RULES AND REGULATIONS
Title 55--PUBLIC WELFARE
DEPARTMENT OF PUBLIC WELFARE
[55 PA. CODE CH. 1223]
Outpatient Drug and Alcohol Clinic Services
[32 Pa.B. 5513] The Department of Public Welfare (Department) by this order adopts amendments to Chapter 1223 (relating to outpatient drug and alcohol clinic services) to read as set forth in Annex A, under section 443.3(1) of the Public Welfare Code (code) (62 P. S. § 443.3(1)).
Notice of proposed rulemaking is omitted in accordance with section 204(1)(iv) of the act of July 31, 1968 (P. L. 769, No. 240) (CDL) (45 P. S. § 1204(1)(iv)) and 1 Pa. Code § 7.4(1)(iv) (relating to omission of notice of proposed rulemaking) because the final-omitted rulemaking relates to Commonwealth benefits. Additionally, notice of proposed rulemaking is omitted for good cause as unnecessary in accordance with section 204(3) of the CDL and 1 Pa. Code § 7.4(3) as this final-omitted rulemaking benefits Medical Assistance (MA) recipients as well as providers by allowing for drug and alcohol treatment services to be more efficiently and expeditiously provided. The final-omitted rulemaking provides for the elimination of the current requirement for an outpatient drug and alcohol clinic's supervisory physician to perform a comprehensive medical examination within 15 days following intake and before the provision of treatment. In many instances, this requirement unnecessarily delayed treatment to individuals requiring drug and alcohol services.
Providers, consumers, advocacy groups and Department of Health (DOH) officials have worked closely with the Department in establishing this regulatory change based on current DOH requirements relating to staff qualifications for drug and alcohol clinics in 28 Pa. Code §§ 704.6--704.8 (relating to qualifications for the position of clinical supervisor; qualifications for the position of counselor; and qualifications for the position of counselor assistant). These staff requirements ensure that individuals who seek drug and alcohol services are initially assessed and determined to require treatment by professionally trained staff, without the need for a comprehensive medical examination by a physician.
Purpose
The purpose of this final-omitted rulemaking is to:
1. Eliminate the need for the outpatient drug and alcohol clinic's supervisory physician to perform a comprehensive medical examination within 15 days following intake and before the provision of treatment.
2. Require a level of care assessment for each patient prior to admission to the clinic and the provision of treatment by a Drug and Alcohol Addictions Professional (DAAP). A DAAP must be trained in the use of the Pennsylvania Client Placement Criteria (PCPC) for adults, American Society of Addiction Medicine (ASAM) Patient Placement Criteria (PPC) for adolescents or an alternative level of care criteria approved by the DOH or other criteria jointly approved by both the DOH and the Department.
3. Require, within 15 days following intake, the clinic's supervisory physician to review and verify each patient's level of care assessment, psychosocial evaluation and initial treatment plan prior to the provision of any treatment beyond the 15th day following intake. If this condition is not met, payment will not be made for outpatient drug and alcohol clinic services.
4. Require a physician to perform a comprehensive medical examination or psychiatric evaluation, when medically necessary, as indicated by the level of care assessment or the clinic's supervisory physician's review.
Background
Current § 1223.52(a)(6) (relating to payment conditions for various services) requires a drug and alcohol clinic's supervisory physician to examine and evaluate a potential patient, determine the patient's diagnosis and develop an initial treatment plan within 15 days following intake and before the provision of treatment. This final-omitted rulemaking was developed at a time when drug and alcohol clinics did not have clinical or ongoing training requirements for staff. Since that time, standards have been promulgated by the DOH in 28 Pa. Code Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities). Based on the DOH requirements, the Department and DOH maintain contractual arrangements with managed care organizations and single county authorities that ensure qualified staff perform a patient's level of care assessment prior to admission to an outpatient drug and alcohol clinic and the provision of treatment.
In addition to the DOH regulatory standards relating to staffing in drug and alcohol clinics, drug and alcohol treatment programs serving DOH and MA eligible patients have been required to use the approved standards of clinical necessity or guidelines; PCPC for adults and ASAM PPC for adolescents. The DOH approved standards of clinical necessity or guidelines were developed to address the medical need for the placement of the patient in the level, type and duration of treatment necessary and to address the degree of direct medical management. Patient level of care assessment and the application of the DOH approved placement criteria is conducted by a DAAP trained in the use of the PCPC or ASAM PPC.
As a result of the DOH regulatory standards relating to drug and alcohol clinic staffing qualifications, the Department was requested to reexamine the regulations requiring the clinic's supervisory physician to perform the comprehensive medical examination. Based on input from consumers, providers and advocacy groups, the Department determined that § 1223.52(a)(6) created unnecessary barriers to expedient drug and alcohol clinic services. The Department also considered and adopted the Pennsylvania Psychiatric Society's recommendation to provide payment for a comprehensive medical examination or psychiatric evaluation by a physician, when either the level of care assessment or the physician's review indicates the need.
This final-omitted rulemaking does not apply to methadone maintenance clinics because of Federal law requirements in 42 CFR 8.12(f)(2) (relating to Federal opiod treatment standards). Federal regulations require a comprehensive medical examination be performed for each MA recipient before dispensing methadone to the MA recipient.
Need for Final-Omitted Rulemaking
This final-omitted rulemaking is necessary to eliminate the need for the outpatient drug and alcohol clinic's supervisory physician to perform a comprehensive medical examination within 15 days following intake and before the provision of treatment. This final-omitted rulemaking also provides for consistency with the DOH regulations by allowing a DAAP trained in the use of PCPC for adults or ASAM PPC for adolescents or an alternative level of care criteria approved by the DOH or other criteria jointly approved by both the DOH and the Department to perform a level of care assessment for each patient prior to admission to the clinic and the provision of treatment.
Affected Individuals
MA outpatient recipients seeking drug and alcohol services will be affected by the final-omitted rulemaking with the exception of methadone maintenance clients.
Providers of outpatient drug and alcohol services with the exception of methadone maintenance clinics are subject to the final-omitted rulemaking. Affected clinics have sought and are already aware of this final-omitted rulemaking.
Summary of Amendment
Sections 1223.2, 1223.14 and 1223.41 (relating to definitions; noncovered services; and participation requirements) and § 1223.52 are amended or added to reflect current staff qualification standards by the DOH in 28 Pa. Code §§ 704.6--704.8 and in accordance with State Civil Service Commission standards. The final-omitted rulemaking allows for individual level of care assessments and the application of the DOH approved placement criteria to be conducted by a DAAP trained in the use of the PCPC for adults and ASAM PPC for adolescents. An assessment eliminates the need for the outpatient drug and alcohol clinic's supervisory physician to perform a comprehensive medical examination within 15 days following intake and before the provision of treatment. This allows MA recipients the benefit of access to medically necessary drug and alcohol treatment services in a more expeditious manner.
Fiscal Impact
Public Sector
The Department's Office of Medical Assistance Programs (OMAP) does not anticipate any fiscal impact on the public sector other than minor cash flow costs over 1 year that is estimated to be approximately $222,000.
Private Sector and General Public
The OMAP does not anticipate any fiscal impact on the private sector or the general public.
Paperwork Requirements
There are no additional reports or new forms needed to comply with the final-omitted rulemaking.
Sunset Date
The OMAP will evaluate the effectiveness of this final-omitted rulemaking on an ongoing basis. Necessary and appropriate changes will be made in response to letters, recommendations and comments from other offices, agencies and individuals and as a result of Departmental findings. No sunset date is required.
Public Comment
Although the final-omitted rulemaking is being adopted without prior notice, interested persons are invited to submit written comments, within 30 days of the date of this publication to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, Attention: Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Persons with a disability may use the AT&T Relay Service, (800) 654-5984 (TDD users).
Regulatory Review Act
Under section 5.1(c) of the Regulatory Review Act (71 P. S. § 745.5a(c)), on September 12, 2002, the Department submitted copies of this final-omitted rulemaking to the Independent Regulatory Review Commission (IRRC) and to the Chairpersons of the House Committee on Health and Human Services and the Senate Committee on Public Health and Welfare. On the same date, the final-omitted rulemaking was submitted to the Office of Attorney General for review and approval under the Commonwealth Attorneys Act (71 P. S. §§ 732-101--732-506).
Under section 5.1(a) of the Regulatory Review Act, on October 2, 2002, this final-omitted rulemaking was deemed approved by the House and Senate Committees. Under section 5.1(e) of the Regulatory Review Act, on October 24, 2002, IRRC met and approved this final-omitted rulemaking.
Findings
The Department finds that:
(1) Notice of proposed rulemaking is omitted because this rulemaking relates to Commonwealth benefits in accordance with section 204(1)(iv) of the CDL and 1 Pa. Code § 7.4(1)(iv).
(2) Notice of proposed rulemaking is unnecessary under section 204(3) of the CDL and 1 Pa. Code § 7.4(3).
(3) The adoption of this final-omitted rulemaking in the manner provided in this order is necessary and appropriate for the administration and enforcement of the code.
Order
The Department, acting under the code, orders:
(a) The regulations of the Department, 55 Pa. Code Chapter 1223, are amended by amending §§ 1223.2, 1223.14. 1223.41 and 1223.52 to read as set forth in Annex A, with ellipses referring to the existing text of the regulations.
(b) The Secretary of the Department shall submit this order and Annex A to the Attorney General and General Counsel for approval as to legality and form as required by law.
(c) The Secretary of the Department shall certify this order and Annex A and deposit them with the Legislative Reference Bureau as required by law.
(d) This order shall take effect immediately upon publication in the Pennsylvania Bulletin.
FEATHER O. HOUSTOUN,
Secretary(Editor's Note: For the text of the order of the Independent Regulatory Review Commission, relating to this document, see 32 Pa.B. 5582 (November 9, 2002).)
Fiscal Note: 14-476. (1) General Fund;
MA--
OutpatientMA--
Capitation(2) Implementing Year 2001-02 is
-0-
-0-(3) 1st Succeeding Year 2002-03 is
$83,000
$139,0002nd Succeeding Year 2003-04 is
-0-
-0-3rd Succeeding Year 2004-05 is
-0-
-0-4th Succeeding Year 2005-06 is
-0-
-0-5th Succeeding Year 2006-07 is
-0-
-0-
MA--
OutpatientMA--
Capitation(4) 2000-01 Program-- $668,586,000 $1,487,944,000 1999-00 Program-- $622,669,000 $1,384,763,000 1998-99 Program-- $695,935,000 $1,026,075,000 (7) Medical Assistance Outpatient and Capitation; (8) recommends adoption. Funding is included in the 2002-03 budget for this regulatory change.
Annex A
TITLE 55. PUBLIC WELFARE
PART III. MEDICAL ASSISTANCE MANUAL
CHAPTER 1223. OUTPATIENT DRUG AND ALCOHOL CLINIC SERVICES
GENERAL PROVISIONS § 1223.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
* * * * * DAAP--Drug and alcohol addictions professional--One of the following:
(i) An individual who is certified as an addictions counselor by a Statewide certification body and who is a member of a National certification body.
(ii) An individual who is certified by another state government's substance abuse counseling certification board.
(iii) An individual possessing a minimum of a bachelor's degree in social science and 2 years experience in treatment/case management services for persons with substance abuse/addiction disorders.
(iv) An individual meeting the qualifications of one of the following:
(A) Drug and Alcohol Case Management Specialist.
(B) Drug and Alcohol Case Management Specialist Trainee.
(C) Drug and Alcohol Case Management Supervisor.
(D) Drug and Alcohol Counselor.
(E) Drug and Alcohol Counselor Assistant.
DAC--Drug and alcohol counselor--An individual who provides a wide variety of treatment services which may include performing diagnostic assessments for chemical dependency, developing treatment plans, and providing individual and group counseling. This individual shall meet the education and experience requirements in 28 Pa. Code § 704.7 (relating to qualifications for the position of counselor).
DACA--Drug and alcohol counselor assistant--An individual in an entry level position who provides treatment services under the direct supervision of a trained counselor or clinical supervisor. This individual shall meet the education, experience, supervision and training requirements in 28 Pa. Code §§ 704.8 and 704.11 (relating to qualifications for the position of counselor assistant; and staff development program).
DACMSP--Drug and alcohol case management specialist--An individual who meets the minimum experience and training requirements established by the State Civil Service Commission for DACMSP.
DACMST--Drug and alcohol case management specialist trainee--An individual who meets the minimum experience and training requirements established by the Civil Service Commission for DACMST.
DACMSU--Drug and alcohol case management supervisor--An individual who meets the minimum experience and training requirements established by the Civil Service Commission for DACMSU.
* * * * * Level of care assessment--A face-to-face interview with an individual using the most current edition of the Pennsylvania Client Placement Criteria for adults and the most current edition of the American Society of Addiction Medicine Patient Placement Criteria for adolescents to ascertain the severity of alcohol or other drug use and degree of impairment by identifying the biomedical, emotional/behavioral and environmental effects of that use in order to determine proper placement and treatment for the individual.
* * * * * Psychosocial evaluation--A composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the individual's current situation.
* * * * *
COVERED AND NONCOVERED SERVICES § 1223.14. Noncovered services.
Payment will not be made for the following types of services regardless of where or to whom they are provided:
* * * * * (14) Methadone maintenance clinic services provided before the date of the physician's comprehensive medical examination, diagnosis and treatment plan.
(15) Services provided without a level of care assessment for each patient prior to admission to the clinic.
(16) Services provided within or beyond the 15th calendar day following intake, without the clinic's supervisory physician's review and approval of the patient's level of care assessment, psychosocial evaluation, treatment plan and determination of the patient's diagnosis as specified in § 1223.52(a)(6)(i).
PROVIDER PARTICIPATION § 1223.41. Participation requirements.
In addition to the participation requirements established in Chapter 1101 (relating to general provisions), drug/alcohol outpatient clinics shall meet the following participation requirements:
* * * * * (11) Ensure that a DAAP performs a level of care assessment for each patient prior to admission to the clinic and the provision of treatment.
PAYMENT FOR OUTPATIENT DRUG/ALCOHOL CLINIC SERVICES § 1223.52. Payment conditions for various services.
(a) Elibilty for payment. The following conditions shall be met by an outpatient drug and alcohol clinic, as applicable, to be eligible for payment:
* * * * * (6) With the exception of methadone maintenance clinic services, a DAAP shall perform a level of care assessment for each patient prior to admission to the clinic and the provision of services.
(i) Within 15 days following intake, the clinic's supervisory physician shall review and verify each patient's level of care assessment, psychosocial evaluation and initial treatment plan prior to the provision of any treatment beyond the 15th day following intake. The clinic's supervisory physician shall verify the patient's diagnosis. The clinic's supervisory physician shall sign and date the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis in the patient's record. Payment will not be made for services provided within or beyond the 15th day following intake, without the clinic's supervisory physician's review and approval of the level of care assessment, psychosocial evaluation, treatment plan and determination of the patient's diagnosis.
(ii) Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic's supervisory physician shall review and update each patient's treatment plan. Each review and update shall be dated, documented and signed in the patient's record by the clinic's supervisory physician.
(iii) The treatment plan and updates shall be based upon the psychosocial evaluation and diagnoses. Treatment shall be provided in accordance with the treatment plan and updates and under the supervision and direction of the clinic's supervisory physician. Clinic supervisory physician reviews and reevaluations of diagnoses, treatment plans and updates shall be done in the clinic.
(iv) A physician may perform a comprehensive medical examination or psychiatric evaluation, when medically necessary, as indicated by either the level of care assessment or the clinic's supervisory physician's review.
(7) For methadone maintenance clinics, following intake and prior to the provision of any services, the clinic's supervisory physician shall perform a comprehensive medical examination on each patient to determine the patient's diagnoses, initial treatment plan and identify any medical conditions. The clinic's supervisory physician shall document and sign the comprehensive medical examination and treatment plan in the patient's record. The treatment plan shall be developed, maintained and periodically reviewed in accordance with the following criteria:
(i) Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic's supervisory physician shall review and update each patient's treatment plan. Each review and update shall be dated, documented and signed in the patient's record by the clinic's supervisory physician.
(ii) The treatment plan and updates shall be based upon the comprehensive medical examination, psychosocial evaluation and diagnoses. Treatment shall be provided in accordance with the treatment plan and updates and under the supervision and direction of the clinic's supervisory physician. Clinic supervisory physician reviews and reevaluations of diagnoses, treatment plans and updates shall be done in the clinic.
[Pa.B. Doc. No. 02-1999. Filed for public inspection November 8, 2002, 9:00 a.m.]
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