1115 SUD Demonstration Budget Neutrality Update
The Department is updating the budget neutrality calculations for the 1115 Substance Use Disorder (SUD) Demonstration. The updated calculations will reflect the changes in bed capacity and reimbursement rates. The increased capacity represents improved access to inpatient SUD services for Medicaid members ages 21 and under. The Department does not anticipate a significant policy or operational impact from the updated calculations. Stakeholders and the public are invited to provide feedback and comments regarding this change.
SUD Provider Forum Update
In light of the recent passage of SB21-137, the Department has decided to repurpose our bimonthly SUD Provider Forum meetings to address the mandates in this legislation. Providers are encouraged to reach out to the Regional Accountable Entity(ies) they work with for technical assistance. We will send out a detailed agenda/project plan for subsequent meetings to help organize our time and meet the deadlines called out in the bill. A summary of key tasks can be found below:
- On or before Oct. 1, 2021, the state Department shall consult with the Office of Behavioral Health in the Department of Human Services, residential treatment providers and Managed Care Entities (MCEs) to develop standardized utilization management processes to determine medical necessity for residential and inpatient substance use disorder treatment.
- Beginning Oct. 1, 2021, and quarterly thereafter, the state Department shall collaborate with the Office of Behavioral Health in the Department of Human Services, residential treatment providers and MCEs to develop a report on the residential and inpatient substance use disorder utilization management statistics.
- On or before Jan. 1, 2022, the state Department shall incorporate the standards developed pursuant to subsection (1) of this section into existing MCE contracts.
- On or before Jan. 1, 2022, each MCE's notice of an adverse benefit determination must demonstrate how each dimension of the most recent edition of "the ASAM criteria for addictive, substance-related, and co-occurring conditions" was considered when determining medical necessity.
- No later than July 1, 2022, the state Department shall contract with an independent third-party vendor to audit thirty-three percent of all denials of authorization for inpatient and residential substance use disorder treatment for each MCE.
- Beginning Dec. 1, 2022, and each December 1 thereafter, the state Department shall submit the results of the audit conducted
- No later than July 1, 2023, the state Department shall contract with one or more independent review organizations to conduct external medical reviews requested for review by a Medicaid provider when there is a denial or reduction for residential or inpatient substance use disorder treatment and Medicaid appeals processes have been exhausted.
The SUD Provider Forum is open to residential SUD providers, the Office of Behavioral Health, Regional Accountable Entities, and Managed Care Service Organiations. Please register in advance using the Zoom registration links for each date.
The Forums are scheduled as follows: