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Substance Abuse Treatment Benefits in Non-Medicaid SCHIP Plans

September 30, 2003

State	Inpatient	Outpatient	Cost Sharing
Alabama	72 hours/episode, not to exceed 20 days/calendar year	20 visits/calendar year	$5 copayment/confinement for inpatient services
Arizona	Covered when medically necessary	Covered when medically necessary	None
Arkansas	Not Covered	Covered only when the primary diagnosis is mental health	$10 copayment per visit
California*	Limits not specified; residential substance abuse treatment services are not covered	20 visits/benefit year	$5 copayment for outpatient services
Colorado	Medical detoxification only; residential substance abuse treatment services are not covered	20 visits/year	For outpatient services; 101% -150% of the FPL, $2 copayment; 151% -185% of the FPL, $5 copayment
Connecticut	Drug: 60 days/year; Alcohol: 45 days/year; 100% coverage for all conditions except mental retardation, learning and motor skills, communication and relational problems; for these, up to 35 days inpatient hospital benefits can be converted to outpatient services (1 inpatient hospital day is equivalent to 1 sub-acute day, 2 partial hospitalization days, 2 intensive outpatient visits or 3 outpatient visits)	60 visits/calendar year 100% coverage; same limitations as with inpatient care (in addition to allowable substitution of inpatient days)	None
Delaware2	Open-ended inpatient based on medical need	30 outpatient visits by MCO; additional visits provided as wraparound benefit by state division of child mental health	None
Florida3	30 days/year for residential care in addition to 7 inpatient days/year for medical detoxificaiton	40 visits/year	$5 copayment/visit for outpatient
Georgia	Limited to short-term acute care in general acute care hospitals up to 30 days/admission	Services are covered through community mental health centers, subject to limitations specified by the Department of Human Resources;  limitations not specified	None
Illinois	Limits not specified	Limits not specified	Kidcare Share, inpatient $2/admission; outpatient $2/visit Kidcare Premium, inpatient $5/admission; outpatient $5/visit
Indiana	FY 2001, FY 2003 covered, except when provided in an institution for the treatment of mental diseases with more than 16 beds	FY 2001, FY 2003 covered, except when provided in an institution for the treatment of mental diseases with more than 16 beds	None
Iowa	Iowa Health Solutions, $9,000/calendar year; $39,000 lifetime benefit for inpatient substance abuse and alcohol services; Wellmark, 30 days/year combined with mental health benefits; John Deere, 30 days/year	Iowa Health Solutions, $1,500/calendar year;  $39,000 lifetime benefit for outpatient substance abuse and alcohol services;  Wellmark, 30 visits/year combined with mental health benefits; John Deere, 30 visits/year	None
Kansas	Covered if medically necessary	Covered if medically necessary	None
Kentucky4*	Acute phase of medical detoxification or must meet criteria for Impact Plus program	Must meet criteria for Impact Plus program	None
Maine	Same as Medicaid	Same as Medicaid	None
Maryland	Limits not specified	Limits not specified	None
Massachusetts	Covered subject to medical necessity	Covered subject to medical necessity	None
Michigan	Covered if medically necessary as determined by substance abuse coordinating agency	Covered if medically necessary	None
Minnesota	Same as Medicaid	Same as Medicaid	None
Mississippi5	$6,000/benefit period; lifetime maximum of $16,000; additional $1,000/benefit period available for alcohol abuse care after lifetime maximum is reached	$6,000/benefit period; lifetime maximum of $16,000; additional $1,000/benefit period available for alcohol abuse care after lifetime maximum is reached	None
Montana6	$6,000/ benefit year of combined inpatient and outpatient services (excluding medical detoxification) until $12,000, then $2,000/year	$6,000/benefit year of combined inpatient and outpatient services (excluding medical detoxification) until $12,000, then $2,000/year	Over 100% of the FPL: $25 for enrollees
Nevada	Covered when medically necessary	Covered when medically necessary	None
New Hampshire	15 days/year of combined mental health and substance abuse services	20 visits/year of combined mental health and substance abuse services	$5 copayment for outpatient services
New Jersey	Plans B and C: covered in an acute care hospital; limits not specified Plan D: detoxification only	Plans B and C: covered if provided by a licensed physician; limits not specified Plan D: rehabilitation not covered	$5 copayment for outpatient services in Plan D
New York	30 days/year of combined mental health, inpatient detoxification and substance abuse services	60 days/year of combined mental health, alcoholism and substance abuse services	None
North Carolina	Requires prior approval from mental health case manager	26 days/year; over 26 days requires approval from mental health case manager	Over 150% of the FPL: $5 copayment per visit
North Dakota	60 days/year of combined mental health and substance abuse treatment; detoxification is covered up to 5 days/admission and is counted toward the 60-day limit	Partial hospitalization up to 120 days for mental health and substance abuse combined; prior authorization required; up to 46 days of inpatient care days can be traded for outpatient care at the rate of 2 outpatient days for 1 inpatient day	$50 deductible for first day inpatient
Oregon	Limited to treatment at a structured, 24-hour, supervised treatment and care facility; limits not specified	None	None
Pennsylvania	7 days of treatment/admission; lifetime limit of 4 admissions;  30 days/year limit for residential treatment, with 90- day lifetime limit	30 full-day sessions or equivalent partial visits/year; 120-day lifetime limit	None
South Dakota	45 days of treatment/year; may be extended if medically necessary	60 hours/year	None
Texas	30 days	30 days	None
Utah	30 days/plan year of  combined substance abuse and mental health benefits	30 visits/plan year of  combined substance abuse  and mental health benefits	Plan A: $3 copayment for services; Plan B: 10% coinsurance for first 10 days; 50% for last 20 days
Vermont7	Prior authorization required; limits not specified	Limits not specified	None
Virginia	Inpatient substance abuse services in a substance abuse treatment facility covered for up to 90 days per enrollee (maximum lifetime benefit); coverage in a free-standing psychiatric hospital or institute of mental disease not covered	Outpatient substance abuse covers outpatient hospital services that are preventive, diagnostic, therapeutic, rehabilitative or palliative in nature and are furnished to outpatients, are furnished by an institution that is licensed or formally approved as a hospital by an officially designated authority for state standard-setting; observation bed services are covered when reasonable and necessary to evaluate a medical condition to determine appropriate level of treatment or non-routine observation for underlying medical complications; outpatient services include emergency services, surgical services, diagnostic, and professional provider services; facility charges also covered	None
Washington7	Limited through the Division of Alcohol and Substance Abuse; limits not specified	Limits not specified	None
West Virginia	30 days/year	26 visits/year; more if medically necessary	None
Wyoming	None	None	None

Key

Cost Sharing = Copayments and other cost-sharing provisions required for services.

Inpatient = Includes residential treatment, rehabilitation, detoxification and psychiatric hospital.

MCOs = Managed care organizations

MH = Mental health.

Outpatient = Includes day treatment, office visits, therapy and psychiatric hospital.

SA = Substance abuse.

Notes

* Did not respond to survey.  Information current as of September 30, 2001.

1 This table describes the cost-sharing requirements in the state-designed programs in each state.  Entries for combination states contain information only on the state-designed component of the plan.  Medicaid expansion states and components are not included in this table because these states offer the same substance abuse benefits as the state's Medicaid program.

2 Delaware's inpatient and outpatient services are provided by the Department of Services to Children, Youth and Their Families once the SCHIP benefit ends.

3 In Florida, the Medicaid expansion, the MediKids program and the CMS Network program have the same benefits package as Medicaid.  Specific benefits for the Healthy Kids program are described in this chart.

4 “Impact Plus” is Kentucky’s program of community-based behavioral health services provided through an agreement between the state’s Medicaid Department and its Department for Public Health.  To be eligible for inpatient or outpatient Impact Plus-covered substance abuse services, recipients must have a current mental health diagnosis that is the primary reason for the treatment.  Substance abuse is treated as a dual diagnosis only.

5 For Mississippi’s program, a benefit period refers to the calendar year that a patient is enrolled, which begins on date of the enrollee’s application approval.

6 Montana’s program does not place a lifetime limit on inpatient and outpatient medical detoxification services.

7 Vermont and Washington provide the same services as their Medicaid programs.

Sources: Data compiled from State Children’s Health Insurance Program (SCHIP) plans, amendments, evaluations and annual reports submitted to  the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration), Sept. 30, 2001, and an additional survey of plans conducted by the National Conference of State Legislatures in October 2003.

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