PROPOSAL
Maryland Register
Issue Date: December 9, 2016
Volume 43 • Issue 25• Pages 1402—1404
Title 10
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Subtitle 09 MEDICAL CARE PROGRAMS
10.09.80 Community-Based Substance Use Disorder Services
Authority: Health-General Article, §§2-104(b), 7.5-204, 7.5-402, 15-103(a)(1), and 15-105(b), Annotated Code of Maryland
Notice of Proposed Action
[16-330-P]
The Secretary of Health and Mental Hygiene proposes to amend Regulations .01, .05, .06, and .08 under COMAR 10.09.80 Community-Based Substance Use Disorder Services.
Statement of Purpose
The purpose of this action is to change methadone reimbursement to better align service delivery with payment. The proposal includes a new bundled rate specifically for medication assisted treatment services and a separate reimbursement for Level 1 counseling services when delivered by appropriately licensed professionals. This proposal adds the ability for opioid treatment programs to be reimbursed separately for services, including an induction service of the selected medication (methadone or buprenorphine), periodic medication management visits, and guest dosing services.
An additional purpose of this proposal is to update regulations to allow certified or licensed addictions programs (provider type 50s) who employ a DATA 2000 waiver physician to be reimbursed for periodic medication management visits and the cost of buprenorphine itself through their certified addictions program.
Comparison to Federal Standards
There is no corresponding federal standard to this proposed action.
Estimate of Economic Impact
The proposed action has no economic impact.
Economic Impact on Small Businesses
The proposed action has minimal or no economic impact on small businesses.
Impact on Individuals with Disabilities
The proposed action has no impact on individuals with disabilities.
Opportunity for Public Comment
Comments may be sent to Michele Phinney, Director, Office of Regulation and Policy Coordination, Department of Health and Mental Hygiene, 201 West Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY 800-735-2258), or email to dhmh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through January 9, 2017. A public hearing has not been scheduled.
.01 Definitions.
A. (text unchanged)
B. Terms Defined.
(1)—(4) (text unchanged)
(5) “DATA 2000 waived provider” means a physician who has received a waiver under the Drug Addiction and Treatment Act of 2000 which expands the clinical context of medication assisted opioid dependency treatment and permits qualified physicians to dispense or prescribe certain narcotic medications that have a lower risk of abuse, like buprenorphine, in settings other than an opioid treatment program.
[(5)] (6)—[(10)] (11) (text unchanged)
[(11)] (12) “Office of Health Care Quality (OHCQ)” means the office within the Department responsible for certification and inspection of programs for the Behavioral Health Administration.
[(12)] (13)—[(18)] (19) (text unchanged)
.05 Covered Services.
A. Comprehensive substance use disorder assessment at a minimum shall:
(1) Be delivered through an:
(a) OHCQ certified or licensed substance use disorder treatment provider; or
(b) Opioid treatment program;
(2) Be completed before providing the community based behavioral health services listed in §§B—I of this regulation;
[(1)] (3)—[(2)] (4) (text unchanged)
B. Level 1 group and individual substance use disorder counseling shall [include]:
(1) Be delivered through an:
(a) OHCQ certified or licensed substance use disorder treatment provider; or
(b) Opioid treatment program;
[(1)] (2) [Services] Include services for participants who require less than 9 hours weekly for adults and 6 hours weekly for adolescents; and
[(2)] (3) [A] Include a written individualized treatment plan, with the participation of the participant based on the comprehensive assessment that shall:
(a)—(b) (text unchanged)
[(3)] (4) [Family] Include family members, if necessary, as long as the participant is also present in a Level 1 group counseling session.
C. Level 2.1 Intensive Outpatient services shall [include]:
(1) Be delivered through an OHCQ certified or licensed substance use disorder treatment provider only;
[(1)] (2) [Services] Include services for participants who require outpatient treatment for 9 or more hours weekly for an adult and 6 or more hours weekly for an adolescent;
[(2)] (3) [A] Include a written individualized treatment plan, with the participation of the participant based on the comprehensive assessment that shall:
(a)—(b) (text unchanged)
[(3)] (4) [A] Include a discharge plan, which includes written recommendations to assist the participant with continued recovery efforts, as well as appropriate referral services.
D. Level 2.5 partial hospitalization services shall [include]:
(1) Be delivered through an OHCQ certified or licensed substance use disorder treatment provider;
[(1)] (2) [Services] Include services for participants who require a minimum of 20 hours weekly of structured outpatient treatment delivered in the following ways:
(a)—(b) (text unchanged)
[(2)] (3) [A] Include a written individualized treatment plan, with the participation of the participant based on the comprehensive assessment that shall:
(a)—(b) (text unchanged)
[(3)] (4) [A] Include a discharge plan, which includes written recommendations to assist the participant with continued recovery efforts, as well as appropriate referral services.
E. Ambulatory withdrawal management service shall:
(1) Be delivered through an OHCQ certified or licensed substance use disorder treatment provider;
(2) Include the following services as medically necessary:
(a) Administration and monitoring of medication, including administration and monitoring of psychotropic medication by qualified staff, as necessary; and
(b) Managing withdrawal symptoms;
(3) Include a participant progress note added to the participant’s record after each session.
F. Buprenorphine and other medication assisted treatment delivered by an OHCQ certified or licensed substance use disorder treatment provider that employs a DATA 2000 waived provider shall:
(1) Be delivered by a DATA 2000 waived provider;
(2) Include pharmacological interventions, including the use of FDA-approved opiate agonist and partial agonist treatment medications to provide treatment, support, and recovery to opioid-addicted participants;
(3) Include, at a minimum, medical services required to be provided by the Program that:
(a) Ensure that participants receive a dose adequate to alleviate withdrawal symptoms;
(b) Employ dose increases and behavior therapy before mandatory detoxification for participants continuing to use drugs;
(c) Establish participant dosing based on an individual need;
(d) Provide flexible dosage tapering and withdrawal management with dosage reductions at the participant’s request;
(4) Include ordering and administering non-narcotic drugs; and
(5) Include point of care presumptive drug testing that shall be:
(a) Presumptive in nature and performed at the point of care; and
(b) Capable of being read by direct optical observation only.
[E.] G. Opioid maintenance therapy service delivered through the use of methadone or buprenorphine by opioid treatment programs shall include:
[(1) A comprehensive substance use disorder assessment as described in §A of this regulation;]
[(2)] (1) (text unchanged)
[(3)] (2) The following services:
(a) (text unchanged)
(b) Point of care presumptive drug testing;
(c) Definitive drug testing when completed by a laboratory;
[(b)] (d) Substance use disorder and related counseling as recommended in the individualized treatment plan; [and]
(e) Periodic medication management; and
[(c)] (f) Ordering and administering non-narcotic drugs; [and]
(4) A discharge plan, which includes written recommendations to assist the participant with continued recovery efforts, as well as appropriate referral services[.]; and
(5) Guest dosing arrangements with other opioid treatment programs, as medically necessary.
[F.] H. [Buprenorphine] Medication assisted treatment induction service delivered by opioid treatment programs shall include the following services, as medically necessary:
[(1) A comprehensive substance use disorder assessment as described in §A of this regulation; and
(2) The following services as clinically indicated:]
[(a)] (1) Pharmacological interventions, including the use of one of the following FDA-approved opiate agonist and partial agonist treatment medications to provide treatment, support, and recovery to opioid-addicted participants[;]:
(a) Buprenorphine; or
(b) Methadone;
[(b)] (2)—[(c)] (3) (text unchanged)
[G. Buprenorphine maintenance therapy delivered by an opioid treatment program shall include:
(1) An individualized treatment plan that shall be reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law;
(2) The following services as clinically indicated:
(a) Pharmacological interventions, including the use of FDA-approved opiate agonist and partial agonist treatment medications to provide treatment, support, and recovery to opioid-addicted participants;
(b) Substance use disorder and related counseling as recommended in the individualized treatment plan;
(c) Medical services, including, but not limited to, those required to be provided by the Program that:
(i) Ensure that participants receive a dose adequate to alleviate withdrawal symptoms;
(ii) Employ dose increases and behavior therapy before mandatory detoxification for participants continuing to use drugs;
(iii) Establish participant dosing on an individual need;
(iv) Provide flexible dosage tapering at the participant’s request; and
(v) Include a withdrawal management plan with dosage reductions; and
(d) Ordering and administering non-narcotic drugs; and
(3) A discharge plan, which includes written recommendations to assist the participant with continued recovery efforts, as well as appropriate referral services.
H. Ambulatory withdrawal management service shall include:
(1) A comprehensive substance use disorder assessment as described in §A of this regulation;
(2) The following services as clinically indicated:
(a) Administration and monitoring of medication, including administration and monitoring of psychotropic medication by qualified staff, as necessary; and
(b) Managing withdrawal symptoms; and
(3) A participant progress note added to the participant’s record after each session.]
.06 Limitations.
A. (text unchanged)
B. Providers may not be reimbursed by the Program for:
(1)—(4) (text unchanged)
(5) Level 1 group or individual counseling during the same week as a Level 2.1 Intensive Outpatient treatment[,] or Level 2.5 Partial Hospitalization[, Buprenorphine Induction, or Buprenorphine Maintenance Therapy] service unless the participant has been discharged from or admitted to a new level of care[:];
(6) (text unchanged)
[(7) Opioid maintenance therapy delivered by an opioid treatment program during the same week as a Level 1 group or individual counseling session, Level 2.1 Intensive Outpatient treatment or Level 2.5 Partial Hospitalization;]
(7) Level 1 group or individual counseling during the same week as Level 1 group or individual counseling offered by another provider;
(8) (text unchanged)
[(9) Buprenorphine induction delivered by an opioid treatment program during the same week as a Level 1 group or individual counseling session, Level 2.1 Intensive Outpatient treatment, Level 2.5 Partial Hospitalization or Opioid Maintenance Therapy;]
[(10)] (9) Buprenorphine maintenance therapy delivered by an opioid treatment program, an OHCQ certified, or a licensed substance use disorder treatment provider during the same week as [a Level 1 group or individual counseling session, Level 2.1 Intensive Outpatient treatment, Level 2.5 Partial Hospitalization or Opioid] Methadone Maintenance Therapy;
[(11)] (10) Ambulatory withdrawal management during the same week as [an opioid maintenance therapy, buprenorphine induction, or buprenorphine maintenance] services delivered by an opioid treatment program;
[(12)] (11) (text unchanged)
[(13)] (12) Services delivered by federally qualified health centers other than those billed using T-codes that may include the following delivered by two separate appropriately licensed providers:
(a) One T-code for mental health services per day with associated mental health procedure code; and
(b) One T-code for substance use disorder services with associated H-code per day;
[(14)] (13) Services rendered but not appropriately documented to the level of service;
[(15)] (14)—[(18)] (17) (text unchanged)
C.—E. (text unchanged)
F. The Department shall pay participating opioid treatment programs, per participant, per week provided the participant received ongoing opioid treatment medications and at least one face-to-face documented treatment service in the [week] month for which the Program is billed.
G. In order for an opioid treatment program to bill for [buprenorphine] medication assisted treatment induction, the provider shall bill this service only in the first week of treatment per participant or in the first week of treatment after a break from treatment of at least 6 months.
H.—I. (text unchanged)
J. All drug screening lab claims submitted to the ASO by providers other than opioid treatment programs shall list the applicable substance use disorder diagnosis.
.08 Payment Procedures.
A.—C. (text unchanged)
D. [Rates] Effective July 1, 2016, rates for the services outlined in this regulation shall be as follows:
(1) For services outlined in this regulation, as delivered through an OHCQ certified or licensed substance use disorder treatment provider:
[(1)] (a) Comprehensive substance use disorder assessment — [$142] $144.82;
[(2)] (b) Level 1 group substance use disorder counseling — [$39] $39.78 per session;
[(3)] (c) Level 1 individual substance use disorder counseling — [$20] $20.40 per 15-minute increment with a maximum of six 15-minute increments per day;
[(4)] (d) Level [2.5] 2.1 Intensive Outpatient treatment — [$125] $127.50 per diem;
[(5)] (e) Level 2.5 Partial Hospitalization half day session — [$130] $132.60 per diem;
[(6)] (f) Level 2.5 Partial Hospitalization full day session — [$210] $214.20 per diem;
[(7) Opioid Maintenance Therapy — $80 per participant per week;
(8) Buprenorphine Induction — $200 per participant per week;
(9) Buprenorphine Maintenance Therapy — $75 per participant per week; and]
[(10)] (g) Ambulatory Withdrawal Management — [$70] $71.40 per diem[.];
(h) Point of care presumptive drug test — $11.81 per test; and
(i) Buprenorphine and other medication assisted treatment through office based evaluation and management visits, according to COMAR 10.09.02.07D.
(2) For services outlined in this regulation as delivered through an opioid treatment programs:
(a) Comprehensive substance use disorder assessment —$144.84;
(b) Level 1 group substance use disorder counseling —$39.78 per session;
(c) Level 1 individual substance use disorder counseling —$20.40 per 15-minute increment with a maximum of six 15-minute increments per day;
(d) Opioid Maintenance Therapy —$63.00 per participant per week;
(e) Medication Assisted Treatment Induction —$204 per participant per week;
(f) Buprenorphine Maintenance Therapy —$56.00 per participant per week; and
(g) Periodic medication management through office based evaluation and management visits, according to COMAR 10.09.02.07D.
E.—G. (text unchanged)
VAN T. MITCHELL
Secretary of Health and Mental Hygiene
