NC Medicaid is increasing the Substance Abuse Intensive Outpatient Program (SAIOP) and Substance Abuse Comprehensive Outpatient Treatment (SACOT) reimbursement rates to reflect a 29.2% increase over the current rates. This increase reflects combined annual inflation since the rates were last increased in 2012. These changes will be effective Aug. 1, 2024.
SAIOP and SACOT inflationary increases will apply for services delivered to Medicaid members enrolled in Standard Plans, Tailored Plans and NC Medicaid Direct /Prepaid Inpatient Health Plans (PIHPs). These changes align with existing Clinical Coverage Policy 8A and are intended to address increased service costs, sustain provider participation within the Medicaid program, and support access to care statewide.
Basis of Inflationary Increases
SAIOP and SACOT services do not have Medicare-covered service counterparts, but are included in DHB State Plan Medicaid fee schedules. State Plan reimbursement levels for this group of services are documented on the Enhanced Mental Health Services fee schedule on the NCDHHS Download Fee Schedules webpage. The updated State Plan rates were developed using annual inflationary trend factors from the Medicare Economic Index (MEI) for the period between SFY 2012 and SFY 2024.
Rate Increase Amounts
| Service Type | Service Description | Service Code | Current State Plan Fee Schedule Rate | Aggregate Adjustment | Updated State Plan Fee Schedule Rate (effective 8/1/24) |
|---|---|---|---|---|---|
| ASAM 2.1 | SA Intensive Outpatient Program | H0015 | $133.72 | +29.2% | $170.03 |
| ASAM 2.5 | SA Comprehensive Outpatient Treatment | H2035 | $46.07 | +29.2% | $58.61 |
Note: Inflationary increases will be uniform across all Standard Plans, Tailored Plans, and NC Medicaid Direct.
Fee Schedules
The Enhanced Mental Health Fee Schedule for Standard Plans, Tailored Plans/PIHPs, and NC Medicaid Direct has been updated to reflect the SAIOP and SACOT increased rates.
- The updated fee schedule was posted to the NCDHHS Download Fee Schedules webpage on Aug. 2, 2024.
- Health plans will have 45-days after receiving official notification and access to the posted fee schedule to implement the fee schedule changes.
- Rate increases will be effective Aug. 1, 2024.
- Health plans are encouraged to reprocess claims with dates of service occurring between the effective date of this rate change and their system implementation date of the updated rate.
- Providers should consult their contracted health plan for more information.
Until a pending contract amendment goes into effect, increased rates for SAIOP and SACOT are not rate floors or rate ceilings. However, health plans are expected to increase provider reimbursement accordingly. Providers should directly engage with health plans regarding their current contracted rates and take into account the August 1 fee schedule increases and pending contract amendment that will establish the new rates as floors.
In addition to the inflationary increases, the Department is continuing to engage stakeholders on new/updated SAIOP and SACOT policies and will set subsequent rates based upon any new or expanded requirements contained in the final versions of those policies. Effective Oct. 1, 2024, the Department is planning to implement rate floors across all substance use disorder (SUD) services. More details regarding the establishment of the rate floors will be released in a subsequent Medicaid bulletin.
Effects in Managed Care
Tailored Plans/PIHPs capitation rates will be adjusted beginning Aug. 1, 2024, to account for revised SAIOP and SACOT reimbursement rates.
Contact
Medicaid.ProviderReimbursement@dhhs.nc.gov
Standard Plan PHP, Tailored Plan, and PIHP contact information is available on the NC Medicaid Health Plan Contacts and Resources webpage.