This article applies to NC Medicaid Direct and NC Medicaid Managed Care.
As a part of the NC 1115 Substance Use Disorder (SUD) Demonstration Waiver, NC Medicaid has developed stand-alone SUD clinical coverage policies and has expanded its SUD benefits array to align with the American Society of Addiction Medicine (ASAM) Criteria, 3rd edition. The following NC Medicaid clinical coverage policies (CCP) with an effective date of Jan. 1, 2026, promulgated on Jan. 2, 2026, can be accessed on the NC Medicaid Program Specific Clinical Coverage Policies webpage.
New stand-alone clinical coverage policies effective Jan. 1, 2026:
- 8A-12 – Substance Abuse Intensive Outpatient Program (SAIOP) (ASAM Level 2.1)
SAIOP provides a structured program of skilled treatment services for adults or adolescents with a primary SUD diagnosis. This service provides 9-19 hours of skilled treatment services per week for adults, and 6-19 hours of skilled treatment services per week for adolescents. Treatment services include individual, group, and family counseling, medication management through consultation and referral, educational groups and service coordination activities provided in amounts, frequencies and intensities appropriate to the objectives of the beneficiary’s Person-Centered Plan (PCP). SAIOP treatment services can be delivered during the day, weekend or evening. This service is covered by Standard Plans, Local Management Entity/Managed Care Organizations (LME/MCOs), Tailored Plans and the Child and Family Specialty Plan.
- 8A-13 – Substance Abuse Comprehensive Outpatient Treatment (SACOT) (ASAM Level 2.5)
SACOT is a clinically intensive partial hospitalization program that provides skilled treatment services in a structured outpatient recovery environment, for beneficiaries aged 18 and older with a primary SUD diagnosis. This service provides 20 or more hours of clinically intensive programming per week. SACOT services consist of individual, group, and family counseling, medication management through consultation and referral, and service coordination activities. In addition, SACOT must include access to psychiatric, medical, and laboratory services, educational groups and other therapies. This service is covered by Standard Plans, Local Management Entity/Managed Care Organizations (LME/MCOs), Tailored Plans and the Child and Family Specialty Plan.
- 8D-5 – Clinically Managed Residential Services (Substance Abuse Non-Medical Community Residential Treatment) (ASAM Level 3.5)
This service is designed to serve an adult, adolescent or a pregnant and parenting beneficiary with specific functional limitations due to their SUD. A beneficiary meeting this level of care has significant social and psychological issues complicating their recovery. This service provides a 24-hour structured, safe and stable living environment. This service helps the beneficiary develop recovery skills to prevent immediate relapse or the continuation of use upon transfer to a less intensive level of care. A beneficiary meeting this level of care may be experiencing justice system involvement, co-occurring mental illness, and impaired functioning. Clinically Managed Residential Services are tailored to meet a beneficiary’s level of readiness to change. This service is covered by Local Management Entity/Managed Care Organizations (LME/MCOs), Tailored Plans and the Child and Family Specialty Plan.
- 8D-6 – Medically Monitored Intensive Inpatient Services (formerly Substance Abuse Medically Monitored Community Residential Treatment) (ASAM Level 3.7)
This is a non-hospital rehabilitation, facility-based service for an adult or adolescent beneficiary with a substance use disorder. This service is for a beneficiary who needs intensive medical or psychological monitoring in a 24-hour setting. This service is for a beneficiary whose biomedical and emotional, behavioral or cognitive problems are so severe that they require subacute inpatient treatment. This service is covered by Local Management Entity/Managed Care Organizations (LME/MCOs), Tailored Plans and the Child and Family Specialty Plan.
New clinical coverage policies effective Jan. 1, 2026:
- 8A-10 – Clinically Managed Residential Withdrawal Management Services (ASAM Level 3.2 WM)
This service is an organized, facility-based service that is delivered by trained staff who provide 24-hour supervision, observation and support for a beneficiary who is intoxicated or experiencing withdrawal. This service is intended for a beneficiary who is not at risk of severe withdrawal symptoms or severe physical and psychiatric complications. Moderate withdrawal symptoms can be safely managed at this level of care. This service emphasizes the utilization of peer and social supports to safely assist a beneficiary through withdrawal. This service is covered by Standard Plans, Local Management Entity/Managed Care Organizations (LME/MCOs), Tailored Plans and the Child and Family Specialty Plan.
- 8D-3 – Clinically Managed Low-Intensity Residential Treatment Services (ASAM Level 3.1)
This service is provided in a 24-hour, seven days a week community-based residential setting. This structured and supportive setting provides clinical and recovery services. This service is designed to treat a beneficiary experiencing functional limitations due to their SUD. Clinical and recovery services include individual, group, and family therapy, medication management and psychoeducation. This service is covered by Local Management Entity/Managed Care Organizations (LME/MCOs), Tailored Plans and the Child and Family Specialty Plan.
- 8D-4 – Clinically Managed Population Specific High-Intensity Residential Program (ASAM Level 3.3)
This is a therapeutic rehabilitation service delivered by trained and experienced medical and nursing professionals, as well as clinical and support staff. This service is for a beneficiary with both SUD and traumatic brain injury (TBI). This service provides a 24-hour structured recovery environment in combination with high-intensity clinical services. This service is covered by Local Management Entity/Managed Care Organizations (LME/MCOs), Tailored Plans and the Child and Family Specialty Plan.
NOTE: Providers currently providing any Medicaid service described above must complete the licensure rule waiver request process via the NC Division of Health Service Regulation to continue providing and billing for each service. Providers interested in providing services that are new to the NC Medicaid benefit service array are required to obtain full licensure for the perspective service in addition to completing the licensure rule waiver request process and be enrolled as a NC Medicaid provider via NCTracks.
Amended clinical coverage policies effective Jan. 1, 2026:
Effective Jan. 1, 2026, CCP 8A Enhanced Mental Health and Substance Abuse Services has been amended with the removal of the following SUD services, as these services are now issued as individual, stand-alone clinical coverage policies:
- Substance Abuse Intensive Outpatient Program (SAIOP)
- Substance Abuse Comprehensive Outpatient Treatment Program (SACOT)
- Substance Abuse Non-Medical Community Residential Treatment
- Substance Abuse Medically Monitored Community Residential Treatment
Contact
Provider Ombudsman: 866-304-7062 or Medicaid.ProviderOmbudsman@dhhs.nc.gov