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Alcohol and Drug Treatment Services

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Sacramento
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

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 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.

Alcohol Misuse Screening and Behavioral Counseling

Providers are required to include alcohol misuse screening and behavioral counseling services for Medi-Cal members ages 18 and older annually. This applies to fee-for-service (FFS) primary care physicians (PCPs), including pediatricians treating Medi-Cal members, as alcohol misuse screening and behavioral counseling services are a covered benefit for pediatric members over age 18. For more information, refer to the Training and Attestations section below. 

Alcohol Misuse Screenings

For Medi-Cal members, providers are responsible for annually providing alcohol misuse screening and behavioral counseling services and referrals to treatment for members ages 18 and older through one of the following validated screening tools: The Alcohol Use Disorder Identification Test (AUDIT); or abbreviated AUDIT-Consumption (AUDIT-C); or a single-question screening.

Providers must maintain documentation of the alcohol misuse screening and behavioral counseling. When a member transfers to another provider, the receiving provider must obtain prior records. If no documentation is found, the receiving provider must provide and document the service.

Behavioral Counseling Interventions for Alcohol Misuse

If a provider identifies a Medi-Cal member as engaging in risky or hazardous alcohol use by their affirmative response to the validated screening tools, the provider is required to provide at least one behavioral counseling intervention.

Behavioral counseling intervention may consist of up to three 15-minute sessions, offered in-person, by telephone or by telehealth. Intervention sessions may be combined into one or two visits, if deemed appropriate by the rendering provider. Providers are encouraged to offer behavioral counseling intervention services in their offices to ensure members follow through on interventions. However, a provider may refer a member to another qualified provider off site who can provide intervention services, if necessary.

Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care

The United States Preventive Services Task Force (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:

  • G0442 - annual alcohol misuse screening, 15 minutes
  • G0443 - brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

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.

The Department of Health Care Services (DHCS) requires the use of the following validated screening tools:

  • The Alcohol Use Disorder Identification Test (AUDIT)
  • The Alcohol Use Disorder Identification Test-Consumption (AUDIT-C), or
  • A single-question screening, such as asking, "How many times in the past year have you had (for women and all adults ages 65 and older) four or (for men) five or more drinks in a day?"

Treatment Referral

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 at www.dhcs.ca.gov/services/medi-cal/Pages/SBIRT.aspx, under Referral to Treatment.

Training and Attestations

Training and attestations for AMSC are not required. Primary care physicians (PCPs) may offer alcohol misuse screening and behavioral counseling services in a primary care setting as long as they meet the following requirements:

  • Alcohol misuse screening and behavioral counseling services may be provided by a licensed health care provider or staff working under the supervision of a licensed health care provider, including the following:
    • Licensed physician
    • Physician assistant
    • Nurse practitioner
    • Psychologist
  • At least one supervising licensed provider per clinic or practice may take four hours of alcohol misuse screening and behavioral counseling training after initiating alcohol misuse screening and behavioral counseling services. The training is not required; however, it is recommended.

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).

Criteria for Admission to a Partial Hospital Program

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 clearly documented pattern of substance use or dependence that meets current DSM criteria and is severe enough to interfere with social and occupational functioning and causes significant impairment in activities of daily living.
  • The member is medically stable enough that the criteria for inpatient detoxification services are not met.
  • The member requires up to eight hours of structured treatment per day in order to obtain the most benefit from coordinated services, such as individual, group or family therapy, education, or medical supervision.
  • The member's living situation and social support system are sufficiently stable to allow for treatment in this care setting.
  • There is evidence of sufficient motivation for successful participation in treatment in this care setting.
  • The member has demonstrated, or there is reason to believe, that he or shee can avoid the use of substances between treatment sessions based on an assessment of such factors as intensity of cravings, impulse control, judgment, and pattern of use.

 

Criteria for Admission to a Residential Facility

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 clearly documented pattern of substance use or dependence that meets the current DSM criteria and is severe enough to interfere markedly with social and occupational functioning and cause significant impairment in activities of daily living.
  • The member is medically stable enough that the criteria for inpatient detoxification services are not met.
  • There is clearly documented evidence of the failure of partial hospital or structured outpatient treatment for substance use or dependence meeting the current DSM criteria.
  • The member's living situation is severely impaired as a result of inadequate or unstable support systems, including the work environment, that may jeopardize successful outpatient treatment.
  • There is significant risk of relapse if the member is treated in a less restrictive care setting related to severely impaired impulse control or a co-morbid disorder.
  • Pregnant and postpartum women are eligible to receive substance use services through certified perinatal programs. Women are eligible during the term of pregnancy and for a period of up to 60 days after delivery.

Criteria for Admission to a Structured Outpatient Program

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 clearly documented pattern of substance use or dependence that meets the current DSM criteria and is severe enough to interfere with social and occupational functioning and cause significant impairment in activities of daily living.
  • The member is medically stable enough that the criteria for inpatient detoxification services are not met.
  • The member requires up to four hours of structured treatment per day in order to obtain the most benefit from coordinated services, such as individual, group or family therapy, education, or medical supervision.
  • The member's living situation and social support system are sufficiently stable to allow for structured outpatient treatment at this level of care.
  • There is evidence of sufficient motivation for successful participation in treatment at this level of care.
  • The member has demonstrated, or there is reason to believe, that he or she can avoid the use of substances between treatment sessions based on an assessment of factors such as intensity of cravings, impulse control, judgment, and pattern of use. 

Criteria for Inpatient Detoxification

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:

  • Fluids and medication to modify or prevent withdrawal complications that threaten life or bodily functions
  • 24-hour nursing care with close and frequent observation and monitoring of vital signs
  • Medical therapy, which is supervised and re-evaluated daily by the attending physician in order to stabilize the member's physical condition
  • At least two of the following symptoms of substance withdrawal:
    • tachycardia
    • hypertension
    • diaphoresis
    • significant increase or decrease in psychomotor activity
    • tremor
    • significantly disturbed sleep patterns
    • nausea or vomiting
    • clouding of consciousness with reduced capacity to shift, focus and sustain attention

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 (Tulare, Fresno, Kern, Kings, Los Angeles, Madera, Sacramento, San Diego, San Joaquin, Stanislaus).

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

  • Outpatient heroin detoxification services.
  • Outpatient methadone maintenance services.
  • Outpatient drug-free treatment services.
  • Day care habilitative services.
  • Perinatal residential substance use services.

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. A list of general acute care hospitals is available online at https://hfcis.cdph.ca.gov/servicesandfacilities.aspx . 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:

  • Delirium tremens with any combination of the below clinical manifestations with cessation or reduced intake of alcohol or sedative:
    • hallucinations
    • disorientation
    • tachycardia
    • hypertension
    • fever
    • agitation
    • diaphoresis
  • A score greater than 15 on the Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) form.
  • Alcohol or sedative withdrawal with CIWA score greater than 8 and one or more of the following high risk factors:
    • multiple substance abuse
    • history of delirium tremens
    • unable to receive the necessary medical assessment, monitoring and treatment in a setting with a lower level of care
    • medical comorbidities that make detoxification in an outpatient setting unsafe
    • history of failed outpatient treatment
    • psychiatric comorbidities
    • pregnancy
    • history of seizure disorder or withdrawal seizures
  • Complication of opioid withdrawal that cannot be adequately managed in the outpatient setting due to the following:
    • persistent vomiting and diarrhea from opioid withdrawal
    • dehydration and electrolyte imbalance that cannot be managed in a setting with a lower level of care
Last Updated: 11/09/2019