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From Health Law Daily, January 27, 2015

State options to cover services for substance use and dependence in adolescents

By Michelle L. Oxman, J.D., LL.M.

CMS and the Substance Abuse and Mental Health Services Administration (SAMHSA) have jointly issued guidance for states concerning effective treatments for substance use, substance dependence, and related mental health disorders in adolescents. The guidance addresses both the types of services that have been found effective and the legal authority for covering the services (CMCS and SAMHSA Joint Informational Bulletin, January 26, 2015).

Need for screening. Individuals who begin to abuse alcohol or drugs before the age of 18 are at higher risk for addiction. The effects of alcohol and drugs on the developing brains of children and adolescents have become apparent. The high incidence of comorbid mental health disorders (MHD) in young people with substance use disorders (SUD) also is cause for concern. Therefore, the agencies recommend that every adolescent be screened for SUD and mental health issues. There are several reliable screens that are easily administered. Individuals with positive screens should undergo assessment in order to determine the need for treatment and develop a treatment plan. CMS published additional guidance on screening in March, 2013 (See New and expanded resources available to screen children for mental health, substance use conditions, April 3, 2013).

Continuum of services. Effective treatments for SUD and MHD include outpatient, intensive outpatient, partial hospitalization, and residential or inpatient therapy. Outpatient care may include individual, group, or family counseling. The expert panel found that both psychotherapeutic and behavioral interventions affect the neurobiology of young people and that certain therapies have the support of scientific evidence. The therapy used should be appropriate to the developmental stage of the child. To be covered as part of the adolescent’s treatment for SUD or MHD, family counseling must address the needs of the adolescent with the disorder.

Intensive outpatient therapy takes anywhere from six to 19 hours per week, which may occur after school, days, evenings, or weekends. Concurrent psychiatric treatment is offered as appropriate to the adolescent’s condition. The next level of intensity is partial hospitalization, sometimes called “day treatment,” which involves 20 or more hours of intensive programming per week. The treatment may include individual, family, or group counseling; medication management; education; and other therapies, including occupational and recreational therapy.

Other features. Medication can be an effective tool to treat youth with SUD and MHD. Medication management should be accompanied by appropriate therapy. Certain drugs have been approved by the FDA specifically to treat opioid dependence. Case management services may be used, and peer-to-peer support may be provided both to the adolescent and to the parent or caregiver.

Residential treatment. This form of treatment involves 24-hour staffing and a structured environment. It may be necessary in order to manage withdrawal, and it is sometimes effective in reducing substance use to a level that may be addressed in intensive outpatient treatment. State agencies should be careful to distinguish residential treatment for individuals under 21 from the services of an institution for mental diseases.

Legal authority for services. Screening and assessment would be a standard component of early and periodic screening, diagnosis, and treatment. Many of the services described above are included in Soc. Sec. Act Sec. 1905(a), including physician, hospital, and clinic services, rehabilitative therapies, and the services of other licensed professionals. State agencies may combine these services as early and periodic screening, diagnosis, and treatment (EPSDT), home- and community-based services (HCBS) under a waiver under Soc. Sec. Act Sec. 1915(c) or under the state plan. They also may use the medical home benefit under Soc. Sec. Act Sec. 1945.

Quality reporting requirements include two measures for SUD treatment, and SAMHSA has developed National Outcome Measures as well. State agencies are cautioned to take the risk of fraud seriously whenever they purchase SUD or MHD services.

MainStory: TopStory MedicaidNews CMSNews

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