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 7 - Payment for Services and Supplies › Section 51516.1 - Reimbursement Rates for Drug Medi-Cal Substance Abuse Program Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reimbursement
					 for Naltrexone treatment, outpatient drug free treatment, day care
					 rehabilitative, and perinatal residential treatment services shall be based on
					 the lowest of the following:
(1) The
					 provider's usual and customary charge to the general public for the same or
					 similar services;
(2) The
					 provider's allowable cost of providing the services, as specified in Section
					 11818
					 of the Health and Safety Code; or
(3) The statewide maximum allowances (SMAs)
					 for Fiscal Years 2003-2004, 2004-2005, 2005-2006, 2006-2007, 2007-2008,
					 2008-2009, 2009-2010, 2010-2011, 2011-2012, 2012-2013, and 2013-2014 which the
					 Department shall establish in accordance with Sections
					 14021.6
					 and
					 14021.9(c)
					 of the Welfare and Institutions Code.
The SMAs for the following Drug Medi-Cal substance abuse
						program services for Fiscal Year 2003-2004 are:
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Naltrexone services, per face-to-face
								visit
$21.19
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$70.25
$106.08
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$32.33
$53.22
Day care rehabilitative, per face-to-face
								visit
$67.85
$74.44
Perinatal residential treatment services, per
								day
N/A
$76.18
The SMAs for the following Drug Medi-Cal substance abuse
						program services for Fiscal Year 2004-2005 are:
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Naltrexone services, per face-to-face
								visit
$21.19
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$63.90
$106.08
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$30.60
$46.97
Day care rehabilitative, per face-to-face
								visit
$67.93
$75.99
Perinatal residential treatment services, per
								day
N/A
$76.18
The SMAs for the following Drug Medi-Cal substance abuse
						program services for Fiscal Year 2005-2006 are:
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Naltrexone services, per face-to-face
								visit
$21.19
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$64.16
$106.08
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$30.85
$48.16
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Day care rehabilitative, per face-to-face
								visit
$67.98
$77.27
Perinatal residential treatment services, per
								day
N/A
$77.46
The SMAs for the following Drug Medi-Cal substance abuse
						program services for Fiscal Year 2006-2007 are:
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Naltrexone services, per face-to-face
								visit
$21.19
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$64.16
$106.08
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$30.85
$48.16
Naltrexone services, per face-to-face
								visit
$19.07
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$66.53
$95.23
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$28.27
$57.26
Day care rehabilitative, per face-to-face
								visit
$61.05
$73.04
Perinatal residential treatment services, per
								day
N/A
$89.90
The SMAs for the following Drug Medi-Cal substance abuse
						program services for Fiscal Year 2007-2008 are:
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Naltrexone services, per face-to-face
								visit
$21.19
N/A
Naltrexone services, per face-to-face
								visit
$21.19
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$74.79
$106.08
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$31.56
$63.62
Day care rehabilitative, per face-to-face
								visit
$67.55
$79.92
Perinatal residential treatment services, per
								day
N/A
$96.81
The SMAs for the following Drug Medi-Cal substance abuse
						program services for Fiscal Year 2008-2009 are:
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Naltrexone services, per face-to-face
								visit
$21.19
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$74.99
$106.08
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$31.45
$63.62
Day care rehabilitative, per face-to-face
								visit
$67.96
$82.90
Perinatal residential treatment services, per
								day
N/A
$95.21
The SMAs for the following Drug Medi-Cal substance abuse
						program services for Fiscal Year 2009-2010 are:
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Naltrexone services, per face-to-face
								visit
$19.07
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$66.53
$95.23
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$28.27
$57.26
Day care rehabilitative, per face-to-face
								visit
$61.05
$73.04
Perinatal residential treatment services, per
								day
N/A
$89.90
The SMAs for the following Drug Medi-Cal substance abuse
						program services for Fiscal Year 2010-2011 are:
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Naltrexone services, per face-to-face
								visit
$19.07
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$67.53
$96.66
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$28.69
$55.95
Day care rehabilitative, per face-to-face
								visit
$61.97
$74.14
Perinatal residential treatment Services, per
								day
N/A
$91.25
The SMAs for the following Drug Medi-Cal substance abuse
						program services for Fiscal Year 2011-2012 are:
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Naltrexone services, per face-to-face
								visit
$19.07
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$69.59
$99.61
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$29.57
$53.80
Day care rehabilitative, per face-to-face
								visit
$63.86
$76.40
Perinatal residential treatment Services, per
								day
N/A
$92.45
The SMAs for the following Drug Medi-Cal substance use
						disorder services for Fiscal Year 2012-2013 are:
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Naltrexone services, per face-to-face
								visit
$19.07
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$71.25
$101.99
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$30.28
$61.33
Day care rehabilitative, per face-to-face
								visit
$65.38
$78.23
Perinatal residential treatment Services, per
								day
N/A
$96.28
The SMAs for the following Drug Medi-Cal substance use
						disorder services for Fiscal Year 2013-2014 are:
Service
								Function
Maximum Allowance Non-Perinatal Unit of
								Service
Maximum Allowance Perinatal Unit
								of Service
Naltrexone services, per face-to-face
								visit
$19.07
N/A
Outpatient drug free treatment services,
								face-to-face individual counseling session, per
								person
$72.32
$103.52
Outpatient drug free treatment services,
								face-to-face group counseling session, per
								person
$29.39
$62.24
Day care rehabilitative, (July 1, 2013 to December
								31, 2013) per face-to-face visit
$62.15
$79.39
Intensive Outpatient Treatment, (January 1, 2014 to
								June 30, 2014) Per face-to-face visit
$62.15
$79.39
Perinatal residential treatment services, per
								day
N/A
$97.72
(A) The SMA
					 for counseling sessions for outpatient drug free treatment services shall be
					 prorated annually as follows:
1. The SMA for
					 an individual counseling session shall be prorated annually using the
					 percentage computed by dividing the total actual time for all counseling
					 sessions by the total time which would have been spent if all counseling
					 sessions were 50 minutes in duration. This percentage (not to exceed 100
					 percent) shall be applied to the SMA to determine the maximum reimbursement
					 rate.
For example: Total Session Time/(50 minutes x Number of
						Sessions) x SMA = Prorated SMA.
2. The SMA for a group counseling session
					 shall be prorated annually using the percentage computed by dividing the total
					 actual time for all counseling sessions by the total time which would have been
					 spent if all counseling sessions were 90 minutes in duration. This percentage
					 (not to exceed 100 percent) shall be applied to the SMA per person to determine
					 the maximum reimbursement rate.
For example: Total Session Time/(90 minutes x Number of
						Sessions) x SMA = Prorated SMA.
3. To qualify as a group counseling session
					 there shall be at least one Medi-Cal beneficiary in a group of no less than
					 four and no more than ten individuals.