| (a) Subject to the specifications, conditions, limitations,
and requirements established by the Health and Human Services Commission
(HHSC) or its designee, substance use disorder treatment services
are those services provided by a provider or facility licensed by
the HHSC to provide substance use disorder treatment services.
(b) Substance use disorder has the definition assigned
in the most current American Psychiatric Association's Diagnostic
and Statistical Manual of Mental Disorders.
(c) Covered outpatient substance use disorder treatment
services include:
(1) assessment;
(2) outpatient group and individual counseling;
(3) medication assisted treatment; and
(4) outpatient withdrawal management.
(d) Covered outpatient substance use disorder treatment
services are limited as follows.
(1) One assessment per episode of care, which must
be performed at the start of each new episode of care.
(2) A maximum of 135 sessions per person, per calendar
year for outpatient group counseling services. Additional services
beyond this limit may be considered with documentation of the supporting
medical necessity for continued treatment services. Using their best
judgement, a provider determines the length of time that constitutes
a group session depending on the group members, the focus of the session,
and other relevant variables.
(3) A maximum of 26 hours per person, per calendar
year of outpatient individual counseling services. Additional services
beyond this limit may be considered with documentation of the supporting
medical necessity for continued treatment services.
(4) Medication assisted treatment duration is determined
on an individual basis, based on the person's unique needs and treatment
goals. Medication assisted treatment is the use of Food and Drug Administration-approved
medications in combination with psychosocial treatment to treat substance
use disorders, particularly alcohol and opioid use disorders, in compliance
with 42 Code of Federal Regulations Part 8. Medication Assisted Treatment
for Opioid Use Disorders, and applicable state rules.
(5) Outpatient withdrawal management is limited to
an appropriate duration of service based on medical necessity and
level of intoxication for a maximum of 21 days per episode of care.
There are no limits on the number of episodes of care.
(e) Covered residential substance use disorder treatment
services include:
(1) residential withdrawal management; and
(2) residential treatment.
(f) Covered residential substance use disorder treatment
services are billed on an outpatient claim form and are limited as
follows.
(1) Residential withdrawal management is limited to
an appropriate duration of service based on medical necessity and
level of intoxication for a maximum of 21 days per episode of care.
There are no limits on the number of episodes of care.
(2) Residential treatment is limited to an appropriate
duration of service based on medical necessity and severity of substance
use disorder for a maximum of 35 days per episode of care and no more
than two episodes of care per rolling six month period, and four episodes
per rolling 12 month period. Additional episodes within the six-month
or 12-month time frame may be considered with documentation of medical
necessity.
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| Source Note: The provisions of this §354.1311 adopted to be effective July 1, 1990, 15 TexReg 3431; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective August 27, 1996, 21 TexReg 7730; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective January 1, 2011, 35 TexReg 10195; amended to be effective August 10, 2021, 46 TexReg 4845 |
