Billing for medicaid-covered addiction treatment services in California is a complex undertaking, but it’s not magic. There are just some rules you must know and some guidelines that you must follow in order to maximize your success.
In this post, we’ll cover some of the main considerations you’ll want to keep in mind as you submit Medi-Cal claims in the Golden State.
What makes California's addiction treatment medicaid coverage unique?
California is often considered a leader in the country in terms of Medicaid coverage. This state lays claim to a number of “firsts” in the addiction treatment medicaid coverage world, including:
First state to extend medicaid coverage to peer support services
First state to extend medicaid coverage to contingency management
In California, a number of reform efforts have targeted behavioral health coverage under the state’s Medicaid program, also known as Medi-Cal. These efforts include a massive overhaul of the behavioral healthcare delivery system, turning it into a managed care model, called the Drug Medi-Cal Organized Delivery System (DMC-ODS) or “Drug Medi-Cal” for short.
Does Medicaid cover addiction treatment in California?
Yes, absolutely.
California has one of the most robust coverage programs for addiction treatment patients of any medicaid program in the country. Medi-Cal covers every level of care recognized by the American Society of Addiction Medicine, including inpatient, outpatient, residential, medically managed detoxification, partial hospitalization, and intensive outpatient addiction treatment programs.
Does Medi-Cal cover peer support services and contingency management programs?
Yes. California was the first state in the nation to add these evidence-based interventions to its Medicaid coverage.
For peer support services, you’ll use these two CPT codes: H0025 (Behavioral health prevention education service - delivery of services with target population to affect knowledge, attitude and/or behavior) and/or H0038 (Self-help/peer services, per 15 minutes). Which code you choose will depend on the nature of the peer support session. H0025 is used when the services are delivered in a group setting. H0038 is used when services are provided one-on-one. Both H0025 and H0038 have a maximum of 96 units that can be billed.
For contingency management, you’ll use H0050, which represents one 15 minute unit of “Alcohol and/or drug services, brief intervention.” H0050 is considered one of the catch-alls for
“miscellaneous drug and alcohol services” under CMS. Contingency management is a behavioral intervention that uses intermittent rewards to encourage behavioral change. In the context of treatment for substance use disorder, providers often use contingency management schemes to reward clean UAs and encourage patient progress.
Does Medi-Cal cover medication assisted treatment or MAT?
Yes. Nearly all MAT medications are covered under Medicaid in California, including: Buprenorphine, Vivitrol, Disulfiram, Naloxone or Narcan, Vivitrol, Acamprosate and Methadone.
The CPT code for Methadone dosing, for example, is H0020. MAT dosing that doesn’t involve Methadone is represented by S5000 (Prescription drug, generic) or S5001 (Prescription drug, brand name). Additional Medication Assisted Treatment is covered under H2010 (Comprehensive medication services, per 15 minutes).
Additionally, all Medicaid ready providers are now required to offer or accommodate patients who chose to make MAT a part of their treatment plan in California. Providers who prohibit patients from taking MAT medications may not receive Medi-Cal dollars.
Does Medi-Cal cover sober living homes?
No. Sober living homes are still not a part of ASAM’s continuum of care, so they are typically not covered by any state’s medicaid program, including California's Medi-Cal program.
Does Medi-Cal cover residential drug and alcohol treatment?
Yes. Residential treatment is covered under Medicaid in California. H0019 is the most typical CPT code used when billing Medi-Cal for residential treatment. Because residential treatment is included in ASAM’s continuum of care, all clinical services, including room and board, are covered by Medicaid.
What’s the best resource for getting Medi-Cal addiction treatment billing questions answered online?
It’s a good idea to start with the Drug Medi-Cal Billing Manual created by the California Department of Healthcare Services’ Behavioral Health Financing Branch. The most recent version was released in January 2023 and it covers details on CPT codes, exclusions, same-day lockouts and more.
What’s Medi-Cal’s “No Wrong Door For Mental Health Services” policy and how does it affect addiction treatment providers?
As part of an initiative to ensure that Medi-Cal patients receive timely mental health care, Medicaid reimburses providers for assessment services regardless of whether or not the patient is found to, in fact, suffer from SUD. This essentially incentivizes assessments for providers who otherwise may have been less enthusiastic about assessing patients for SUD.
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