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    v1.0.30
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthDelaware SUD Policy Coverage Update | OpenPayer
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    CurrentDelaware Department of Health and Social ServicesPolicy 17-002

    Coverage for Substance Use Disorder

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    This bulletin governs Medicaid coverage and medical-necessity determinations for treatment of drug and alcohol dependencies, including placement, continued stay, and transfer or discharge from treatment programs. Medicaid health plans must provide access comparable to private insurance and may not use prior authorization as a barrier to medically necessary covered services.

    Policy Summary
    PayerDelaware Department of Health and Social Services
    PolicyCoverage for Substance Use Disorder
    Policy CodePolicy 17-002
    Change TypeUpdated and clarified
    Effective DateSeptember 29, 2017
    Next Review DateN/A
    Key ActionUse the full American Society of Addiction Medicine criteria for coverage determinations, and do not use prior authorization as a barrier to medically necessary treatment.
    SourceLink
    POLICY UPDATE CHANGES

    Medicaid health plans must use the full American Society of Addiction Medicine criteria to determine medical necessity for placement, continued stay, and transfer or discharge of patients with substance use disorder.

    The policy provides coverage for five days of detoxification-center treatment and 30 days of intensive outpatient treatment when medically necessary, aligned with the residential treatment option.

    5 daysDetoxification-center treatment protection
    30 daysIntensive outpatient program treatment protection
    Full ASAM criteria

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Required medical-necessity framework
    No barrierPrior authorization restriction for specified services

    Medical Necessity and Covered Treatment

    ASAM medical-necessity determination

    Covered when medical necessity is established using the full set of American Society of Addiction Medicine criteria.

    ASAM-based medical necessity

    • Determination type

      • Placement in a substance use disorder treatment program is being determined.
      • Continued stay in a substance use disorder treatment program is being determined.
      • Transfer or discharge of a patient with substance use disorder is being determined.

    Detoxification, intensive outpatient, and residential treatment

    The following services are covered when medically necessary under the full set of American Society of Addiction Medicine criteria.

    Specified treatment services

    • Detoxification-center treatment is provided for five days when medically necessary.5 days

      Prior authorization must not be a barrier.

    • Intensive outpatient program treatment is provided for 30 days when medically necessary.30 days

      Prior authorization must not be a barrier.

    • Residential treatment is provided as an aligned treatment option when medically necessary.

      The bulletin does not specify a residential treatment duration; prior authorization must not be a barrier to medically necessary related residential treatment services.

    Prior Authorization and Access

    Prior Authorization

    Do not let prior authorization delay medically necessary treatment

    Do not use prior authorization as a barrier to medically necessary treatment for drug and alcohol dependencies. Members must receive coverage for detoxification-center treatment, intensive outpatient program treatment, and related residential treatment services when medical necessity is determined using the full set of American Society of Addiction Medicine criteria.

    • Detoxification-center treatment: 5 days when medically necessary.
    • Intensive outpatient program treatment: 30 days when medically necessary.
    • Use the full ASAM criteria for placement, continued stay, and transfer or discharge determinations.

    Policy Scope

    This policy addresses Medicaid coverage for substance use disorder treatment involving drug and alcohol dependencies. Medicaid health plans must use the full set of American Society of Addiction Medicine (ASAM) criteria to determine medical necessity for placement, continued stay, and transfer or discharge from treatment programs. Covered protections include medically necessary treatment in detoxification centers, intensive outpatient programs, and aligned residential treatment options.

    Substance Use Disorder Treatment Programs

    Substance use disorder treatment programs

    Medical-necessity determinations for substance use disorder treatment programs must address the following level-of-care decisions.

    Placement in a substance use disorder treatment program is medically necessary under the full set of American Society of Addiction Medicine criteria.

    Applies to drug and alcohol dependencies.

    Continued stay in the substance use disorder treatment program is medically necessary under the full set of American Society of Addiction Medicine criteria.
    Transfer or discharge decisions for a patient with substance use disorder must be determined using the full set of American Society of Addiction Medicine criteria.

    The policy addresses transfer or discharge determinations but does not specify separate discharge criteria.

    Covered Treatment Settings

    Detoxification

    Covered when medically necessary under the full set of American Society of Addiction Medicine criteria.

    Detoxification-center treatment is covered for five days when medically necessary under the full set of American Society of Addiction Medicine criteria.5 days

    Prior authorization must not be a barrier.

    Intensive Outpatient Program

    Covered when medically necessary under the full set of American Society of Addiction Medicine criteria.

    Intensive outpatient treatment: Intensive outpatient program treatment is covered for 30 days when medically necessary under the full set of American Society of Addiction Medicine criteria.30 days

    Prior authorization must not be a barrier.

    Protected Treatment Durations

    Detoxification-center treatment
    Protected duration5 days
    ServiceDetoxification-center treatment
    Coverage conditionWhen medically necessary under the full set of American Society of Addiction Medicine criteria
    Intensive outpatient program treatment
    Protected duration30 days
    ServiceIntensive outpatient program treatment
    Coverage conditionWhen medically necessary under the full set of American Society of Addiction Medicine criteria
    Policy Summary
    PayerDelaware Department of Health and Social Services
    PolicyCoverage for Substance Use Disorder
    Policy CodePolicy 17-002
    Change TypeUpdated and clarified
    Effective DateSeptember 29, 2017
    Next Review DateN/A
    Key ActionUse the full American Society of Addiction Medicine criteria for coverage determinations, and do not use prior authorization as a barrier to medically necessary treatment.
    SourceLink
    On This Page
    Medical Necessity and Covered TreatmentPrior Authorization and AccessPolicy ScopeSubstance Use Disorder Treatment ProgramsCovered Treatment SettingsProtected Treatment Durations

    Residential treatment

    Covered when medically necessary under the full set of American Society of Addiction Medicine criteria.

    Residential treatment is included as an aligned treatment option for the specified substance use disorder coverage protections when medically necessary under the full set of American Society of Addiction Medicine criteria.

    The bulletin does not specify a residential treatment duration. Prior authorization must not be a barrier to medically necessary related residential treatment services.