Common use of Substance Abuse Treatment Clause in Contracts

Substance Abuse Treatment. This agreement covers medically necessary services for the treatment of substance abuse in a hospital, substance abuse treatment facility, or an acute substance abuse rehabilitation/residential facility that is: • reviewed and approved by us; and • licensed under the laws of the State of Rhode Island or by the state in which the facility is located as a hospital, a substance abuse treatment facility, or an acute substance abuse residential/rehabilitative facility. We review network and non-network programs, hospital or inpatient facilities, acute substance abuse rehabilitation/residential facilities and the specific services provided. We decide whether a program, hospital or inpatient facility, acute substance abuse rehabilitation/residential facility, or specific services rendered meets our program requirements, content and criteria. If our program requirements, content and criteria are not met, the services are not covered under this agreement. Our program content and criteria are defined below. Inpatient Hospital If you are an acute inpatient in a general or specialty hospital for behavioral health services, we cover medically necessary acute hospital services for detoxification. See Section 3.20 - Inpatient Hospital Services for additional information. Preauthorization is recommended. Substance Abuse Treatment Facility This agreement covers medically necessary services at an Acute Rehabilitation or Acute Substance Abuse Residential facility when reviewed by us and we decide that, at a minimum, the following program criterion has been met: • Certified clinical staff available twenty-four (24) hours per day, seven (7) days a week to meet the member’s medical and psychological needs. o includes a registered nurse (RN) available on site a minimum of eight (8) hours day and on call twenty-four (24) hours a day; o when on call, the RN must be able to be on site within one (1) hour of a call. • Program must be supervised by a licensed independent clinician that is in charge of the program and the staff; o Licensed independent clinicians are defined as the following: ▪ M.D. , D.O., or R.N. with advanced training and prescriptive privileges (i.e. Clinical Nurse Specialist), ▪ Ph.D. LICSW, LMHC, LMFT, or an individual with an equivalent independent practicing license in the state in which the program operates. • Program must have a licensed physicians on staff who is available twenty-four (24) hours per day, seven (7) days per week to evaluate patients and adjust medication as needed and provide medical oversight of all patients in the program. • Program structure must include evidenced-based treatment at a minimum of six (6) hours of clinical programming per day Monday through Friday, and four (4) hours per day on weekends. Recreational, educational and other complementary activities, including, but not limited to, Tai Chi, yoga, personal training, meditation time, exercise, etc., do not count towards the above noted clinical hourly program requirements as they are non- covered, non-clinical services. Recreation therapy, non-medical self-care, or self-help training (e.g., Alcoholics Anonymous (AA), Narcotics Anonymous (NA) meetings/services, etc.) are non-covered services and do not count toward the above noted clinical hourly program requirements. (Please see the Related Exclusion section below for more information.)

Substance Abuse Treatment. This agreement covers medically necessary services for the treatment of substance abuse in a hospital, substance abuse treatment facility, or an acute substance abuse rehabilitation/residential facility that is: • reviewed and approved by us; and • licensed under the laws of the State of Rhode Island or by the state in which the facility is located as a hospital, a substance abuse treatment facility, or an acute substance abuse residential/rehabilitative facility. We review network and non-network programs, hospital or inpatient facilities, acute substance abuse rehabilitation/residential facilities and the specific services provided. We decide whether a program, hospital or inpatient facility, acute substance abuse rehabilitation/residential facility, or specific services rendered meets our program requirements, content and criteria. If our program requirements, content and criteria are not met, the services are not covered under this agreement. Our program content and criteria are defined below. Inpatient Hospital If you are an acute inpatient in a general or specialty hospital for behavioral health services, we cover medically necessary acute hospital services for detoxification. See Section 3.20 - Inpatient Hospital Services for additional information. Preauthorization is recommended. Substance Abuse Treatment Facility This agreement covers medically necessary services at an Acute Rehabilitation or Acute Substance Abuse Residential facility when reviewed by us and we decide that, at a minimum, the following program criterion has been met: • Certified clinical staff available twenty-four (24) hours per day, seven (7) days a week to meet the member’s medical and psychological needs. o includes a registered nurse (RN) available on site a minimum of eight (8) hours day and on call twenty-four (24) hours a day; o when on call, the RN must be able to be on site within one (1) hour of a call. • Program must be supervised by a licensed independent clinician that is in charge of the program and the staff; o Licensed independent clinicians are defined as the following: ▪ ƒ M.D. , D.O., or R.N. with advanced training and prescriptive privileges (i.e. Clinical Nurse Specialist), ▪ ƒ Ph.D. LICSW, LMHC, LMFT, or an individual with an equivalent independent practicing license in the state in which the program operates. • Program must have a licensed physicians on staff who is available twenty-four (24) hours per day, seven (7) days per week to evaluate patients and adjust medication as needed and provide medical oversight of all patients in the program. • Program structure must include evidenced-based treatment at a minimum of six (6) hours of clinical programming per day Monday through Friday, and four (4) hours per day on weekends. Recreational, educational and other complementary activities, including, but not limited to, Tai Chi, yoga, personal training, meditation time, exercise, etc., do not count towards the above noted clinical hourly program requirements as they are non- covered, non-clinical services. Recreation therapy, non-medical self-care, or self-help training (e.g., Alcoholics Anonymous (AA), Narcotics Anonymous (NA) meetings/services, etc.) are non-covered services and do not count toward the above noted clinical hourly program requirements. (Please see the Related Exclusion section below for more information.)