Section 354.1311 - Benefits and Limitations(a) Subject to the specifications, conditions, limitations, and requirements established by the Health and Human Services Commission (HHSC) or its designee, substance use disorder treatment services are those services provided by a provider or facility licensed by the HHSC to provide substance use disorder treatment services.(b) Substance use disorder has the definition assigned in the most current American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.(c) Covered outpatient substance use disorder treatment services include: (2) outpatient group and individual counseling;(3) medication assisted treatment; and(4) outpatient withdrawal management.(d) Covered outpatient substance use disorder treatment services are limited as follows. (1) One assessment per episode of care, which must be performed at the start of each new episode of care.(2) A maximum of 135 sessions per person, per calendar year for outpatient group counseling services. Additional services beyond this limit may be considered with documentation of the supporting medical necessity for continued treatment services. Using their best judgement, a provider determines the length of time that constitutes a group session depending on the group members, the focus of the session, and other relevant variables.(3) A maximum of 26 hours per person, per calendar year of outpatient individual counseling services. Additional services beyond this limit may be considered with documentation of the supporting medical necessity for continued treatment services.(4) Medication assisted treatment duration is determined on an individual basis, based on the person's unique needs and treatment goals. Medication assisted treatment is the use of Food and Drug Administration-approved medications in combination with psychosocial treatment to treat substance use disorders, particularly alcohol and opioid use disorders, in compliance with 42 Code of Federal Regulations Part 8. Medication Assisted Treatment for Opioid Use Disorders, and applicable state rules.(5) Outpatient withdrawal management is limited to an appropriate duration of service based on medical necessity and level of intoxication for a maximum of 21 days per episode of care. There are no limits on the number of episodes of care.(e) Covered residential substance use disorder treatment services include: (1) residential withdrawal management; and(2) residential treatment.(f) Covered residential substance use disorder treatment services are billed on an outpatient claim form and are limited as follows. (1) Residential withdrawal management is limited to an appropriate duration of service based on medical necessity and level of intoxication for a maximum of 21 days per episode of care. There are no limits on the number of episodes of care.(2) Residential treatment is limited to an appropriate duration of service based on medical necessity and severity of substance use disorder for a maximum of 35 days per episode of care and no more than two episodes of care per rolling six month period, and four episodes per rolling 12 month period. Additional episodes within the six-month or 12-month time frame may be considered with documentation of medical necessity.1 Tex. Admin. Code § 354.1311
The provisions of this §354.1311 adopted to be effective July 1, 1990, 15 TexReg 3431; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; Amended to be effective August 27, 1996, 21 TexReg 7730; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; Amended to be effective January 1, 2011, 35 TexReg 10195; Amended by Texas Register, Volume 46, Number 32, August 6, 2021, TexReg 4845, eff. 8/10/2021