Departm ent of Health Care Services - PDF Document

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  1. State of California—Health and Hum an Services Agency Departm ent of Health Care Services JENNIFER KENT DIRECTOR EDMUND G. BROWN JR. GOVERNOR September 14, 2018 DATE: ALL PLAN LETTER 18-014 SUPERSEDES ALL PLAN LETTER 17-016 TO: ALL MEDI-CAL MANAGED CARE HEALTH PLANS SUBJECT: ALCOHOL MISUSE: SCREENING AND BEHAVIORAL COUNSELING INTERVENTIONS IN PRIMARY CARE PURPOSE: The purpose of this All Plan Letter (APL) is to clarify the Medi-Cal managed care health plans (MCPs) primary care requirement to provide Alcohol Misuse Screening and Behavioral Counseling Interventions1 to members ages 18 and older who misuse alcohol. This APL was formerly named “Screening, Brief Intervention and Referral to Treatment for Misuse of Alcohol.” This APL aligns with the April 2018 updates to the Preventive Services Medi-Cal Provider Manual2 and supersedes APL 17-016. BACKGROUND: MCPs are contractually required to provide all preventive services consistent with the United States Preventive Services Task Force (USPSTF) Grade A and B recommendations. As of May 2013, the USPSTF assigned a Grade B recommendation for Alcohol Misuse Screening and Behavioral Counseling Interventions in Primary Care. The USPSTF recommends that clinicians screen adults ages 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.3 The USPSTF uses the term “alcohol misuse” to define a spectrum of behaviors, including risky or hazardous alcohol use (e.g., harmful alcohol use and alcohol abuse or dependence). Risky or hazardous alcohol use means drinking more than the recommended daily, weekly, or per-occasion quantity of alcohol, resulting in increased risk for adverse health consequences (e.g., the National Institute on Alcohol Abuse and cal.ca.gov/pubsdoco/publications/masters-mtp/part2/prev_m01o03.doc 3 The USPSTF Final Recommendation Statement on Alcohol Misuse Screening and Behavioral Health Counseling Interventions in Primary Care can be found at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/alcohol- misuse-screening-and-behavioral-counseling-interventions-in-primary-care 1 Also known as Alcohol Misuse Screening and Counseling. 2 The Preventive Services Medi-Cal Provider Manual can be accessed at: https://files.medi- Managed Care Quality and Monitoring Division 1501 Capitol Avenue, P.O. Box 997413, MS 4400 Sacramento, CA 95899-7413 Phone (916) 449-5000 Fax (916) 449-5005 www.dhcs.ca.gov https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/prev_m01o03.doc

  2. APL 18-014 Page 2 Alcoholism (NIAAA) and the U.S. Department of Agriculture define “risky use” as consuming more than four drinks on any day or fourteen drinks per week for men, or more than three drinks on any day or seven drinks per week for women (as well as any level of consumption under certain circumstances.))4 Alcohol misuse plays a contributing role in a wide range of health conditions such as hypertension; gastritis; liver disease, including cirrhosis; pancreatitis; certain types of cancer, such as breast and esophageal cancers; cognitive impairment; anxiety; and depression.5 Research findings implicate alcohol misuse as a major risk factor for trauma, including falls, drowning, fires, motor vehicle accidents, homicide, and suicide.6 Research findings also link alcohol use during pregnancy to fetal alcohol syndrome.7 Counseling interventions in the primary care setting can positively affect risky drinking behaviors in adults by reducing weekly alcohol consumption and increasing long-term adherence to recommended drinking limits. Brief behavioral counseling interventions decrease the proportion of persons who engage in episodes of heavy drinking. Indirect evidence supports the effect of screening and brief behavioral counseling interventions on reducing the probability of traumatic injury or death, especially related to motor vehicle accidents.8 According to the NIAAA, problem drinking that becomes severe is given the medical diagnosis of alcohol use disorder (AUD). AUD is a chronic relapsing brain disease characterized by compulsive alcohol use, loss of control over alcohol intake, and a negative emotional state when not using.9 Recommendation Statement available at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/alcohol- misuse-screening-and-behavioral-counseling-interventions-in-primary-care 5 Corrao G, Bagnardi V, Zambon A, La Vecchia C. A meta-analysis of alcohol consumption and the risk of 15 diseases. Prev Med. 2004; 38(5):613-9. Reference to this research is available at: https://www.ncbi.nlm.nih.gov/pubmed/15066364. 6 Cherpitel CJ, Ye Y. Alcohol-attributable fraction for injury in the U.S. general population: data from the 2005 National Alcohol Survey. J Stud Alcohol Drugs. 2008; 69(4):535-8. Reference to this research is available at: https://www.ncbi.nlm.nih.gov/pubmed/18612569. 7 Centers for Disease Control and Prevention. Update: trends in fetal alcohol syndrome—United States, 1979–1993. MMWR Morb Mortal Wkly Rep. 1995; 44(13):249-51, available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00036699.htm. 8 USPSTF Final Recommendation Statement can be found at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/alcohol- misuse-screening-and-behavioral-counseling-interventions-in-primary-care 9 The NIAAA webpage can be found at: https://www.niaaa.nih.gov/alcohol-health/overview-alcohol- consumption/alcohol-use-disorders. 4 See the definition of alcohol misuse and risky or hazardous alcohol use in the USPSTF Final https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-use-disorders

  3. APL 18-014 Page 3 AUD is a mental health condition recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM), and as such, MCPs must provide mental health parity services for members screened and determined to have an AUD. Specifically, the Medicaid and Children’s Health Insurance Program Managed Care Final Rule (CMS-2390-F)10 requires Medicaid Managed Care Organizations to provide coverage for certain benefits required under the Mental Health Parity and Addiction Equity Act of 2008,11 including Subpart K – Parity in Mental Health and Substance Use Disorder Benefits.12 As of October 2, 2017, MCPs are required to comply with the Mental Health Parity rule.13 The general parity requirement stipulates that financial requirements or treatment limitations for mental health benefits may not be more restrictive than the predominant financial requirements or treatment limitations applied to medical or surgical benefits.14 POLICY: Alcohol Misuse Screening Consistent with USPSTF recommendations and the Preventive Services Medi-Cal Provider Manual, MCPs must annually screen adult members 18 years of age and older for alcohol misuse.15 Although MCPs must provide one alcohol misuse screening per year,16 additional screenings must be provided when medically necessary. Medical necessity must be documented by the member’s PCP or primary care team. The USPSTF considers the following three tools as the instruments of choice for screening for alcohol misuse in the primary care setting. Accordingly, MCPs must use one of these validated screening tools when screening members for alcohol misuse: 1. The Alcohol Use Disorders Identification Test (AUDIT); 2. The abbreviated AUDIT-Consumption (AUDIT-C); and 3. A single-question screening, such as asking, “How many times in the past year have you had 4 (for women and all adults older than 65 years) or 5 (for men) or more drinks in a day?” https://www.ecfr.gov/cgi-bin/ECFR?SID=109e4ec90691b51122679c6299de4728&mc=true&page=browse 13 42 CFR 438.930. 14 42 CFR 438.910(b). 15 Please note that youth aged 18-21 are eligible for additional screening benefits under the Early and Periodic Screening, Diagnostic, and Treatment benefit per APL 18-007. APLs are available at: http://www.dhcs.ca.gov/formsandpubs/Pages/MgdCarePlanPolicyLtrs.aspx. 16 Healthcare Common Procedure Coding System (HCPCS) codes can be found in the Medi-Cal Provider Manual available at: https://files.medi-cal.ca.gov/pubsdoco/publications/masters- mtp/part2/prev_m01o03.doc. 10 Federal Register: 81 FR 27497 11 Pub. L. 110-343, enacted on October 3, 2008. 12 42 CFR 438.900 et seq. The Electronic Code of Federal Regulations is accessible at: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/prev_m01o03.doc

  4. APL 18-014 Page 4 Behavioral Counseling Interventions for Alcohol Misuse MCPs must offer members with brief behavioral counseling interventions, as specified by the Preventive Services Medi-Cal Provider Manual17 to reduce alcohol misuse when, during the screening process, a member is identified as being engaged in risky or hazardous drinking. Behavioral counseling interventions for alcohol misuse vary in their specific components, administration, length, and number of interactions, but may include cognitive behavioral strategies, such as action plans, drinking diaries, stress management, or problem solving. Interventions may be delivered by face-to-face sessions, written self-help materials, computer- or Web-based programs, or telephone counseling. MCPs must offer at least one, but may offer up to a maximum of three, behavioral counseling interventions for alcohol misuse per year. Additional behavioral counseling interventions must be authorized when medically necessary; however, medical necessity must be documented by the member’s PCP.18 Referral to Mental Health and/or Alcohol Use Disorder Services MCPs must ensure that members who, upon screening and evaluation, meet the criteria for an AUD as defined by the current DSM (DSM-5, or as amended), or whose diagnosis is uncertain, are referred for further evaluation and treatment to the county department for alcohol and substance use disorder treatment services, or a DHCS- certified treatment program. MCPs must ensure that PCPs maintain documentation of the alcohol misuse screening (see below) of their members. When a member transfers from one PCP to another, the receiving PCP must obtain the member’s prior medical records, including those pertaining to the provision of preventive services. MCPs must include alcohol misuse and behavioral counseling intervention services in their member-informing materials. MCPs must also maintain policies and procedures to ensure that providers in primary care settings offer and document alcohol misuse screening services required by this APL and the Preventative Services Medi-Cal Provider Manual.19 MCPs are responsible for ensuring that their delegates and subcontractors comply with all applicable state and federal laws and regulations, contract requirements, and other https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/prev_m01o03.doc 18 Ibid. 19 The Preventive Services Medi-Cal Provider Manual can be accessed at: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/prev_m01o03.doc 17 The Preventive Services Medi-Cal Provider Manual can be accessed at the following link:

  5. APL 18-014 Page 5 DHCS guidance, including APLs and Policy Letters. These requirements must be communicated by each MCP to all delegated entities and subcontractors. If you have any questions regarding this APL, please contact your Managed Care Operations Division Contract Manager. Sincerely, Original signed by Nathan Nau Nathan Nau, Chief Managed Care Quality and Monitoring Division Attachment

  6. APL 18-014 Page 6 Attachment: Definitions and Resources DEFINITIONS Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care means screening for alcohol misuse and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. Behavioral Counseling Interventions for Alcohol Misuse means activities delivered by primary care clinicians and related health care staff to assist patients in adopting, changing, or maintaining behaviors proven to affect health outcomes and health status including appropriate alcohol use. use. Alcohol Use Disorder means that a patient meets the criteria in the DSM for a substance use disorder resulting from alcohol use. substance use disorder resulting from alcohol use. means that a patient meets the criteria in the DSM for a means activities delivered by primary care clinicians and related health care staff to assist patients in adopting, changing, or maintaining behaviors proven to affect health outcomes and health status including appropriate alcohol ADDITIONAL RESOURCES For clinician support: NIAAA’s Clinician Guide “Helping Patients Who Drink Too Much” provides two methods for screening: a “single question” to use during a clinical interview and a written self-report instrument (AUDIT). http://www.niaaa.nih.gov/guide screening instruments for alcohol misuse are available from the SAMHSA-HRSA Center for Integrated Health Solutions (www.integration.samhsa.gov/clinical-practice/screening- tools). Note: Although instruments are available for download, it does not include instructions/training for their implementation. The AUDIT and Alcohol Use Disorder Identification Test—Consumption (AUDIT-C) A complete guide to clinical implementation of the AUDIT screening instrument is available from the World Health Organization. http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf Technical Manuals: Technical Assistance Publication 33: Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment http://store.samhsa.gov/shin/content//SMA13- 4741/TAP33.pdf Abuse Treatment http://www.ncbi.nlm.nih.gov/books/NBK64967/pdf/TOC.pdf Treatment Improvement Protocols 35: Enhancing Motivation for Change in Substance Quick Guide http://store.samhsa.gov/shin/content/SMA12-4097/SMA12-4097.pdf