This MassHealth provider manual chapter establishes participation requirements for substance use disorder (SUD) treatment programs billing MassHealth. It governs a broad continuum of SUD services including ASAM Level 4.0 medically managed inpatient, ASAM Level 3.7 acute treatment/detox, ASAM Level 3.5 clinical stabilization, ASAM Level 3.1 co-occurring enhanced residential, ASAM Level 2.1 intensive outpatient (including E-SOAP), and outpatient SUD services. Providers must comply with enrollment, staffing, recordkeeping, scope-of-service, and billing requirements set forth in 130 CMR 418.000 and 130 CMR 450.000.
View official sourceCommonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 4. Program Regulations 130 CMR 418.000: Substance Use Disorder Treatment Services 418.401: Introduction ........................................................................................................ 4-1 418.402: Definitions ......................................................................................................... 4-1 418.403: Eligible Members ............................................................................................... 4-8 418.404: Provider Eligibility ............................................................................................. 4-8 418.405: Provider Enrollment Process ............................................................................... 4-9 418.406: Required Notifications and Reports .................................................................... 4-9 418.407: Revocation of Enrollment ................................................................................. 4-10 418.408: Site Inspection ................................................................................................…4-11 418.409: Scope of Services .............................................................................................. 4-11 418.410: Supervision and Other Staff Requirements ...................................................... 4-16 418.411: Recordkeeping Requirements ........................................................................... 4-21 418.412: Service Limitations ........................................................................................... 4-21 418.413: In-state Providers: Maximum Allowable Fees ................................................. 4-22 418.414: Out-of-state Providers: Maximum Allowable Fees ......................................... 4-23 418.401: Introduction 130 CMR 418.000 establishes requirements for participation of substance use disorder treatment programs in MassHealth and governs public and private programs. All substance use disorder treatment programs participating in MassHealth must comply with MassHealth regulations, including but not limited to, 130 CMR 418.000, and 130 CMR 450.000: Administrative and Billing Regulations. 418.402: Definitions The following terms used in 130 CMR 418.000 have the meanings given in 130 CMR 418.402 unless the context clearly requires a different meaning. Acupuncture Withdrawal Management. The insertion of metal needles through the skin at certain points on the body, with or without the use of herbs, with or without the application of an electric current, and with or without the application of heat to the needles, skin, or both, for members experiencing the dysfunctional effects of the use of alcohol and/or other drugs, whose primary need is management of withdrawal symptoms, and thereafter, support services for the establishment and maintenance of recovery. Acute Treatment Services (ATS). ASAM Level 3.7 Medically Managed Residential Treatment, a 24-hour, seven days-a-week, medically managed inpatient addiction treatment service that provides evaluation and medically supervised withdrawal management services and/or induction onto maintenance treatment. These services are delivered by nursing, case management, recovery support, and counseling staff under a physician-approved protocol and physician-directed procedures and under the direction of a licensed medical professional (i.e., physician, advanced practice registered nurse, physician assistant). Services include biopsychosocial assessment, induction onto FDA-approved medications for substance use disorders as clinically indicated, treatment planning, individual and group counseling, psychoeducational groups, and discharge planning. Advanced Practice Registered Nurse. An individual licensed by the Massachusetts Board of Registration in Nursing pursuant to M.G.L. c. 112, § 80B and 244 CMR 4.00: Advanced Practice Registered Nursing. Adverse Incident. An occurrence that represents actual or potential serious harm to the well- being of a member, or to others under the care of a provider. Adverse incidents may be the result of the actions of a member served, actions of a staff member providing services, incidents that compromise the health and safety of the member receiving treatment at the program, or the operations of the provider. American Society of Addiction Medicine (ASAM). A professional society in the field of addiction medicine that sets diagnostic and dimensional criteria for the delivery of substance use disorder treatment which includes a continuum of five basic levels of care from Early Intervention to Medically Managed Intensive Inpatient Treatment. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-1 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 At Risk for Homelessness. Any member who does not have sufficient resources or support networks (e.g., family, friends, faith-based or other social networks) immediately available to prevent them from moving to an emergency shelter or another place not meant for human habitation. Behavioral Health Disorder. Any disorder pertaining to mental health or substance use, as defined by the current edition of the Diagnostic and Statistical Manual of Mental Disorders. Case Consultation. Intervention, including scheduled audio-only telephonic, audio-video, or in- person meetings, for behavioral and medical management purposes on a member’s behalf with agencies, employers, or institutions which may include the preparation of reports of the member’s psychiatric status, history, treatment, or progress (other than for legal purposes) for other physicians, agencies, or insurance carriers. Case Management or Care Coordination. Coordinated approach to the delivery of health, substance abuse, mental health, and social services, linking clients with appropriate services to address specific needs and achieve stated goals. Certified Addiction Counselor (CAC). An individual who has received “Certification of Alcohol and Drug Counselors” provided by the Massachusetts Board of Substance Abuse Counselor Certification (MBSACC). There are three levels of certification: CAC, CADC, CADC II. Clinical Stabilization Services (CSS). ASAM Level 3.5 Clinically Managed High-Intensity Residential Services, a 24-hour, seven-days-a-week, clinically managed high-intensity residential treatment services offered in community settings. The services are delivered by nursing, case management, clinical, and recovery support staff under the direction of a licensed medical provider (i.e., physician, advanced practice registered nurse, physician assistant). The services include comprehensive biopsychosocial multidimensional assessments and treatment planning, therapeutic milieu, intensive psychoeducation, individual and group counseling, outreach to families and significant others, linkage to medications for addiction treatment, case management with connection to primary care, community supports and aftercare planning for members beginning to engage in recovery from substance use disorders, and recovery support services. Clinician. An individual with a minimum of a master’s degree in one of the following disciplines or a closely related field: clinical psychology, education counseling, medicine, psychology, psychiatric nursing, rehabilitative counseling, or social work, and who has a minimum of one year of supervised substance use disorder counseling experience. Community Support Program for Homeless Individuals (CSP-HI). A specialized form of CSP for members who are experiencing homelessness as described in 130 CMR 461.000. CSP-HI includes assistance from specialized professionals who, based on their unique skills, education, or lived experience, have the ability to engage and support individuals experiencing homelessness in searching for permanent supportive housing, preparing for and transitioning to an available housing unit, and, once housed, coordinating access to physical health, behavioral health, and other needed services geared toward helping them sustain tenancy and meet their health needs. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-2 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 Co-occurring Disorder. A diagnosis of both a substance use disorder and one or more behavioral health disorders. Co-occurring Enhanced Residential Rehabilitation Services for Substance Use Disorder (COE- RRS). ASAM Level 3.1 Clinically Managed Low-Intensity Residential Services, a 24-hour, seven-days-per-week, clinically enhanced residential service that provides a safe, structured environment in the community. This service supports a member’s recovery from substance use disorders and moderate to severe mental health conditions while reintegrating them into the community and returning to social, vocation/employment, and/or educational roles. Scheduled, goal-oriented, and evidence-based clinical services are provided in conjunction with ongoing support and assistance in developing and implementing recover skills. Counselor. An individual who has a minimum of a high school diploma or equivalent and a minimum of one year of supervised counseling experience in substance use disorder treatment or a closely related field. Couples Counseling. Rehabilitative counseling provided to a couple whose primary complaint is disruption of their marriage, family, or relationship due to substance use and/or co-occurring disorders. Direct and Continuous Supervision. Ongoing supervision provided to unlicensed staff and not independently licensed staff at a frequency of no less than one hour of supervision per week for full-time employees. Supervision time may be pro-rated based on scheduled hours for employees employed less than full-time. Direct and continuous supervision must be delivered by an independently licensed staff member or certified peer supervisor who is employed by the agency. Enhanced Structured Outpatient Addiction Program (E-SOAP). ASAM Level 2.1 Intensive Outpatient Services, a program that provides short-term, clinically intensive, structured day and/or evening SUD services. E-SOAP specifically serves specialty populations such as members experiencing homelessness and members at risk of experiencing homelessness, members who are pregnant or members who have been pregnant in the last 12 months, and adolescents. Family Counseling. The psychotherapeutic treatment of more than one member of a family simultaneously in the same session where the primary complaint is disruption of the family due to substance use and/or co-occurring disorders. Group Counseling. The use of psychotherapeutic and evidence-based counseling techniques in the treatment of a group of individuals, most of whom are not related by blood, marriage, domestic partnership, or legal guardianship, having a primary complaint that is associated with substance use and/or co-occurring disorders. Homelessness. A condition of any member who lacks a fixed, regular, and adequate nighttime residence, and who has a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings including a car, park, abandoned building, bus or train station, airport, or camping group; or who is living in Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-3 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 a supervised publicly or privately operated emergency shelter designated to provide temporary living arrangements, including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, or local government programs for low income individuals. This includes those members who are exiting an institution (e.g., jail, hospital) where they resided for 90 days or less and were residing in an emergency shelter or place not meant for human habitation immediately before entering the institution. Individual Counseling. Psychotherapeutic services provided to a member whose primary complaint is substance use and/or co-occurring disorders. Individual Treatment Plan. A treatment plan based on results of the multidimensional biopsychosocial assessment and created in collaboration with the member, as defined by 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. Individualized Treatment Stabilization Services (ITS) Tier 1. A program that provides integrated ASAM Level 3.7 (ATS) and ASAM Level 3.5 (CSS) services in a single unit or location for stabilization and continuity of care. ITS Tier 1 programs must meet all expectations for both service models, including licensure requirements. ITS Tier 1 serves members who are involuntarily committed to treatment due to the severity and level of impairment caused by their SUD. Individualized Treatment Stabilization Services (ITS) Tier 2. An integrated program that provides enhanced ASAM Level 3.7 (ATS) and ASAM Level 3.5 (CSS) services in a single unit or location for stabilization and continuity of care. ITS Tier 2 must meet all expectations for both service models. ITS Tier 2 serves members who have co-occurring disorders and multiple unsuccessful treatment episodes at lower levels of care who would benefit from fewer transitions between levels of care and enhanced engagement interventions. Licensed Alcohol and Drug Counselor (LADC). An individual who has applied for and has been deemed qualified as defined under 105 CMR 168.000: Licensure of Alcohol and Drug Counselors and duly licensed by the Department of Public Health to provide treatment for individuals with a substance use disorder as a Licensed Alcohol Drug Counselor I (LADC I), Licensed Alcohol Drug Counselor II (LADC II), or Licensed Alcohol Drug Counselor (LADC) Assistant. Licensed Practical Nurse. An individual licensed by the Massachusetts Board of Registration in Nursing in accordance with M.G.L. c. 112, § 74 and in compliance with 244 CMR 3.00: Registered Nurse and Licensed Practical Nurse. Medical Director. A physician licensed to practice medicine with specialized training in addiction medicine, who assumes responsibility for administering all medical services performed by the program, either by performing them directly or by delegating specific responsibility to authorized program physicians and qualified healthcare professionals functioning under the Medical Director’s direct supervision. Medically Managed Inpatient Treatment ASAM Level 4.0 Services. Intensive inpatient services provided in a hospital setting. These programs treat members with acute medically complex Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-4 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 withdrawal management needs, as well as co-occurring biomedical and/or psychiatric conditions. Medically managed intensive inpatient levels of care are licensed by the Massachusetts Department of Public Health under 105 CMR 130.000: Hospital Licensure and 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. Medication Management. Management of medication including resident self-administration oversight, storage, and coordination of all medication prescribed during treatment. Medication Specialist. A staff member in residential rehabilitation programs who is responsible for the oversight, storage, and coordination of self-administration of medication. Medication Visit. A member visit specifically for prescription review and monitoring of psychotropic medication by a psychiatrist, psychiatric clinical nurse specialist, physician, physician assistant, or advanced practice registered nurse or administration of prescribed intramuscular medication by a physician, nurse, or physician assistant. Medication for Addiction Treatment. Use of a medication approved by the federal Food and Drug Administration (FDA) for the treatment of a substance use disorder. Medication for Opioid Use Disorder. Use of a medication approved by the FDA for the treatment of an opioid use disorder. Mental Health Disorder. Any disorder pertaining to mental health, as defined by the current edition of the Diagnostic and Statistical Manual of Mental Disorders. Motivational and Supportive Services. Counseling as a component of acupuncture withdrawal management treatment services that: (1) encourages members to remain in acupuncture withdrawal management treatment; (2) helps members obtain necessary additional medical and social services; (3) includes HIV/AIDS and other risk assessments and education services; and (4) motivates members to participate in ongoing outpatient substance use disorder treatment. Opioid Treatment Program (OTP). A program that provides opioid treatment services. An OTP must be federally certified by the Substance Abuse Mental Health Services Administration (SAMHSA) and must be licensed as an opioid treatment program by the Department of Public Health under 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. OTPs must conform to the federal opioid treatment standards in 42 CFR 8.12. Opioid Treatment Services. Services rendered in Opioid Treatment Programs, which include a biopsychosocial assessment and treatment of a member, using FDA-approved medications (including methadone, buprenorphine, buprenorphine/naloxone, and naltrexone), along with a comprehensive range of medical and rehabilitative services, when clinically necessary, to alleviate the adverse medical, psychological or physical effects incident to opioid dependence. Opioid Treatment Services encompass withdrawal management services and maintenance treatment. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-5 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 Peer Recovery Coach. An individual currently in recovery who has lived experience with substance use or other addictive disorders and/or co-occurring mental health disorders and has been trained to help their peers with a similar experience to gain hope, explore recovery, and achieve life goals. Peer recovery coaches engage in an equitable, non-clinical relationship with the member focused on removing obstacles to recovery. Peer recovery coaches link members to the recovery community and engage in mentoring. Peer Recovery Coach for Pregnant and Postpartum Members (PRC-PP). A specialized peer recovery coach who has pregnancy and/or postpartum lived experience or has completed specialized training. PRC-PPs provide non-clinical peer recovery support to individuals in or seeking recovery who are pregnant or have been pregnant in the last 12 months. Pharmacotherapy. A type of therapy providing therapeutic treatment with pharmaceutical drugs. Physician Assistant. An individual who is registered by the Board of Registration of Physician Assistants in accordance with M.G.L. c. 112, § 9I and 263 CMR: Board of Registration of Physician Assistants. Program Director. An individual employed by the Licensed or Approved Provider who is responsible for the administrative and programmatic day-to-day operations of a program of substance use disorder treatment services and may provide supervision of all non-clinical staff. Quality Management. A systematic and ongoing process for monitoring, evaluating, and improving the quality and appropriateness of services provided to members, with focused attention on addressing cultural, ethnic, and language needs. Recovery Support Navigator. A paraprofessional who receives specialized training in the essentials of substance use disorder or other addictive disorders and evidence-based techniques such as motivational interviewing, and who supports members in accessing and navigating the SUD treatment system through activities that can include care coordination, case management, and motivational support. Recovery Support Navigator for Pregnant and Postpartum Members (RSN-PP). A specialized recovery support navigator who receives specialized training to provide recovery support navigator services to individuals who are pregnant or have been pregnant in the last 12 months. Registered Nurse. An individual licensed by the Massachusetts Board of Registration in Nursing in accordance with M.G.L. c. 112, § 74 and in compliance with 244 CMR 3.00: Registered Nurse and Licensed Practical Nurse. Release of Information (ROI). A document that allows a patient to authorize and revoke what information they want to release from their patient record, who it can be released to, how long it can be released for, and under what statutes and guidelines it is released. Residential Rehabilitation Services (RRS). ASAM Level 3.1 Clinically Managed Low-Intensity Residential Services, are clinically managed low-intensity residential services that provide a 24 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-6 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 hour, seven-days-a-week, supervised structured and comprehensive rehabilitative environment. These services support members’ independence and resilience to help them fully stabilize in recovery. Scheduled, goal-oriented clinical services are provided in conjunction with ongoing support and assistance to help members develop and maintain interpersonal skills necessary for developing and implementing recovery skills. Specialized RRS services tailored for the needs of youth, transitional age youth, young adults, families, and pregnant and port-partum individuals are also available to eligible members. Structured Outpatient Addiction Program (SOAP). ASAM Level 2.1 Intensive Outpatient Services, a substance use disorder treatment service that provides short-term, multi-disciplinary, clinically intensive structured treatment to address the sub-acute needs of members with substance use disorders and/or co-occurring disorders. These services may be used as a transition service in the continuum of care toward lower intensity outpatient programs or accessed directly. Substance Use Disorder (SUD). Any disorder pertaining to substance use as defined by the current edition of the Diagnostic and Statistical Manual of Mental Disorders. Substance Use Disorder Outpatient Counseling Service. ASAM Level 1.5, an outpatient counseling service that is a rehabilitative treatment service for members and their families experiencing the effects of substance use and/or co-occurring disorders. Substance Use Disorder Treatment Organization (Organization). An entity that owns and operates one or more substance use disorder treatment program(s). Substance Use Disorder Treatment Program (Program). A provider that holds a license or approval under 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs, that delivers a comprehensive group of medical, clinical, and psychosocial treatment services to members seeking treatment for substance use disorders, which may include co-occurring mental health disorders. Telehealth. The use of synchronous or asynchronous audio, video, electronic media or other telecommunications technology, including, but not limited to: (1) interactive audio-video technology; (2) remote patient monitoring devices; (3) audio-only telephone; and (4) online adaptive interviews, for the purpose of evaluating, diagnosing, consulting, prescribing, treating, or monitoring a patient’s physical health, oral health, mental health, or substance use disorder condition. Transitional Support Services (TSS). ASAM Level 3.1 Clinically Managed Low-Intensity Residential Services, are active treatment and reassessment services provided on a short-term basis in a 24-hour community-based setting to members with a substance use disorder. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-7 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 418.403: Eligible Members (A) (1) MassHealth Members. The MassHealth agency pays for substance use disorder treatment services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. Covered services for each MassHealth coverage type are set forth in 130 CMR 450.105: Coverage Types. (2) Members of Emergency Aid to the Elderly, Disabled and Children Program. Covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, are set forth in 130 CMR 450.106: Emergency Aid to the Elderly, Disabled and Children Program. (3) Special Services for Pregnant Members. (a) Eligibility Period. A substance use disorder treatment plan for a pregnant member may provide for no more than 10 consecutive months of service from the initiation of treatment. Services may be initiated as soon as the pregnancy is clinically verified or at any month during the pregnancy. (b) Eligibility for special services for pregnant members continues until the last day of the calendar month in which the 12-month postpartum period ends. Other substance use disorder treatment services described in 130 CMR 418.000 may be available to pregnant members during or after this eligibility period. (B) For information on verifying member eligibility and coverage type, see 130 CMR 450.107: Eligible Members and the MassHealth Card. (C) For limitations on mental health and substance use disorder services provided to members enrolled with a MassHealth managed care provider, see 130 CMR 450.105: Coverage Types and 130 CMR 450.124: Behavioral Health Services. 418.404: Provider Eligibility (A) In State. Each program is eligible to participate only if the program is: (1) for provider types eligible for such enrollment, enrolled as a Medicare provider; (2) licensed or approved by the Massachusetts Department of Public Health to provide the appropriate substance use disorder treatment service pursuant to 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs and as defined in 130 CMR 418.404 (A); (3) enrolled and actively participating with the MassHealth agency as a billing provider, as evidenced by the issuance of a Provider Identification and Service Location (PIDSL) number for the provision of substance use disorder treatment services at that location. (B) Out of State. Each out-of-state program is eligible to participate only if the program: (1) meets the following criteria: (a) is licensed by the appropriate state agency under whose jurisdiction it operates to provide equivalent substance use disorder services; Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-8 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 (b) participates in its own state's medical assistance program or its equivalent; and (c) has a rate of reimbursement established by the appropriate rate setting regulatory body of its state. (2) for provider types eligible for such enrollment, is a Medicare-participating provider; and (3) is enrolled and actively participating with the MassHealth agency as a provider of substance use disorder services, and obtains a MassHealth PIDSL number. 418.405: Provider Enrollment Process (A) A separate, complete application for enrollment as a MassHealth substance use disorder treatment provider must be submitted for each site. The applicant must submit the appropriate provider enrollment application to the MassHealth agency. The MassHealth agency may request additional information or perform a site inspection to evaluate the applicant's compliance with the regulations in 130 CMR 418.000. (1) Based on the information in the enrollment application, information known to the MassHealth agency about the applicant, and on the findings from any site inspection deemed necessary, the MassHealth agency will determine whether the applicant is eligible for enrollment. (2) The MassHealth agency will notify the applicant of the determination in writing within 60 days of the MassHealth agency’s receipt of a completed application. An application will not be considered complete until the applicant has responded to all MassHealth requests for additional information, and MassHealth has completed any required site inspection. (B) If the MassHealth agency determines that the applicant is not eligible for enrollment, the notice will contain a statement of the reasons for that determination, including but not limited to incomplete application materials and recommendations for corrective action, if appropriate, so that the applicant may reapply for enrollment once corrective action has been taken. (C) The enrollment is valid only for the provider types and locations described in the application and is not transferable to other programs operated at other locations by the applicant. Any additional program established by the applicant at a satellite clinic or other location must separately apply for enrollment and be enrolled with the MassHealth agency to receive payment. 418.406: Required Notifications and Reports (A) Annual Report. Each substance use disorder treatment program must submit an annual attestation, on forms furnished by the MassHealth agency, and file them with the MassHealth agency by September 30 of each year. The program must provide documentation supporting this attestation upon request by the MassHealth agency. The attestation must include at minimum: (1) a statement that the program has reviewed and updated, as necessary, its written policies and procedures during the reporting period; (2) a statement that the program has completed ongoing review of staffing licensure and license eligibility, including licensure verification with specific attention to provider administrative and clinical management staff; Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-9 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 (3) a statement describing the current language capacities, capacity to provide services to specialized populations, and utilization of evidenced-based modalities of the program; (4) a statement that the program complies with 130 CMR 418.000; and (5) any other information that the MassHealth agency may request. (B) Staffing and Personnel Reports. Each program must provide additional staffing or personnel information as requested by the MassHealth agency. (C) Adverse Incident Reports. Each program must report adverse incidents to the MassHealth agency within 24 hours of discovery of the incident, or, if the incident occurs on a holiday or weekend, on the next business day, in a format specified by the MassHealth agency. (D) Loss of Licensure or Accreditation. (1) Each program must inform the MassHealth agency within 15 days of any citation or loss of licensure or accreditation issued to the program by another agency, including but not limited to: (a) the Department of Public Health; (b) an out of state provider’s relevant state licensing agency; (c) the Joint Commission; or (d) the Commission on Accreditation of Rehabilitation Facilities (CARF). (2) For purposes of this provision, a citation is any deficiency correction order related to health and safety issues as defined in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs, issued by the Department of Public Health or any other agency. (E) Each program must comply with all reporting requirements that may pertain to the practice, facility, or staffing of the program, as directed by the MassHealth agency. 418.407: Revocation of Enrollment (A) The MassHealth agency has the right to review a substance use disorder treatment program’s continued compliance with the conditions for enrollment referred to in 130 CMR 418.405 and the reporting requirements in 130 CMR 418.406, upon reasonable notice and at any reasonable time during the program's hours of operation. The MassHealth agency has the right to revoke a provider’s enrollment, subject to any applicable provisions of 130 CMR 450.000 Administrative and Billing Regulations, if such review reveals that the program has failed to or ceased to meet such conditions. (B) If the MassHealth agency determines that there exists good cause for the imposition of a lesser sanction than revocation of enrollment, it may withhold payment, temporarily suspend the program from participation in MassHealth, or impose some other lesser sanction as the MassHealth agency sees fit, pursuant to the processes in 130 CMR 450.000, as applicable. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-10 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 418.408: Site Inspection (A) The MassHealth agency may, at any time, conduct announced or unannounced site inspections of any program to determine compliance with applicable regulations. Such site inspections need not pertain to any actual or suspected deficiency in compliance with the regulations. (B) After any site inspection where deficiencies are observed, the MassHealth agency will prepare a written site inspection report. The site inspection report will include the deficiencies found, and the period within which the deficiency must be corrected. The program must submit a corrective action plan, within the timeframe set forth by the MassHealth agency, for each of the deficiencies cited in the report, including the specific corrective steps to be taken, a timetable for these steps, and the date by which full compliance will be achieved. The MassHealth agency will review the corrective action plan and will accept the corrective action plan only if it conforms to these requirements. 418.409: Scope of Services (A) The MassHealth agency pays only for services furnished by substance use disorder treatment programs, in accordance with 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs, as follows: (1) Opioid Treatment Programs. The MassHealth agency will pay for opioid treatment programs services rendered by medical, counseling, peer, and paraprofessional staff under the direction of the Medical Director and delivered in conformance with the following: (a) the administration and dispensing of FDA-approved medications for the treatment of opioid use disorders for the purposes of medically supervised withdrawal or maintenance treatment; (b) multidimensional biopsychosocial evaluation and treatment planning either performed by, or reviewed and signed off by, the clinical director or the clinical director’s independently licensed designee; (c) individual and group counseling by a clinician; (d) psychoeducation on the disease of addiction; (e) discharge planning and coordination of services; (f) for pregnant members, coordination with OB/GYN, pediatrics, and any other appropriate medical, social services providers, and state agencies; and (g) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (2) Medically Managed Inpatient Services (ASAM Level 4.0). The MassHealth agency will pay for medically managed inpatient services rendered by medical, counseling, peer, and paraprofessional staff under the direction of a physician and delivered in conformance with the following: (a) daily medical services, including medically managed withdrawal management (b) management of moderate to severe medical complexities; (c) induction onto maintenance treatment; (d) coordination with and/or referral to Medications for Addiction Treatment and Medications for Opioid Use Disorder providers; (e) multidimensional biopsychosocial evaluation and treatment planning either performed by, or reviewed and signed off by, the clinical director or the clinical director’s Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-11 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 independently licensed designee; (f) treatment of mental health co-occurring disorders; (g) individual and group counseling; (h) psychoeducation on the disease of addiction, as clinically appropriate; (i) case management, discharge planning, and coordination of services; and (j) for pregnant members, coordination with OB/GYN, pediatrics, and any other appropriate medical, social services providers, and state agencies; and; (k) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (3) Acute Treatment Services – ASAM Level 3.7 Medically Managed Residential Treatment (ATS). The MassHealth agency will pay for acute treatment services rendered by medical, counseling, peer, and paraprofessional staff under the direction of the Medical Director, and delivered in conformance with the following: (a) medically managed withdrawal management; (b) management of mild to moderate medical complexities; (c) induction onto maintenance treatment; (d) coordination with and/or referral to Medications for Addiction Treatment and Medications for Opioid Use Disorder providers; (e) multidimensional biopsychosocial evaluation and treatment planning either performed by, or reviewed and signed off by, the clinical director or the clinical director’s independently licensed designee; (f) facilitate access to treatment of mental health co-occurring disorders either directly or through referral; (g) individual and group counseling; (h) psychoeducation on the disease of addiction; (i) case management; (j) discharge planning and coordination of services; (k) for pregnant members, coordination with OB/GYN, pediatrics, and any other appropriate medical, social services providers, and state agencies; and (l) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (4) Clinical Stabilization Services – ASAM Level 3.5 Clinically Managed High-Intensity Residential Services (CSS). The MassHealth agency will pay for clinical stabilization services rendered by medical, counseling, peer, and paraprofessional staff under the direction of the Medical Director and delivered in conformance with the following: (a) management of mild medical complexities; (b) coordination with and/or referral to Medications for Addiction Treatment and Medications for Opioid Use Disorder providers; (c) multidimensional biopsychosocial evaluation and treatment planning either performed by, or reviewed and signed off by, the clinical director or the clinical director’s independently licensed designee; (d) facilitate access to treatment of mental health co-occurring disorders either directly or through referral; (e) individual and group counseling; (f) psychoeducation on the disease of addiction; (g) case management; Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-12 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 (h) discharge planning and coordination of services; (i) for pregnant members, provide coordination with OB/GYN, pediatrics, and any other appropriate medical and social services providers, and state agencies; and (j) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (5) Individualized Treatment Stabilization Services (ITS). The MassHealth agency will pay for Tier 1 and Tier 2 ITS services rendered by medical, counseling, peer, and paraprofessional staff under the direction of the Medical Director and delivered in conformance with the following: (a) all services listed in 130 CMR 418.409(3) and (4); (b) psychopharmacology services; (c) treatment of mental health and co-occurring disorders; (d) a minimum of six hours of clinical programming available each day, seven days a week; (e) clinical programming must include evidence-based practices such as cognitive- behavioral therapy (CBT) and acceptance and commitment therapy (ACT), as well as other targeted behavioral interventions that promote skill-building; and (f) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (6) Residential Rehabilitation Services – ASAM Level 3.1 Clinically Managed Low- Intensity Residential Services (RRS). The MassHealth agency will pay for residential rehabilitative services rendered by clinicians, case managers, counselors, and recovery support staff under the direction of a clinical director and delivered in conformance with the following: (a) a minimum of five hours of clinical programming, individual, and/or group counseling sessions per week; (b) a daily schedule of activities designed to facilitate member participation in, and transition to, the community and to promote recovery; (c) individualized case management services; (d) coordination with and/or referral to Medications for Addiction Treatment and Medications for Opioid Use Disorder providers; (e) medication management services; (f) for pregnant members, provide coordination with OB/GYN, pediatrics, and any other appropriate medical, social services providers, and state agencies; and (g) facilitate access to recovery support navigator services and peer recovery coach services either directly or through referral. (7) Transitional Support Services – ASAM Level 3.1 Clinically Managed Low-Intensity Residential Services (TSS). The MassHealth agency will pay for transitional support services delivered in conformance with ASAM Clinically Managed Low-Intensity Residential Services. (8) Structured Outpatient Addiction Programs – ASAM Level 2.1 (SOAP). The MassHealth agency will pay for structured outpatient addiction programs rendered by clinical and paraprofessional staff and delivered in conformance with the following: (a) SOAP services must provide specific programming that addresses the symptoms of co-occurring addiction and psychiatric disorders. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-13 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 (b) full therapeutic programming must be provided three to seven days a week and 3.5 hours a day, including but not limited to: 1. multidimensional biopsychosocial evaluation and treatment planning either performed by, or reviewed and signed off by, the clinical director or the clinical director’s independently licensed designee; 2. individual, group, and family counseling by a clinician; 3. treatment and recovery planning; 4. psychoeducational services; 5. case management; 6. relapse prevention education; 7. peer support and recovery-oriented services; and 8. discharge planning and coordination of services. (c) SOAP staff must provide case management upon intake and establish linkages to the member’s community to support the member through treatment and upon discharge. (d) SOAP program must coordinate with and refer members to Medications for Addiction Treatment and Medications for Opioid Use Disorder, and other behavioral health providers as necessary. (e) SOAP program must refer members to services that address social determinants of health, as indicated in the member’s assessment (e.g., food pantries, domestic violence agencies, vocational services). (9) Enhanced Structured Outpatient Addiction Program – ASAM Level 2.1 (E-SOAP). E- SOAP must also provide services to address the needs of specialty populations, including pregnant members or members who have been pregnant in the last 12 months, members experiencing or who are at risk for experiencing homelessness, and adolescents. In addition to meeting all the requirements for SOAP in 130 CMR 418.409, the MassHealth agency will pay for enhanced structured outpatient addiction programs rendered by clinical and paraprofessional staff and delivered in conformance with the following: (a) when provided to pregnant members, E-SOAP must include coordination with OB/GYN, pediatrics, and any other appropriate coordination with other medical, social services providers, and state agencies; (b) when provided to members experiencing or who are at risk of experiencing homelessness, E-SOAP must provide direct linkages to CSP-HI providers, coordination and linkages to housing resources, and any other appropriate coordination with other medical and social services providers; and (c) when provided to adolescents, E-SOAP must provide family counseling, coordination with pediatrics and family care providers, coordination with school resources including recovery high schools as appropriate, referral to and coordination with Children’s Behavioral Health Initiative (CBHI) providers, coordination with the Department of Children and Families as appropriate, and connection to or provision of evidence-based modalities. (10) Acupuncture Withdrawal Management. The MassHealth agency will pay for outpatient acupuncture withdrawal management services, which may include acupuncture treatments and motivational and supportive services. A provider may not bill separately for these components. (11) Peer Recovery Coaches. The MassHealth agency will pay for peer recovery coach services delivered in conformance with the following: Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-14 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 (a) services must be part of the member’s overall treatment plan; (b) a wellness or recovery plan must be developed jointly with the member, as appropriate; and (c) services must assist the member in creating personally meaningful links to treatment, recovery support services, and support the member’s capacity to engage in services and supports, as needed. (12) Peer Recovery Coaches for Pregnant and Postpartum Members (PRC-PP). The MassHealth agency will pay for peer recovery coach services for pregnant and postpartum members clinically determined to be pregnant or to have been pregnant in the past 12 months, delivered in conformance with the following: (a) services must be delivered in accordance with all the underlying requirements for peer recovery coach services pursuant to 130 CMR 418.409(11); (b) services must include the adoption of an existing plan of safe care or the development of a plan of safe care in compliance with all relevant state and federal requirements, including the Child Abuse Protection and Treatment Act. The plan of safe care must be adopted or developed with the participation and consent of the member; and (c) services must support the member’s capacity to engage in medical services, including obstetric/gynecological services and pediatric services, and social services and supports that promote maternal and infant health, development, and wellness. (13) Recovery Support Navigators. The MassHealth agency will pay for recovery support navigator services delivered in conformance with the following: (a) identify existing providers and services, including collection of current individual treatment plans, medical/nursing care plans, or state agency service plans; (b) develop goals and objectives in conjunction with the member, that guide the activities of the recovery support navigator in support of current individual treatment plans, medical/nursing care plans, or state agency service plans; (c) orient the member to recovery treatment options, and community and recovery supports available to the member; and (d) assist the member with engagement in treatment services. (14) Recovery Support Navigators for Pregnant and Postpartum Members (RSN-PP). The MassHealth agency will pay for recovery support navigator services for pregnant and postpartum members clinically determined to be pregnant or to have been pregnant in the past 12 months, delivered in conformance with the following: (a) services must be delivered in accordance with all the underlying requirements for recovery support navigator services pursuant to 130 CMR 418.409(13); (b) services must include coordination with providers and supports that promote maternal and infant health, development, and wellness. Providers include both medical and social services providers, including obstetric/gynecological and pediatric providers; and (c) services must include the adoption of an existing plan of safe care or the development of a plan of safe care in compliance with all relevant state and federal requirements, including the Child Abuse Protection and Treatment Act. The plan of safe care must be adopted or developed with the participation and consent of the member. (15) Substance Use Disorder Outpatient Counseling Services – ASAM Level 1.5 Outpatient Therapy. The MassHealth agency will pay for outpatient therapy rendered by clinical staff under the direction of the Clinical Director, delivered in conformance with the following: (a) multidimensional biopsychosocial evaluation and treatment planning either Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-15 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 performed by, or reviewed and signed off by, the clinical director or the clinical director’s independently licensed designee; (b) individual and group counseling; (c) psychoeducation on the disease of addiction; (d) discharge planning and coordination of services; and (e) for pregnant members, coordination with OB/GYN, pediatrics, and any other appropriate medical, social services providers, and state agencies. (B) The MassHealth agency pays for all medically necessary substance use disorder treatment services for EPSDT-eligible members in accordance with 130 CMR 450.140: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services: Introduction, without regard to service limitations described in 130 CMR 418.412 and with prior authorization. 418.410: Supervision and Other Staff Requirements (A) Staff Supervision Requirements. (1) Unlicensed or Not Independently Licensed Staff. All professionals who are unlicensed, who are in a profession without licensure, or who are not independently licensed or certified as a peer supervisor must receive direct and continuous supervision. Direct and continuous supervision may be provided using telehealth technology. (2) Independently Licensed and Certified Peer Supervisor Staff. All independently licensed professionals and certified peer supervisors must receive supervision in accordance with the relevant licensing requirements and program policy. Supervision may be provided using telehealth technology. (3) The supervising clinician is primarily responsible for the care of the member. For any care delivered by a professional under supervision, there must be documentation in the clinical chart that the chart was reviewed by the supervising clinician. (4) All supervision must be documented in files accessible for review by the MassHealth agency. Supervision notes must, at a minimum, contain information regarding frequency of supervision, format of supervision, supervisor’s signature and credentials, and general content of supervision session. (B) Required Qualifications of Certain Professional and Paraprofessional Staff. (1) Peer Recovery Coaches. Peer recovery coaches must meet the following requirements: (a) have at least two years of sustained recovery; and (b) hold, or be actively working to obtain, credentialing as a Certified Addiction Recovery Coach (CARC) through the Massachusetts Board of Substance Abuse Counselor Certification, or alternative licensure or certification process, as directed by EOHHS. (2) Peer Recovery Coaches for Pregnant and Postpartum Members. Peer recovery coaches for pregnant and postpartum members must meet the following requirements: (a) have at least two years of sustained recovery; (b) hold, or be actively working to obtain, credentialing as a Certified Addiction Recovery Coach (CARC) through the Massachusetts Board of Substance Abuse Counselor Certification, or alternative licensure or certification process, as directed by EOHHS; and Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-16 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 (c) have lived experience as a pregnant or postpartum individual or have completed specialized training in providing peer recovery coaching services to pregnant and postpartum individuals. (3) Recovery Support Navigators. Recovery support navigators must hold a bachelor’s degree in social work, psychology, or a related behavioral health field, or have two years of relevant work experience and/or lived experience with a primary diagnosis of substance use disorder. (4) Recovery Support Navigators for Pregnant or Postpartum Members. Recovery support navigators for pregnant and postpartum members must meet the following requirements: (a) hold a bachelor’s degree in social work, psychology, or a related behavioral health field, or have two years of relevant work experience and/or lived experience with a primary diagnosis of substance use disorder; and (b) have lived experience as a pregnant or postpartum individual or have completed specialized training in providing recovery support navigator services to pregnant and postpartum individuals. (5) Certified Alcohol Counselor (CAC) and Certified Alcohol and Drug Addiction Counselor (CADAC). There are three levels of certification: CAC, CADC, CADC II. Each level must have received a “Certification of Alcohol and Drug Counselors” provided by the Massachusetts Board of Substance Abuse Counselor Certification (MBSACC). (6) Licensed Alcohol and Drug Counselor I. A licensed alcohol and drug counselor must be licensed by the Department of Public Health pursuant to 105 CMR 168.00: Licensure of Alcohol and Drug Counselors. (C) Minimum Staffing Composition Requirements for Services. In addition to the requirements set forth in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs, programs must meet the following staffing requirements to provide each service: (1) Acute Treatment Services – ASAM Level 3.7 Medically Managed Residential Treatment (ATS). Programs delivering medically monitored intensive inpatient services must designate at a minimum the following staff: (a) Medical Director. A program must designate one physician who is responsible for the provision of all medical services provided by the program. The Medical Director may provide medical services directly or delegate the provision of direct services to a nurse practitioner or physician assistant working under their supervision. The medical director, or a designated nurse practitioner or physician assistant working under their supervision must be available, either on-site or remotely, for consultation and to facilitate admissions 24 hours per day, seven days per week, including weekends and holidays to ensure the provision of high-quality care. The Medical Director must be available to be onsite during any hours of program operation, as needed. (b) Clinical Director. A program must designate one individual employed on a full-time basis who is responsible for the adequacy and appropriateness of member care, and oversight of quality management. The Clinical Director must meet the minimum requirements set forth in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. (c) Program Director. A program must designate one individual, employed on a full- time basis, who is responsible for the daily administration and operation of the program. (d) Nurse Manager. A program must designate one individual, employed on a full-time Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-17 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 basis, who is responsible for ensuring on-site nursing coverage 24 hours per day, seven days a week, and provide direct and continuous supervision of nursing staff. (e) Nursing Staff. A program must schedule all daytime shifts with at least one RN-level nurse during day and evening shifts and schedule all overnight shifts with at least one of either an RN-level or licensed practical nurse. (f) Recovery Specialist. A program must schedule at least one recovery specialist for each shift. (g) Counseling Staff. Programs serving members younger than 18 years old must schedule counseling staff to cover a minimum of 12 hours a day, seven days a week. All other programs must provide sufficient staff coverage on all shifts to ensure patient needs are met. (h) Case Manager. Programs serving members younger than 18 years old must designate case management staffing such that there is a minimum of eight hours of case management services provided at least five days a week. All other programs must designate sufficient staff coverage to ensure that patient needs are met. (i) Other Medical Professionals. The program must have available, whether on staff or by contract, at least one OB/GYN to facilitate medically necessary care to pregnant members. (j) Other Clinical Staff. The organization must employ at least one independently licensed clinician, in addition to the Clinical Director, to support additional oversight of clinical adequacy, and appropriateness of member care and quality management of the program. (2) Clinical Stabilization Services – ASAM 3.5 Clinically Managed High-Intensity Residential Services (CSS). Programs delivering clinically managed high-intensity residential services must designate at a minimum the following staff: (a) Medical Director. A program must designate one physician who is responsible for the provision of all medical services provided by the program. The Medical Director may also provide medical services directly or delegate the provision of direct services to an advanced practice nurse practitioner or physician assistant working under their supervision must be available on-site or remotely for consultation and to facilitate admissions 24 hours per day, seven days per week, including weekends and holidays to ensure the provision of high-quality care. The Medical Director must be available to be onsite during any hours of program operation, as needed. (b) Clinical Director. A program must designate one individual employed on a full-time basis who is responsible for the adequacy and appropriateness of member care, and oversight of quality management. The Clinical Director must meet the minimum requirements set forth in 105 CMR 164.000 Licensure of Substance Use Disorder Treatment Programs. (c) Program Director. A program must designate one individual, employed on a full- time basis, who is responsible for the daily administration and operation of the program. (d) Nursing Staff. The program must ensure that no less than 40 hours of nursing coverage is available on a weekly basis including weekends and holidays. (e) Counseling Staff. A program must schedule, at a minimum, the full-time equivalent of 2.5 counseling staff members to be present 12 hours a day, seven days a week. (f) Recovery Specialist. A program must schedule at least one recovery specialist for each shift. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-18 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 (g) Case Manager. A program must schedule, at a minimum, one case manager or care coordinator on a full-time basis, five days a week. (h) Other Clinical Staff. The organization must employ at least one independently licensed clinician, in addition to the Clinical Director, to support additional oversight of clinical adequacy, and appropriateness of member care and quality management of the program. (3) Individualized Treatment Stabilization Services (ITS) Tiers 1 and 2. Programs delivering individualized treatment services must meet all staffing requirements for both ASAM 3.7 (ATS) and ASAM 3.5 (CSS) services pursuant to 130 CMR 418.410 and 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs, and must designate, at minimum, a master’s level clinician to provide individual and group counseling services. (4) Residential Rehabilitation Services (RRS) and Transitional Support Services (TSS) – ASAM Level 3.1 Clinically Managed Low-Intensity Residential Services. Programs delivering residential rehabilitation services or transitional support services must meet all staffing requirements pursuant to 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. In addition, RRS and TSS programs must designate, at a minimum, a medication specialist. (5) Opioid Treatment Programs (OTPs). Programs delivering OTP services must designate at a minimum the following staff: (a) Medical Director. A program must designate one physician with documented clinical experience with opioid-dependent, alcohol, and other drug-dependent individuals, or 40 hours of documented continuing education in treating addicted individuals and medications for treatment of addiction, including all FDA-approved medications for treatment of opioid use disorder, who is responsible for the provision of all medical services provided by the program. The Medical Director may provide medical services directly or delegate such direct service provision to an advanced practice registered nurse or physician assistant who has received midlevel waiver approval through Bureau of Substance Addiction Services and SAMHSA and who are working under the supervision of the Medical Director. The Medical Director is responsible for coverage of admission requests during evening and weekend hours. (b) Clinical Director. A program must designate one individual who is independently licensed as a Licensed Alcohol and Drug Counselor I (LADC I), Licensed Independent Clinical Social Worker (LICSW), Licensed Marriage and Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), or psychologist. The Clinical Director is responsible for adequacy and appropriateness of member care, and oversight of quality management. (c) Program Director. A program must designate one individual, employed on a full- time basis, who is responsible for the daily administration and operation of the program. (d) Nurse Manager. A program must designate a Nurse Manager who is employed by the program to oversee the provision of nursing services and provide direct and continuous supervision of all nursing staff employed by the OTP. (e) Nursing Staff. A program must ensure nursing coverage for operations, including during evening and weekend hours. (f) Clinical Staff. The program or the organization must employ at least one additional independently licensed clinician in addition to the Clinical Director., The program must employ sufficient clinicians to ensure individual, group, and family counseling is Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-19 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 provided to meet the needs of members seeking the service. (6) Structured Outpatient Addiction Programs (SOAP) – ASAM Level 2.1. Programs delivering structured outpatient addiction program services must designate at a minimum the following staff: (a) Program Director. A program must designate one individual, employed on a full- time basis, who is responsible for the daily administration and operation of the program. (b) Clinical Director. A program must designate one individual employed on a full-time basis who meets the minimum requirements set forth in 105 CMR 164.000 Licensure of Substance Use Disorder Treatment Programs. The Clinical Director is responsible for adequacy and appropriateness of member care, and oversight of quality management. (c) Clinical Staff. A program must employ sufficient clinical staff who meet the minimum requirements set forth in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs to ensure individual, group, and family counseling, as well as treatment planning, is provided to meet the needs of members seeking the service; and (d) Case Manager. A program must designate one case manager responsible for helping clients obtain medically necessary services by providing information, referral coordination, discharge planning, and follow-up. (e) Other Clinical Staff. The organization must employ at least one independently licensed clinician, in addition to the Clinical Director, to support additional oversight of clinical adequacy, and appropriateness of member care and quality management of the program. (7) Enhanced Structured Outpatient Addiction Programs (E-SOAP) – ASAM Level 2.1. Programs delivering E-SOAP services must meet all requirements for SOAP services set forth in 130 CMR 418.409(8) and must designate at a minimum, the following staff: (a) Case Manager. A program must employ, on a full-time basis, at least one case manager working under the supervision of the clinical director. The case manager is responsible for helping members obtain medically necessary services by providing information, referral coordination, discharge planning, and follow-up. Case managers must ensure individuals are connected to appropriate services, including OB/GYN, pediatrics, family care providers, CSP-HI, housing resources, school resources, and other medical/social services providers or state agencies. (b) Other Clinical Staff. The organization must employ at least one independently licensed clinician, in addition to the Clinical Director, to support additional oversight of clinical adequacy, and appropriateness of member care and quality management of the program. (c) Clinical Staff. In addition to the clinical staffing requirements set forth in 130 CMR 418.410, program staff must also ensure that clinicians trained in: 1. family and adolescent counseling; 2. services for members experiencing or at risk of experiencing homelessness; and 3. members who are pregnant are available for members enrolled in this service. (8) Medically Managed Inpatient Treatment – ASAM Level 4.0. Programs delivering these services must ensure that members receive daily medical services provided by a physician or their designee as well as designating a primary nurse for each member. The program must have available, whether on staff or by contract, at least one OB/GYN to facilitate medically necessary care to pregnant members. (9) Substance Use Disorder Outpatient Counseling Services – ASAM Level 1.5 Outpatient Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-20 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 Therapy. Programs delivering these services must designate at a minimum: (a) Clinical Director. A program must designate one individual who is independently licensed as a Licensed Alcohol and Drug Counselor I (LADC I), Licensed Independent Clinical Social Worker (LICSW), Licensed Marriage and Family Therapist (LMFT), Licensed Mental Health Counselor (LMHC), or psychologist. The Clinical Director is responsible for adequacy and appropriateness of member care, and oversight of quality management. (b) Program Director. A program must designate one individual, employed on a full- time basis, who is responsible for the daily administration and operation of the program. (c) Clinical Staff. A program must employ sufficient clinicians to ensure individual, group, and family counseling is provided to meet the needs of members seeking the service. 418.411: Recordkeeping Requirements (A) Each program provider must maintain member records in accordance with 130 CMR 450.000: Administrative and Billing Regulations and 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. Member records must be complete, accurate, and properly organized. The member’s record must include a complete record of all services provided to members directly, referrals made, if the appointment was kept, and a progress note for each counseling session, including the treatment modality and duration and the therapist's discipline and degree, written and signed by the primary therapist. (B) Program Records. The substance use disorder treatment program must retain documentation reflecting compliance with the requirements of 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. (C) Availability of Records. All records must be made available to the MassHealth agency, upon request. 418.412: Service Limitations (A) In addition to the requirements set forth in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs, programs must adhere to the following service limitations: (1) Opioid Treatment Services. (a) Payment for oral opioid agonist and partial agonist medication is limited to one dose per member per day. Payment for providing a take home supply is limited to the amounts and frequency set forth in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. (b) Payment for opioid partial agonist medication, whether a single-agent or in combination with naloxone, is limited to one dose per member per day. Payment for a take-home supply is limited to the amounts and frequency set forth in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. (c) Payment for administering injectable opioid antagonist medication is limited to one dose per member per month. (d) Payment for administering injectable opioid partial agonist medication is limited to one dose per member per month. (e) Payment for drug screens for members receiving opioid agonist, partial agonist, and Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-21 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 antagonist medication is limited to the amounts and frequency set forth in 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. (2) Residential Rehabilitative Services – ASAM Level 3.1 Clinically Managed Low- Intensity Residential Services (RSS). The MassHealth agency will pay for the first 90 days of residential rehabilitation services per episode of care. (3) Case Consultation. (a) The MassHealth agency will pay a provider only for a case consultation that involves a personal meeting with a professional of another agency. Personal meetings may be conducted via audio-only telephonic, audio-video, or in person meetings. (b) The MassHealth agency will pay for case consultation only when written communication, and other non-reimbursable forms of communication clearly, will not suffice. Such circumstances must be documented in the member’s record. Such circumstances are limited to situations in which the program and the other party are actively involved in the treatment or management programs with the member (or family members) and where a lack of face-to-face communication would impede a coordinated treatment program. (c) The MassHealth agency will not pay for court testimony. (4) Acupuncture Withdrawal Management. (a) Each session must last at least 45 minutes and no more than 60 minutes. (b) All members seeking acupuncture withdrawal management services must be screened to ensure that acupuncture treatment is not medically contraindicated. If the screening determines that acupuncture treatment is medically contraindicated, the provider should assist the member in obtaining an alternative form of treatment. The screening may be performed by a physician assistant, an advanced practice registered nurse, or a registered nurse. The member is appropriate for acupuncture withdrawal management services if the screening determines that the member: 1. has no history of seizures, delirium tremens, or other life-threatening withdrawal symptoms; and 2. is oriented to time, place, and person. (5) Peer Recovery Coach Services and Peer Recovery Coach Services for Pregnant and Postpartum Members. The MassHealth agency pays for peer recovery coach services and peer recovery coach services for pregnant and postpartum members as rendered pursuant to 101 CMR 418.409. The MassHealth agency does not pay for peer recovery coach services or peer recovery coach services for pregnant or postpartum members that are clinical or medical in nature and outside the scope of the position. (6) Structured Outpatient Addition Program and Enhanced Structured Outpatient Addiction Program Services – ASAM 2.1. The MassHealth agency does not pay for SOAP or E-SOAP services for members who also receive group counseling in substance use disorder outpatient counseling services on the same day. (7) Telehealth. Services including the prescribing of controlled substances must be in accordance with state and federal regulations 418.413: In-state Providers: Maximum Allowable Fees The Massachusetts Executive Office of Health and Human Services determines the maximum Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-22 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 allowable fees for substance use disorder treatment services. Payment is always subject to the conditions, exclusions, and limitations set forth in 130 CMR 418.000. Reimbursement for a service will be the lower of the following: (A) the maximum allowable fee listed in the applicable fee schedule pursuant to 101 CMR 346.00: Rates for Certain Substance-Related and Addictive Disorders Programs, and 101 CMR 444: Rates for Certain Substance Use Disorder Services; or (B) the program's usual and customary fee. 418.414: Out-of-state Providers: Maximum Allowable Fees Payment to a substance use disorder treatment program located out of state will be in accordance with the applicable rate schedule of its state's Medicaid Program or its equivalent and is always subject to the applicable conditions, exclusions, and limitations set forth in 130 CMR 418.000. REGULATORY AUTHORITY 130 CMR 418.000: M.G.L. c. 118E, §§ 7 and 12. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-23 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025 This page is reserved Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 418.000) Page 4-24 Substance Use Disorder Treatment Manual Transmittal Letter SUD-24 Date 03/28/2025