PUBLIC NOTICE
Department of Health Services
Substance Use Disorder (SUD) Treatment in a Residential Setting
The State of Wisconsin reimburses providers for services provided to Medical Assistance recipients under the authority of Title XIX of the Social Security Act and ss. 49.43 to 49.47, Wisconsin Statutes. This program, administered by the State's Department of Health Services (the Department), is called Medical Assistance (MA) or Medicaid. In addition, Wisconsin has expanded this program to create the BadgerCare Plus programs under the authority of Title XIX and Title XXI of the Social Security Act and s. 49.471 of the Wisconsin Statutes. Federal statutes and regulations require that a state plan be developed that provides the methods and standards for reimbursement of covered services. A plan that describes the reimbursement system for the services (methods and standards for reimbursement) is in effect. Change in Covered Services and Payment Methods
Recipients of services under Medical Assistance, BadgerCare, and BadgerCare Plus (recipients) can receive a range of substance use disorder (SUD) treatment services, including outpatient, intensive outpatient, medication-assisted treatment, inpatient, and medically supervised withdrawal services. The Department will add coverage for SUD treatment in a residential setting for recipients with moderate to severe SUD. Coverage will include both high intensity and low intensity levels of treatment, with placement based on the recipient’s level of need. Treatment services will include individual counseling/therapy; group counseling/therapy; family counseling/therapy; psychoeducation; medication dispensing and administration; nursing services; case management; peer support services; recovery coaching.
Providers of SUD treatment services in a residential setting are required to use procedure code H0018 and include appropriate modifiers. All claims must include a modifier identifying the intensity level of the service: low intensity (TF) or high intensity (TG). Claims may also include one or more modifiers describing the member: member is an adolescent (HA), member is pregnant (HD), and member has intellectual disabilities (HI).
February 1, 2021 SUD Treatment Services in a Residential Setting Rates |
HCPCS | Modifier | Modifier Description | Base Reimbursement Rate | Additional Reimbursement Rate |
H0018 | TF* | Low Intensity | $ 99.84 | No Rate |
H0018 | TF HA** | Low Intensity and Member Is an Adolescent | No Rate | $ 40.00 |
H0018 | TF HD** | Low Intensity and Member Is Pregnant | No Rate | $ 15.00 |
H0018 | TF HI** | Low Intensity and Member Has Intellectual Disabilities | No Rate | $ 15.00 |
H0018 | TG* | High Intensity | $ 221.87 | No Rate |
H0018 | TG HA** | High Intensity and Member Is an Adolescent | No Rate | $ 80.00 |
H0018 | TG HD** | High Intensity and Member Is Pregnant | No Rate | $ 30.00 |
H0018 | TG HI** | High Intensity and Member Has Intellectual Disabilities | No Rate | $ 30.00 |
* All claims must include a modifier identifying the intensity level of the service. |
** Claims may also include one or more modifiers describing the member. |
The change will be effective February 1, 2021, and will apply to claims with dates of service on or after that date. The change to Medicaid, BadgerCare, and BadgerCare Plus is projected to result in increased annual expenditures of $43.5 million all funds (AF), composed of $26.8 million federal match (FED) and $16.7 million state funds/general purpose revenue (GPR).
Copies of Changes
Copies of the SUD treatment in a residential setting may be obtained free of charge by calling or writing:
Mail:
Laura Brauer
Bureau of Benefits Policy
Division of Medicaid Services
P.O. Box 309
Madison, WI 53701-0309
Phone:
(608) 266-5368
Fax:
(608) 266-1096
Attention: Laura Brauer
E-Mail:
Copies of the state plan change will be made available for review at the main office of any county department of social services or human services.
Written Comments
Written comments are welcome. Written comments on the proposed changes may be sent by FAX, e-mail, or regular mail to the Division of Medicaid Services as described above. All written comments will be reviewed and considered.
Because the State Office Building at 1 West Wilson Street, Madison, Wisconsin is currently closed to the public, written comments will not be available for in person public review. Requests to review written comments received may be submitted to the Division of Medicaid Services as described above. Revisions may be made in the proposed change based on comments received.
