Finding information about billing Medicaid for addiction treatment services in Pennsylvania can be difficult. Today’s post contains some tips and tricks - as well as some handy resources - to point you in the direction of the answers you need. 

What addiction treatment services are covered under Medicaid in Pennsylvania? 

Here are the levels of care for substance use disorder treatment that are currently recognized by Pennsylvania’s Medicaid program: 

• SUD Case management 

• SUD Intensive outpatient 

• SUD partial hospital 

• SUD supplemental services 

• Inpatient hospital 

• Methadone maintenance 

• Non-hospital SUD treatment (including clinical managed low-intensity residential services, long-term clinically managed high intensity residential, short-term clinically managed high-intensity residential, medically monitored intensive inpatient services, and non-hospital detoxification)

• Outpatient SUD clinical services (including clinical evaluations, family therapy, group therapy, individual therapy, MAT, and ambulatory detox)

• Peer support services

• Tobacco cessation

• Buprenorphine (Suboxone) services

This list does not include mental health services, which often co-occur with SUD treatment for Medicaid patients in Pennsylvania. You can download a more detailed list of both of these levels of care here. 

What is Medicaid called in Pennsylvania?

Pennsylvania’s Medicaid system is simply referred to as “Medical Assistance” or MA in Pennsylvania. There is no commercial-sounding name for the program in Pennsylvania (ex: Medi-Cal). 

You can help patients apply for Medicaid or update their information through the COMPASS system.

How do you submit Medicaid claims for addiction treatment in Pennsylvania? 

There are several ways to go about this, but the easiest way is to use a third-party billing software certified to communicate with the state’s billing system. It’s even more convenient when that third-party billing software is built into your EHR, which you’ll find with an all-in-one solution like Behave Health. 

Alternatively, you can submit a claim through a clearinghouse or directly through the state’s PROMISe system. You can find more FAQ about submitting Medicaid claims in Pennsylvania here. 

What is the HealthChoices program and how does it relate to addiction treatment services and Medicaid billing in Pennsylvania?

Pennsylvania contracts behavioral healthcare and addiction treatment services out to Managed Care Organizations (MCOs) through the Behavioral Healthchoices program. Each county has a different Managed Care Organization that it contracts with to manage and deliver those services to patients. These programs allow patients some degree of freedom to choose between covered providers in order to tailor their care to their needs and personal preferences. 

Should addiction treatment providers accept Medicaid in Pennsylvania? What are the pros and cons of this business choice?

As you’re learning more about how to bill Medicaid for addiction treatment in Pennsylvania, remember that context matters. 

First, keep in mind that many addiction treatment patients in Pennsylvania are losing their health insurance during the Medicaid unwinding process. It’s more important than ever to ensure that your patients are active in the state’s Medicaid system. 

Second, don’t forget that Pennsylvania’s reimbursement rates for Medicaid services are dangerously low. If your program chooses to accept Medicaid in Pennsylvania, be sure that you’re aware of this issue and be prepared to cut costs where possible in order to keep overhead low.

Do all addiction treatment services require prior authorization for Medicaid patients in Pennsylvania?

No. Some services can be provided without prior authorization. Please see the next question for a complete list of the services which do require prior authorization. 

Which addiction treatment services require prior authorization for Medicaid patients in Pennsylvania?

Prior authorization must be obtained before providing many behavioral healthcare services to Medicaid patients in Pennsylvania. 

Here’s a list of the levels of care for behavioral health that require prior authorization for Medicaid patients in Pennsylvania:

• Intensive behavioral health services (IBHS)

• Case management 

• Certified recovery specialists 

• Community rehabilitative resident host homs 

• Community Treatment teams or Assertive community treatment 

• Electroconvulsive therapy 

• Family-based mental health services 

• Family-focused solution-based 

• Family functional therapy 

• Intensive outpatient services 

• Multisystemic therapy 

• Peer support specialists 

• Partial hospitalization program (acute and non-acute)

• Peer support specialists 

• Partial hospitalization program (residential/partial, acute and non-acute)

• Psychiatric rehabilitation 

• Psychiatric rehabilitation clubhouse

• Psychological testing 

• Residential treatment facilities 

• School-based partial hospitalization program

Are peer support services for addiction treatment and behavioral health covered under Pennsylvania Medicaid?

Yes. According to the outpatient fee schedule maintained on the state’s Human Services website, Self-Help/Peer Services are considered a covered service for Medicaid patients in Pennsylvania. You can bill each 15 minute increment of service under the CPT code H0038.

Is sober living covered under Medicaid programs in Pennsylvania? 

No. Sober living is typically not covered under public health insurance programs and is rarely covered under private plans. In Pennsylvania, only levels of care that are recognized by ASAM are covered by Medicaid. Sober living homes are not part of the recognized continuum of care according to the ASAM standards. 

The most recent edition of the ASAM Criteria did honor the tradition of sober living by attempting to codify the “rules of conduct” that sober living homes must follow. While the new edition places sober living in a position of promenece - and rightfully so - it still does not include sober living as a valid entity as far as billing is oncerned.

Behave Health Knows Medicaid Billing in Pennsylvania

Behave Health is committed to making it easier - and more profitable - to operate evidence-based, results-focused addiction treatment centers.

Our all-in-one app puts clinical, administration, staff, admissions, alumni, residents, treatment plans, billing, insurance authorizations and more - all at your fingertips.

Get your free trial started today and see why more addiction treatment centers prefer Behave Health.

PS. Just getting started with behavioral health? Need help with certification, too? Behave Health can also help direct you to the right resources for help with Licensing or Accreditation by either The Joint Commission or CARF. Mention to your product specialist that you’re interested in this service after you start your free trial!