Health Net, its affiliated health plans and subcontracting providers are available to coordinate referrals for members requiring substance use treatment and services. Members receiving services under this program remain enrolled in Health Net. Participating primary care physicians (PCPs) are responsible for maintaining continuity of care for the member.

Alcohol and drug treatment services are excluded from Health Net's coverage responsibilities under Health Net's Medi-Cal managed care contract. These services are administered by Counties and overseen by the state of California.

Health Net, its affiliated health plans and subcontracting providers are available to coordinate referrals for members requiring substance use treatment and services. Members receiving services under this program remain enrolled in Health Net. Participating primary care physicians (PCPs) are responsible for maintaining continuity of care for the member. Additionally, participating providers must maintain documentation of Screening, Assessment, Brief Interventions and Referral to Treatment (SABIRT) services provided to members. When a member transfers from one PCP to another, the receiving PCP must attempt to obtain the member’s prior medical records, including those pertaining to the provision of preventive services. Member medical records must include the following:

Consistent with U.S. Preventive Services Task Force (USPSTF) Grade A or B recommendations, AAP/Bright Futures, and the Medi-Cal Provider Manual, Managed Care Plans (MCPs) must provide alcohol and drug SABIRT services for members 11 years of age and older, including pregnant women. These services may be provided by providers within their scope of practice, including, but not limited to, physicians, physician assistants, nurse practitioners, certified nurse midwives, licensed midwives, licensed clinical social workers, licensed professional clinical counselors, psychologists and licensed marriage and family therapists.

Alcohol and drug use screening must be conducted using validated screening tools. Validated screening tools include, but are not limited to:

When a screening is positive, validated assessment tools should be used to determine if

alcohol use disorder (AUD) or substance use disorder (SUD) is present. Validated alcohol and drug assessment tools may be used without first using validated screening tools. Validated assessment tools include, but are not limited to:

For members with brief assessments that reveal unhealthy alcohol use, brief misuse counseling should be offered. Appropriate referral for additional evaluation and treatment, including medications for addiction treatment, must be offered to members whose brief assessment demonstrates probable AUD or SUD. Alcohol and/or drug brief interventions include alcohol misuse counseling and counseling a member regarding additional treatment options, referrals, or services. Brief interventions must include the following:

The USPSTF recommends that clinicians screen adults ages 18 or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.

The following HCPCS codes may be used to bill for these services:

Code G0442 is limited to one screening per year, any provider, unless otherwise medically necessary. Code G0443 may be billed on the same day as code G0442. Code G0443 is limited to three sessions per recipient per year, any provider, unless otherwise medically necessary.

Providers are responsible for referring members who meet criteria for alcohol and drug disorders to a county drug program for services. These services are not covered by Health Net. A list of county contacts for local substance use disorder treatment information and referrals is available on the DHCS website, under Referral to Treatment.

Member medical records must include the following:

PCPs must maintain documentation of SABIRT services provided to members. When a member transfers from one PCP to another, the receiving PCP must attempt to obtain the member’s prior medical records, including those pertaining to the provision of preventive services.

Participating providers are responsible for providing services in a manner that ensures coordinated and continuous care to all members needing alcohol and drug treatment services, including timely referrals.

On receipt of a specific written request from the member, the primary care physician (PCP) must transfer requested summaries of the member's records to the substance abuse practitioner or program and to any organization where future care will be rendered. Any transfer of member medical records and other information must be done in a manner consistent with appropriate confidentiality standards.

A member receiving services under the Health Net Alcohol and Drug Treatment program remains enrolled with Health Net. The PCP and Health Net Health Services staff retain the responsibility for maintaining continuity of care for the member. The PCP is responsible for the coordination of the members care with the Alcohol and Drug Treatment program case managers and Health Net Health Services staff. The PCP monitors the member to ensure that follow-up care is provided as necessary.

A number of screening instruments are available to the primary care physician (PCP) to assist in detecting substance use. Refer to samples of the Drug Use Questionnaire (PDF), Red Flags for Alcohol or Drug Abuse (PDF), T-Ace (PDF), and TWEAK Test (PDF).

A member is a candidate for admission in a partial hospital program for treatment of substance use if all the following criteria are met:

A member is a candidate for referral for admission to a residential facility for the treatment of substance use if all the following are present:

A member is a candidate for referral for admission to a structured outpatient program for the treatment of substance use if all the following are present:

A member is a candidate for acute inpatient detoxification if symptoms are present that suggest that the failure to use this level of treatment would be life threatening or cause permanent impairment once substance use has stopped. All of the following must be present:

Participating providers are responsible for performing all preliminary testing and procedures necessary to develop a diagnosis. Referrals to Drug Medi-Cal (D/MC) or Fee-for-Service Medi-Cal (FFS/MC) programs must include the appropriate medical records supporting the diagnosis and additional documentation. The referring provider must obtain a signed release from the member prior to making the referral.

The final decision on the acceptance of a member for FFS/MC or D/MC services (authorization of the referral) rests solely with the county alcohol and drug program.

The alcohol and drug treatment services covered by the Drug Medi-Cal (D/MC) program include:

Voluntary inpatient detoxification (VID) is a Medi-Cal fee-for-service (FFS) benefit. VID services are excluded from Health Net's coverage responsibilities and are the responsibility of the Medi-Cal FFS program. Health Net members receiving VID services remain enrolled with Health Net and primary care physicians (PCPs) remain responsible for coordinating ongoing care and services unrelated to VID.

Participating providers must refer members to a VID provider in a general acute care hospital. VID services require authorization. It is the VID provider's responsibility to submit the Treatment Authorization Request (TAR) to the local Medi-Cal field office for approval.

Health Net Medi-Cal members who meet medical necessity criteria may receive VID services in a general acute care hospital. To receive VID services, a member must have one or more of the following: