Access to Services to Treat Substance Use Disorders (acute treatment and clinical stabilization; preauthorization rules)
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Governs insured health plans issued, delivered or renewed in Massachusetts and requires coverage and limits on preauthorization for medically necessary substance use disorder services and abuse-deterrent opioids; affects carriers, DPH-certified/licensed providers, and plan members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Substance Use Disorder Services
DPH-certified/licensed provider services: preauthorization prohibition
Covered when ALL of the following are met
When met, plans shall not require preauthorization for services including early intervention, outpatient (including medically assisted therapies), intensive outpatient, partial hospitalization, residential, clinically managed detoxification, medically monitored intensive inpatient (ASAM 3.7), and medically managed intensive inpatient services (ASAM 4). Carriers should monitor the DPH list of licensed/certified providers on the DPH website to identify providers exempt from prior authorization requirements.
Services that are not included in an insured health plan's benefits may be excluded from coverage. Carriers should take appropriate steps to notify relevant contracting providers and clearly identify any substance use disorder services that are not covered under the plan.
For plans that operate a closed provider network, services delivered by providers who are not part of the network may remain subject to prior authorization and other utilization review procedures unless the carrier’s network is found to be inadequate to provide access to the specified substance use disorder services.
Provider Responsibilities and Billing/Authorization Rules
Do not require prior authorization for initial 14 days of acute/clinical stabilization care
Insured health plans shall cover and shall not require preauthorization for a 14-day period of medically necessary acute treatment and clinical stabilization services (ASAM levels 4, 3.7 and 3.5) for an insured obtaining those services, provided the facility gives the carrier appropriate notification of the admission within 48 hours. Carriers may initiate utilization review on day 7 but may not impose restrictions or deny future medically necessary services until at least 14 consecutive days have been provided.
- Applies to acute treatment and clinical stabilization services (ASAM levels 4, 3.7, 3.5).
- Preauthorization prohibition applies for the initial 14 consecutive days of medically necessary care.
- Facility must provide admission notification within 48 hours (see notification requirements).
- Carriers may begin utilization review procedures on day 7 but may not deny or restrict care before 14 days have elapsed.
Cover abuse-deterrent opioids with formulary parity
Insured health plans must provide coverage for abuse-deterrent opioid drug products identified on the Drug Formulary Commission's formulary on a basis not less favorable than non-abuse-deterrent opioid products covered by the plan; the DOI will issue further guidance after the Commission completes the formulary.
- Parity requirement applies to abuse-deterrent opioid drug products specified on the Drug Formulary Commission formulary.
- Further DOI administration guidance will follow once the formulary is completed.
Provide admission/first-visit notification to carrier within 48 hours
For acute treatment and clinical stabilization services, the facility must notify the carrier of the admission within 48 hours and may provide only the patient's name, the patient's coverage information, and the initial treatment plan.
- Notification timeframe: within 48 hours of admission or first visit for services intended to apply for more than one day.
- Required notification content: patient name, information about the patient's coverage with the carrier's plan, and the initial treatment plan.
Retroactive denials risk tied to failure to notify within 48 hours
Carriers should not retroactively deny substance use disorder services unless appropriate notifications are not made within 48 hours of the initial service or admission that leads to the provision of the services.
- A retroactive denial is permitted only when the facility fails to provide the required 48-hour notification of the initial service or admission.
- This applies to services defined in the statute and described in the bulletin.
Key Definitions
Levels of Care and Placement Criteria
Substance Use Disorder Treatment Modalities
SUD treatment modalities
Services delivered by DPH-certified or licensed providers are not subject to preauthorization when they are covered by the insured health plan.
Visit Limits and Authorization Durations
Background and Context
This bulletin defines levels of care using ASAM terminology and describes service settings across the continuum—from early intervention and outpatient modalities through intensive inpatient detoxification and medically monitored inpatient services. Examples include outpatient and medically assisted therapies, intensive outpatient and partial hospitalization, residential services, clinically managed detoxification, and medically monitored intensive inpatient detoxification (ASAM level 3.7).
The bulletin also explains operational expectations for these services: the Massachusetts Department of Public Health (DPH) will maintain a list of DPH-certified or -licensed providers, carriers should monitor that list, and for services intended to extend beyond a single day carriers may require notification within 48 hours of the first visit or admission. Carriers may initiate utilization review beginning on the 7th day of a patient’s stay, but may not impose restrictions or deny future medically necessary services before an initial continuous period of 14 consecutive days of acute treatment or clinical stabilization has been provided without preauthorization.
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