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Missouri Screening, Brief Intervention, Referral and Treatment: An Analysis of

National Funding Trends for SBI Services

Technical Report · March 2014

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Prepared by the

Missouri Institute of Mental Health

Rita E. Adkins, MPA

Joseph G. Grailer, MFA

Mandy R. Lay, BA

Barbara E. Keehn, BSN, RN

April, 2013 Revised March, 2014

MISSOURI SCREENING, BRIEF INTERVENTION, REFERRAL AND TREATMENT: AN ANALYSIS OF NATIONAL FUNDING TRENDS FOR SBI SERVICES

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Missouri Screening, Brief Intervention, Referral and Treatment: An Analysis of National Funding Trends for SBI Services

Highlights

• Due to the current fiscal situation, state revenues are down while expenditures have continued to rise. As a result, states have been charged with finding new ways to contain escalating healthcare costs. Since 50% of patients admitted to trauma centers are under the influence of alcohol or illicit substances and almost a third of all Emergency Department visits in 2009 were alcohol- and/or drug-related, reducing risky use and the resultant personal and societal costs should be a top priority.

• There is a growing body of evidence that Screening, Brief Intervention and Referral to Treatment (SBIRT) is effective in reducing drinking and substance use problems. Based on the outcomes from Missouri’s SBIRT (MOSBIRT) program, those individuals receiving brief interventions show reductions in risky use, along with improvements in employment, housing, legal involvement and physical and mental health.

• Numerous studies have indicated that there is a cost savings of from $3.81 to $5.60 for each dollar invested in screening for risky use.

• The most promising approach to sustaining SBIRT services in Missouri and its associated financial, personal, and societal benefits is for Mo HealthNet to fund the State Medicaid codes already on the state’s fee schedule, thereby allowing for reimbursement of SBI services.

• There are currently 22 states across the nation with Medicaid (H0049 and H0050) and/or CPT codes (99408 and 99409) open for SBI reimbursement. Missouri has the Medicaid codes on the fee schedule, but does not have a fee assigned for billing. The average rate for screening is about $25 per unit, with rates of around $40 per unit for the brief intervention.

• In addition, some states use the Health and Behavior Assessment/Intervention (HBAI) codes of 96150-96155 to bill for SBIRT services. There are 29 states using these codes.

• Based on experience with the Missouri SBIRT project, the potential costs to activate the SBI codes for MO HealthNet adults over 18 would be negligible, especially in light of the potential cost savings.

• Based on the hypothetical scenario presented, activating the codes would account for an additional $9 million in Medicaid expenditures, an increase of less than 0.11% of total Medicaid expenditures in 2010. Of this total, Missouri should only be responsible for 35%, or $3.11 million. The potential benefits from this investment could range from $38 to $56 million, or 1,089% to 1,600% in medical and societal costs.

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I. Introduction In 2008, the Missouri Division of Alcohol and Drug Abuse reported that the societal costs for substance abuse were estimated to be $7 billion annually, with approximately 10% of Missouri citizens needing treatment. The cost to society was reported to average $17,300 for each substance-addicted individual (Missouri Division of Alcohol and Drug Abuse, 2008). That same year, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded funding to Missouri to provide expanded capacity to identify individuals with risky substance use in medical settings and intervene appropriately through a Screening, Brief Intervention and Referral to Treatment (SBIRT) program. Since that time, MOSBIRT, the Missouri SBIRT program, has been successfully implemented at health care facilities in Springfield, Columbia, and St. Louis. In 2012, MOSBIRT was extended to all of Missouri's Health Care Homes (18 Federally Qualified Health Centers, 6 Hospital Affiliated Clinics and one Independent Rural Health Clinic) with over 60 new locations in all. Early identification of risky behaviors is crucial in improving health outcomes and reducing health care and societal expenditures.

There is a growing body of evidence about SBIRT’s effectiveness in reducing drinking and substance use problems. Those individuals receiving brief interventions show improvements in employment, housing, legal, physical and emotional health as well as exhibiting decreases in their substance use. These improvements in social and health domains are supported by the MOSBIRT outcomes (Adkins & Noel, 2011). However, once the federal funding for the MOSBIRT program ends on September 30, 2013, there are concerns for maintaining Screening and Brief Intervention (SBI) practices in Missouri. The most promising approach to sustaining SBIRT services, as well as the associated financial, personal, and societal benefits, is to fund the State Medicaid codes that allow for reimbursement of SBI services.

II. The Personal and Societal Costs of Substance Abuse Excessive alcohol use has been associated with a number of negative health and society outcomes. Drinking too much can lead to individual health issues, including cirrhosis of the liver, obesity, certain types of cancer, high blood pressure, stroke, and type 2 diabetes.

Figure 1: Physiological Consequences of Risky Drinking Source: (Cole, Bogenschutz, & Hungerford, 2011)

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The use of alcohol or illicit drugs can also lower inhibitions, leading to riskier behaviors and potential harm to the user, including homicide, sexual assault and suicide. Risky behaviors as a result of substance use are also a major factor affecting the incidence of traumatic injury. Almost 50% of patients admitted to trauma centers are under the influence of alcohol or illicit substances (Gentilello, Ebel, Wickizer, Salkever, & Rivara, 2005; Gentilello et at., 1999) while almost a third of all Emergency Department visits in 2009 were alcohol- and/or drug-related (National Institute on Drug Abuse, 2011). In addition to healthcare costs associated with illness, hospitalizations, and premature deaths, there are also increased costs due to trauma from vehicular, sporting and work-related accidents.

While substance misuse often results in negative health outcomes and resultant increased healthcare costs for the individual, there are also associated negative costs to society. In fact, in its 2011 study, the Office of National Drug Control Policy estimated that the societal cost of substance use was $193 billion (United States Department of Justice, 2011). Substance misuse also negatively impacts individuals, families and communities through decreases in worker productivity and increases in homelessness. The National Institute on Drug Abuse (2011) estimates that local, state and federal government assumes 45% of the cost of substance misuse while individuals and their families account for 44% of the costs. SBIRT has been shown to be effective in helping to alleviate these personal and societal costs.

III. SBIRT is an Effective Solution Community-based screening for health risk behaviors has been recognized as a cost-effective way to improve the quality of healthcare in the United States (Babor et al., 2007). As risky substance use may lead to injury or negative health consequences, research and clinical experience supports SBIRT as an effective intervention for persons at risk for the development of substance-related health and social problems. This fact has led the Centers for Medicare and Medicaid Services (CMS) to conclude that the evidence for screening and behavioral counseling to reduce alcohol misuse is reasonable and necessary for the prevention or early detection of illness or disability (Centers for Medicare and Medicaid Services, 2011). A number of studies have demonstrated that the return on investment for SBIRT services range from $3.81 to $5.60 for each dollar spent (Fleming et al., 2000; Estee, Wickizer, He, Shah, & Mancuso, 2010; Gentilello et al., 2005; Kraemer, 2007) lead the CMS to cover annual screenings and behavioral counseling services for those screening positively (Centers for Medicare and Medicaid Services, 2011). Furthermore, alcohol SBIRT services generate the fourth greatest return on medical investment according to the National Commission on Prevention Priorities, behind daily aspirin use, childhood immunizations and smoking cessation programs (Partnership for Prevention, 2010). A Robert Wood Johnson publication from July, 2012 reported that providing 90 percent of the U.S. population with three clinical preventive services—tobacco-cessation screening and assistance; discussing daily aspirin use; and alcohol screening with brief counseling—would each generate an estimated net savings of more than $1 billion, per year (based on 2006 data). In addition, these three services each would prevent the loss of more than 100,000 years of life per year (Crum, 2012).

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IV. What is SBIRT? Many people are unaware that their alcohol and/or other drug use is excessive, but are willing to make behavioral changes once they become aware of the risks to their health. Screening for substance use offers a cost-effective way to identify these persons at-risk for substance-related problems.

SBIRT is an evidence-based prevention program that systematically screens individuals to identify, reduce and prevent problematic use of alcohol and drugs (Madras et al., 2009). Typically conducted in medical settings, SBIRT has been shown to be effective in emergency departments (Desy & Perhats, 2008), community health centers (Madras et al., 2009) and physicians’ offices (Fleming et al., 2002), as well as through Employee Assistance Programs (Osilla, Zellmer, Larimer, Neighbors, & Marlatt, 2008; Osilla et al., 2010).

Studies have shown that patients who screen positive for unhealthy levels of alcohol and drug use respond more positively to brief interventions than those who drink heavily (Fleming et al., 2002), therefore SBIRT is designed to target those with risky use, focusing on those not yet at the level of a diagnosable problem. An analysis of over 40 treatment approaches for alcohol use treatments found that screening and brief intervention was the single most effective treatment method for those not actively seeking treatment (Miller & Wilbourne, 2002). For those with evidence of higher risk levels, there are protocols in place for referral for diagnosis and treatment.

Screening and brief intervention uses a structured set of questions designed to identify individuals at risk of substance misuse. Those identified as being at risk engage in a brief discussion with a service provider using an evidence-based brief intervention. These brief interventions (one 5- to 15-minute session or up to six 1-hour sessions, depending on the patient’s level of risk) are used to increase the patient’s awareness of his/her substance use and its consequences. The provider gives nonjudgmental feedback and suggestions in the form of useful information and personal recommendations for change. Using motivational interviewing techniques, the service provider then attempts to motivate the person to reduce their risky use.

Screening

Incorporated in the normal routine in medical and other community settings, screening provides identification of individuals with problems related to alcohol and/or substance use. Those answering positively to prescreen are administered the ASSIST, the full screening instrument.

Brief Education Brief Coaching Referral to Treatment Following a screening result indicating moderate risk, a brief 5-15 minute intervention is provided, involving motivational discussion focused on raising individuals’ awareness of their substance use and its consequences, and motivating them toward behavioral change.

Following a screening result of moderate to high risk, a brief coaching is provided. This also involves motivational discussion and client empowerment, but is more comprehensive. It includes assessment, education, problem solving, coping mechanisms & building a supportive social environment.

Following a screening result of possible dependence, a referral to treatment is provided. This is a proactive process that facilitates access to care for those individuals requiring more extensive treatment than SBIRT provides and ensures access to appropriate level of care for all screened.

Source: (Substance Abuse and Mental Health Services Administration, 2008)

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V. SBIRT in Missouri MOSBIRT, Missouri's SBIRT project, emphasizes prevention, early detection, and early intervention of substance use, and builds upon the work of previous grantees by incorporating the evidence-based practices into a tablet computer. Using this system (MOSBox), the health coaches at the original MOSBIRT medical sites conduct face-to-face screenings of all individuals entering the medical facilities for signs of the misuse of prescription and illicit drugs, alcohol, and tobacco. All individuals are initially screened for risky behaviors with one to four questions. A web-based system, eSBIRT, has also recently been developed, and is used by the Behavioral Health Consultants with Health Home patients at the Federally Qualified Health Centers. All Health Home patients are screened annually.

Those who score positively from the prescreen questions (generally less than 30%) are administered an additional screening, the World Health Organization’s Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Individuals who are identified as being at-risk (8-9%) in the second-level screen are provided a personalized feedback report describing their individual risks, comparing their substance use with peers, and providing specific behavioral change recommendations based on their readiness to change (see appendix 1 for an example of the personalized feedback report generated by MOSBox and eSBIRT electronic systems designed to aid in the SBI process). This report is used by MOSBIRT’s trained staff to guide service delivery.

Most of the at-risk individuals will exhibit moderate risk scores and are offered a 5-15 minute intervention using Motivational Interviewing (Carroll et al., 2006; Vasilaki, Hosier, & Cox, 2006). Those with higher levels of risk can get up to six sessions of behavioral coaching, or for those who already show symptoms of abuse or dependence, the staff will employ an evidence-based warm hand-off approach. This method links patients with potential substance abuse problems with specialists, using face-to-face or phone transfer to get them into a specialized substance abuse treatment program. As of December, 2012, over 80,000 patients have been screened across the state of Missouri, with nearly 7,000 individuals receiving interventional services. A detailed description of the MOSBIRT process can be found in Appendix II.

MOSBIRT Screening (N=80,887) Thru 12/31/2012

No Further Intervention

Low Risk (N=74,162, 91.7%)

Brief Education

Moderate Risk (N=4,355, 5.4%)

Brief Coaching

Moderate/High Risk (N=1,013, 1.2%)

Referred to Treatment

Severe Risk (N=1,357, 1.7%)

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VI. MOSBIRT Outcomes MOSBIRT is designed as a universal screening process, meaning that all patients over 18 are screened, provided their health is not compromised to the point of unfeasibility. A detailed description of the MOSBIRT process can be found in Appendix II.

National Outcome Measures (NOMS): Intake and 6-Month Follow-Up of Those Screening Positive

To measure the effectiveness of the MOSBIRT project, a random sample of patients receiving an intervention is administered a 6-month follow-up interview. The outcomes chart the progress of patients for whom both intake and 6-month follow-up data were available. As of December 31, 2012, the follow-up rate for 6-month patients was 75.3%. The progress on the NOMs for the patients receiving follow-up interviews (N=176) follows. Please note that the number of patients by NOM varies, as those receiving Brief Education are only asked the substance use questions.

Abstinence — The percentage of patients who reported that they did NOT use increased 511.1% from intake to 6 month follow-up (N=176). Number of days of substance use in the past 30 days at intake and 6-month follow-up show declines as follows:

Crime and Criminal Justice — The percentage of patients who reported NO arrests within the past 30 days increased by 11.3% from intake to 6-month follow-up (N=61).

Employment/Education — The percentage of patients reporting they were currently employed or attending school increased by 33.3% from intake to 6-month follow-up (N=43).

Health/Behavioral/Social Consequences — The percentage of patients reporting no alcohol or illegal drug related health, behavioral or social consequences increased by 53.1% from intake to follow-up (N=65).

Stability in Housing — The percentage of patients reporting that they had a permanent place to live in the community did not change from intake to follow-up (N=64)

The successes demonstrated to date with MOSBIRT services would further reduce societal costs by proactively addressing risky behaviors before they become full blown addictions. Early detection of risk behaviors that negatively impact health is not only important for the quality of life issues of Missouri’s citizens, it is also an important component in controlling for both personal and societal health care costs.

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VII. Study of Codes Nationwide a) Background

Medical procedures are billed using codes, either through the Healthcare Common Procedure Coding System (HCPCS) or the Common Procedure and Terminology (CPT) code sets. The HCPCS codes consist of Level 1 (CPT codes) and Level II (State codes). The American Medical Association (AMA) maintains the CPT coding system, while the Centers for Medicare and Medicaid Services (CMS) maintains the Level II State codes. These Level II codes are nationally standardized and are 5-digit, beginning with a letter followed by 4 digits. As of January, 2007, CMS designated HCPCS codes H0049 for substance use screening and H0050 for Brief interventions. The following year, the AMA approved several billing codes, including 99408 for 15 minutes of SBI and 99409 for 30 minutes of SBI Substance Abuse and Mental Health Services Administration, 2012). While a billing amount is suggested by the CMS, states have the ability to determine its own billing amounts. Though Missouri currently has the Medicaid codes on the fee schedule, a dollar amount allowing providers to bill for SBI services has not been assigned to the codes. Without these billing amounts, practitioners do not have the ability to get reimbursed for SBI services. Without reimbursement, there is no incentive to conduct these services, despite the known personal and societal benefits to doing so.

b) Purpose

In an effort to present MO HealthNet with a rationale for supporting SBIRT services, the authors examined the states that have funded the billing codes in an attempt to determine the fiscal and societal costs and benefits encountered.

c) Methods

A review of the literature revealed that while a number of states (including Missouri) have the SBIRT codes on its Medicaid fee schedule, they do not have a billing amount assigned to the codes (open for reimbursement) (Fussell, Rieckmann, & Quick, 2011; Anderson & Bhang, 2009). We contacted other states that had received SAMHSA funding for SBIRT services to gain a better understanding for how to approach getting the SBI and HBAI codes funded, and, based on their experience, we elected to employ qualitative methods. With input from Dr. Joe Parks, Director of the Missouri Institute of Mental Health, we developed a questionnaire designed to gather information from the states of their current status of the SBI and HBAI codes on their Medicaid fee schedules (see Appendix III).

In August, 2012, the Director of State Medicaid for Missouri, Dr. Ian McCaslin, sent a request to the National Association of Medicaid Directors to complete this questionnaire. We received information from 6 states and DC, indicating that 5 states had the codes listed on their state Medicaid fee schedule, with 1 state (CO) and DC reporting the SBI codes with a billing amount assigned, and 2 states (CA and OK) and DC having a billing amount assigned to their HBAI codes listed on their Medicaid fee schedule.

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To supplement the minimal responses received, we surveyed state Medicaid agencies by telephone and email, with little success. Fussell, Riechmann, and Quick (2011) found that web searches corroborated information reported by phone interviews, validating the Medicaid fee schedules posted on the web. We therefore opted to conduct web searches for all state Medicaid fee schedules. These web investigations were conducted from September, 2012 to December, 2012, with all states having the public information posted on their websites.

d) Results of Code Analysis

Screening, Brief Intervention (SBI) Codes:

Currently, reimbursement for SBIRT screening is not provided consistently. There are opportunities for expanding SBI as the Affordable Care Act (ACA) will require that all employer and Medicare plans cover prevention services that the US Prevention Services Task Force (USPSTF) has concluded are effective (Brolin et al., 2012). Alcohol screening and brief intervention are on the list of effective clinical prevention treatments.

The AMA and CMS guideline for healthcare providers who conduct Screening and Brief Intervention follows, with billing codes that can be used to ensure that SBI services are reimbursed follows:

Payer Code Description Fee Schedule

All Payers

CPT 99408

Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

$33.41

CPT 99409

Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

$65.51

Medicaid H0049 Alcohol and/or drug screening $24.00

H0050 Alcohol and/or drug service, brief intervention, per 15 minutes $48.00

Medicare G0396 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes

$29.42

G0397 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes

$57.69

Source: (Substance Abuse and Mental Health Administration, 2012)

An analysis of the states that have the SBI codes on the Medicaid fee schedule (H0049 and H0050) and the commercial CPT codes (99408 and 99409) indicate a range of fees allocated to the SBI codes, as follows:

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Survey of Medicaid Reimbursement Rates for SBI (n=51, All states and DC)

# of States w/Code on Fee Schedules # of States w/Code

SBI Code # of States w/Code Funded But Not Funded Not on Fee Schedule

H0049 (Screening) 7 (Range $14.49-$30.24, Avg $23.30) 13 31

H0050 (Brief Intervention) 8 (Range $19.50-$64.26, Avg $35.42) 12 31

99408 (15 min SBI) 17 (Range $14.07-$54.25, Avg $27.85) 14 20

99409 (30 Min SBI) 17 (Range $27.60-$105.90, Avg $55.10) 14 20

Missouri has all SBI codes on the Medicaid fee schedule, but does not have a fee assigned to allow for billing of services.

Some State Medicaid Agencies (SMAs) bundle all services into one rate, a prospective payment system (PPS). One state (DE) listed minimal rates of less than $2, so were excluded from the average rate list for the 99408 and 99409 codes. The state of Tennessee contracts with outside providers that maintain their own fee schedule, so they were counted as having the codes funded, but the prices were not included in the averages. In some states, there are different rates based on facility/non-facility charges, with minimal differences of 30-60 cents between the 2 charges. In these cases, an average of the 2 charges was used in the calculations of the mean charges.

Billing for SBIRT

There are also state differences in the level of provider that is eligible to bill for SBI. However, only a few states actually list the provider able to bill for the SBI codes on its Medicaid fee schedule. For instance, in North Carolina the billing rates for the SBI code of 99408 is listed as $30.73 for a non-facility Nurse Midwife and $29.46 for a Facility Physician, Physician Assistant, & Nurse Practitioner, while New Jersey lists a rate of $15.21 for a “specialist” and $12.93 for a “non-specialist”. Alaska stipulates a $58.65 for a physician and $49.85 for a nurse practitioner.

While there is no provider stipulated for the remainder of the states with a billing amount listed, The American College of Surgeons Committee on Trauma (COT) states that

“Brief intervention does not have to be administered by a state-certified substance abuse counselor or by other clinicians with advanced training in substance abuse treatment. After relatively little training, brief intervention can be performed by anyone capable of showing respect and concern for injured patients. In addition to mental health or substance abuse counselors, the COT believes that there are multiple people in each trauma center who can meet these criteria, including surgeons and other MDs, psychologists, physician assistants, nurses, social workers and spiritual care workers.” (Substance Abuse and Mental Health Services Administration, 2007)

Babor, et al. (2006) found that using paraprofessional staff to deliver brief interventions has been shown to be as effective as those delivered by licensed practitioners. The average incremental costs of the intervention in their study was $4.16 per patient using licensed practitioners compared to $2.82 using mid-level specialists.

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While the New York State Department of Health reimburses for SBIRT services provided by physicians, nurse practitioners, nurse midwives and psychologists with 4 hours of training in SBIRT skills, paraprofessionals with minimum hours of SBIRT training can also bill under the provider number of a licensed provider, such as a hospital or clinic. The following table lists the provider types eligible to perform SBIRT and bill under a licensed provider/facility:

Provider Type Required Training/Certification

Physician Assistants 4 hours Registered Nurses 4 hours, unless qualified

as a CARN Licensed Practical Nurses 4 hours Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) 4 hours Licensed Mental Health Counselors 4 hours Licensed Marriage and Family Therapist 4 hours Certified School Counselor 4 hours Certified Rehabilitation Counselor 4 hours OASAS-credentialed professionals including Credentialed Alcoholism and Substance Abuse Counselors (CASACs), Credentialed Prevention Professionals (CPPs) and Credentialed Problem Gambling Counselors

4 hours

Health Educators and unlicensed individuals (may only provide SBIRT services under the supervision of a licensed health care professional, following consistent protocols)

12 hours

Source: (New York State Department of Health, 2011)

The MOSBIRT project has produced a document that details the training requirements for each step of the SBIRT process. Training for a licensed or unlicensed staff to administer the prescreen requires 2 hours of training, 6 hours of training for full screening and other assessments, and 10 hours to screen and provide a brief intervention. The document detailing the Clinical Definitions of MOSBIRT services can be found in Appendix IV.

Health and Behavior Assessment/Intervention (HBAI) Codes:

Some states use Health and Behavior Assessment/Interventions codes to identify psychological and behavioral factors important to the prevention, treatment and management of physical health problems. These codes are used for services performed by nonphysician health care professionals to assess a patient’s behavior and emotional state that are important to the treatment and management of physical health problems. There are five reimbursement codes for health and behavior assessment and intervention that are sometimes used for SBI services. The health and behavior assessment and intervention codes follow (American Medical Association, 2006):

96151 – An assessment of the patient to evaluate the patient’s condition and determine the need for further treatment. A re-assessment may be performed by a clinician other than the one who conducted the patient’s initial assessment.

96152 – The intervention service provided to an individual to modify the psychological, behavioral, cognitive, and social factors affecting the patient’s physical health and well-being. Examples include increasing the patient’s awareness about his or her disease and

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using cognitive and behavioral approaches to initiate physician prescribed diet and exercise regimens.

96153 – The intervention service provided to a group. An example is a smoking cessation program that includes educational information, cognitive-behavioral treatment and social support. Group sessions typically last for 90 minutes and involve 8 to 10 patients.

96154 – The intervention service provided to a family with the patient present. For example, a psychologist could use relaxation techniques with both a diabetic child and his or her parents to reduce the child’s fear of receiving injections and the parents’ tension when administering the injections.

96155 – The intervention service provided to a family without the patient present. An example would be working with parents and siblings to shape the diabetic child’s behavior, such as praising successful diabetes management behaviors and ignoring disruptive tactics.

An analysis of the states that have the HBAI codes on the Medicaid fee schedule (96151-96155) indicate that states have activated these codes more often than the SBI codes. The range of fees allocated to the HBAI codes follow:

Survey of Medicaid Reimbursement Rates for HBAI (n=51, All states and DC)

# of States w/Code on Fee

Schedules # of States w/Code

HBAI Code # of States w/Code Funded But Not Funded Not on Fee Schedule

96151 (Screening) 29 (Range $14.86-$31.01, Avg $18.89) 11 11

96152 (Brief Intervention) 27 (Range $5.30-$32.24, Avg $17.84) 11 13

96153 (Group Intervention) 26 (Range $3.22-$18.96, Avg $5.31) 11 14

96154 (Family/Pt Intervention 27 (Range $13.86-$28.96, Avg $17.85) 11 13

96155 (Family W/O Pt Intervention) 15 (Range $13.81-$30.15, Avg $18.67) 13 23

Missouri has all SBI codes on the Medicaid fee schedule, but does not have a fee assigned to allow for billing of services.

See Appendix VI for HBAI codes and fees by state.

These codes can be used to address a number of physical health issues, including patient adherence to medical treatment and health related risky behavior prevention, and do not require a mental health diagnosis. However, there are same day billing restrictions by behavioral health practitioners for the HBAI codes and the psychiatric codes of CPT 90801-90899. While the billing restrictions were designed to reduce inappropriate billing, the rule may impede the providers’ ability to bill for the full range of services provided (Brolin et al., 2012).

There are also restrictions on the providers that may bill for the HBAI codes. Non-physicians such as clinical psychologists and other mental health specialist may bill Medicaid under the HBAI codes, but in some cases licensed social workers may not. In some states there are different billing amounts based on the provider, but in all cases, there are minimal differences. For instance, in South Carolina, there are different reimbursement rates based on the provider as follows:

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• Out Pt Rehab, Community Health, Public Health Clinic, HIV Clinic, Early Intervention: $15.76

• Podiatrist: $17.08 • Nurse Midwife, Physician’s Assistant: $19.26 • Certified Nurse Practitioner, Nurse Anesthetist: $19.27 • Osteopath, Qualified Mental Health Provider, Psychologist, Radiology, School Based

Services: $22.15. (The average of these billing amounts was used for the mean in the calculations above.)

VIII. Conclusions The Spring, 2012 update of The Fiscal Survey of States from the National Association of Budget Officers (NASBO) and the National Governors Association (NGA) indicates that while state revenues are returning to their pre-recession levels, budgetary expenses have remained at the higher levels. Medicaid expenditures account for a large proportion of the increases to Missouri’s annual budget. In fact, Medicare spending increased by 20% in FY 2012, following a 23% increase in FY 2011, while federal Medicaid spending decreased 8%, with the expiration of the higher matching rates set by the American Recovery and Reinvestment Act (National Governors Association and the National Association of the State Budget Officers, 2012). As a result, states have been charged with finding new ways to contain escalating healthcare costs.

The emphasis of SBIRT services is on prevention, early detection and early intervention, which reduces both health risks and the resultant costs of care. In 2000, alcohol consumption was the 3rd leading cause of preventable death in the United States, with 85,000 actual deaths (Mokdad, Marks, Stroup, Gerberding, 2004). With escalating health care costs, sustaining SBIRT services in Missouri will provide for the “prevention or early detection of illness or disability” (Centers for Medicare and Medicaid Services, 2011).

Potential Financial Impact on Missouri-Costs

SBIRT is based on a public health model that requires universal screening; therefore all Missouri citizens using the clinics, Emergency Departments, and FQHC’s where SBIRT is employed are screened.

In an effort to determine the potential financial impact of funding Medicaid codes for screening and brief intervention for all Missouri citizens covered under Mo HealthNet, the following scenario is presented:

In fiscal year 2011, Missouri had 348,700 nonelderly adults covered under Medicaid (Henry J. Kaiser Family Foundation, Missouri: Nonelderly with Medicaid). Maciosek, Catfield, Flattemesch, Edwards and Solberg (2010) suggested that a 90% utilization rate be used for cost calculations, as not everyone will obtain preventative services, even if they are promoted and widely available. Assuming 90% of these adults was provided SBIRT services at the full Medicaid recommended rate of $24, the cost of screening would be approximately $7.5 million.

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Based on the intervention rate experienced with MOSBIRT, 8-9% of Medicaid patients screened would exhibit at-risk substance use, qualifying for a brief intervention. Assuming 9% of those screened required brief interventions, and that these services were billed at the Medicaid-recommended rate of $48, the potential cost would account for an additional $1.4 million. With this scenario, the total cost for all SBIRT services in Mo HealthNet recipients would account for an additional $9 million.

Even in this exaggerated scenario, the financial impact to Missouri would be negligible, especially when the personal and societal benefits received are taken into account. The total Medicaid expenditures for Missouri in 2010 were over $8 billion (Henry J. Kaiser Family Foundation, Missouri: Medicaid Spending). The addition of SBIRT services would increase expenditures by less than 0.11% at full cost. Assuming a Federal share of 65%, Missouri would be responsible for only $3.11 million, an increase of less than 0.04%.

Potential Financial Impact on Missouri-Benefits

When determining the potential financial impact on Missouri, it is important to remember that previous studies have shown a return on investment for SBIRT services, with some estimates ranging from $3.81 to $5.60 for every dollar spent (Fleming et al., 2000; Estee et al., 2010; Gentilello et al., 2005; Kraemer, 2007). Based on the results of these studies and the above scenario, Missouri could have realized a return on its roughly $3.11 million investment of about $38 to $56 million in medical and societal costs, or 1,089% to 1,600%.

A 2010 study analyzing the estimated cost of adopting 20 evidence-based clinical prevention services found that a medical cost of $9 for alcohol screening and brief educational services yielded a savings of $20 (Maciosek, et al., 2010). A November, 2008 Missouri Division of Alcohol and Drug Abuse report indicates that the cost to treat a substance addicted individual was $1,346. The potential savings of preventing the 28,245 individuals at risk for substance misuse from developing a diagnosable problem requiring treatment services is $38 million, not taking into account the societal cost savings.

Research suggests that existing medical staff can be trained to screen patients for risky use and intervene effectively with little training (Bernstein et al., 2007) at low cost (Babor et al., 2006). Using the training guidelines developed by the MOSBIRT project for SBIRT services, training existing health care professionals can be accomplished at minimal cost while reducing future substance use and its associated fiscal and societal costs. Therefore it is recommended that policy makers support increased use of evidence-based preventative services with the goal of improving the health of all citizens using scarce health dollars. With this in mind, the most promising approach to SBIRT sustainability is to fund the State Medicaid codes that allow for reimbursement of SBI services.

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“The way we treat alcohol problems is to wait until it’s malignant substance use and someone has addiction. It’s as if we didn’t treat high blood pressure until someone had a stroke or a heart attack. Broadening the base (for alcohol problems) means that we don’t just look at the top of the pyramid and wait until someone comes to the hospital with acedias or jaundice, we focus lower on the pyramid when people are just drinking too much. Just like high blood pressure, it is simpler, easier to treat and more responsive when you go after it early. It is harder to treat, more expensive and chronic if you wait until it’s ingrained and present for many years...

I certainly have to tell medical audiences that in terms of evidence of efficacy in brief interventions, there is almost nothing in medicine that has as much evidence behind it.”

—LARRY GENTILELLO, MD, PROFESSOR OF SURGERY AT THE UNIVERSITY OF TEXAS, SOUTHWESTERN MEDICAL SCHOOL

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References Adkins, R.E., Noel. J.G. (July, 2011) The Missouri Screening, Brief Intervention and Referral to

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American Medical Association. (2006). CPT 2006: Current Procedural Terminology Professional Edition. Chicago: AMA.

Anderson, T., & Bhang, E. (2009). Medicaid Reimbursement for Screening and Brief Intervention: Massachusetts’ Preparations. Boston, MA, UMass Medical School:Commonwealth Medicine.

Babor, T. F., Higgins-Biddle, J. C., Dauser, D., Burleson, J. A., Zarkin, G. A., & Bray, J. (2006). Brief interventions for at-risk drinking: Patient outcomes and cost-effectiveness in managed care organizations. Alcohol & Alcoholism, 41(6), 624-631.

Babor, T. F., McRee, B. G., Kassebaum, P. A., Grimaldi, P. L., Ahmed, K., & Bray, J. (2007). Screening, brief intervention, and referral to treatment (SBIRT): Toward a public health approach to the management of substance abuse. Substance Abuse, 28(3), 7-30. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2007-19015-003&site=ehost-live;babor@nso.uchc.edu

Bernstein, E., Bernstein, J., Feldman, J., Fernandez, W., Hagan, M., Mitchell, P. et al. (2007). An evidence-based alcohol screening, brief intervention and referral to treatment (SBIRT) curriculum for emergency department (ED) providers improves skills and utilization. Substance Abuse, 28(4), 79-92. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2007-19016-001&site=ehost-live;ebernste@bu.edu

Brolin, M., Quinn, A., Sirkin, J. T., Horgan, C. M., Parks, J., Easterday, J. et al. (2012). Financing of behavioral health services within federally qualified health centers. Truven Health Analytics.

Carroll, K. M., Ball, S. A., Nich, C., Martino, S., Frankforter, T. L., Farentinos, C. et al. (2006). Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study. Drug & Alcohol Dependence, 81(3), 301-312.

Centers for Medicare and Medicaid Services . (2011). Decision memo for screening and behavioral counseling interventions in primary care to reduce alcohol misuse. Retrieved from: www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=249

Cole, S., Bogenschutz, M., & Hungerford, D. (2011). Motivational Interviewing and Psychiatry: Use in addiction treatment, risky drinking and routine practice. FOCUS, 9, 42-54.

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Crum, R. (2012). Highest-value preventive services save billions if applied to 90 Percent of U.S. population: Identifying the highest-value clinical and community preventive services (Program Results Report). Retrieved from: http://www.rwjf.org/content/dam/farm/reports/program_results_reports/2012/rwjf73150

Desy, P. M., & Perhats, C. (2008). Alcohol screening, brief intervention, and referral in the emergency department: An implementation study. Journal of Emergency Nursing, 34(1), 11-19. Retrieved from http://pt.wkhealth.com/pt/re/jenu/abstract.00005465-200802000-00007.htm

Estee, S., Wickizer, T., He, L., Shah, M. F., & Mancuso, D. (2010). Evaluation of the Washington State Screening, Brief Intervention, and Referral to Treatment Project: Cost Outcomes for Medicaid Patients Screened in Hospital Emergency Departments. Medical Care, 48(1), 18-24. Retrieved from http://journals.lww.com/lww-medicalcare/Fulltext/2010/01000/Evaluation_of_the_Washington_State_Screening,.4.aspx

Fleming, M. F., Mundt, M. P., French, M. T., Manwell, L. B., Stauffacher, E. A., & Barry, K. L. (2002). Brief physician advice for problem drinkers: Long-term efficacy and benefit-cost analysis. Alcoholism: Clinical & Experimental Research, 26(1), 36-43.

Fleming, M. F., Mundt, M. P., French, M. T., Manwell, L. B., Stauffacher, E. A., & Barry, K. L. (2000). Benefit-Cost Analysis of Brief Physician Advice With Problem Drinkers in Primary Care Settings. Medical Care, 38(1). Retrieved from http://journals.lww.com/lww-medicalcare/Fulltext/2000/01000/Benefit_Cost_Analysis_of_Brief_Physician_Advice.3.aspx

Fussell, H. E., Rieckmann, T. R., & Quick, M. B. (2011). Medicaid Reimbursement for Screening and Brief Intervention for Substance Misuse. Psychiatric Services, 62(3). Retrieved from http://ps.psychiatryonline.org/article.aspx?articleID=102247

Gentilello, L. M., Ebel, B. E., Wickizer, T. M., Salkever, D. S., & Rivara, F. P. (2005). Alcohol interventions for trauma patients treated in emergency departments and hospitals - A cost benefit analysis. Annals of Surgery, 241(4), 541-550.

Gentilello, L. M., Rivara, F. P., Donovan, D. M., Jurkovich, G. J., Daranciang, E., Dunn, C. W. et al. (1999). Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Annals of Surgery, 230(4), 473-480.

Henry J. Kaiser Family Foundation. (n.d.). Missouri: Medicaid spending. Retrieved March 25, 2013, from State Health Facts: http://www.statehealthfacts.org/profileind.jsp?cat=4&sub=47&rgn=27

Henry J. Kaiser Family Foundation. (n.d.b). Missouri: Nonelderly with Medicaid. Retrieved March 25, 2013, from State Health Facts: http://www.statehealthfacts.org/profileind.jsp?cat=3&sub=42&rgn=27

Kraemer, K. L. (2007). The Cost-Effectiveness and Cost-Benefit of Screening and Brief Intervention for Unhealthy Alcohol Use in Medical Settings. Substance Abuse, 28(3), 67-77. Retrieved from http://www.informaworld.com/10.1300/J465v28n03_07

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Maciosek, M. V., Catfield, A. B., Flattemesch, T. J., Edwards, N. M., & Solberg, L. I. (2010). Greater use of preventive services in U.S. health care could save lives at little or no cost. Health Affairs, 29(9), 1656-1660. Retrieved from http://doh.state.fl.us/AlternateSites/KidCare/council/12-3-10/12-3-10_KCC-Agenda.pdf

Madras, B. K., Compton, W. M., Avula, D., Stegbauer, T., Stein, J. B., & Clark, H. W. (2009). Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Dependence, 99(1-3), 280-295. Retrieved from http://www.sciencedirect.com/science/article/B6T63-4TP7H5K-1/2/20544d43778daf01cf12d40c5e38b855

Miller, W. R., & Wilbourne, P. L. (2002). Mesa Grande: a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction, 97(3), 265-277.

Missouri Division of Alcohol and Drug Abuse. (2008). The Burden of Substance Abuse on the State of Missouri. Missouri Department of Mental Health.

Mokdad AH, M. J. S. D. G. J. (2004). Actual causes of death in the united states, 2000. Jama: Journal of the American Medical Association, 291(10), 1238-1245. doi:doi: 10.1001/jama.291.10.1238. Retrieved from http://dx.doi.org/10.1001/jama.291.10.1238

National Governors Association and the National Association of the State Budget Officers. (2012). The Fiscal Survey of States 2012 (Spring, 2012). Washington, DC: National Association of State Budget Officers. Retrieved from: http://www.nasbo.org/sites/default/files/Spring%202012%20Fiscal%20Survey%20of%20States.pdf

National Institute on Drug Abuse. (2011). Drug-Related Hospital Emergency Room Visits. Retrieved from: http://www.drugabuse.gov/publications/drugfacts/drug-related-hospital-emergency-room-visits

New York State Department of Health. (2011). Medicaid Expands Coverage for Screening, Brief Intervention, and Referral to Treatment (SBIRT). Medicaid Update, 27(8), 1-28. Retrieved from http://www.naswnys.org/JUNE2011.pdf

Osilla, K. C., dela, C. E., Miles, J. N., Zellmer, S., Watkins, K., Larimer, M. E. et al. (2010). Exploring productivity outcomes from a brief intervention for at-risk drinking in an employee assistance program. Addictive Behaviors, 35(3), 194-200.

Osilla, K. C., Zellmer, S. P., Larimer, M. E., Neighbors, C., & Marlatt, G. A. (2008). A brief intervention for at-risk drinking in an employee assistance program. Journal of Studies on Alcohol & Drugs, 69(1), 14-20.

Partnership for Prevention. (n.d.). Rankings of Preventative Services for the US Population. Retrieved March 27, 2013, from Partnership for Prevention website: http://www.prevent.org/National-Commission-on-Prevention-Priorities/Rankings -of-Preventative-Services-for-the-US-population.aspx

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Substance Abuse and Mental Health Services Administration. (2007). Alcohol Screening and Brief Intervention (SBI) for Trauma Patients. American College of Surgeons Committee on Trauma. Retrieved from: http://www.samhsa.gov/csatdisasterrecovery/featuredReports/01-alcohol%20SBI%20for%20Trauma%20Patients.pdf

Substance Abuse and Mental Health Services Administration. (2008). About. American College of Surgeons Committee on Trauma. Retrieved from: http://sbirt.samhsa.gov/about.htm

Substance Abuse and Mental Health Services Administration. (2012). Coding for SBI Reimbursement. Office of National Drug Control Policy. Retrieved from: http://www.samhsa.gov/prevention/sbirt/coding.aspx

United States Department of Justice. (2011). The Economic Impact of Illicit Drug Use on American Society. Washington, DC. Retrieved from: http://www.justice.gov/archive/ndic/pubs44/44731/44731p.pdf

Vasilaki, E. I., Hosier, S. G., & Cox, W. M. (2006). The efficacy of motivational interviewing as a brief intervention for excessive drinking: A meta-analytic review. Alcohol and Alcoholism, 41(3), 328-335. Retrieved from http://alcalc.oxfordjournals.org/content/41/3/328.abstract

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Appendix I: Example of Personalized Feedback Report

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Appendix II: MOSBIRT Procedures and WHO-ASSIST Screen

MOSBIRT Procedures

MOSBIRT is based on a public health model with universal screening. Everyone is screened, not just the patients that appear to have or report having a substance use problem. There is a short Prescreen of 5 questions, with a longer screening for those scoring a positive Prescreen. The steps in MOSBIRT follow:

1. Pre-Screen: There are 5 questions asked of each patient seen. A “yes” answer to one of

questions 2-5 requires a further screening. Approximately 33% of patients will score

positive for further screening. For those scoring

negatively, the patient is congratulated on

having no substance abuse risk factors, provided

with any other information about substance use

and misuse that they wish, and sent on their way.

2. Full Screen: For the patients with a positive pre-

screen, an evidence-based screening tool is

administered. The World Health Organization’s

Alcohol, Smoking, Substance Involvement Screening

Test (ASSIST) is used for the MOSBIRT project. The

ASSIST was developed in 1997 for use in primary

health care settings where risky behaviors often

go undetected, as most health care professionals

are trained to recognize dependence, but not

risky behaviors that may lead to an addiction.

About 40% of those with a positive prescreen score positively on the ASSIST, qualifying for one

of three interventions, depending on the risk level indicated on the completed full screen.

Interventions: Health Coaches or Behavioral Health Consultants are trained in Motivational

Interviewing techniques and Motivational Enhancement Therapy and conduct a brief

MOSBIRT Prescreen Questions 1. Have you used any tobacco products in the

past three months? Yes No 2. Females (and Males over 65): When was

the last time you had 4 standard drinks in a day or night? Was that within the last 3 months? Yes No Males: When was the last time you had 5 standard drinks in a day or night? Was that within the last 3 months? Yes No

3. In the last twelve months, did you ever find yourself drinking more than you meant to? Yes No

4. In the last twelve months, did you ever think that maybe you should cut down on your drinking? Yes No

5. In the last twelve months, did you smoke pot, use another street drug, or use a prescription painkiller, stimulant, or sedative for a non-medical reason? Yes No

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motivational conversation intended to initiate a health-related behavior change. About 105 of

patients screened will qualify for one of the SBIRT interventions, as follows:

• A Brief Education is conducted with those scoring at moderate risk for

substance use incorporating the Feedback, Responsibility, Advice, Menu,

Empathy and Self-Efficacy (FRAMES) model. A tailored feedback form using

information from the patient’s self-report, compares their use to relative

normative data. This 5-15 minute conversation is for those that score with a

moderate risk. About 5-6% of total patients seen will qualify for a brief

intervention.

• A Brief Coaching session starts immediately following a positive ASSIST for

those at high risk for substance use. An additional 5 sessions of motivational

enhancement therapy and cognitive behavioral therapy (MET/CBT) are held

either face-to-face (at facility) or by phone. Those qualifying for this

intervention account for about 1-2% of total patients seen.

• A Referral to Treatment is made for those individuals with an ASSIST score

above 27 for alcohol or drugs. They receive a referral to a specialized service

provider for further evaluation. They are introduced to the treatment liaison

who will work to get them connected with an appropriate substance abuse

treatment provider. This is expected to be a warm handoff with the staff

member being responsible for getting the patient into the hands of the

provider. This handoff includes providing transportation or other supports

needed to facilitate treatment entry. About 1.5-2% of total patients seen will

be referred for further evaluation.

The ASSIST screen for those with a positive score on the Prescreen follows:

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Appendix III: Survey of Medicaid Reimbursement Rates

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Appendix IV: Clinical Definitions of MOSBIRT Services

Overview MOSBIRT is a prevention and early intervention initiative to do population based screening on adults 18 and older. Screenings are conducted in general medical settings for risky alcohol and drug use and provide evidence based brief education, brief coaching and referrals to specialty treatment providers.

PreScreen A PreScreen is a rapid way to identify individuals who may be at risk for an alcohol or drug use condition and would benefit from further screening. The MOSBIRT prescreening questionnaire contains five questions about the use of tobacco, alcohol and drugs. A prescreen should be considered an integral part of routine preventative care. A provider or any other staff member can administer the prescreen in writing, verbally, or through technological means. Training Requirements: Licensed or unlicensed staff may administer the PreScreen with a minimal amount of training. Training can be accomplished face-to-face or via the Internet. The specific requirements are:

• Two (2) hours of training that includes the science behind MOSBIRT and interviewing skills.

Screening and Assessments Patients with a positive response to a prescreen require further screening to categorize their substance use. MOSBIRT utilizes the World Health Organization’s Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) to determine low, medium or high risk for each substance, the Mental Health Questionnaire, Readiness to Change Alcohol and/or Drug and the Personalized Feedback Report to provide tailored comments based on their reported use. A provider or any other staff member can administer the screening and other assessments in writing, verbally, or through technological means. Training Requirements: Completion of the training requirements for the prescreen along with:

• Four (4) hours of training on the proper techniques for asking questions, the purpose and administration of the individual assessments.

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Brief Education A Brief Education is provided to those patients whose substance use scores are in the moderate risk range. These patients exhibit moderate risky or problem alcohol and/or drug use but are not dependent. One session of motivational education is provided to induce a change in their substance use behavior. This is typically done immediately following the Screening and Assessments and utilizes the FRAMES model. A provider or any other staff member can provide this intervention face-to-face or through other technological means. Training Requirements: Completion of the training requirements for the prescreen and screening and assessments along with:

• Four (4) hours of training on Basic Motivational Interviewing and the FRAMES model. Brief Coaching Brief Coaching is a six session manualized service with the patient using techniques from Motivational Enhancement and Cognitive Behavioral Therapy. These patients exhibit higher risk or problem alcohol and/or drug use but may not yet be dependent. The primary goal of these sessions is to enhance the patient’s motivation to change their substance use and to develop skills needed to achieve abstinence or reduce the negative impacts of substance use on their lives. Staff licensed to provide substance abuse and/or mental health services in Missouri and who have been trained in the manualized services can provide this service face-to-face or through technological means. Training Requirements: Completion of Brief Education training along with:

• Eight (8) hours of training on Advanced Motivational Interviewing and successful completion of the manualized six sessions brief coaching.

Referral Patients whose risk score indicates high risk will be referred to an alcohol and drug specialty provider for further evaluation and if warranted, treatment. Using a warm hand-off method, the patient will be linked to appropriate services and provided support and assistance throughout the process. Any trained staff can perform this function. Training Requirements

• Two (2) hours of training on the science behind MOSBIRT and providing a warm hand-off.

State 99408 99409 H0049 H0050 SourceMedicare FY 2013 Not on fee schedule Not on fee schedule $36.84 (G0396) $71.02 (G0398) Fee scheduleAlabama Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleAlaska $54.25 $105.90 Not on fee schedule Not on fee schedule Fee scheduleArizona Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleArkansas Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule SurveyCalifornia Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule SurveyColorado $29.46 $64.26 $29.46 $64.26 SurveyConnecticut Manually Priced Manually Priced Not on fee schedule Not on fee schedule Fee scheduleDC $30.24 $58.84 $30.24 Listed/ Not open SurveyDelaware $0.96 $1.91 Listed/ Not open Listed/ Not open Fee scheduleFlorida Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleGeorgia Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule SurveyHawaii FY 2013 Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open InterviewIdaho $30.01 $58.62 Not on fee schedule Not on fee schedule Fee scheduleIllinois Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule SurveyIndiana $23.29 $45.70 Listed/ Not open Listed/ Not open Fee scheduleIowa Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleKansas FY 2013 $24.00 $48.00 $24.00 $24.00 Survey, emailKentucky Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule SurveyLouisiana Not on fee schedule Not on fee schedule $14.49 $33.81 Fee scheduleMaine Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleMaryland FY 2011 Not on fee schedule Not on fee schedule $21.41 $42.52 Fee scheduleMassachusetts Listed/ Not open Listed/ Not open Not on fee schedule Not on fee schedule Fee scheduleMichigan Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleMinnesota $25.88 $50.95 Listed/ Not open Listed/ Not open Fee scheduleMississippi Listed/ Not open Listed/ Not open Not on fee schedule Not on fee schedule Fee scheduleMissouri Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleMontana $32.90 $64.67 Listed/ Not open Listed/ Not open Fee scheduleNebraska Listed/ Not open Listed/ Not open Not on fee schedule Not on fee schedule Fee scheduleNevada Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleNew Hampshire Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleNew Jersey $14.07 $27.60 Not on fee schedule Not on fee schedule Fee scheduleNew Mexico Listed/ Not open Listed/ Not open Not on fee schedule Not on fee schedule Fee scheduleNew York Not on fee schedule Not on fee schedule $19.50 $19.50 Fee scheduleNorth Carolina $29.95 $59.48 Not on fee schedule Not on fee schedule Fee scheduleNorth Dakota Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleOhio Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleOklahoma Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule SurveyOregon $24.21 $47.39 Not on fee schedule Not on fee schedule Fee schedulePennsylvania Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleRhode Island Not on fee schedule Not on fee schedule Listed/ Not open Listed/ Not open Fee scheduleSouth Carolina $26.78 $52.29 Not on fee schedule Not on fee schedule Fee scheduleSouth Dakota 2013 Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleTennessee * * * * Fee scheduleTexas Not on fee schedule Not on fee schedule Not on fee schedule $26.30 Fee scheduleUtah Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleVermont $21.38 $41.68 Listed/ Not open Listed/ Not open Fee scheduleVirginia $23.39 $46.07 Individual Consideration $25.00 Fee scheduleWashington Listed/ Not open Listed/ Not open Not on fee schedule Not on fee schedule Fee scheduleWest Virginia Listed/ Not open Listed/ Not open Not on fee schedule Not on fee schedule Fee scheduleWisconsin Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleWyoming Listed/ Not open Listed/ Not open $24.00 $48.00 Fee schedule

SBI CODES: All rates listed are for 2012 unless otherwise stated. (Bolded rates are averaged)

* TennCare services are offered through managed care entities. Medical and behavioral services are covered by "at risk" Managed Care Organizations in each region of the state, and each participating MCO creates their own contracts with providers, maintains their own fee schedules, and has their own in-network specialists and providers.

Appendix V: SBI Codes by State

State 96151 96152 96153 96154 96155 SourceMedicare $20.11 $19.04 $4.45 $18.69 Not on fee schedule Fee scheduleAlabama Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleAlaska $31.01 $29.50 Not on fee schedule $28.96 Not on fee schedule Fee scheduleArizona $16.71 $15.84 $3.79 $15.55 $18.98 Fee scheduleArkansas Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule SurveyCalifornia $23.29 $32.24 $9.08 Not on fee schedule Not on fee schedule SurveyColorado Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule SurveyConnecticut $14.86 $14.35 $3.45 $13.86 $14.64 Fee scheduleDC $16.95 $16.05 $3.81 $15.76 $19.68 SurveyDelaware $19.56 $18.54 $4.29 $18.20 Listed/ Not open Fee scheduleFlorida Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleGeorgia Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule SurveyHawaii FY 2013 $19.06 $18.24 $3.99 $17.70 $17.14 InterviewIdaho $18.03 $17.13 $4.10 $16.82 Not on fee schedule Fee scheduleIllinois Listed/ Not open Not on fee schedule Not on fee schedule Listed/ Not open Not on fee schedule SurveyIndiana $19.19 $18.37 $3.99 $17.83 $17.29 Fee scheduleIowa $19.21 $18.23 $4.16 $17.89 Not on fee schedule Fee scheduleKansas Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleKentucky Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule SurveyLouisiana $15.52 $14.78 $3.54 $14.51 $15.64 Fee scheduleMaine Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleMaryland FY 2011 $16.81 $5.30 Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleMassachusetts Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleMichigan Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Not on fee schedule Fee scheduleMinnesota $18.35 $17.38 $3.89 $17.05 Listed/ Not open Fee scheduleMississippi Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleMissouri Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleMontana $17.76 $16.87 $4.01 $16.57 $19.79 Fee scheduleNebraska Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleNevada See fee schedule See fee schedule See fee schedule See fee schedule Not on fee schedule Fee scheduleNew Hampshire $15.40 $14.68 $3.22 $14.24 $13.81 Fee scheduleNew Jersey See fee schedule See fee schedule See fee schedule See fee schedule See fee schedule Fee scheduleNew Mexico $22.79 Listed/ Not open $18.96 $27.29 Listed/ Not open Fee scheduleNew York Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleNorth Carolina $18.49 Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleNorth Dakota $26.90 $25.51 Listed/ Not open $25.05 $30.15 SurveyOhio Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleOklahoma $18.59 $17.65 $4.10 $17.32 $20.57 SurveyOregon $15.29 $14.52 $13.57 $14.27 Not on fee schedule Fee schedulePennsylvania $19.94 $19.60 $4.48 $18.59 Not on fee schedule Fee scheduleRhode Island Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleSouth Carolina $17.18 $16.34 $3.72 $16.06 Not on fee schedule Fee scheduleSouth Dakota FY 2013 $19.04 $18.10 $4.30 $17.77 Not on fee schedule Fee scheduleTennessee * * * * * Fee scheduleTexas Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleUtah $18.08 $17.66 $4.04 $16.99 $22.11 Fee scheduleVermont $16.76 $15.88 $3.66 $15.59 Listed/ Not open Fee scheduleVirginia $16.36 $15.51 $3.70 $15.22 $13.62 Fee scheduleWashington Listed/ Not open Listed/ Not open $6.30 $19.26 $19.26 Fee scheduleWest Virginia Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee scheduleWisconsin Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Not on fee schedule Fee scheduleWyoming Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Listed/ Not open Fee schedule

HBAI CODES: All rates listed are for 2012 unless otherwise stated. (Bolded rates are averaged)

* TennCare services are offered through managed care entities. Medical and behavioral services are covered by "at risk" Managed Care Organizations in each region of the state, and each participating MCO creates their own contracts with providers, maintains their own fee schedules, and has their own in-network specialists and providers.

Appendix VI: HBAI Codes by State

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