Skip to main content

Substance Use Disorder Benefits to Change for Texas Medicaid January 1, 2019

Last updated on 11/16/2018

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after January 1, 2019, substance use disorder (SUD) benefits will change for Texas Medicaid.

Overview of Benefit Changes

Major changes to this medical benefit policy include the following:

  • Updated benefit language
  • Prior authorization changes
  • Procedure code updates
  • Diagnosis code updates

Updated Benefit Language

SUDs are chronic, relapsing medical illnesses that require an array of best practice medical and psychosocial interventions of sufficient intensity and duration to achieve and maintain remission and support progress toward recovery. SUD may include problematic use of alcohol, prescription drugs, illegal drugs (e.g., cannabis, opioids, stimulants, inhalants, hallucinogens, “club” drugs, other synthetic euphoriants), and other substances that may be identified in the future.

Treatment for SUD is a benefit of Texas Medicaid for individuals who meet the criteria for a substance-related disorder, as outlined in the current edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).

SUD treatment services are individualized, age-appropriate medical and psychosocial interventions designed to treat an individual’s problematic use of alcohol or other drugs, including prescription medication.

SUD services may include the following:

  • Withdrawal management services
  • Individual and group SUD counseling in an outpatient setting
  • Residential treatment services
  • Medication assisted treatment
  • Evaluation and treatment (or referral for treatment) for co-occurring physical and behavioral health conditions

Level of care (e.g., outpatient, residential, inpatient hospital) and specific services provided must adhere to current evidence-based industry standards and guidelines for SUD treatment, such as those outlined in the current edition of the American Society of Addiction Medicine’s Treatment Criteria for Addictive Substance-Related and Co-Occurring Conditions, as well as the licensure requirements outlined in Texas Administrative Code (TAC) Title 25 Chapter 448 pertaining to Standards of Care.

SUD treatment services (outpatient or residential) may only be delivered in a licensed chemical dependency treatment facility (CDTF). Medication assisted treatment (MAT) may also be delivered by appropriately trained physicians, nurse practitioners (NPs), clinical nurse specialists (CNSs), and physician assistants (PAs) in the office setting.

SUD withdrawal management in an inpatient hospital setting may be provided for individuals who meet hospital level of care requirements as a result of the severity of their withdrawal syndrome and/or the severity of their co-occurring conditions. These services may be reimbursed as general hospital inpatient services.

The treatment setting and the intensity or level of services will vary depending on the severity of the individual’s SUD and what is clinically appropriate. The intensity or level of services refers to the number of hours of services per week, as well as the types of services the individual receives.

Upon admission into a treatment setting, a face-to-face multi-dimensional assessment must be conducted by a qualified credentialed counselor (QCC) or intern as defined in DSHS TAC §448.101 to determine a course of treatment that is medically necessary and clinically appropriate. The assessment must be signed off by a QCC.

Evaluation, Treatment, or Referral for Co-Occurring Conditions

CDTFs shall facilitate access to physical health, mental health, and ancillary services if those services are not available through the program and are necessary to meet treatment goals or individual needs.

Individuals in residential CDTFs commonly require medications unrelated to their SUD treatment for which costs are not covered in the reimbursement for SUD or MAT services. These medications, if included in the Medicaid formulary, may be obtained and reimbursed through the individual’s Medicaid pharmacy benefit.

Individuals in residential CDTFs also commonly require other services that are benefits of Texas Medicaid, but not included in the CDTF rate. Claims for these services can be submitted by the appropriate providers.

CDTFs should screen each individual for risk for contracting tuberculosis, Hepatitis B and C, HIV antibody, and sexually transmitted infections, and if appropriate, provide access to testing and follow up. Testing may be performed on site and billed by the ordering provider if appropriate testing facilities are available that are compliant with the rules and regulations for the Clinical Laboratory Improvement Amendments (CLIA). Providers that do not comply with CLIA are not reimbursed for laboratory services.

Withdrawal Management Services

Withdrawal management, formerly known as detoxification, is the medical and behavioral treatment of individuals experiencing or potentially experiencing withdrawal symptoms as a result of ceasing or reducing substance use.

Withdrawal management involving opioids, alcohol, sedatives, hypnotics, or anxiolytics will vary depending on the severity of the withdrawal symptoms experienced but will typically involve medications to treat symptoms in addition to supportive care, observation, and monitoring. Withdrawal management involving stimulants, inhalants, and cannabis typically involves supportive care, observation and monitoring, and medications to treat withdrawal symptoms as required.

Withdrawal management may be performed in an outpatient setting for individuals experiencing mild to moderate withdrawal symptoms that can be successfully, as well as safely, managed outside of a residential setting or an inpatient hospital. Withdrawal management in a residential setting may be required for individuals whose multidimensional assessment indicates one or more of the following circumstances that would make outpatient withdrawal management unsafe and/or unsuccessful:

  • A level of severity of withdrawal, medical, and/or mental health complication
  • Sufficient challenges with readiness to change, ability to stop using, and/or social support

Withdrawal management in an inpatient hospital setting may be required for individuals whose severity of medical withdrawal (e.g., impending delirium tremens, severe withdrawal seizures), comorbid medical conditions (e.g., severe liver impairment, acute pneumonia, endocarditis, dementia), and/or comorbid psychiatric conditions (e.g., severe suicidality, acute and unstable psychosis or mania) requires a hospital level of care.

Individual and Group SUD Counseling in an Outpatient Setting

Counseling for substance use disorders is designed to assist individuals in developing a better understanding of their SUD, help to establish treatment goals and plans for achieving those goals, and provide interventions to assist individuals in accordance with the plan. The overall intent of the service is to assist individuals in understanding their SUD and developing the skills and supports needed to address their SUD over time. Counseling may be done individually or in a group setting with multiple members. Group counseling sessions are limited to a total of 16 individuals per session.

Outpatient counseling services are appropriate for the following:

  • Individuals with less severe disorders
  • Individuals who are in the early stages of change
  • As a step down from more intensive services
  • Individuals who are stable but for whom ongoing monitoring is appropriate

Note: For individuals unable or unwilling to access SUD treatment services at a CDTF, psychotherapy delivered by a licensed practitioner of the healing arts (LPHA) may be an alternative treatment option to address an individual’s SUD.

Outpatient services may be appropriate at the start of treatment, throughout treatment, or after an episode of residential or inpatient treatment, depending on individual acuity, severity, comorbidity, needs, or preferences. Outpatient services can address active symptoms as well as provide ongoing treatment for individuals in partial or full remission who need continuing help to maintain progress. Abstinence should not necessarily be a requirement for participation in outpatient services.

Residential Treatment Services

Residential treatment programs provide a structured therapeutic environment where individuals reside with staff support and deliver comprehensive substance use disorder treatment with attention to co-occurring conditions as appropriate. The frequency and duration of services should be based on meeting the individual’s needs and achieving the individual’s treatment goals.

Residential services are appropriate for individuals who require a structured therapeutic environment to stabilize SUD and develop coping and recovery skills. Residential treatment programs may specialize in the unique needs of a specific population such as adolescents, or pregnant or parenting women with children.

Episodes of residential treatment may be required for individuals with more severe SUD, more significant medical or psychiatric comorbidities, more significant challenges with sustaining motivation or maintaining control in an outpatient setting, and/or a living environment that jeopardizes their current ability to be successful in outpatient treatment.

Residential SUD treatment services may only be provided by a licensed CDTF.

Medication Assisted Treatment

MAT is the use of FDA-approved medications in combination with psychosocial treatment to treat substance use disorders, particularly alcohol and opioid use disorders.

MAT is a recognized best practice for alcohol use disorder (AUD) and opioid use disorder (OUD). All individuals with AUD and OUD should be educated about the availability of MAT and the evidence supporting MAT and have the opportunity to receive MAT regardless of where they are receiving SUD services. This could be accomplished on site or through a written agreement with a collaborating opioid treatment program (OTP) or office-based opioid treatment (OBOT) program.

Initiation or induction of MAT can appropriately occur in lieu of withdrawal management for opioid use disorders, may begin early in withdrawal management for either AUD or OUD, and can be initiated as appropriate at any point in time during the course of treatment. Duration of MAT is determined on an individual basis, depending on the individual’s unique needs and treatment goals.

Determination of which MAT medication to use is also an individualized treatment decision based on provider assessment and the individual’s needs and treatment goals. Providers are encouraged to offer as many treatment options as possible (within the parameters of their licensing and scope of practice) to maximize the individual’s choice and access to care.

MAT may be utilized as appropriate, as part of the service array delivered by outpatient providers or residential treatment services programs at CDTFs.

Opioid treatment programs (also referred to as narcotic treatment programs) are the only settings permitted by law to provide methadone for OUD and must comply with additional federal and state requirements, rules on licensure and scope of practice, including physician delegation, supervision, and prescriptive authority. Opioid treatment programs can also provide or administer other forms of MAT.

CDTFs, physicians, NPs, and PAs may prescribe and provide for the administration of long acting injectable naltrexone (Vivitrol) to treat cravings associated with either opioid use disorder or alcohol use disorder.

Physicians, NPs, and PAs who have received a federal waiver to dispense buprenorphine may choose to incorporate this form of MAT into their medical practice while also providing or referring for other types of treatment services (also referred to as OBOT).

Certain MAT medications to treat alcohol and opioid use disorders (such as buprenorphine, disulfiram, acamprosate, and naltrexone), are available as a pharmacy benefit and may be prescribed to individuals by their physician or other qualified health care professional. Providers may refer to the Vendor Drug Program Formulary for additional information on covered medications.

Prescribing of certain MAT medications may be done via telemedicine presuming all other applicable state and federal laws are followed.

A prescription for an opioid antagonist (e.g., naloxone) should be given to all individuals receiving treatment for opioid use disorder, and instruction should be provided on how to administer if needed.

Claims for urinalysis drug screens ordered by a physician, NP, or CNS to monitor compliance with MAT may be submitted by the individually-enrolled physician or other qualified health-care professional.

The following MAT procedure codes may be separately reimbursed from withdrawal management and treatment services in the outpatient or residential setting:

Procedure Codes

H0020

H2010

J0570

J2315

Q9991

Q9992

Exclusions

SUD treatment services for tobacco use disorder as the primary diagnosis are not a covered benefit, although a comprehensive SUD treatment approach should address tobacco use if reducing or eliminating this substance is part of the individual’s treatment goal.

With the exception of prescribing MAT medications via telemedicine, SUD treatment services may not be delivered via telemedicine or telehealth.

Prior Authorization Changes

All prior authorization requests must be completed and signed by a Qualified Credentialed Counselor (QCC).

Prior authorization requests for outpatient treatment services beyond the annual limitation of 135 units of group services and 26 hours of individual services per calendar year will no longer be limited to individuals who are 20 years of age and younger. Requests may be submitted for individuals of any age.

Prior authorization may be considered for individuals enrolled in a Medicaid MCO when admitted to SUD services, and whose eligibility changes to fee-for-service during treatment. Requests must be submitted within three business days after the date that fee-for-service eligibility started.

Revised Forms

Beginning January 1, 2019, the following revised prior authorization forms are to be used when submitting prior authorization requests:

  • Outpatient Withdrawal Management Authorization Request Form
  • Outpatient Substance Use Disorder Counseling Extension Request Form
  • Residential Withdrawal Management Authorization Request Form
  • Residential Substance Use Disorder Treatment Request Form (Revised August 31, 2018)

The following forms will no longer be accepted after January 31, 2019:

  • Ambulatory (Outpatient) Detoxification Authorization Request Form
  • Ambulatory (Outpatient) Substance Use Disorder Counseling Extension Request Form
  • Residential Detoxification Authorization Request Form
  • Residential Substance Use Disorder Treatment Request Form (Revised February 1, 2016)

If the discontinued forms are submitted on or after February 1, 2019, TMHP will return the form to the provider with a request that the revised form be submitted with all required documentation.

Providers may refer to the article titled, "Revised Prior Authorization Forms for Substance Use Disorder Services to be Effective January 1, 2019," which was published on this website November 16, 2018, for additional information about the revised forms.

Procedure Code Updates

Modifiers HF and HG will no longer be required to identify the SUD services performed.

The following providers will be added as payable for procedure codes H2010 and J2315:

Procedure Code

Place of Service

Provider Type

H2010

Office setting

NP, CNS, PA providers

J2315

Outpatient setting

CDTF

Diagnosis Codes

The following diagnosis codes will be added as payable for procedure codes H0004 and H0005:

Diagnosis Codes

F10121

F1014

F10150

F10151

F10180

F10181

F10182

F10221

F10231

F1024

F10250

F10251

F1026

F1027

F10280

F10282

F10921

F1094

F10950

F10951

F1096

F1097

F10980

F10981

F10982

F11121

F11122

F11129

F1114

F11150

F11151

F11221

F1123

F1124

F11250

F11251

F1190

F11921

F1193

F1194

F11950

F11951

F12121

F12150

F12151

F12221

F12250

F12251

F1290

F12921

F12950

F12951

F1310

F13121

F1314

F13150

F13151

F1319

F13221

F13230

F13231

F13232

F13239

F1324

F13250

F13251

F1326

F1327

F1329

F1390

F13921

F13930

F13931

F13932

F13939

F1394

F13950

F13951

F1396

F1397

F14121

F1414

F14150

F14151

F14221

F1423

F1424

F14250

F14251

F1490

F14921

F1494

F14950

F14951

F15121

F1514

F15150

F15151

F15221

F1523

F1524

F15250

F15251

F1590

F15921

F1593

F1594

F15950

F15951

F16121

F1614

F16150

F16151

F1621

F16221

F1624

F16250

F16251

F1690

F16921

F1694

F16950

F16951

F18121

F1814

F18150

F18151

F1817

F18221

F1824

F18250

F18251

F1827

F1890

F18921

F1894

F18950

F18951

F1897

F19121

F1914

F19150

F19151

F1916

F1917

F19221

F19230

F19231

F19232

F19239

F1924

F19250

F19251

F1926

F1927

F1990

F19921

F19930

F19931

F19932

F19939

F1994

F19950

F19951

F1996

F1997

The following diagnosis codes will no longer be payable for procedure codes H0004 and H0005:

Diagnosis Codes

F17208

F17209

F17218

F17219

F17228

F17229

F17298

F17299

For more information, call the TMHP Contact Center at 800-925-9126.