SUBSTANCE ABUSE INTENSIVE OUTPATIENT PROGRAM

Modified on Thu, 27 Apr, 2023 at 1:58 PM

SERVICE DEFINITION AND REQUIRED COMPONENTS

SA Intensive Outpatient Program (SAIOP) means structured individual and group addiction activities and services that are

provided at an outpatient program designed to assist adult and adolescent consumers to begin recovery and learn skills for

recovery maintenance. The program is offered at least 3 hours a day, at least 3 days a week, with no more than 2 consecutive

days between offered services, and distinguishes between those individuals needing no more than 19 hours of structured

services per week (ASAM Level II.1). The recipient must be in attendance for a minimum of 3 hours a day in order to bill this

service. SAIOP services shall include a structured program consisting of, but not limited to, the following

services:

1. Individual counseling and support;

2. Group counseling and support;

3. Family counseling, training or support;

4. Biochemical assays to identify recent drug use (e.g. urine drug screens);

5. Strategies for relapse prevention to include community and social support systems in treatment;

6. Life skills;

7. Crisis contingency planning;

8. Disease Management; and

9. Treatment support activities that have been adapted or specifically designed for persons with physical disabilities, or persons

with co-occurring disorders of mental illness and substance abuse/dependence or mental retardation/developmental disability and

substance abuse/dependence.

SAIOP can be designed for homogenous groups of recipients e.g., pregnant women, and women and their children; individuals

with co-occurring MH/SA disorders; individuals with HIV; or individuals with similar cognitive levels of functioning. Group

counseling shall be provided each day SAIOP services are offered. SAIOP includes case management to arrange, link or

integrate multiple services as well as assessment and reassessment of the recipient’s need for services. SAIOP services also

informs the recipient about benefits, community resources, and services; assists the recipient in accessing benefits and

services; arranges for the recipient to receive benefits and services; and monitors the provision of services. Consumers may

be residents of their own home, a substitute home, or a group care setting; however, the SAIOP must be provided in a setting

separate from the consumer’s residence. The program is provided over a period of several weeks or months.

A service order for SAIOP must be completed by a physician, licensed psychologist, physician’s assistant or nurse practitioner

according to their scope of practice prior to or on the day that the services are to be provided.

PROVIDER REQUIREMENTS

SAIOP must be delivered by practitioners employed by a substance abuse provider organization that meet the provider

qualification policies, procedures, and standards established by DMH and the requirements of 10A NCAC 27G. These policies

and procedures set forth the administrative, financial, clinical, quality improvement, and information services infrastructure

necessary to provide services. Provider organizations must demonstrate that they meet these standards by being endorsed by

LME. Within three years of enrollment as a provider, the organization must have achieved national accreditation. The

organization must be established as a legally recognized entity in the United States and qualified/registered to do business as

a corporate entity in the State of North Carolina.

Organizations that provide SAIOP must provide “first responder” crisis response on a 24/7/365 basis to recipients who are

receiving this service.

STAFFING REQUIREMENTS

Persons who meet the requirements specified for CCS, LCAS, LCAS-P, and CSAC under Article 5C may deliver SAIOP. The

program must be under the clinical supervision of a CCS or a LCAS who is on site a minimum of 50% of the hours the service

is in operation. Services may also be provided by staff that meet the requirements specified for QP or AP status for Substance

Abuse according to 10A NCAC, under the supervision of a LCAS or CCS. The maximum face-to-face staff-to- client ratio is not

more than 12 adult consumers to 1 QP based on an average daily attendance. The ratio for adolescents will be 1:6.

Paraprofessional level providers who meet the requirements for Paraprofessional status according to 10A NCAC 27G and who

have the knowledge, skills, and abilities required for the population and age to be services may deliver SAIOP, under the

supervision of a LCAS or CCS. Paraprofessional level providers may not provide services in lieu of on-site service provision by

a qualified professional, LCAS, CCS, LCAS-P, or CSAC.

SERVICE TYPE / SETTING

Facility licensed under 10A NCAC 27G .4400.

CLINICAL REQUIREMENTS

THE SHIP GROUP COMMUNITY SERVICES

Policies & Procedures Manual

173

See Service Definition and Required Components.

UTILIZATION MANAGEMENT

Authorization by the statewide vendor is required. The amount, duration, and frequency of SAIOP Service must be included in an

individual’s authorized Person Centered Plan. Services may not be delivered less frequently than the structured program set forth in

the service description above. Recipients may be seen for the initial 30 days of treatment without a prior authorization. Services

provided after this initial 30 day “pass-through” period require authorization from the Medicaid approved vendor. This pass-through is

available only once per calendar year. Reauthorization shall not exceed 60 days. Under exceptional circumstances, one additional

reauthorization up to 2 weeks can be approved. This service is billed with a minimum of 3 hours per day as an event.

ENTRANCE CRITERIA

The recipient is eligible for this service when

A. There is an Axis I substance abuse disorder present;

AND

B. Level of Care Criteria, level II.1 NC Modified A/ASAM

CONTINUED STAY CRITERIA

The desired outcome or level of functioning has not been restored, improved, or sustained over the time frame outlined in the

recipient’s Person Centered Plan or the recipient continues to be at risk for relapse based on history or the tenuous nature of the

functional gains or any one of the following applies:

A. Recipient has achieved positive life outcomes that support stable and ongoing recovery, and additional goals are indicated.

B. Recipient is making satisfactory progress toward meeting goals.

C. Recipient is making some progress, but the Person Centered Plan (specific interventions) needs to be modified so that greater

gains, which are consistent with the recipient's pre-morbid level of functioning, are possible or can be achieved.

D. Recipient is not making progress; the Person Centered Plan must be modified to identify more effective interventions

E. Recipient is regressing; the Person Centered Plan must be modified to identify more effective interventions.

DISCHARGE CRITERIA

Recipient’s level of functioning has improved with respect to the goals outlined in the Person Centered Plan, inclusive of a transition

plan to step down, or no longer benefits, or has the ability to function at this level of care and any of the following apply:

1. Recipient has achieved positive life outcomes that support stable and ongoing recovery.

2. Recipient is not making progress, or is regressing and all realistic treatment options have been exhausted indicating a need for

more intensive services.

3. Recipient no longer wishes to receive SAIOP services.

DOCUMENTATION REQUIREMENTS

Minimum standard is a daily full service note for each day of SAIOP that includes the recipient’s name, Medicaid identification

number, date of service, purpose of contact, describes the provider’s interventions, the time spent performing the intervention,

the effectiveness of interventions, and the signature and credentials of the staff providing the service. A documented discha rge

plan will be discussed with the recipient and included in the record.

EXPECTED OUTCOMES

The expected outcome of SAIOP is abstinence. Secondary outcomes (i.e., in abstinent patients) include: sustained

improvement in health and psychosocial functioning, reduction in any psychiatric symptoms (if present), reduction in public

health and/or safety concerns, and a reduction in the risk of relapse as evidenced by improvement in empirically supporte d

modifiable relapse risk factors.

SERVICE EXCLUSIONS/LIMITATIONS

SAIOP cannot be billed during the same authorization as SA Comprehensive Outpatient Treatment, all detoxification

services levels, Non-Medical Community Residential Treatment or Medically Monitored Community Residential Treatment.

Note: For recipients under the age of 21, additional products, services, or procedures may be requested even if they do not appear in the

N.C. State Plan or when coverage is limited to those over 21 years of age. Service limitations on scope, amount, or frequency described in

the coverage policy may not apply if the product, service, or procedure is medically necessary.

1.0 Description of the Procedure, Product, or Service

Buprenorphine and buprenorphine-naloxone combination product serves as an alternative to methadone as

an evidence-based treatment of beneficiaries with opioid use disorders. This policy outlines the

requirements for providers who prescribe buprenorphine and buprenorphine- naloxone combination

product for the treatment of opioid use disorders in the office-based setting.

Public law 106-310 Section 3501, Drug Addiction Treatment Act of 2000 (DATA 2000) permits providers

who meet certain qualifications to dispense or prescribe narcotic medications that have a lower risk of

abuse, like buprenorphine and buprenorphine-naloxone combination product that are approved by the

Food and Drug Administration (FDA) for opioid use disorders in settings other than an opioid treatment

program (OTP), such as a provider’s office. This allows beneficiaries who need the opioid agonist

treatment to receive this treatment in a qualified provider’s office providing certain conditions are met.

Due to the national opioid use epidemic and additional need for buprenorphine prescribers, the Substance

Abuse and Mental Health Services Administration (SAMHSA) is developing a training and DATA waiver

program for nurse practitioners (NP) and physician assistants (PA). NPs and PAs may take the eight-hour

DATA-waiver course for treatment of opioid use disorder. For the additional 16 hours, SAMHSA will also

offer the training through the PCSS-MAT once it has been developed. NPs and PAs who have completed

the required training, and seek to become DATA-waiver providers for up to 30 beneficiaries, will be able to

apply to do so beginning in early 2017.

Office-based Opioid Treatment (OBOT) is defined as treatment of opioid use disorders in the clinical

setting by a qualified provider as defined under Public Law 106-310 Section 3501(a)(G)(ii) to prescribe

buprenorphine or buprenorphine-naloxone medications. Opioid use disorder is considered a chronic

condition, and the management of this disorder is incorporated into the general care of the beneficiary.

Treatment goals of Office-based Opioid Treatment are to reduce or stop opioid use, to improve the

beneficiary’s overall health and social functioning, and to help the beneficiary avoid some of the more

serious consequences of opioid addiction.

Association.