Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 746. Limitations and payments for services

7 AAC 43.746. Limitations and payments for services

(a) The division will reimburse for substance abuse rehabilitative services with the following limitations:

(1) assessment and diagnosis services are limited to two in a consecutive 12-month period and to one group of necessary tests, evaluations, interviews, or examinations for each admission to a program, at the lesser of the rate routinely charged to the general public or $50 per service;

(2) the total combination of individual, group, and family counseling provided as outpatient services is limited to no more than 40 hours in any consecutive 12-month period and reimbursement is subject to the following limitations:

(A) outpatient individual counseling is limited to the lesser of the rate routinely charged to the general public or $50 per hour;

(B) outpatient group counseling is limited to the lesser of the rate routinely charged to the general public or $20 per hour for each Medicaid recipient present;

(C) outpatient family counseling, which must be attended by at least one Medicaid recipient who is admitted to an approved substance abuse treatment program for at least half of each session, is limited to the lesser of the rate routinely charged to the general public or $45 per hour;

(3) outpatient care coordination services, for which each reimbursable contact must be at least twenty minutes in length, and is limited to a maximum of eight hours in any consecutive six-month period, at the lesser of the rate routinely charged to the general public or $30 per hour;

(4) outpatient rehabilitation treatment services is limited to ten hours per week and to a maximum of 40 hours in any consecutive 12-month period, at the lesser of the rate routinely charged to the general public or $40 per hour;

(5) intensive outpatient services must be provided for at least three days or evenings per week and for at least eight hours per week, but are limited to a maximum of 12 hours per week, and may not exceed eight consecutive weeks in any consecutive 12-month period, at the lesser of the rate routinely charged to the general public or $45 per hour; in any day in which intensive outpatient services are provided, the division will not separately reimburse for individual, group, and family counseling, care coordination, or rehabilitation treatment services provided to the recipient as outpatient services;

(6) intermediate services are limited to 20 hours per week, not to exceed eight weeks in any consecutive 12-month period, at the lesser of the rate routinely charged to the general public or $50 per hour; in any day in which intermediate services are provided, the division will not separately reimburse for individual, group, and family counseling, care coordination, or rehabilitation treatment services provided to the recipient as outpatient services;

(7) a medical evaluation upon admission for treatment for a recipient seeking methadone treatment, which must be conducted by a physician, at the lesser of the amount routinely charged to the general public or $300 per evaluation;

(8) an intake physical for a non-methadone recipient, which must be conducted by a physician, a physician's assistant, or an advanced nurse practitioner, at the lesser of the rate routinely charged to the general public or $150 per physical;

(9) a treatment plan review for a methadone recipient, which must be conducted by a physician, at the lesser of the rate routinely charged to the general public or $30 per review;

(10) medication management, as defined in 7 AAC 43.1990, at the lesser of the rate routinely charged to the general public or $35 per visit;

(11) dispensing of methadone or antabuse, which must be conducted by a physician, an advanced nurse practitioner, a physician's assistant, a registered nurse, or a licensed practical nurse, at the lesser of the rate routinely charged to the general public or $10 per visit;

(12) urinalysis, which must be performed by a laboratory certified under 42 C.F.R. 493, as amended November 1, 1993, at the lesser of the rate routinely charged to the general public or the amount determined under 7 AAC 43.125; the division will directly reimburse either a substance abuse rehabilitative services provider which operates a certified laboratory on its premises or a certified laboratory which furnishes services to the provider and is enrolled as a Medicaid provider; the division will directly reimburse for services furnished by an out-of-state laboratory only if the laboratory is enrolled as a Medicaid provider in this state and is certified for Medicaid reimbursement in the state in which it is located; and

(13) detoxification is limited to 12 admissions in any consecutive 12-month period, at the lesser of the rate routinely charged to the general public or $150 for each consecutive 24-hour period; the division will not pro-rate or otherwise reimburse for any service period less than 24 consecutive hours.

(b) Except as provided in (c) of this section, a provider of substance abuse rehabilitative services may exceed the service limits of this section for a recipient who is 21 years of age or older only upon written approval by the division of alcoholism and drug abuse in the department of a written request by the provider.

(c) A provider of substance abuse rehabilitative services may exceed the service limits of this section for a recipient who is under 21 years of age or for a recipient of any age who is pregnant only if the provider enters a statement containing medical justification into the recipient's clinical record.

History: Eff. 2/23/94, Register 129

Authority: AS 47.05.010

AS 47.07.030

Editor's note: Before Register 129, April 1994, part of the substance of 7 AAC 43.746 was contained in 7 AAC 43.928 - 7 AAC 43.937 which were adopted by emergency regulation and allowed to lapse on 12/3/92. The history note for 7 AAC 43.746 does not reflect the history note for those sections.