California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 4 - Scope and Duration of Benefits › Section 51341.1 - Drug Medi-Cal Substance Use Disorder Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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.