to the address listed in Subsection (q)(1)(A)
within ninety (90) calendar days from the date the provider and/or county
received written notification of the decision to disallow claims.
(C) The Substance Use Disorders Prevention,
Treatment, and Recovery Services Division (SUDPTRSD) shall acknowledge the
letter within fifteen (15) calendar days of its receipt.
(D) The SUDPTRSD shall inform the provider
and/or county of the SUDPTRSD's decision and the basis for the decision within
fifteen (15) calendar days after the SUDPTRSD's acknowledgement notification.
The SUDPTRSD shall have the option of extending the decision response time if
additional information is required from the provider and/or county. The
provider and/or county will be notified if the SUDPTRSD extends the response
time limit.
(2) A
provider and/or county may initiate a second level appeal, grievance or
complaint to the Office of Administrative Hearings and Appeals.
(A) The second level process may be pursued
only after complying with first-level procedures and only when:
(i) The SUDPTRSD has failed to acknowledge
the grievance or complaint within fifteen (15) calendar days of its receipt,
or
(ii) The provider and/or county
is dissatisfied with the action taken by the SUDPTRSD where the conclusion is
based on the SUDPTRSD's evaluation of the merits. The second-level appeal shall
be submitted to the Office of Administrative Hearings and Appeals within thirty
(30) calendar days from the date the SUDPTRSD failed to acknowledge the
first-level appeal or from the date of the SUDPTRSD's first-level appeal
decision.
(B) All
second-level appeals made in accordance with this section shall be directed to:
OFFICE OF ADMINISTRATIVE HEARINGS AND APPEALS
1029 J STREET, SUITE 200
SACRAMENTO, CA 95814
(C) In referring an appeal, grievance, or
complaint to the Office of Administrative Hearings and Appeals, the provider
and/or county shall submit all of the following:
(i) A copy of the original written grievance
or complaint sent to the SUDPTRSD.
(ii) A copy of the SUDPTRSD's report to which
the appeal, grievance, or complaint applies.
(iii) If received by the provider and/or
county, a copy of the SUDPTRSD's specific finding(s), and conclusion(s)
regarding the appeal, grievance, or complaint with which the provider and/or
county is dissatisfied.
Notes
Cal. Code Regs. Tit. 22, §
51341.1
1. New
section filed 12-14-95 as an emergency; operative 12-14-95 (Register 95, No.
50). A Certificate of Compliance must be transmitted to OAL by 4-12-96 or
emergency language will be repealed by operation of law on the following
day.
2. Repealed by operation of Government Code section
11346.1
(Register 96, No. 16).
3. New section filed 4-16-96 as an emergency;
operative 4-16-96 (Register 96, No. 16). A Certificate of Compliance must be
transmitted to OAL by 8-14-96 or emergency language will be repealed by
operation of law on the following day.
4. Certificate of Compliance
as to 4-16-96 order transmitted to OAL 8-13-96 and filed 9-25-96 (Register 96,
No. 39).
5. Amendment of section and NOTE filed 5-12-97 as an
emergency; operative 5-12-97 (Register 97, No. 20). A Certificate of Compliance
must be transmitted to OAL by 9-9-97 or emergency language will be repealed by
operation of law on the following day.
6. Amendment of section
heading, section and NOTE filed 6-30-97 as an emergency; operative 7-1-97
(Register 97, No. 27). A Certificate of Compliance must be transmitted to OAL
by 10-29-97 or emergency language will be repealed by operation of law on the
following day.
7. Certificate of Compliance as to 5-12-97 order
transmitted to OAL 8-13-97 and filed 9-23-97 (Register 97, No.
39).
8. Amendment of section heading, section and NOTE refiled
10-6-97 as an emergency; operative 10-29-97 (Register 97, No. 41). A
Certificate of Compliance must be transmitted to OAL by 2-26-98 or emergency
language will be repealed by operation of law on the following
day.
9. Amendment of section heading, section and NOTE refiled
1-14-98 as an emergency; operative 2-26-98 (Register 98, No. 3). A Certificate
of Compliance must be transmitted to OAL by 6-26-98 or emergency language will
be repealed by operation of law on the following day.
10.
Certificate of Compliance as to 1-14-98 order, including further amendment of
section heading, section and NOTE, transmitted to OAL 6-11-98 and filed 6-29-98
(Register 98, No. 27).
11. Change without regulatory effect amending
subsection (p)(1)(E) filed 5-17-2006 pursuant to section
100, title 1, California Code of
Regulations (Register 2006, No. 20).
12. Change without regulatory
effect amending section heading, section and NOTE filed 12-16-2013 pursuant to
section 100, title 1, California Code of
Regulations (Register 2013, No. 51).
13. Amendment of section and
NOTE filed 6-25-2014 as an emergency; operative 6-25-2014 (Register 2014, No.
26). A Certificate of Compliance must be transmitted to OAL by 12-22-2014 or
emergency language will be repealed by operation of law on the following
day.
14. Amendment of section and NOTE refiled 12-17-2014 as an
emergency pursuant to Welfare and Institutions Code section
14124.26(c)(2);
operative 12-22-2014 (Register 2014, No. 51). A Certificate of Compliance must
be transmitted to OAL by 6-22-2015 pursuant to Welfare and Institutions Code
section
14124.26(c)(2)
or emergency language will be repealed by operation of law on the following
day.
15. Certificate of Compliance as to 12-17-2014 order, including
amendment of (h)(1)(A)(v) and new subsections (h)(1)(A)(v)(a)-(b), transmitted
to OAL 6-4-2015 and filed 7-14-2015; amendments effective 7-14-2015 pursuant to
Government Code section
11343.4(b)(3)
(Register 2015, No. 29).
16. New subsections (b)(28)-(b)(28)(B) and
subsection renumbering filed 8-17-2015 as a deemed emergency exempt from OAL
review pursuant to Welfare and Institutions Code section
14043.75;
operative 8-17-2015 (Register
2015,
No. 34). A Certificate of Compliance must be transmitted to OAL by 2-16-2016 or
emergency language will be repealed by operation of law on the following
day.
17. Certificate of Compliance as to 8-17-2015 order transmitted
to OAL 12-30-2015 and filed 2-11-2016 (Register 2016, No.
7).
Note: Authority cited: Section
20, Health and Safety Code;
Sections
10725,
14021,
14021.3,
14021.5,
14021.6,
14021.30,
14021.51,
14043.75,
14124.1,
14124.24,
14124.26
and
14124.5,
Welfare and Institutions Code; Statutes of 2011, Chapter 32, and Statutes of
2012, Chapter 36. Reference: Sections
14021,
14021.3,
14021.5,
14021.6,
14021.33,
14021.51,
14043.7,
14053,
14107,
14124.1,
14124.2,
14124.20,
14124.21,
14124.24,
14124.25,
14124.26,
14131,
14132.21,
14132.905,
14133
and
14133.1,
Welfare and Institutions Code; Sections
436.122,
456.21,
456.22 and
456.23, Title 42, Code of Federal
Regulations; Statutes of 1996, Chapter 162, Items 4200-101-0001 and
4200-102-0001; and Statutes of 2011, Chapter 32, and Statutes of 2012, Chapter
36.
1. New
section filed 12-14-95 as an emergency; operative 12-14-95 (Register 95, No.
50). A Certificate of Compliance must be transmitted to OAL by 4-12-96 or
emergency language will be repealed by operation of law on the following
day.
2. Repealed by operation of Government Code section
11346.1
(Register 96, No. 16).
3. New section filed 4-16-96 as an emergency;
operative 4-16-96 (Register 96, No. 16). A Certificate of Compliance must be
transmitted to OAL by 8-14-96 or emergency language will be repealed by
operation of law on the following day.
4. Certificate of Compliance
as to 4-16-96 order transmitted to OAL 8-13-96 and filed 9-25-96 (Register 96,
No. 39).
5. Amendment of section and Note filed 5-12-97 as an
emergency; operative 5-12-97 (Register 97, No. 20). A Certificate of Compliance
must be transmitted to OAL by 9-9-97 or emergency language will be repealed by
operation of law on the following day.
6. Amendment of section
heading, section and Note filed 6-30-97 as an emergency; operative 7-1-97
(Register 97, No. 27). A Certificate of Compliance must be transmitted to OAL
by 10-29-97 or emergency language will be repealed by operation of law on the
following day.
7. Certificate of Compliance as to 5-12-97 order
transmitted to OAL 8-13-97 and filed 9-23-97 (Register 97, No.
39).
8. Amendment of section heading, section and Note refiled
10-6-97 as an emergency; operative 10-29-97 (Register 97, No. 41). A
Certificate of Compliance must be transmitted to OAL by 2-26-98 or emergency
language will be repealed by operation of law on the following
day.
9. Amendment of section heading, section and Note refiled
1-14-98 as an emergency; operative 2-26-98 (Register 98, No. 3). A Certificate
of Compliance must be transmitted to OAL by 6-26-98 or emergency language will
be repealed by operation of law on the following day.
10.
Certificate of Compliance as to 1-14-98 order, including further amendment of
section heading, section and Note, transmitted to OAL 6-11-98 and filed 6-29-98
(Register 98, No. 27).
11. Change without regulatory effect amending
subsection (p)(1)(E) filed 5-17-2006 pursuant to section 100, title 1,
California Code of Regulations (Register 2006, No. 20).
12. Change
without regulatory effect amending section heading, section and Note filed
12-16-2013 pursuant to section 100, title 1, California Code of Regulations
(Register 2013, No. 51).
13. Amendment of section and Note filed
6-25-2014 as an emergency; operative 6-25-2014 (Register 2014, No. 26). A
Certificate of Compliance must be transmitted to OAL by 12-22-2014 or emergency
language will be repealed by operation of law on the following
day.
14. Amendment of section and Note refiled 12-17-2014 as an
emergency pursuant to Welfare and Institutions Code section
14124.26(c)(2);
operative 12/22/2014
(Register
2014, No. 51). A Certificate of Compliance must be transmitted to
OAL by 6-22-2015 pursuant to Welfare and Institutions Code section
14124.26(c)(2)or
emergency language will be repealed by operation of law on the following
day.
15. Certificate of Compliance as to 12-17-2014 order, including
amendment of (h)(1)(A)(v) and new subsections (h)(1)(A)(v)(a)-(b), transmitted
to OAL 6-4-2015 and filed 7-14-2015; amendments effective
7/14/2015 pursuant to Government
Code section
11343.4(b)(3)
(Register
2015, No. 29).
16. New subsections (b)(28)-(b)(28)(B)
and subsection renumbering filed 8-17-2015 as a deemed emergency exempt from
OAL review pursuant to Welfare and Institutions Code section 14043.75;
operative 8-17-2015 (Register 2015, No. 34). A Certificate of Compliance must
be transmitted to OAL by 2-16-2016 or emergency language will be repealed by
operation of law on the following day.
17. Certificate of
Compliance as to 8-17-2015 order transmitted to OAL 12-30-2015 and filed
2-11-2016 (Register 2016, No. 7).