317:30-5-241.7. Medication-assisted treatment (MAT) services for eligible individuals with opioid use disorder (OUD)
(a) Definitions. The following words and terms, when used in this section, shall have the following meaning, unless the context clearly indicates otherwise:
(1) "Medication-assisted treatment (MAT)" means an evidence-based practice approved by the Food and Drug Administration (FDA) to treat opioid use disorder, including methadone and all biological products licensed under federal law for such purpose. MAT also includes the provision of counseling and behavioral therapy.
(2) "Office-based opioid treatment (OBOT)" means a fully contracted SoonerCare provider that renders MAT services in OBOT settings. OBOT providers must have capacity to provide all drugs approved by the FDA for the treatment of opioid use disorder, directly or by referral, including for maintenance, detoxification, overdose reversal, and relapse prevention, and appropriate counseling and other appropriate ancillary services.
(3) "Opioid treatment program (OTP)" means a program or provider:
(A) Registered under federal law;
(B) Certified by the Substance Abuse and Mental Health Services Administration (SAMHSA);
(C) Certified by ODMHSAS, unless deemed an exempted entity as defined by federal law;
(D) Registered by the Drug Enforcement Agency (DEA);
(E) Registered by the Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD); and
(F) Engaged in opioid treatment of individuals by use of an opioid agonist treatment medication, including methadone.
(4) "Opioid use disorder (OUD)" means a cluster of cognitive, behavioral, and physiological symptoms in which the individual continues use of opioids despite significant opioid-induced problems.
(5) "Phase I" means a minimum ninety (90) day period in which the member attends the opioid treatment program for observation of medication assisted treatment daily or at least six (6) days a week.
(6) "Phase II" means the phase of treatment for members who have been admitted for more than ninety (90) days and who have successfully completed Phase I.
(7) "Phase III" means the phase of treatment for members who have been admitted for more than six (6) months and who have successfully completed Phase II.
(8) "Phase IV" means the phase of treatment for members who have been admitted for more than nine (9) months and who have successfully completed Phase III.
(9) "Phase V" means the phase of treatment for members who have been admitted for more than one (1) year.
(10) "Phase VI" means the phase of treatment for members who voluntarily seek medically supervised withdrawal and abstinence from all drugs, including methadone as prescribed. A member may enter this phase at any time in the treatment and rehabilitation process.
(b) Coverage. The SoonerCare program provides coverage of medically necessary MAT services in OTPs, including but not limited to, methadone treatment, to eligible individuals with OUD. An OTP must have the capacity to provide the full range of services included in the definition of MAT and must document both medication dosing and supporting behavioral health services, including but not limited to, individual, family and group therapy and rehabilitation services. MAT services and/or medications may also be provided in OBOT settings per OAC 317:30-5-9(b)(17).
(c) OTP requirements. Every OTP provider shall:
(1) Have a current contract with the OHCA as an OTP provider;
(2) Hold a certification as an OTP from ODMHSAS, unless deemed an exempted entity as defined by federal law;
(3) Hold a certification from the Substance Abuse and Mental Health Services Administration (SAMHSA);
(4) Be appropriately accredited by a SAMHSA-approved accreditation organization;
(5) Be registered with the DEA and the OBNDD; and
(6) Meet all state and federal opioid treatment standards, including all requirements within OAC 450:70.
(d) Individual OTP providers. OTP providers include a:
(1) MAT provider who is a physician, physician's assistant (PA), or advanced practice registered nurse (APRN) who may prescribe, dispense, and administer medications in accordance with state and federal law and the Oklahoma Medicaid State Plan.
(2) OTP behavioral health services practitioner who is a practitioner that meets the qualifications in OAC 317:30-5-240.3, except for family support and training providers, qualified behavioral therapy aide providers, multi-systemic therapy providers, and case manager I providers, for the provision of outpatient behavioral health services.
(e) Intake and assessment. OTPs shall conduct intake and assessment procedures in accordance with OAC 450:70-3-5 through OAC 450:70-3-7.
(f) Service phases. In accordance with OAC 450:70-6-17.2 through OAC 450:70-6-17.8, the OTP shall have structured phases of treatment and rehabilitation to support member progress and to establish requirements regarding member attendance and service participation. The OTP shall utilize ASAM criteria to determine the appropriate level of care during each phase of treatment. Treatment requirements for each phase shall include, but not limited to, the following:
(1) During phase I, the member shall participate in a minimum of four (4) treatment sessions per month, including, but not exclusive to, therapy, rehabilitation, case management, and peer recovery support services.
(2) During phase II, the member shall participate in at least two (2) treatment sessions per month during the first ninety (90) days, including, but not exclusive to, therapy, rehabilitation, case management, and peer recovery support services. After the initial ninety (90) days in Phase II, the member shall participate in at least one (1) treatment session per month.
(3) During phase III, phase IV and phase V, the member shall participate in at least one (1) treatment session per month, including, but not exclusive to, therapy, rehabilitation, case management, and peer recovery support services.
(4) During phase VI, the LBHP, licensure candidate or certified alcohol and drug counselor (CADC) determines the frequency of therapy or rehabilitation service sessions with input from the member.
(5) If an OTP is providing MAT medications to members receiving residential substance use disorder services, the required minimum services for the OTP may be delivered by the residential substance use disorder provider. The OTP provider shall document the provision of these services and the provider delivering such services in the member's service plan.
(g) Service plans. In accordance with OAC 450:70-3-8, a service plan shall be completed for each member upon completion of the admission evaluation. The service plan shall be based on the patient's presenting problems or diagnosis, intake assessment, biopsychosocial assessment, and expectations of their recovery.
(1) Service plan development. Service plans shall be completed by an LBHP or licensure candidate. Service plans completed by a licensure candidate must be co-signed and dated by a fully-licensed LBHP.
(2) Service plan content. Service plans shall address, but not limited to, the following:
(A) Presenting problems or diagnosis;
(B) Strengths, needs, abilities, and preferences of the member;
(C) Goals for treatment with specific, measurable, attainable, realistic and time-limited;
(D) Type and frequency of services to be provided;
(E) Dated signature of primary service provider;
(F) Description of member's involvement in, and responses to, the service plan and his or her signature and date;
(G) Individualized discharge criteria or maintenance;
(H) Projected length of treatment;
(I) Measurable long and short term treatment goals;
(J) Primary and supportive services to be utilized with the patient;
(K) Type and frequency of therapeutic activities in which patient will participate;
(L) Documentation of the member's participation in the development of the plan; and
(M) Staff who will be responsible for the member's treatment.
(3) Service plan updates. Service plan updates shall be completed by an LBHP or licensure candidate. Service updates completed by a licensure candidate must be co-signed and dated by a fully-licensed LBHP. Service plan review and updates shall occur no less than every six (6) months and shall occur more frequently if required based upon the service phase or certain circumstances:
(A) Change in goals and objectives based upon member's documented progress, or identification of any new problem(s);
(B) Change in primary therapist or rehabilitation service provider assignment;
(C) Change in frequency and types of services provided;
(D) Critical incident reports; and/or
(E) Sentinel events.
(4) Service plan timeframes. Service plans shall be completed by the fourth visit after admission.
(h) Progress notes. Progress notes shall be completed in accordance with OAC 317:30-5-248(3).
(i) Discharge planning. All members shall be assessed for biopsychosocial appropriateness of discharge from each level of care using ASAM criteria that includes a list of symptoms for all six (6) dimensions and each of the levels of care, to determine a clinically appropriate placement in the least restrictive level of care. This organized process involves a professional determination by an LBHP or licensure candidate for appropriate placement to a specific level of care based on the following symptoms and situations:
(1) Acute intoxication and/or withdrawal potential;
(2) Biomedical conditions and complications;
(3) Emotional, behavioral or cognitive conditions and complications;
(4) Readiness to change;
(5) Relapse, continued use or continued problem potential; and
(6) Recovery/living environment.
(j) Service exclusions. The following services are excluded from coverage:
(1) Components that are not provided to or exclusively for the treatment of the eligible individual;
(2) Services or components of services of which the basic nature is to supplant housekeeping or basic services for the convenience of a person receiving covered services;
(3) Telephone calls or other electronic contacts (not inclusive of telehealth);
(4) Field trips, social, or physical exercise activity groups;
(k) Reimbursement. To be eligible for payment, OTPs shall:
(1) Have an approved provider agreement on file with the OHCA. Through this agreement, the OTP assures that they are in compliance with all applicable federal and State Medicaid law and regulations, including, but not limited to, OHCA administrative rules, ODMHSAS administrative rules, and the Oklahoma Medicaid State Plan.
(2) Obtain prior authorization for applicable drugs and services by the OHCA or its designated agent before the service is rendered by an eligible provider. Without prior authorization for applicable drugs and services, payment is not authorized.
(3) Record the National Drug Code (NDC) number for each drug used in every encounter at the time of billing.
(4) Be reimbursed pursuant to the methodology described in the Oklahoma Medicaid State Plan.