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Substance Use Disorder: Understanding Levels of Care

Nicki Gardes - Friday, February 14, 2020

If you care about someone struggling with substance use disorder, it’s important to understand how professionals in the field consider various treatment options and how they make decisions about their recommendations. This article offers information on The American Society of Addiction Medicine’s (ASAM) standardized criteria for assessing the treatment needs of individuals with a substance use disorder.

While this is not the only criteria, the ASAM criteria has become the most widely used and comprehensive set of guidelines for assessment, treatment planning, placement, continued stay, and transfer/discharge of individuals with substance use disorders. In order to access the right treatment, you must start with an ASAM assessment.

In order to access the appropriate level of care and get it paid for – either through insurance or Medicaid - a person needs an assessment by a professional who is certified and/or licensed to conduct the assessment. These include:

  • Treatment Providers
    Treatment providers will do an assessment prior to enrolling a person in a treatment program. Many of them will conduct a screening over the phone to determine whether the level of treatment that they offer is the appropriate level of care.
  • County Health Departments
    Many County Health Departments conduct assessments or have a contract with an organization to provide this service. If you are not sure what level of care is needed, then getting an assessment to determine the appropriate level can be a good idea.

ASAM criteria is used to assess a person’s treatment needs in each of six dimensions. These include:

  • Dimension 1: Acute Intoxication and/or Withdrawal Potential
  • Dimension 2: Biomedical Conditions and Complications
  • Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications
  • Dimension 4: Readiness to Change
  • Dimension 5: Relapse / Continued Use Potential
  • Dimension 6: Recovery Environment

The intensity of treatment progresses along a continuum from zero to four depending on the needs of the person in each of these six dimensions. This continuum of care includes:

Level .5 - Early Intervention
Includes DUI programs.

Level 1 - Outpatient
Less than 9 hours/week for adults or less than 6 hours/week for adolescents

Level 2.1 - Intensive Outpatient
9 or more hours/week for adults or 6 or more hours/week for adolescents

Level 2.5 - Partial Hospitalization
20 hours or more/week outpatient

Level 3.1 – Clinically Managed Low-Intensity Residential
Halfway Houses. 24 hour living support with at least 5 hours clinical services/week (may be provided on-site or in an outpatient services program).

Level 3.3 - Clinically Managed Population Specific High-Intensity Residential
Adults only. 24 hour care for adults with significant cognitive impairments. Includes specialized programming.

Level 3.5 - Clinically Managed Residential – High Intensity for Adults, Medium Intensity for Adolescents
24 hour care with clinical staff including addiction counselors, social workers, or licensed professional counsellors and allied health professionals. No on-site physician, but nursing staff.

Level 3.7 - Medically Monitored Inpatient – Intensive for Adults, High-Intensity for adolescents
Highly structured 24 hour services. Physician available on-site 24 hours daily, along with RNs, addiction counsellors and other clinical staff.

Level IV - Medically Managed Intensive Inpatient
Daily direct care from a physician. Hospital-based setting.

There are other specifications to these levels of care, including withdrawal management and opioid treatment services.

Payment

In the past, just because an individual was assessed at needing a certain level of care, it didn’t mean that an insurer would approve paying for that level of care.

Maryland Medicaid did not cover residential settings for adults, and only covered level 3.7 for adolescents. This has changed. Medicaid now pays for level 3.3, 3.5 and 3.7 for adults: two non-consecutive residential stays in a rolling year, up to 30 days as needed. The Behavioral Health Administration covers the non-Medicaid-reimbursable portion of costs.

Private insurers would often require that an individual fail first at a lower level of care before they would approve a more intensive level of care, despite an ASAM assessment determination. New Maryland legislation passed in the 2019 legislative session stipulates that an insurer must use the ASAM assessment determination when deciding on placement coverage. There is a rub, however, in that some insurance plans are exempt from this requirement. Your insurer should tell you if they are/are not exempt from Maryland State insurance regulations.

Getting an ASAM assessment is the start on the road to recovery, and it should be used throughout treatment planning. It is important that loved ones know what it means.

Note: MCF’s family peer support team can help you with this and will support your family throughout the journey of substance use, recovery and beyond. Reach out to us at info@mdcoalition.org or 410-730-8267. Our services are provided at no cost to families and are confidential.

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