NYSDOH Office of Health Insurance Programs

• Standards is also available in Portable Document Format (PDF)

Criteria Standards for the Authorization and Utilization Management of Harm Reduction Services

Effective July 1, 2018 each Medicaid Managed Care (MMC) plan, including mainstream MMC Plans, HIV Special Needs Plans (HIV SNPs), and Health and Recovery Plans (HARPs) policy, procedures and coverage criteria for the authorization and utilization management of harm reduction services will be reviewed by the New York State Department of Health (the Department) to ensure its clinical appropriateness. Such criteria must be submitted to and approved by the Department before it may be used for Service Authorization Request determinations. Department approved criteria standards may not be implemented until January 1, 2019.

1. Submission
   1. Each MMC Plan that chooses to adopt criteria for the authorization and utilization management of harm reduction services must submit the criteria (and any subsequent amendment to such criteria) electronically to the Department’s Bureau of Managed Care Certification & Surveillance (BMCCS) BML: bmccsmail@health.ny.gov Attention: Medical Director – Harm Reduction Services Standards for Department review and approval prior to use.
   2. The submission must include the MMC Plan’s Chief Medical Officer’s approval of its criteria for the authorization and utilization management of harm reduction services.
   3. The MMC Plan’s submission must clearly demonstrate compliance with Department guidance of harm reduction services, and all applicable Medicaid managed care program requirements.
   4. Any change to a MMC Plan’s criteria for the authorization and utilization management of harm reduction services must be submitted to the Department for review and approval prior to use.
2. Criteria Requirements
   
   To be considered satisfactory, a MMC Plan’s criteria for the authorization and utilization management of harm reduction services must, at a minimum:
   1. Reflect that the MMC Plan will be responsible for covering harm reduction services as set forth in the approved State Plan Amendment, for their enrollees;
   2. Reflect that there is no limitation in the amount and duration of harm reduction services. Harm reduction services continue until the SEP staff determines that the service goals have been met or if the client decides he/she no longer wants to participate in services; reflect that client can re–enroll in HRS services as many times as needed
   3. Be based on evidenced–based practice and/or nationally established clinical practice guidelines, when available, and developed in compliance with Public Health Law Article 49;
   4. Be aligned with a fully integrated client–oriented approach to the health and wellness of substance users that promotes the physical and psychosocial health of the enrollee, and addresses the wide–range of needs that are usually associated with substance use disorder;
   5. Consider the physician or other licensed practitioner recommendations, and the enrollee’s individual service plan when determining the appropriateness of requested harm reduction treatment strategies, and services;
   6. Reflect that harm reduction services covered by Medicaid may only be provided by NYSDOH– authorized and waivered SEPs which are enrolled as Medicaid providers;
   7. Reflect that services are provided in accordance with an individual service plan;
   8. Reflect that when utilization of harm reduction services significantly deviates from expected level of care, the MMC Plan will consider each enrollee’s case on an individual basis to determine the individuals progress, or lack of progress, related to the existing individual service plans. Consideration needs to be given to the following:
      1. The enrollee’s current condition, effectiveness of previous services, and environmental factors that may be affecting the desired outcomes;
      2. Additional service gaps that could address unmet needs;
      3. How, or if, the individual service plan can be adapted to facilitate achievement of goals.
      4. Recognition that: 1) behavioral changes as a result of participation in harm reduction services are incremental; 2) harm reduction services may result in stabilization of some clients without changing or stopping substance use.
   9. Reflect that referrals to appropriate clinical and supportive services are a critical component of harm reduction services and that MMC Plans must facilitate access to such services including substance use disorder (SUD) treatment when an enrollee is ready;
   10. Reflect that harm reduction services must be recommended in writing by a physician or other licensed practitioner;
   11. Include processes and procedures for communicating its criteria for the authorization and utilization management of harm reduction services to enrollees and their providers.
3. Requirement for MMC Plan Authorization Policy and Procedures
   1. MMC Plans may not require prior authorization for harm reduction services;
   2. Concurrent review and retrospective review criteria must be implemented in compliance with all relevant statutes and regulations, including but not limited to New York State Public Health Law Article 49;
   3. All service authorization determinations must be made pursuant to the enrollee’s individual services plan and in coordination with the enrollee’s providers;
   4. Reflect that the MMC Plan will be responsible for covering harm reduction services outside of the service area; through out–of–network arrangements with NYSDOH authorized and waivered SEPs.
   5. Service Authorization determinations must consider the following continuity of care requirements as provided in the Harm Reduction Services guidance paper:
      1. Current managed care plan enrollees receiving grant–funded harm reduction services prior to the July 1, 2018, effective date, are permitted to keep their current provider of harm reduction services;
      2. Enrollees may utilize services at more than one harm reduction organization in a provider network. Each harm reduction organization will keep an up–to–date plan of care for the enrollee;
      3. Enrollees may enter harm reduction services via referral from sources such as the SEP where harm reduction services take place, a health care provider, a managed care plan, a health home, or a substance use disorder treatment program. Upon request, the MMC Plan must coordinate appropriate referrals for the enrollee to attend a participating harm reduction services organization for initial assessment and development of a plan of care;
      4. To ensure continuity of care, MMC Plans must consider all harm reduction organization discharge plans available to them.
         1. A discharge plan should be provided by the harm reduction organization to the enrollee, and with the enrollee´s consent, to his/her legal guardian where applicable and to his/her designated care provider within fifteen (15) days of the notice of or request for disenrollment.