In compliance with NCGS § 108D-35(b), which was amended by Section 9E.22.(g) of Session Law 2023-134, and to further improve rapid access and reduce barriers to substance use disorder services for members enrolled in a Standard Plan, NC Medicaid is making updates to add the Substance Abuse Intensive Outpatient Program (SAIOP), Substance Abuse Comprehensive Outpatient Treatment (SACOT) and social setting detox to the NC Medicaid Standard Plan service array.
Because social setting detox is a new service which is not currently covered under the approved the NC Medicaid State Plan Amendment (SPA), this service will not be added to the Standard Plan array until the SPA is approved by the Center for Medicare and Medicaid Services (CMS) and the service policy is promulgated. The information in this bulletin details the implementation of SAIOP and SACOT in NC Medicaid Managed Care Standard Plans.
Effective Oct. 3, 2023, Standard Plans will cover SAIOP and SACOT for their members. Standard Plans have until Dec. 21, 2023, to implement these services for their members, and coverage for these services will be available retroactively for dates of service beginning on or after Oct. 3, 2023.
Like other Standard Plan benefits, Standard Plans must contract with any willing provider unless the provider fails to meet the Department’s applicable objective quality standards for participation as a Medicaid enrolled provider; or when a provider refuses to accept network rates.
Even though Standard Plans will offer these services (SAIOP and SACOT), utilization of or need for these services will remain a qualifying reason to move a member in need of SAIOP or SACOT services to NC Medicaid Direct or into the NC Medicaid Managed Care Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plan, upon launch, as required in NC General Statute 108D-40. Therefore, any member using these services will move from their Standard Plan to Medicaid Direct (or to a Tailored Plan after launch) so that they have a full complement of behavioral health, traumatic brain injury (TBI) and I/DD services. Per the Department’s transition of care policy, LME/MCOs shall permit the member to continue seeing their provider, regardless of network status following a transition between plans and when the member is in an ongoing course of treatment.
After NC Medicaid has received evidence of the member’s receipt of SACOT or SAIOP services, the member will be moved into Medicaid Direct or into the Tailored Plan, upon launch, based on the Tailored Plan eligibility criteria. NC Medicaid monitors service utilization and diagnoses based on review of fee-for-services claims, LME/MCO encounters and Standard Plan encounters monthly and leverages that information to determine Members eligible for Medicaid Direct (or Tailored Plans once launched).
Eligibility changes based on this process are effective at the beginning of the month following identification by NC Medicaid. The Request to Move process should be leveraged by providers and/or members to move a member back to Medicaid Direct (or to a Tailored Plan once launched) if the member has a need to move more quickly than the automated process performed by NC Medicaid. Please note that members still have choice and if the member would like to talk through their options, they can call the NC Medicaid Enrollment Broker to discuss those options.
NC Medicaid will provide Standard Plans with information verifying providers who currently provide SACOT and SAIOP services. Providers intending to offer these services should validate that their NCTracks enrollment includes approval of SACOT and SAIOP services, selectable under the Community/Behavioral Health Taxonomy (251S00000X). If needed, providers may submit an NCTracks Manage Change Request (MCR) to update their provider enrollment in NCTracks to request Department approval to render SACOT and/or SAIOP services. Refer to the NCTracks Provider Record Maintenance fact sheets on the NCTracks User Guides and Fact Sheets page.
Standard Plans will conduct outreach to contract with providers to provide these services for members in their Standard Plan. At this time, NC Medicaid will not be establishing a statewide rate for SACOT and SAIOP services for NC Medicaid Managed Care but is evaluating inclusion of rates for these services as a part of NC Medicaid’s SUD rate assessment currently under development and plans to issue guidance on these rates in early 2024. In the meantime, Standard Plans will negotiate rates directly with providers and are encouraged to consider historical regional rates set by the LME/MCOs in establishing provider rates.
Contact
For contracting and other questions, please contact health plans leveraging the information on the Health Plan Contacts and Resources page.