New York State (NYS) carved in Behavioral Health (BH) services into the Medicaid Advantage Plus (MAP) Plan benefit package effective January 1, 2023.

This guidance outlines the claiming requirements necessary to ensure proper BH claim submission with respect to MAP Plans. Each BH service transitioning to the Medicaid Managed Care reimbursement model is covered in detail below. This manual should be used in conjunction with the MAP coding taxonomy for BH which was prepared by the Office of Mental Health (OMH) for MAP Plan and provider use found here.

MAP Plans are a type of Dual Eligible-Special Needs Plan (D-SNP) combined with a Medicaid Managed Long-Term Care (MLTC) Plan, which administers Medicare and Medicaid benefits, including Medicaid long-term care services. Utilization management and eligibility requirements for mental health and addiction services included in the MAP benefit package are the same as the requirements in Medicaid Health and Recovery Plans (HARPs) and the Mainstream Managed Care Plans. For more details please see Behavioral Health Guidance for Managed Care Organizations Carving Behavioral Health into Medicaid Advantage Plus and Medicaid Advantage Plus (MAP) Model Contract.

Note: This manual only addresses MAP Plan BH billing guidance. It does not supersede applicable regulatory requirements or procedures for admission to a program, record keeping, initial and on-going treatment planning and reviews, etc. Those standards are in the regulations for each program.

Covered Services - Behavioral Health Services Carve-in Crosswalk

The behavioral health services that must be covered by MAP Plans are detailed in Tables 1-3 below. Some of these services are new to MAP effective January 1, 2023, and some are already part of the MAP benefit package. The tables also provide clarification on whether or not each service is covered by Medicaid and/or Medicare as underlying components of the MAP Plan. Please note, however, that even if a service is covered by "Medicaid-only" it is still a required component of the MAP benefit package and must be covered by the MAP Plan.

Table 1: Combined Medicare Advantage and Medicaid Advantage Plus Benefit Package for Mental Health (MH) Services
OMH Service	OMH Regulation 14 NYCRR	MAP Medicaid Coverage (Before Jan 2023)		MAP Medicaid Coverage (Beginning Jan 2023)		MAP Medicare Coverage
		Hospital	Freestanding	Hospital	Freestanding	Hospital	Freestanding
Psychiatric Inpatient	Parts 580, 582, and 587	Covered (days in excess of the Medicare 190-day lifetime maximum)		Covered		Covered (Medicare 190-day lifetime maximum)
Mental Health Outpatient Treatment and Rehabilitative Services	Part 599	Covered	Covered	Covered	Covered	Covered	Covered
Assertive Community Treatment (ACT)	Part 508	Carved-out		Covered		Not Covered
Continuing Day Treatment (CDT)	Sections 587.10 & 588.7	Carved-out		Covered		Not Covered
Comprehensive Psychiatric Emergency Program (CPEP)	Parts 590 & Part 591	Carved-out		Covered		Not Covered
Partial Hospitalization (PH)	Sections 587.12 & 588.9	Carved-out		Covered		Not Covered
Personalization Recovery Oriented Services (PROS)	Part 512	Carved-out		Covered		Not Covered (except for the clinic component)
Crisis Residence	Part 589	Carved-out		Covered		Not Covered

Table 2: Combined Medicare Advantage and Medicaid Advantage Plus Benefit Package for Substance Use Disorder (SUD) Services
OASAS Service	OASAS Regulation 14 NYCRR	MAP Medicaid Coverage (Before Jan 2023)		MAP Medicaid Coverage (Beginning Jan 2023)		MAP Medicare Coverage
		Hospital	Freestanding	Hospital	Freestanding	Hospital	Freestanding
Medically Managed Withdrawal and Stabilization – Inpatient	Section 816.6	Covered		Covered		Covered
Medically Supervised Withdrawal and Stabilization – Inpatient	Section 816.7	Covered	Carved-out	Covered	Covered	Covered	Not Covered
Medically Supervised Withdrawal and Stabilization – Outpatient	Section 816.8 and Part 822	Covered	Covered	Covered	Covered	Covered	Not Covered
Inpatient Rehabilitation	Part 818	Covered	Carved-out	Covered	Covered	Covered	Not Covered
Addiction Treatment Center - State Operated Inpatient Rehabilitation	Part 818		Carved-out		Covered		Not Covered
Residential Services	Part 820		Carved-out		Covered		Not Covered
Outpatient Clinic	Part 822	Covered	Covered	Covered	Covered	Not Covered (see note**)	Not Covered (see note**)
Outpatient Rehabilitation	Part 822	Covered	Covered	Covered	Covered	Not Covered (see note**)	Not Covered (see note**)
Opioid Treatment Program	Part 822	Carved-out	Carved-out	Covered	Covered	Covered	Covered

**Medicare Coverage Note: Medicare eligible services like psychotherapy and some medication assisted treatment are covered only when delivered by a Medicare enrollable practitioner and billed as a practitioner claim.

Table 3: Combined Medicare Advantage and Medicaid Advantage Plus Benefit Package for Behavioral Health Services with Joint OMH and OASAS Oversight
OMH and OASAS Service	OMH/OASAS Regulation	Medicaid Coverage (Before Jan 2023)		Medicaid Coverage (Beginning Jan 2023)		Medicare Coverage
		Hospital	Freestanding	Hospital	Freestanding	Hospital	Freestanding
Community Oriented Recovery and Empowerment (CORE) Services	N/A		Carved-out*		Covered		Not Covered
Mobile Crisis	N/A	Carved-out		Covered		Not Covered

*Community Oriented Recovery and Empowerment (CORE) Services were implemented February 1, 2022. CORE Services are only available to eligible individuals enrolled in Medicaid Managed Care and are available for eligible MAP enrollees beginning January 1, 2023.

Medicaid Advantage Plus (MAP) is an "integrated plan", funded by both Medicare and Medicaid and covering both sets of services (some of which are held in common). As such, for any given service only a single claim is submitted to the MAP plan and that single claim is for both the Medicare and Medicaid sides of the plan. It is up to the MAP plan to accept the single claim and make a single payment to the provider. The Medicare and Medicaid aspects of coverage are described below.

Services Covered by Medicaid Only (requiring government rates)

As of January 1, 2023, MAP Plans are required to pay government rates, meaning at least.

100 percent of the Medicaid rate for the following covered services when delivered to individuals enrolled in MAP Plans when the service is provided by an Office of Addiction Services and Supports (OASAS) and OMH licensed, certified, or designated program.

Medicaid rates are required for the following three categories of services:

1. OMH Government Rate Services
   • Assertive Community Treatment (ACT)
   • Continuing Day Treatment (CDT)
   • Comprehensive Psychiatric Emergency Program (CPEP)
   • Partial Hospitalization (PH)
   • Personalized Recovery Oriented Services (PROS), except the clinic component
2. OMH/OASAS Government Rate Services
   • Community Oriented Recovery and Empowerment (CORE) Services
   • Psychosocial Rehabilitation (PSR)
   • Community Psychiatric Support and Treatment (CPST)
   • Family Support and Training (FST)
   • Empowerment Services - Peer Supports (Peer Supports)
   • Crisis Intervention
   • Mobile Crisis (21 and over)
   • Crisis Residence programs for adults
   • Residential Crisis Support
   • Intensive Crisis Residence
   • OASAS Government Rate Services
     • Part 822 Outpatient Services: Clinic, Rehabilitation, Opioid Treatment
     • Part 820 Residential Treatment - There are three elements, Stabilization, Rehabilitation, and Reintegration

Services Covered by Medicare and Medicaid (requiring "higher of" logic)

As of January 1, 2023, MAP Plans are required to pay the "higher of" what Medicare or Medicaid would pay for the following BH ambulatory services that are reimbursable under both Medicare and Medicaid. As Medicaid is the payer of last resort, Medicaid is responsible for any remaining balance after the Medicare payment, up to the Medicaid rate if the Medicaid rate for the service is higher than Medicare. Medicaid reimburses 100 percent of the patient cost-sharing responsibility if the Medicare rate¹ is higher than the Medicaid rate. The "higher of" requirement applies to the following services:

• Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS)
• Personalized Recovery Oriented Services (PROS) (Clinic component)
• Outpatient Medically Supervised Stabilization and Withdrawal (Detox)
• Outpatient Substance Use Disorder (SUD) Clinic
• Outpatient Substance Use Disorder (SUD) Rehabilitation
• Outpatient Opioid Treatment Program

NOTE: If the practitioner performing the "higher of" service is not allowable under Medicare (e.g., OASAS Credentialed Alcoholism and Substance Abuse Counselor (CASAC), the MAP Plan must reimburse the service at the Medicaid rate.

Medicaid Advantage Plus (MAP) and Managed Care Plan Claiming

The MAP Plans shall support both paper and electronic submission of claims for all claim types. Claims will be submitted using the 837i (electronic) or UB-04 (paper) institutional claim form. This will allow for use of rate codes which will inform the Plans of the type of BH program submitting the claim and the service(s) being provided.

Providers will enter the rate code in the header of the claim as a value code. This is done in the value code field² by first typing in "24" and following that immediately with the appropriate four-digit rate code. This is the standard mechanism historically and currently used in Medicaid FFS billing. Any time the provider includes a rate code on the claim, the Plan should include it on the encounter record.

NYS will give MAP Plans a complete listing of all existing providers and the rate codes they bill under, as well as the rate amounts by Medicaid Management Information System (MMIS) ID (aka Provider ID) and locator code and/or National Provider ID (NPI) and zip+4. This list will also be posted on the OMH³ and OASAS⁴ websites.

Billing requirements depend on the type of service provided; however, every electronic claim submitted will require, at minimum, the following:

• Use of the 837i (electronic) or UB-04 (paper) claim format,
• Medicaid rate code,
• Diagnosis code(s),
• Procedure code(s),
• Procedure code modifiers (as needed), and
• Units of service.

Medicaid Advantage Plus (MAP) and Managed Care Plan Encounter Reporting

Rate codes will be an element to be submitted to the Encounter Intake System (EIS) for all inpatient and outpatient Mental Health (MH)/ Addiction services. Rate codes are a recognized and mandatory data element in encounter reporting for all services that are licensed, certified, and/or designated by OMH and OASAS. MAP Plans must accept rate codes on all BH inpatient and outpatient claims and include those rate codes on encounters submitted to the EIS.

All Medicaid encounters submitted for MAP enrollees must include both Medicare and Medicaid expenses. MAP Plans shall submit all encounters as a Medicaid encounter regardless of whether there is a Medicaid share. MAP Plans are not to submit a separate Medicare encounter. All other services will be reported to the EIS using the appropriate X12 837 Post Adjudicated Claims Data Reporting format.

Claims Testing

To facilitate a smooth transition to Managed Care billing, the MAP Plans will reach out and offer billing/claim submission training to newly contracted providers and providers in active negotiation to contract. This will include testing claims submission and processing, and issuance of MAP Plans' contact and support information to assist providers with claims submission.

Providers are expected to test the claims submission process with MAP Plans for all delivered services prior to the service implementation date and upon executing a new contract. This should begin at least 90 days prior to the implementation date. Even when providers already bill Medicaid Managed Care Plans for behavioral health services, claims testing is strongly encouraged, especially for those services that are dually covered by Medicaid and Medicare (see sections V-VIII) as there are unique processes for billing these services.

Only certain combinations of CORE and State Plan services are allowed by Medicaid within an individual's current treatment plan. The grid below shows the allowable service combinations.

________________________________________

<sup>1. Assertive Community Treatment (ACT) services includes Adult, Young Adult and Youth ACT. 1
2. ACT and PROS co-enrollment is permitted for up to 3 months in a 12-month period. A PROS provider may bill at Level 1, 2 or 3 of the PROS Monthly Base Rate. An ACT provider may bill for the partial step-down payment level of services. 2
3. Services comparable to OMH Mental Health Outpatient Treatment and Rehabilitative Services are available through CORE CPST. Enrollees may access non-duplicative services through CORE CPST in a single month for the following purposes:</sup>

• Access to a psychiatric prescriber (e.g., psychiatric assessment/evaluation, medication management, health monitoring) if the CORE CPST provider does not have a prescriber. Receiving psychotherapy through OMH Mental Health Outpatient Treatment and Support Services and CORE CPST is duplicative. Medication management and supporting activities through OMH Mental Health Outpatient Treatment and Support Services is duplicative if the CORE CPST provider has a prescriber on staff.
• Transition from CORE CPST to OMH Mental Health Outpatient Treatment and Support Services (including CCBHC), allowing for a warm handoff during the clinic pre-admission process (3 sessions).
• The CORE CPST provider should maintain communication with the prescriber to ensure integrated treatment/care. 3

<sup>4. See regulations for exceptions: MHOTRS Service Guidance - 7/18/2023 (ny.gov) 4
5. There are no co-enrollment restrictions for an individual in pre-admission status at PROS. Individuals who are in pre-admission do not have the PROS RE codes on their file. 5
6. CSC partial and full visits cannot be billed in the same day. 6
7. See the CORE Services and CCBHC Allowable Service Combinations (ny.gov) or the CORE Benefit and Billing Guidance regarding the exceptions to co-enrollment with CCBHC and CORE. 7
8. Services comparable to Mobile Crisis, Crisis Residence, and Crisis Stabilization services are available through CCBHCs. Enrollees may access non-duplicative services through CCBHCs. 8</sup>

Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS)⁵

OMH Medicaid Clinic Regulations (Part 599)⁶ Medicare Claims Processing Manual
Clinic-Based Intensive Outpatient Program (IOP) Guidance
Integrated Outpatient Services (IOS): Updated Billing for Offsite and Primary Care Services for OMH Host Sites

OMH MHOTRS is already included in the MAP Plan benefit package for both hospital-based and free-standing facilities. For the MHOTRS procedures allowable under Medicare, MAP Plans currently pay the Medicare negotiated rate, and Medicaid's responsibility is 100% of the enrollee's cost sharing, encompassing all deductibles, co-pays, and co-insurance amounts. After January 1, 2023, MAP Plans will pay the "higher of" what Medicare or Medicaid would pay for MHOTRS services and procedures allowable under both Medicare and Medicaid and will pay the Medicaid rate if the service and the professional performing the service are allowable under Medicaid, but not allowable under Medicare⁷.

OMH MHOTRS uses Ambulatory Patient Groups (APGs) as the basis for Medicaid fee-for-service and Medicaid Managed Care Plan (MMCP) payments for mental health services (aka, Medicaid mandated rate for OMH MHOTRS). The most up-to date mental health service weights, diagnosis weights, and APG peer group base rates can be found at the OMH MHOTRS Fiscal/Billing Resources page of the OMH website. For more information on OMH Clinic, please see Part 599 Mental Health Outpatient Treatment and Rehabilitative Service (MHOTRS) Program page.

MAP Plans will determine if a service is medically necessary in accordance with the procedures and requirements outlined in the MAP Model Contract, Appendix F.1.1 Section titled Organizational Determinants.

Assertive Community Treatment (ACT)

ACT Regulations (Part 508)
ACT Program Guidelines

ACT services are billed once per month using one rate code for the month's services. There are three types of monthly payments which are dependent on the number and type of contacts with the recipient or collaterals8: full, partial step-down, or inpatient. Claims are submitted using the last day of the month in which the services were rendered as the date of service. A contact is defined as a face-to-face interaction of at least 15 minutes duration where at least one ACT service is provided between an ACT team staff member and the recipient or collateral. The MAP coding taxonomy for BH Services indicates the procedure code (H0040) and modifier combinations to be used with the ACT rate codes. For more information on ACT rate codes, please see section titled: Assertive Community Treatment (ACT) in the New York State Health and Recovery Plan (HARP) / Mainstream Behavioral Health Billing and Coding Manual.

Continuing Day Treatment (CDT)

CDT Operational Regulations (Section 587.10)
CDT Reimbursement Regulations (Section 588.7)

CDT services are billed on a daily basis. The reimbursement rates are separated into three tiers: 1-40 hours, 41-64 hours, and 65+ hours. These three tiers span across two types of visits: full day (4 hours minimum) and half-day (2 hours minimum). Tiers are determined by totaling the number of full-day and half-day regular visits, based on their hour equivalents. As the hours accumulate throughout the month, the provider will need to move from one tier to another to bill. Each subsequent tier has a decline in payment. Providers must keep track of the number of hours-of-service provision in order to know what rate code (tier) should be billed. When the program hours of any single visit include more than one tier, the provider of service will be reimbursed at the tier that applies to the first hour of that visit. Each CDT service tier has a unique combination of rate code / procedure code / modifier code(s). For more information on CDT rate codes, please see, section titled: Continuing Day Treatment (CDT) in the New York State Health and Recovery Plan (HARP) / Mainstream Behavioral Health Billing and Coding Manual.

Comprehensive Psychiatric Emergency Program (CPEP)

CPEP Operational Regulations (Part 590)
CPEP Reimbursement Regulations (Part 591)
CPEP Program Guidance

CPEP is claimed on a daily basis. A patient may receive one triage or one referral or one full emergency visit service in one calendar day. If a patient receives one of each, the CPEP will receive reimbursement for the full emergency visit. A provider may be reimbursed for either one crisis outreach service or one interim crisis service and either one triage and referral visit or one full emergency visit per recipient, per one calendar day. If more than one service is provided, then more than one claim must be submitted (one claim for each rate code). For more information on CPEP rate codes, please see section titled: Comprehensive Psychiatric Emergency Program (CPEP) in the New York State Health and Recovery Plan (HARP) / Mainstream Behavioral Health Billing and Coding Manual.

Partial Hospitalization (PH)

PH Medicaid Operational Regulations (Section 587.12)
PH Medicaid Reimbursement Regulations (Section 588.9)
Medicare Claims Processing Manual

PH provides active treatment designed to stabilize and ameliorate acute systems, serves as an alternative to inpatient hospitalization, or reduces the length of a hospital stay within a medically supervised program. These services are reimbursable through the following four groups of rate codes under Medicaid.

Regular Rate Codes 4349 - 4352, Crisis Rate Codes 4357 - 4363 – A partial hospitalization claim is submitted on a daily basis. The applicable rate code / procedure code / modifier code(s) combination is dependent on the number of hours of service a day. The combination is listed in the MAP coding taxonomy. Reimbursement is provided for service duration of at least four hours and not more than seven hours per recipient, per day.

Collateral Service (4353, 4354) – Clinical support services of at least 30 minutes in duration but not more than two hours of face-to-face interaction between one or more collaterals and one therapist with or without a recipient.

Group Collateral Service (4355, 4356) – Clinical support services of at least 60 minutes in duration, but not more than two hours, provided to more than one recipient and/or his or her collaterals. The service does not need to include recipients and cannot include more than 12 collaterals and/or recipients in a face-to face interaction with a therapist.

Pre-admission (4357 - 4359, 4349 - 4352) – Visits of one to three hours are billed using the crisis visit rate codes (4357, 4358, 4359). Visits of four hours or more are billed using partial hospitalization regular rate codes (4349, 4350, 4351, 4352). Per the coding crosswalk, the UA modifier is required on all partial hospitalization pre-admission claims.

Personalized Recovery Oriented Services (PROS)

PROS Regulations (Part 512)
PROS Program Guidance
Medicare Claims Processing Manual

For all PROS services other than clinic treatment, billing will follow the Medicaid billing procedures. PROS units are accumulated during the course of each day the individual participates in the PROS program and are aggregated to a monthly total to determine the PROS monthly base rate for the individual. The PROS unit is determined by the duration of program participation, which includes a combination of on-site and off-site program participation and service frequency. Daily program participation is measured in 15-minute increments, rounded down to the nearest quarter hour. In order to accumulate PROS units for a day, a PROS program must deliver a minimum of one medically necessary PROS service to an individual or collateral on that day. The maximum number of PROS units per individual per day is five. Services provided in a group format must be at least 30 minutes in duration. Services provided individually must be at least 15 minutes in duration. A minimum of two PROS units must be accrued for an individual during a calendar month in order to bill the monthly base rate. The table for the calculation of "PROS Units" (based on "program hours" and "number of services"), may be found on page 13 of the New York State Health and Recovery Plan (HARP) / Mainstream Behavioral Health Billing and Coding Manual. This table is used on a daily basis to calculate the PROS units for the day. At the end of the month, the daily units for each day in the month are accumulated to determine the total units for the month. For any additional questions regarding PROS services other than clinical treatment services please see page 12, section titled: Personalized Recovery Oriented Services (PROS) in the New York State Health and Recovery Plan (HARP) / Mainstream Behavioral Health Billing and Coding Manual.

For PROS clinic treatment services, providers will use the Medicare required procedure code and/or revenue codes as well as the Medicaid required rate codes. Institutional claim form (837i) must be used to allow rate codes to be reported. Currently PROS clinic in MAP is reimbursed at the Medicare negotiated rate and Medicaid's responsibility is 100% cost sharing, encompassing all deductibles, co-pays, co-insurance amounts, and any subscriber premiums. As of January 1, 2023, MAP Plans are required to pay the "higher of" what Medicare or Medicaid would pay for PROS clinic services and procedures that are allowable under both Medicare and Medicaid and will pay the Medicaid rate if the service and the professional performing the service are allowable under Medicaid, but not allowable under Medicare.

For more information on Medicare billing, please see the Medicare Claims Processing Manual.

The Centers for Medicare and Medicaid Services (CMS) authorized Adult Behavioral Health Home and Community Based Services (BH HCBS) as a demonstration benefit under NYS' Medicaid Section 1115 Medicaid Redesign Team (MRT) Waiver. To improve access to services, NYS has transitioned four (4) BH HCBS to a new service array called Community Oriented Recovery and Empowerment (CORE) Services. These services are Community Psychiatric Support and Treatment (CPST), Psychosocial Rehabilitation (PSR), Family Support and Training (FST), and Empowerment Services – Peer Support (Peer Support). All other existing BH HCBS remain available as BH HCBS with previously established requirements, workflows, and processes. MAP Plans will offer CORE Services as a covered benefit for eligible enrollees.

Medicaid Recipient Restriction Exception (RRE) code H9 will be used to identify MAP enrollees eligible for CORE Services. Providers serving an enrollee may submit one claim per day for each rate code / procedure code / modifier combination. In accordance with the CORE Services Operations Manual, and if clinically indicated, providers may submit claims for an in- person visit and telehealth visit for the same rate code in the same day.

The rate code, procedure code, and modifier combinations are listed in the MAP Plan coding taxonomy. For additional CORE Services claiming and billing resources, including allowable service combinations, please see the CORE Benefit and Billing Guidance.

The Crisis Intervention benefit is comprised of three service components: Mobile Crisis, Crisis Residence, and Crisis Stabilization Centers services (CSC). Initially, CSC will be covered under FFS, and NYS will issue guidance at such time it will carve into managed care.

Mobile Crisis Services

Mobile Crisis Program Guidance

The Mobile Crisis component of the Crisis Intervention Benefit includes the following services and corresponding activities. Each service is eligible for reimbursement separately when delivered in accordance with NYS issued billing guidance.

• Telephonic triage and crisis response;
• Mobile crisis response;
• Telephonic crisis follow-up; and
• Mobile crisis follow-up

MAP Plans must reimburse both participating and non-participating Mobile Crisis providers for services provided to their enrollees in accordance with the OMH billing guidelines. Mobile Crisis services are billed daily and use the rate code, CPT, and modifier combination to differentiate between services. For additional information on Mobile Crisis services for ages 21 and over in the Crisis Intervention Benefit please see the Crisis Intervention Benefit: Mobile Crisis Component Benefit and Billing Guidance.

Mobile crisis services provided to youth ages 18 to 20 are not the responsibility of the MAP Plans and are covered by Medicaid Fee-for-Service. For additional information for recipients ages 18 to 20, please see the Medicaid State Plan Children and Family Treatment and Support Services Provider Manual for Children's Behavioral Health Early and Periodic Screening and Diagnostic Treatment (EPSDT) Services.

Crisis Residence Services

Crisis Residence Operation Guidance (Part 589)
Adult Crisis Residence Benefit and Billing Guidance

Only Crisis Residence providers licensed by NYS OMH are permitted to bill for Crisis Residence services provided to a MAP enrollee. Each Crisis Residence program type has its own rate code, procedure code, and modifier(s) combination that must be used. Crisis Residence programs are for adults ages 18 years and older must follow the Adult Crisis Residence Benefit and Billing Guidance.

Children's Crisis Residence services provided to youth ages 0-20 will not be the responsibility of the MAP Plans and will be covered by Medicaid Fee-for-Service. For more information, refer to the Crisis Intervention Benefit: Children's Crisis Residence Program Benefit and Billing Guidance.

1. OASAS Ambulatory Services

Outpatient Clinic Service

Outpatient Clinic programs provide treatment services to individuals presenting with difficulties associated with their use/misuse of substances, and/or have a problem with gambling related concerns. Family members and/or significant others who are affected by another's addiction can also receive services in this setting.

Outpatient services may be delivered at different levels of intensity responsive to the severity of the problems presented by the patient. The length of stay and the intensity (as measured by frequency and duration of visits) will vary during the course of treatment. In general, persons are engaged in more frequent outpatient treatment visits earlier in the treatment process; visits generally become less frequent as treatment progresses.

Treatment may include but is not limited to the following services: group and individual counseling; Medication for Addiction Treatment (MAT), education about, orientation to, and opportunity for participation in, relevant and available self-help groups; addiction awareness and relapse prevention; HIV and other communicable disease education, risk assessment, supportive counseling, and referral; and family treatment. In addition, social and health care services, skill development in accessing community services, activity therapies, information and education about nutritional requirements, and vocational and educational evaluation must be available either directly or through written agreements. Procedures are provided according to an individualized assessment and treatment plan. The OASAS Medicaid APG Clinical and Billing Document provides a comprehensive listing of the services for Outpatient Treatment listed in this section.

Opioid Treatment Programs (OTP)

In addition to the services described for the Outpatient Clinic, OTPs target those with Opioid Use Disorder. OTPs assist to stabilize individuals with either methadone or other Medication Assisted Treatment (MAT) so that individuals can achieve optimum functioning and/or ability to utilize additional treatment services.

"Intensive Outpatient Service" (IOS)

IOS Services are employed within the Outpatient Clinic or OTP setting. This outpatient treatment service is provided by a team of clinical staff for individuals who require a time-limited, multi-faceted array of services, structure, and support to initiate a period of recovery from their addiction. Rather than a set format of services, IOS is meant to be specific to the person and what they need. Using evidence-based practices such as Coping Skills Training, Motivational Enhancement, Cognitive Behavioral Therapy, and Dialectical and Behavioral Training, counseling and support services are intended to stabilize individuals for their next step in treatment.

Outpatient Rehabilitation Services

Outpatient Rehabilitation Services are a configuration of services designed to improve functioning for individuals with more chronic conditions emphasizing development of basic skills in prevocational and vocational competencies, personal care, nutrition, communication, and community competency. Individuals should be scheduled for between three and five days a week for a minimum of two hours per service date.

Medically Supervised Outpatient Withdrawal (MSOW)

MSOW services are appropriate for persons who are suffering from mild to moderate withdrawal or persons experiencing non-acute physical or psychiatric complications associated with their substance use disorder and who are unable to detox on their own without withdrawal complications, but who retain a stable living environment.

Physical Health Services

Physical Health services are services provided outside of regulatory requirements. Physical Health Services encompass a wide range of assessment and treatment procedures performed by medical staff for identifying and treating physical problems associated with addiction.

Examples of Physical Health services may include, but are not limited to, immunizations, hepatitis, TB/HIV testing, pregnancy testing, and preventative care. Laboratory services not required by regulation would also fall under the physical health rate code.

Physical Health procedures are reimbursed using the Physical Health Rate Code and appropriate E/M code (most commonly CPT codes in the range 99202 - 99205, 99211 - 99215). Each claim should include the diagnosis of the issue being treated as the primary diagnosis code.

2. OASAS Non-ambulatory Programs

Withdrawal and Stabilization Services

Medically managed withdrawal and stabilization in a hospital setting certified by the Department of Health as an Article 28 clinic under Public Health Law and Medically Managed Withdrawal Services by OASAS. Medically managed withdrawal and stabilization services are designed for individuals who are acutely ill from alcohol- related and/or substance-related addictions or dependence, including the need for medical management of persons with severe withdrawal or risk of severe withdrawal symptoms, and may include individuals with or at risk of acute physical or psychiatric co-morbid conditions. This level of care includes the 48-hour observation bed. Individuals who have stabilized in a medically managed detoxification service may step-down to a medically supervised service within the same service setting or may be transferred to another service setting.

Medically Supervised Inpatient Detoxification – This service provides treatment of moderate withdrawal symptoms and non-acute physical or psychiatric complications. This service is physician directed and staffed 24 hours a day 7 days a week with medical staff and includes 24-hour emergency medical coverage. Medically supervised withdrawal services provide: bio- psycho-social assessment, medical supervision of intoxication and withdrawal conditions; pharmacological services; individual and group counseling; level of care determination; and referral to other appropriate services. Medically supervised withdrawal and stabilization services are appropriate for persons who are intoxicated by alcohol and/or substances, who are experiencing or who are expected to experience withdrawal symptoms that require medical oversight. Individuals who have stabilized in a medically managed or medically supervised inpatient withdrawal service may step-down to a medically supervised outpatient withdrawal (MSOW) service.

Inpatient Rehabilitation

OASAS-certified 24-hour, structured, short-term, intensive treatment services provided in a hospital or free-standing facility. Medical coverage and individualized treatment services are provided to individuals with substance use disorders who are not in need of medical detoxification or acute care and are unable to participate in, or comply with, treatment outside of a 24-hour structured treatment setting. Individuals may have mental or physical complications or comorbidities that require medical management or may have social, emotional, or developmental barriers to participation in treatment outside of this setting. Treatment is provided under direction of a physician medical director and the staff includes nursing and clinical staff 24 hours 7 days per week. Activities are structured daily to improve cognitive and behavioral patterns and improve functioning to allow for the development of skills to manage chronic patterns of substance use and develop skills to cope with emotions and stress without return to substance use. People who are appropriate for inpatient care have co-occurring medical or psychiatric conditions or who are using substances in a way that puts them in harm. Many experience a decrease in the ability to reason and have impaired judgment that interferes with decision making, risk assessment, and goal setting and need a period of time for the consequences of substance use to diminish.

Residential Services

Stabilization Services in a Residential Setting–OASAS-certified providers of residential programs that also provide medical and clinical services including: medical evaluation; ongoing medication management and limited medical intervention; ancillary withdrawal and medication assisted substance use treatment; psychiatric evaluation and ongoing management; and group, individual and family counseling focused on stabilizing the individual and increasing coping skills until the individual is able to manage feelings, urges and craving, co-occurring psychiatric symptoms and medical conditions within the safety of the residence.

This service has a physician who serves as medical director and a psychiatrist, nurse practitioner or physician assistant who provides and oversees psychiatric treatment. Medical staff are available in the residence daily, but 24-hour medical/nursing services are not. There is medical staff available on call 24/7 and there are admitting hours 7 days per week.

Rehabilitative Services in a Residential Setting –OASAS certified providers of residential programs that also provide rehabilitative services for individuals who are stable enough to manage emotional states, urges and cravings, co-occurring psychiatric symptoms and medical conditions within the safety of a residential setting. This service has a physician who serves as a medical director, and a nurse practitioner or psychiatrist who provide and oversee psychiatric treatment. Additionally, this service has nursing staff on site daily and clinical staff who monitor for medical and psychiatric symptoms that are stable. Services include medical monitoring of chronic conditions including routine medication management and individual, group and family counseling focused on rehabilitation. The service requires a treatment plan to address functional needs including personal and interpersonal functioning. The treatment program teaches individuals to manage emotions and behaviors and interactions with others with increasing independence.

For OASAS services in the MAP benefit package, providers will claim using the Medicaid rate codes shown in the table below. Shaded fields are not applicable. Less commonly used rate codes are in parenthesis. Additional information on OASAS services can be found at New York State Health and Recovery Plan (HARP) / Mainstream Behavioral Health Billing and Coding Manual and OASAS Billing Guidance. Part 841 (Medical Assistance for Addiction Services) is the OASAS reimbursement regulation.

		Rate Codes
Service	OASAS Reg	Hospital	Freestanding
Medically Managed Withdrawal and Stabilization - Inpatient	Section 816.6	4800
Medically Supervised Withdrawal and Stabilization - Inpatient	Section 816.7	4801, 4802, 4803	4220
Medically Supervised Withdrawal and Stabilization - Outpatient	Section 816.8 and Part 822	1528	1540
Inpatient Rehabilitation	Part 818	2957, 2993	4213
Addiction Treatment Center - State Operated Inpatient Rehabilitation	Part 818		4202
Residential Services	Part 820		1144, 1145, (and 1146 upon CMS approval)
Outpatient Clinic	Part 822	1528 (or 1118, 1132, 1552)	1540 (or 1114, 1468, 1486) FQHCs: 4273, 4274, 4275
Outpatient Rehabilitation	Part 822	1561 (or 1558)	1573 (or 1570) FQHCs: 4276, 4277, 4278
Opioid Treatment Program	Part 822	1567 (or 1120, 1134, 1555) Bundles: 7973, 7974, 7975, 7976	1564 (or 1116, 1130, 1471) Bundles: 7969, 7970, 7971, 7972 FQHCs: 1671

The following services remain in Medicaid Fee-for-Service after the January 1, 2023, transition and are not the responsibility of the MAP Plans until otherwise informed.

• Rehabilitation Services Provided to Residents of OMH Licensed Community Residences (CRs) and Family Based Treatment Programs
• OMH Day Treatment
• OASAS Residential Rehabilitation Services for Youth
• Certified Community Behavioral Health Clinics (CCBHC)
• OMH Residential Treatment Facility (RTF)
• OMH Children's Crisis Residence for Youth ages 18-20
• Children and Family Treatment Services and Supports (CFTSS) for Youth ages 18-20
• Children's Home and Community Based Services (HCBS) for Youth ages 18-20

MAP enrollees admitted to the following inpatient/residential programs are not eligible for Medicaid managed care and will be disenrolled from MAP:

• OMH Residential Treatment Facilities
• OMH State-operated Community Residences
• OMH State-operated Psychiatric Centers

Medicaid:

• New York State Health and Recovery Plan (HARP) / Mainstream Behavioral Health Billing and Coding Manual
• Community Oriented Recovery and Empowerment (CORE) Services Benefit and Billing Guidance
• OMH Medicaid Reimbursement Page
• OASAS Billing Guidance

Medicare:

• Medicare Claims Processing Manual
• Medicare Mental Health

MAP:

• Medicaid Advantage Plus (MAP) Model Contract

For billing questions please reach out to the OMH Managed Care Mailbox (OMH-Managed-Care@omh.ny.gov) or the OASAS mailbox (PICM@oasas.ny.gov).

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<sup>1. In this guidance, the Medicare rate is referring to the fee schedule negotiated and agreed to by the MAP Plan and provider in the contract. 1
2. This field is already used by Medicaid Managed Care Plans to report the weight of a low-birth-weight baby. 2
3. Billing Behavioral Health Medicaid services under Managed Care (ny.gov) 3
4. OASAS Reimbursement 4
5. Formerly known as OMH Clinic. 5
6. The updated regulation for MHOTRS is forthcoming. 6
7. Medicare eligible benefits like psychotherapy are covered only when delivered by a Medicare enrollable practitioner. For the list of Medicare-eligible professional types, please refer to pages 7-15 in this Medicare Mental Health reference. 7
8. Collateral Persons: Members of the individual's family or household, family of choice, or others who regularly interact with the individual (e.g., landlord, criminal justice staff, employer), are directly affected by or can affect the individual's condition, and who are identified in the service plan as having a role in the individual's treatment. 8</sup>