The good news is that most states are now reimbursing for peer support services!
The bad news is that each state has different rules, controversies, and limitations of that coverage.
If you’re currently operating an addiction treatment center or sober living home in Massachusetts, Indiana, Missouri, Maryland, and/or Tennessee, read on for more information about Medicaid billing rules that every business owner needs to know.
What are Peer Support Services? Why are They Offered in Some Sober Living Settings?
Peer Support Services, sometimes called Recovery Specialist Services or by other names, is a hands-on form of coaching and community provided by people with lived experience in addiction and early recovery. Peer Support Services are linked to better outcomes for people with SUD, and are often vital in helping the patient transition from a full-time addiction treatment program (inpatient or outpatient) to a stable living arrangement on the “outside.”
Maryland: What are the Peer Support Specialist Rules for Sober Living Homes?
Maryland Medicaid covers peer support services with no copayment requirements, but it does have some limitations on the number of people who may access services. In Maryland, Certified Recovery Specialists only began receiving Medicaid reimbursements in spring 2023, so the program is relatively recent.
If you’re interested in learning more about behavioral health management in Maryland, see our post: Opening an Addiction Treatment Center in Maryland? Here’s How.
Tennessee: TennCare Reimburses Peer Support Services for Addiction Treatment Patients, With Some Fine Print
Tennessee covers peer support specialists under Tenncare, the name for Medicaid in the state. With Tenncare, peer support specialist services are not subject to copays. There are, however, some loose limitations on peer support services in Tennessee. For example, H0038 is not reimbursed more than 4 times per day. While that may sound like a lot of services, in actuality, H0038 only represents 15 minutes of service. Group sessions also have limitations designed to curb insurance fraud. H0038HQ (for group peer support sessions) can only be be billed 24 times per person per day. Tennessee uses the standard H0038 CPT code to represent 15 minutes of peer support work. H0038HQ represents group sessions.
To learn more about Tennessee, see our posts, Medicaid Billing Secrets for Addiction Treatment in Tennessee or Here’s What it Takes to Open an Addiction Treatment Center in Tennessee.
Massachusetts: MassHealth Operates Several Different kinds of Peer Support Services Programs for Addiction Treatment Patients, Sober Living Residents
In Massachusetts, peer support services are covered under the state Medicaid program with no copays or limitations. MassHealth operates free Peer Support Recovery Centers as well as Recovery Coaching and Recovery Support Navigation.
For more information on behavioral health, addiction treatment, and sober living business development in Massachusetts, see our blog posts, Opening an Addiction Treatment Center in Massachusetts Doesn’t Have to Be Difficult and Medicaid Billing for Massachusetts Addiction Treatment Programs.
Indiana: Different Medicaid Plans Handle Peer Support Services Coverage for Addiction Treatment Patients Differently
Indiana has made waves recently by transitioning its Certified Recovery Specialists to a different type of certification, called a Certified Peer Support Professionals certificate. Although Indiana does cover peer support services, patients who are signed up for Medicaid in Indiana under the Medicaid Rehabilitation Option (also known as MRO) may or may not receive reimbursement for peer support services depending on several factors, including their diagnosis and their “level-of-need criteria.” Patients in Indiana who are signed up for the Health Indiana Pan (or HIP) will be responsible for copays when it comes to peer support services, just as they are responsible for “cost sharing” with all non-preventive care services.
If you’re interested in reading more about addiction treatment and sober living business development in Indiana, see our post, Thinking of Opening an Addiction Treatment Center in Indiana? Here’s How.
Missouri: Allows for Reimbursement of Peer Support Services Delivered Via Telehealth
Missouri Medicaid not only covers in-person peer support services under its Medicaid program, it even reimburses for peer support sessions that are conducted virtually. Like most states, Missouri accepts the CPT code, H0038, for peer support services. Missouri recommends the modifier “GT” for virtual or telemedicine appointments.
For more one behavioral health business in Missouri, see our blogs Billing Medicaid for Addiction Treatment in Missouri is Easy. Here's How and Missouri is a Great State for Opening Your Next Addiction Treatment Center.
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