Joint CMCS and SAMHSA Informational Bulletin 
 
 
DATE:  January 26, 2015 
 
FROM:  Vikki Wachino 
                        Acting Director 
Center for Medicaid and CHIP Services 
 
Pamela S. Hyde, J.D. 
Administrator 
Substance Abuse and Mental Health Services Administration 
 
SUBJECT:    Coverage of Behavioral Health Services for Youth with Substance Use 
                       Disorders 
  
 
This informational bulletin, based on evidence from scientific research and the results of a 
Substance Abuse and Mental Health Services Administration (SAMHSA)-supported technical 
expert panel consensus process,1 is intended to assist states to design a benefit that will meet the 
needs of youth with substance use disorders (SUD) and their families and help states comply 
with their obligations under Medicaids Early and Periodic Screening, Diagnostic, and Treatment 
(EPSDT) requirements. The services described in this document are designed to enable youth to 
address their substance use disorders, to receive treatment and continuing care and to participate 
in recovery services and supports. This bulletin also identifies resources that are available to 
states to facilitate their work in designing and implementing a benefit package for these youth 
and their families.    
   
 Background 
 
Brain development during adolescence and emerging adulthood is one element that makes 
youth a period of particularly high vulnerability to SUDs.2 Adolescence is the time most of the 
people who become addicted develop their addiction More than 90 percent of adults with SUDs 
started using before age 18; half of those began before age 15. Individuals who begin drinking 
before age 14 are seven times more likely to develop alcohol dependence than those who begin 
                                                           
1 Substance Abuse and Mental Health Services Administration. (2013). What does the research tell us about good and modern 
treatment and recovery services for youth with substance use disorders? Report of the SAMHSA Technical Expert Panel, 
December 56, 2011. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services 
Administration. 07/01/13 Draft. 
2 SAMHSA, What does the research tell us, p. 44   CMCS Informational Bulletin  Page 2 
 
drinking at age 21.3  The earlier a person begins using, the more likely the substance use disorder 
will develop and continue into adulthood.4  
 
About 6.1 percent of adolescents between the ages of 12 and 17 were classified as substance 
abusive or dependent (alcohol or illicit drugs) in 2012.5,6 The rate of substance abuse or 
dependence among young adults aged 1825 was 18.9 percent7 in 2012.  In addition, abuse of 
prescription drugs is high among youth aged 12 to 17.  In 2010, 3.0 percent of youth reported 
past-month nonmedical use of prescription medications.  Youth who abuse prescription 
medications are also more likely to report use of other drugs. Multiple studies have revealed 
associations between prescription drug abuse and higher rates of cigarette smoking; heavy 
episodic drinking; and marijuana, cocaine, and other illicit drug use among adolescents, young 
adults, and college students.   
 
Youth with SUDs also have high rates of co-occurring mental health disorders.  SUDs increases 
the risk for mental health disorders and vice versa, and the majority of youth with SUDs have a 
co-occurring mental health disorder. In a study of data from the Global Appraisal of Individual 
Needs (GAIN), approximately 90 percent of substance-dependent adolescents under age 15 had 
at least one mental health problem in the past year.8 Furthermore, approximately 88 percent of 
the substance-dependent adolescents between ages 15 and 17 and 84 percent of the young adults 
aged 1825 had co-occurring mental health issues.9  
 
Youth with SUDs also face considerable academic, health-related, relational, and legal 
challenges. These issues also bring costs and consequences to families, communities, and 
society.10  
 
Technical Expert Panel 
 
Unlike other populations with behavioral health conditions, there is a lack of guidance regarding 
the treatment, continuing care and recovery supports needed for youth with SUDs or youth with 
SUDs and co-occurring mental health disorders.  Because the growing body of research on youth 
with SUDs had not been systematically collated, reviewed and translated into practice guidelines, 
SAMHSA convened a technical expert panel comprised of nationally-recognized researchers to 
review the existing literature and utilize a structured process to identify what the research tells us 
about treatment and recovery services for youth with SUDs.   
 
                                                           
3 Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012 National Survey on Drug Use and 
Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance 
Abuse and Mental Health Services Administration, p. 6 
4 Lynskey, M.T. et al. (2003).  Escalation of drug use in early-onset cannabis users vs co-twin controls. JAMA 289:427-33 
5 Dependence or abuse is based on definitions found in the fourth edition of the Diagnostic and Statistical Manual of Mental 
 
Disorders (DSM-IV).
6 2012 National Survey on Drug Use and Health, Table 5.4B 
7 2012 National Survey on Drug Use and Health,  Table 5.4B 
8 Chan, Y., Dennis, M., & Funk, R.. (2008) Prevalence and comorbidity of major internalizing and externalizing problems among 
adolescents and adults presenting to substance abuse treatment. Journal of Substance Abuse Treatment (34), p. 19 
9 Chan, Dennis, & Funk, R.. Prevalence and comorbidity, p. 19 
10 Crowe, A., & Bilchik, S. (1998). Drug identification and testing in the juvenile justice system. Washington, DC: Office of 
 
Justice Programs, U.S. Department of Justice. Available from http://www.ojjdp.gov/pubs/drugid/contents.html
 
   CMCS Informational Bulletin  Page 3 
 
In discussing the optimal benefit design to provide effective treatment for youth with SUDs, 
technical expert panel members affirmed that practice must be rooted in the emerging 
neuroscience research in conjunction with the ever-growing psychosocial treatment effectiveness 
research. They stressed that treatment approaches must be developmentally appropriate and 
incorporate an understanding of the importance of family.   
 
Selected Components of a Continuum of Services and Supports 
 
The consensus findings from the technical expert panel suggest a continuum of treatment and 
recovery services and supports for youth with SUDs. The following section identifies selected 
components of a continuum of services to identify, treat, maintain gains and support recovery for 
youth with substance use or substance use and co-occurring mental health disorders.  
 
Identification 
 
There is evidence that the short- and long-term impact of substance use on the brain suggests 
priority must be given to the screening and early identification of SUDs in youth.11 Because of 
the high rate of co-occurring disorders, every youth should be screened for both substance use 
and mental health disorders wherever they present. Youth with positive screens must be assessed 
with an evidence-based, comprehensive psychosocial assessment instrument that assists in 
identifying the level of severity of substance use disorder and/or substance use and mental health 
disorder and suggests the appropriate level of care.12 
 
Screening 
Screening is essential for identifying and addressing SUDs as early as possible. Screening tools 
are brief self-reports or interviews used as the first step in the process of evaluating whether a 
youth may or may not have an alcohol or drug problem. The outcome of a screening is to 
determine the need for further, more comprehensive assessment. Significant advancements in 
early detection of substance use conditions (including co-occurring mental health conditions) 
have taken place over the past decade. Numerous validated screens are available for use by 
medical professionals, and extensive research has proven them effective. Recommended 
screening tools for adolescents and young adults can be found at: 
http://store.samhsa.gov/product/Identifying-Mental-Health-and-Substance-Use-Problems-of-
Children-and-Adolescents-A-Guide-for-Child-Serving-Organizations/SMA12-4700  
 
Assessment 
An assessment is an integrated series of procedures conducted to provide the basis for an 
individualized treatment or service plan. An assessment should include an intensive evaluation of 
a youths clinical and psychosocial needs and functional level. This service may be conducted by 
an individual provider or by a multi-disciplinary team and should include face-to-face interviews 
with the youth and his/her family and/or significant others, and collateral contacts to determine 
the individuals problems and strengths and to identify natural supports. The assessment should 
                                                           
11 SAMHSA, What does the research tell us, p. 45 
12 SAMHSA, What does the research tell us, p. 66 
 
   CMCS Informational Bulletin  Page 4 
 
inform the development of an initial treatment or service plan, which should include treatment, 
level of care, continuing care and recovery support recommendations and discharge criteria.13  
 
Outpatient Treatment for Youth with Substance Use Disorders 
 
There is evidence that the neurobiology of youth requires unique approaches to treatment for 
SUDs.14 The panel identified evidence that both psychotherapeutic and behavioral interventions 
affect the neurobiology of SUDs in youth. Panelists agreed that The body of controlled studies 
clearly shows that evidence-based psychosocial treatment for youth with SUDs is effective (e.g., 
reduces substance use for youth with SUDs). 15 Motivational enhancement therapy, 
motivational enhancement therapy/cognitive behavioral therapy, and family-based treatments 
each show effectiveness for treating youth with SUDs. The fidelity to and degree of 
implementation of evidence-based practices improves outcomes for youth with SUDs.16 They 
concluded that treatment approaches for youth with SUDs should be individualized to the 
youths specific developmental stage.17 
 
Outpatient treatment for youth with SUDs or substance use and co-occurring mental health 
disorders may be delivered through a number of traditional modalities. Examples of outpatient 
services include:  
 
Individual Counseling/Therapies 
Individual counseling and therapies assist a youth in achieving specific objectives of treatment or 
care for substance use or substance use and co-occurring mental health disorders through a one-
to-one therapeutic relationship. Individual therapy helps to resolve symptoms, increase 
functioning, and facilitate emotional and psychological well-being. Therapy is generally directed 
toward reducing psychosocial stress and teaching coping and problem-solving skills, using 
supportive and cognitive-behavioral approaches that assist the youth in achieving a level of 
functioning capable of supporting and sustaining recovery. 
 
Group Counseling 
Group counseling is a service to assist two or more individuals in achieving treatment objectives 
through the exploration of substance use and/or mental health disorders and their ramifications, 
including an examination of attitudes and feelings and, in the case of SUDs, considering 
alternative solutions and decision making with regard to alcohol and other drug related problems. 
This service focuses on the individuals adaptive skills, involving social interactions to facilitate 
emotional or psychological change, utilizing the shared experiences of the groups members.  
 
Family Therapy 
Family therapy involves the youth and members of his or her family. Family may involve 
members of a biological family or may include extended family members (e.g. grandparents), or 
members of a step-family, foster or adoptive family. This therapy assists families to address 
important issues that may interfere with the youths functioning in the family and the home 
                                                           
13 Draft Good and Modern Continuum of Care Service Definitions, p. 2-3
14 SAMHSA, What does the research tell us, p. 44 
15 SAMHSA, What does the research tell us, p. 46   
16 SAMHSA, What does the research tell us, p. 47 
17 SAMHSA, What does the research tell us, p. 44 
 
   CMCS Informational Bulletin  Page 5 
 
environment.  Family therapy is designed to enhance the individuals insight into family 
interactions, facilitate emotional support and develop alternative strategies to address issues, 
problems and needs.  
 
Intensive Outpatient Treatment 
Intensive outpatient programs (IOPs) differ from regular outpatient treatment as discussed on 
page 4, in terms of the amount of hourly involvement of the youth per week.  Intensive 
outpatient treatment generally provides 6-19 hours per week of services such as individual and 
group counseling, medication management, family therapy, educational groups, occupational and 
recreational therapy, and other therapies. Services are provided in amounts, frequencies, and 
intensities appropriate to the objectives of the treatment plan.18 Examples of IOP programs are 
after-school, day or evening and/or weekend intensive outpatient programs.19 IOP program 
services may be offered in any appropriate setting that meets state licensure or certification 
criteria.20 Co-occurring enhanced intensive outpatient programs offer psychiatric services 
appropriate to the patients mental health condition. Such services are available by telephone and 
on site, or closely coordinated off site.21   
 
Occasionally the youths progress in IOP no longer requires six hours of treatment per week, but 
the youth has not yet made enough stable progress to be referred to a less intensive outpatient 
program.22 In such cases, less than [. . .] six hours per week for adolescents as a transition step 
down in intensity should be considered as a continuation of the IOP program for one or two 
weeks. Such continuity allows for a smoother transition  to [an outpatient level of care] to avoid 
exacerbation and recurrence of signs and symptoms.23 
 
Intensive outpatient treatment differs from partial hospitalization programs in the intensity of 
clinical services that are directly available. Specifically, most intensive outpatient programs have 
less capacity to effectively treat patients who have substantial unstable medical and psychiatric 
problems than do partial hospitalization programs.24  
 
Partial Hospitalization 
Partial hospitalization programs, known in some areas as day treatment, generally feature 20 
or more hours of clinically intensive programming per week, as specified in the patients 
treatment plan.25 Partial hospitalization programs typically have direct access to psychiatric, 
medical and laboratory services, and thus are better able than [IOPs] to meet needs [. . .] which 
warrant daily monitoring or management but which can be appropriately addressed in a 
structured outpatient setting. 26 Services may include individual and group counseling, 
medication management, family therapy, educational groups, occupational and recreational 
therapy, and other therapies. These are provided in the amounts, frequencies, and intensities 
                                                           
18American Society of Addiction Medicine (ASAM). (2013). The ASAM Criteria: Treatment criteria for addictive, substance-
related, and co-occurring conditions. 3rd ed.,  p. 199 
19 ASAM, p. 198 
20 ASAM, p. 198 
21 ASAM, p. 198 
22 ASAM, p. 198 
23 ASAM, p. 198 
24 ASAM, p. 198 
25 ASAM, p. 208
26 ASAM, p. 208 
 
 
   CMCS Informational Bulletin  Page 6 
 
appropriate to the objectives of the treatment plan.27 For adolescents, partial hospitalization 
often occurs during school hours; such programs typically have access to educational services for 
their adolescent patients [. . .] Partial hospitalization program services may be offered in any 
appropriate setting that meets state licensure or certification criteria.28  
 
In addition to the support systems just described for co-occurring capable programs, [partial 
hospitalization] co-occurring enhanced programs offer psychiatric services appropriate to the 
patients mental health condition. Such services are available by telephone and on site, or closely 
coordinated off site, within a shorter time than in a co-occurring capable program. Clinical 
leadership and oversight may be offered by a certified addiction medicine physician with at least 
the capacity to consult with an addiction psychiatrist. Some partial hospitalization services are 
specifically designed to be co-occurring disorders programs in distinction from addiction 
specialty services.29  
 
Medication-Assisted Treatment 
 
There is evidence that in studies with youth, medication-assisted treatment has been shown to 
work best in conjunction with psychosocial treatments and they supported that both counseling 
and case management should be used to facilitate symptom monitoring and medication 
adherence in youth with SUDs.30  
 
Medication-assisted treatment is the treatment of disease with medication(s) that is intended to 
provide a holistic, patient-centered approach to treating substance use and/or mental health 
disorders. Medication must be prescribed by a licensed physician, or other professionals working 
within their scope of practice to prevent, stabilize or ameliorate symptoms arising from a 
behavioral health condition or its treatment. The nature of the services provided (such as dose, 
level of care, and length of service or frequency of visits) is determined by the patients clinical 
needs. Medication-assisted treatment should be considered for adolescents with SUDs when 
clinically indicated, for example, in the situation of relapsive addictive disorders.  
 
There is evidence that pharmacotherapy is promising for treating youth with SUDs; however, 
they cautioned the neurobiology of youth requires unique approaches to pharmacotherapy for 
this population.31  It should be noted that the FDA has approved buprenorphine for opioid 
dependent adolescents age 16 and older. Methadone may also be used in youth ages 16-18 with 
special parameters in place. SAMHSA permits methadone for treatment of opioid use disorders 
in 16-17 year olds with parental consent and in programs specially licensed to provide treatment 
to this age group.  
 
Case Management/Targeted Case Management 
 
The technical expert panel found that low case load, higher fidelity to case management models 
and more time spent on key case management functions are associated with better outcomes for 
                                                           
27 ASAM, p. 210 
28 ASAM, p. 208 
29 ASAM, p. 208 
30 SAMHSA, What does the research tell us, p. 45 
31 SAMHSA, What does the research tell us, p. 45 
 
   CMCS Informational Bulletin  Page 7 
 
youth with SUDs.32 Case management should be developmentally appropriate and should 
include linkage to and monitoring of the youths access to needed medical, social, therapeutic, 
employment, transportation, education or other services that will support his/her overall health 
and wellness.33  The panel also found that case management should also include linkage to 
services for the parents and caregivers as needed.34 They cautioned that the effectiveness of 
case management may depend on the quality and availability of services in the community.35  
 
Using a family-centered, youth-guided, strengths-based case management approach that 
promotes the active participation of the youth, a case management plan should be developed 
after an initial assessment of skills, abilities and needs. The assessment may include 
consultations with families and caregivers and collaboration with physicians or other medical 
professionals. Monitoring and follow-up activities by the case manager ensure that a treatment or 
recovery plan is effectively implemented and adequately addresses the needs of the youth and 
those adjustments are made to the plan when necessary.  More information on case management 
models may be found at: 
http://www.ncbi.nlm.nih.gov/books/NBK64863/pdf/TOC.pdf  
 
Continuing Care   
  
The technical expert panel members found that Continuing care should be provided for all 
youth who enter treatment for SUDs regardless of treatment completion and that continuing 
care initiation within two weeks of leaving treatment improves outcomes for youth with 
SUDs.36 The panel stated that there should be an emphasis on providing youth a choice of 
continuing care services provided in a variety of settings.37  
 
Continuing care may involve home- or community-based weekly meetings with a clinician to 
discuss goals and activities; therapeutic sessions to assess status of use and motivation to change, 
to identify problem areas, and to provide skills or guidelines to address problems; and/or support 
and education for youth and their families. A number of continuing care service models, such as 
Assertive Continuing Care or other assertive outreach efforts are delivered during the first 90 
days after discharge. Assertive outreach approaches improve continuing care initiation and 
retention and enhance positive outcomes of treatment for youth with SUDs. 
 
Recovery Services and Supports 
 
The technical expert panel concluded that the field must focus on early initiation and 
engagement of youth with SUDs in recovery services which should be identified at the 
beginning of treatment, be included in the youth and family service plan, continue after 
discharge,38 and be offered in environments such as high schools, colleges, universities and 
                                                           
SAMHSA, What does the research tell us, p. 51
32SAMHSA, What does the research tell us, p. 51
33 SAMHSA, What does the research tell us, p. 51 
3354  SAMHSA, What does the research tell us, p. 51  
36  SAMHSA, What does the research tell us, p. 51  
37 SAMHSA, What does the research tell us, p. 51 
What does the research tell
38
 SAMHSA,   us, p. 52 
 
   CMCS Informational Bulletin  Page 8 
 
community youth recovery centers.39 They stated that Engagement in pro-social activities 
should be promoted as an essential component of youth treatment and recovery and that the 
implementation of recovery services should attract youth and be developmentally 
appropriate. 40 While the panel acknowledged that studies have demonstrated differential 
effectiveness of recovery support services based on the initial severity of the substance use 
disorder, they concluded that research indicates recovery support services can enhance and 
sustain treatment gains for youth with SUDs. 41 
 
Some examples of recovery services for youth with SUDs and their families include but are not 
limited to: 
 
Youth Peer-to-Peer Recovery Coaching/Peer Mentoring 
The technical expert panel members agreed that peer-to-peer supports are promising for youth in 
recovery and stated that there is a need to increase the availability of both individual and group-
based peer services.42 Peer supports are a set of peer-based activities that engage, educate and 
support a youth to successfully make behavioral changes necessary to recover from disabling 
substance use/mental health disorder conditions. This service is often used in conjunction with 
and in support of appropriate clinical interventions. Service activities include: assisting the 
individual in developing self-management strategies, conducting one-on-one support sessions, 
organizing structured pro-social activities, developing goals and recovery/wellness plans and 
providing crisis support and linkage to natural supports in the workplace and other environments. 
Youth should be matched to age- and developmentally-appropriate peer coaches or mentors who 
are stable in their recovery.  
 
Technological Support Services 
Technical expert panel members found that preliminary studies of the effectiveness of 
technology-based recovery supports are promising. They stated that research demonstrates 
the feasibility of implementing technology-based recovery supports for youth with SUDs and 
that the use of technology to deliver elements of treatment and recovery may result in 
resource (e.g., money, time) savings.43   
 
Technological support services consist of electronic activities designed to provide elements of a 
support system for youth in treatment/recovery that are accessible to youth and hosted in 
electronic platforms conducive to youth involvement. These services create and foster a 
moderated environment for support activities, and include but may not be limited to: making and 
maintaining connections and linkages; encouraging mutual assistance among those who have 
received services; facilitating peer-to-peer support; informing youth about recovery/wellness 
activities and improving retention in treatment/recovery service and supports.   
 
Technological support services may take a variety of forms, including social media, social 
networking sites, texts or emails. Technological support services can be used to communicate 
directly between a provider and an individual to provide reminders or to facilitate 
                                                           
39 SAMHSA, What does the research tell us, p. 53 
40 SAMHSA, What does the research tell us, p. 53
41 SAMHSA, What does the research tell us, p. 53 
42 SAMHSA, What does the research tell us, p. 52  
43 SAMHSA, What does the research tell us, p. 53I  
 
   CMCS Informational Bulletin  Page 9 
 
communication between multiple individuals for the purpose of supporting treatment, wellness 
and recovery. A clinician or therapeutic mentor may use technological support services to 
communicate directly with an individual client (ex. interactive text messaging, email, telephone 
calls, etc.) or on behalf of a client (e.g. texts and email reminders that do not require a personal 
reply). These electronic interactions need specific consent and must be done through secure 
mechanisms. For more information on confidentiality issues, please see 42 CFR information at: 
http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5&node=42:1.0.1.1.2 
 
Parent/Caregiver Support 
Technical expert panel members agreed that Services to families of youth with SUDs should 
include multiple delivery modes (e.g., individual or group meetings, parent-to-parent services, 
technology-based services).44 While panel members acknowledged variability in existing 
parent-to-parent support program components, measures, and results, they found that parent-to-
parent support is a promising approach to enhance treatment and recovery services for youth 
with SUDs.45 
 
The Parent/Caregiver Support service provides a structured one-to-one relationship between a 
parent/caregiver with lived experience who has personally faced the challenges of coping with 
a youth with SUD and parents/caregivers of youth who currently have substance use and/or 
mental health disorders. Services are designed to improve the parent/caregivers capacity to 
ameliorate or resolve the child/youths emotional or behavioral needs and strengthen their 
capacity to parent through educational support, instructional skills, development support, 
emotional and affirmative support, concrete services and advocacy support. Outcomes for 
parents or caregivers are expected to include youth remaining at home and attending school, 
reduced caregiver strain and caregiver empowerment and satisfaction. 
 
Residential Treatment 
 
The technical expert panel found that[residential treatment] is useful in interrupting the 
trajectory of increasing substance use in youth and may be important in addressing the 
exacerbation of substance use disorder symptoms linked to environmental triggers.46 It is 
effective for youth withdrawal management (detox) as well as for providing high intensity 
services for youth with substance use or co-occurring substance use and mental health 
disorders. Residential treatment may aid in reducing youth substance use from a level that 
necessitates residential treatment to a level of substance use more consistent with youth in 
outpatient treatment.47 
 
Residential treatment programs for SUDs offer organized treatment services that feature a 
planned and structured regimen of care in a residential setting.  Staffed 24 hours a day, they are 
typically clinically managed and may be medically monitored and provide short-term, intensive 
treatment and stabilization.  Treatment services adhere to defined policies, procedures and 
clinical protocols, emphasizing active treatment including individual and group therapy.  They 
                                                           
44 SAMHSA, What does the research tell us, p. 53 
45 SAMHSA, What does the research tell us, p. 53
46 SAMHSA, What does the research tell us, p. 48 
47 SAMHSA, What does the research tell us, p. 49  
 
   CMCS Informational Bulletin  Page 10 
 
are facilities where youth can reside safely.  Special attention is paid to linkage with outpatient 
services so that appropriate handoffs to less intensive levels of care occur. Mutual/self-help 
group meetings are usually available on-site.  
 
Residential treatment may coordinate and deliver a comprehensive array of therapeutic services 
which may include but not be limited to: individual, group, family or multi-family group 
therapies; medication-assisted withdrawal/treatment; crisis stabilization; peer to peer support; 
and case management.  
 
Medicaid Financing 
 
Youth with an SUD may be served by numerous systems through a number of funding sources 
when funders communicate effectively to coordinate and reimburse providers for the right 
services and treatments.  A critical funding source for many of the interventions set forth in this 
informational bulletin is Medicaid.  State Medicaid agencies have various options in the 
Medicaid program to cover services for youth with SUDs.   
 
There are some important informational bulletins and guidance that states could use in 
constructing a benefit package for youth with SUD.  For instance, states that are interested in 
developing peer supports for this population should review guidance sent to state Medicaid 
directors on peer supports.  Information regarding coverage of Caregiver supports was provided 
to states last year on an informational bulletin regarding youth with significant mental health 
conditions.  Early identification of youth with SUD was included in another informational 
bulletin.  In addition CMS and its federal partners released information regarding medication 
assisted treatment for individuals (including youth with SUD).  The Resource Section of this 
informational bulletin provides links to these informational bulletins and State Medicaid 
Directors.    
 
There are some important policies that currently exist that may limit a states ability to fully 
provide all of the components of the interventions in this informational bulletin.  For instance, 
payments for individuals in residential facilities should be consistent with CMS policies 
regarding room and board and the payment exclusion for Institutions for Mental Diseases.  In 
addition, educational services are not a Medicaid reimbursable service.   
 
1905(a) Authority 
 
Many of the services that are essential to the implementation of a full continuum of care for 
youth with SUDs may be covered through Title XIX, 1905(a) authority.  Identification and 
treatment for mental health and substance use issues and conditions is available under a number 
of Medicaid service categories, including hospital and clinic services, physician services, and 
services provided by a licensed professional such as a psychologist. States should also make use 
of rehabilitative services. While rehabilitative services can meet a range of childrens treatment 
needs, they can be particularly critical for children with mental health and substance use issues.  
For services such as family therapy or parent/caregiver support, services must address the 
adolescents goals in the treatment plan.   
 
 
   CMCS Informational Bulletin  Page 11 
 
 
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services 
 
EPSDT provides a comprehensive array of prevention, diagnostic, and treatment services for 
low-income infants, children and adolescents under age 21, as specified in Section 1905(r) of the 
Social Security Act (the Act). The EPSDT benefit is designed to assure that children receive 
early detection and care, so that health problems are averted or diagnosed and treated as early as 
possible.  EPSDT entitles enrolled infants, children, and adolescents to any treatment or 
procedure they require (as determined through an EPSDT screen) that is covered  within any of 
the categories of Medicaid-covered services listed in Section 1905(a) of the Act if that treatment 
or service is necessary to correct or ameliorate defects and physical and mental illnesses or 
conditions.    
1915(b) Authority 
 
1915(b) waivers are one of several options available to states that allow the use of managed care 
in the Medicaid Program. When using the 1915(b) authority, states have various options for 
implementing managed care including the authority to restrict the types of providers that people 
can use to access Medicaid benefits and the ability to use the savings to the state from a managed 
care delivery system to provide additional services or selectively contract with providers who 
can provide specific Medicaid services. Utah has used the 1915(b) authority to use selected 
managed care providers for services for youth with SUDs or co-occurring substance use and 
mental health disorders.  Information on this Waiver can be found at 
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Waivers/Downloads/UT_Utah-Prepaid-Mental-Health-Plan_UT-02.pdf  
 
1915(c) Authority  
 
Some states have used the 1915(c) Home and Community-Based Services (HCBS) waiver to 
develop comprehensive benefit designs that include additional supportive services for youth with 
co-occurring substance use and mental health disorders. States have used these waivers to 
expand their array of home and community-based services and supports for this population with 
a view towards improving outcomes and reducing costs. North Carolina uses combined 1915 (b) 
and (c) waivers for youth with substance use or co-occurring substance use and mental health 
disorders. Some of these services include respite and supported employment for older 
adolescents and young adults. More information is available from: 
http://www.ncdhhs.gov/MHDDSAS/providers/1915bcWaiver/index.htm 
 
1915(i) State Plan Amendment 
 
Section 1915(i) provides an opportunity for states to amend their state Medicaid plans to offer 
home and community-based behavioral health services that were previously provided primarily 
through 1915(c) HCBS waiver programs.  A state plan amendment (SPA) can include care 
coordination, respite, and parent and youth support, and other services HCBS for youth with 
substance use, mental health or co-occurring substance use and mental health disorders. Under 
1915(i) states may target services to particular population groups but cannot waive the 
requirement to provide services statewide, nor limit the number of participants in the state who 
 
   CMCS Informational Bulletin  Page 12 
 
may receive services if they meet the population definition. Unlike the 1915(c) waiver program, 
the 1915(i) delinks the provision of services with the requirement that participants must meet an 
institutional level of care. In order to target the initiative and limit costs, states may identify a 
specific population and establish additional needs-based criteria.  
 
Section 2703 Health Homes 
 
Health homes (Affordable Care Act-Section 2703) are a Medicaid state plan option available for 
states to design programs to better serve persons with chronic conditions, including substance 
use or co-occurring substance use and mental disorders. Health homes must provide for an 
individuals primary care and disability-specific service needs, and must provide care 
management and coordination for all of the services needed by each enrolled individual. The 
major goal is to provide more comprehensive, coordinated, and cost-effective care for 
individuals with chronic conditions, including youth with substance use, mental health or co-
occurring substance use and mental health disorders, than generally provided when services are 
fragmented across multiple health providers and organizations. 
 
The health home state plan optional benefit under section 1945 of the Social Security Act is 
statutorily-defined as services for eligible individuals with chronic conditions and does not 
allow for coverage to be limited the age of an individual. However, CMS recognizes that the 
service needs of individuals within a population may vary, and therefore that the treatment 
modalities, protocols and provider networks may involve different approaches for youth as 
compared to adults for key health home activities such as coordinating, managing and 
monitoring services. States may develop different approaches that serve different age groups, 
based on distinctions between the health home needs of the population. Therefore, CMS will 
allow states to submit separate SPAs for home health programs that target youth with substance 
use or co-occurring substance use and mental health disorders as long as another SPA for adults 
with substance use or co-occurring substance use and mental health disorders is submitted 
simultaneously. For more information visit Medicaid.govs Health Homes page:  
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-
Services-and-Supports/Integrating-Care/Health-Homes/Health-Homes.html  
 
1115 Authority  
 
In general, the existing Medicaid authorities, described above, provide states the flexibilities 
necessary to implement their desired reforms.  However, there may be instances when states may 
want to consider a Research and Demonstration Waiver under section 1115 of the Social 
Security Act.  Section 1115 allows the Secretary of Health and Human Services to waive certain 
statutory provisions, allowing for states to test innovative policy and delivery approaches to 
individuals with a SUD, including those targeted to select populations or geographic areas, or 
those that use providers not otherwise covered under Medicaid. CMS is developing additional 
guidance on Section 1115 SUD policy (which will be released in a forthcoming publication) for 
a limited number of proposals to address comprehensive SUD system transformation, ensuring 
integrated and community-based care. 
 
 
   CMCS Informational Bulletin  Page 13 
 
Quality Reporting 
  
National Committee for Quality Assurance 
 
The National Committee for Quality Assurance (NCQA) measures set48 includes two measures 
for alcohol and other drug treatment which apply to individuals age 13 and older as of December 
31 of the measurement year. The initiation of alcohol and other drug (AOD) treatment measure is 
used to assess the percentage of adolescent and adult members with a new episode of AOD 
dependence who initiate treatment through an inpatient AOD admission, outpatient visit, 
intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.49 The 
engagement of AOD treatment measure is used to assess the percentage of adolescent and adult 
members with a new episode of AOD dependence who initiated AOD treatment and who had 
two or more inpatient admissions, outpatient visits, intensive outpatient encounters, or partial 
hospitalizations with any AOD diagnosis within 30 days after the date of the initiation encounter 
(inclusive).50 
 
National Outcome Measures 
 
The National Outcome Measures (NOMs)51 were developed by SAMHSA to measure mental 
health services, substance abuse treatment, and substance abuse prevention. Each priority area is 
measured along ten dimensions to gauge an individuals health and pursuit of treatment. The 
measurements include morbidity, employment/education, crime, housing stability, social 
connectedness, service access and capacity, treatment and retention, perception of care, cost 
effectiveness, and use of evidence based practices. 
 
Program Integrity 
 
In designing a benefit package for youth with SUD, State Medicaid agencies need to give careful 
consideration to potential program integrity vulnerabilities in the system for delivering those 
benefits.  States generally have the option of purchasing SUD benefits on behalf of Medicaid-
eligible youth on a fee-for-service basis, through managed care organizations, or both.  As the 
recent California State Auditors report indicates, whatever purchasing approach a state elects to 
use, the risk of fraud needs to be taken seriously.52  This report identified major issues with how 
the state and the counties monitored the California Drug Medi-Cal program and set forth 
recommendations to improve the oversight of the program.  At a minimum, State Medicaid 
agencies need to ensure that providers furnishing SUD services to youth are properly screened 
prior to enrollment in the program and, if currently enrolled, are periodically revalidated. 
                                                           
48 National Committee for Quality Assurance (NCQA). (2013). HEDIS 2014: Healthcare Effectiveness Data and Information Set. 
Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA) 
49 National Quality Measures Clearinghouse. (2014). Measure summary: Initiation of alcohol and other drug (AOD) treatment. 
Available from http://www.qualitymeasures.ahrq.gov/content.aspx?id=47231.  
50 National Quality Measures Clearinghouse. (2014). Measure summary: Engagement of alcohol and other drug (AOD) treatment. 
Available from http://www.qualitymeasures.ahrq.gov/content.aspx?id=47233.  
51 http://media.samhsa.gov/co-occurring/topics/data/nom.aspx  
52 California State Auditor, California Department of Health Care Services: Its Failure to Properly Administer the Drug Medi-Cal 
Treatment Program Created Opportunities for Fraud, Report 2013-119  (August 19, 2014), 
https://www.auditor.ca.gov/pdfs/factsheets/2013-119.pdf  
 
   CMCS Informational Bulletin  Page 14 
 
Resources: 
Information regarding Early Identification and Screening for Youth with SUD may be found at:  
http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-03-27-2013.pdf 
 
Information on pharmacotherapy for youth with SUD may be found at: 
http://www.medicaid.gov/Federal-Policy-Guidance/downloads/CIB-07-11-2014.pdf 
 
Information regarding coverage of Peer Supports may be found at: 
http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD081507A.pdf 
 
Information regarding Caregiver to Caregiver Support may be found at:  
http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-05-07-2013.pdf  
 
 
References: 
 
American Academy of Pediatrics. (n.d.). Bright Futures Periodicity Schedule. Retrieved July 21, 
2012 from http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html 
 
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental 
disorders. (4th ed.). Washington, DC: American Psychiatric Association. 
 
American Society of Addiction Medicine. (2013). The ASAM Criteria: Treatment criteria for 
addictive, substance-related, and co-occurring conditions. 3rd ed. Change Companies: Carson 
City, NV 
 
California State Auditor, California Department of Health Care Services: Its Failure to Properly 
Administer the Drug Medi-Cal Treatment Program Created Opportunities for Fraud, Report 
2013-119  (August 19, 2014), https://www.auditor.ca.gov/pdfs/factsheets/2013-119.pdf 
 
Centers for Medicare & Medicaid Services. (n.d.). CHIPRA initial core set of children's health 
care quality measures. Available from http://www.medicaid.gov/Medicaid-CHIP-Program-
Information/By-Topics/Quality-of-Care/CHIPRA-Initial-Core-Set-of-Childrens-Health-Care-
Quality-Measures.html 
 
Centers for Medicare & Medicaid Services. (2009). Title 41  Public Health. Code of Federal 
Regulations. Washington, DC: Government Printing Office 
 
Centers for Medicare & Medicaid Services. (June 2014). EPSDT  A guide for states: Coverage 
in the Medicaid benefit for children and adolescents. U.S. Department of Health and Human 
Services. Available from: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-Treatment.html 
 
 
 
   CMCS Informational Bulletin  Page 15 
 
Chan, Y., Dennis, M., & Funk, R.. (2008) Prevalence and comorbidity of major internalizing and 
externalizing problems among adolescents and adults presenting to substance abuse treatment. 
Journal of Substance Abuse Treatment (34) 
 
Crowe, A. & Bilchik, S. (1998) Drug identification and testing in the juvenile justice system. 
Washington, DC: Office of Justice Programs, U.S. Department of Justice. Available from 
http://www.ojjdp.gov/pubs/drugid/contents.html 
 
DMA Health Strategies & Georgetown University Health Policy Institute. (2011). Assessing the 
evidence base: A systematic review of the evidence for selected treatment and recovery services 
for youth with substance use disorders. Briefing paper presented at the Technical Expert Panel 
Meeting What Does the Research Tell Us About Good and Modern Treatment and Recovery 
Services for Youth With Substance Use Disorders? held December 2011. 07/01/13 Draft. 
 
Lynskey M., Heath A., Bucholz K., Slutske W., Madden P., Nelson E., Statham D., Martin N. 
(2003). Escalation of drug use in early-onset cannabis users vs. co-twin controls. Journal of the 
American Medical Association (289), 427-33. 
 
National Committee for Quality Assurance (NCQA). (2013). HEDIS 2014: Healthcare 
Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. 
Washington (DC): National Committee for Quality Assurance (NCQA) 
 
National Quality Measures Clearinghouse. (2014). Measure summary: Initiation of alcohol and 
other drug (AOD) treatment. Available from 
http://www.qualitymeasures.ahrq.gov/content.aspx?id=47231 
 
National Quality Measures Clearinghouse. (2014). Measure summary: Engagement of alcohol 
and other drug (AOD) treatment. Available from 
http://www.qualitymeasures.ahrq.gov/content.aspx?id=47233 
 
Social Security Administration. (n.d.). The Social Security Act of 1935, Title XIX, 1905(a) [42 
U.S.C. 1396d]. Available from http://www.ssa.gov/OP_Home/ssact/title19/1905.htm 
 
Substance Abuse and Mental Health Services Administration. (2006). National outcome 
measures (NOMs) for co-occurring disorders. Available from 
http://www.samhsa.gov/data/NOMsCoOccur2k6.pdf 
 
Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012 
National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, 
HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health 
Services Administration. 
 
Substance Abuse and Mental Health Services Administration. (2013). What does the research 
tell us about good and modern treatment and recovery services for youth with substance use 
disorders? Report of the SAMHSA Technical Expert Panel. Rockville, MD: Center for 
Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. 
 
   CMCS Informational Bulletin  Page 16 
 
07/01/13 Predecisional Working Draft. 
 
Substance Abuse and Mental Health Services Administration, Financing Center for Excellence. 
(2011). Good and modern continuum of care service definitions. Draft.  
 
Virginia Department of Medical Assistance Services. (2013). Crisis stabilization. Presentation of 
highlights of the Virginia Medicaid Community Mental Health Rehabilitative Services Manual. 
Retrieved from http://www.dmas.virginia.gov/Content_atchs/obh/cmh-trngs9.pptx