The American Society of Addiction Medicine defines the baseline standards for levels of care and insurance companies utilize ASAM criteria to determine what level of care a patient is to be authorized for.
They are, in reverse order (following a continuum of care):
This is a level of care that requires medical services to help stabilize the patient who is at-risk for life-threatening acute withdrawal. This is often done at hospitals or specialized detox units that have 24-hour staffing that includes, by requirement, doctors be available daily and nurses available ON-SITE 24-hours.
- 4 – Medically Managed Intensive Inpatient Services
This is a level of care that follows detox. In the case of ASAM 3.7 the residential treatment center is required to have 24-hour nursing on-site with a physician available in the event of sub-acute withdrawal issues.
- 3.7 – Clinical Managed High-Intensity Residential Services
- 3.5 – Clinically Managed Population-Specific High-Intensity Residential Services
- 3.3 – Clinically Managed Low-Intensity Residential Services
Outpatient Levels of Care
These are levels of care where the patient is no longer in need of any 24-hour treatment and will typically live at home and go to treatment during the day, or live in a sober living while attending daytime or evening treatment sessions.
- 2.5 – Partial Hospitalization Services (PHP)
- 2.1 – Intensive Outpatient Services (IOP)
- 1 – Outpatient Services (OP)
- 0.5 – Early Intervention
CLICK HERE to see a detailed accounting of these levels of care as defined by ASAM.
Typically one might see a pathway through the continuum of care that looks like this:
DETOX ⇒ RESIDENTIAL ⇒ PHP ⇒ IOP ⇒ OP
THE ETHICS CHALLENGE
While in outpatient levels of care they might live in a structured sober living home. Sober living is a NON-CLINICAL situation.
- Sober living homes do NOT offer treatment.
- Sober living homes do NOT provide therapy.
- Sober living homes may NOT bill insurance for UA testing.
- Sober living homes do NOT hold or monitor or dispense medications. If a client required that they would assess as needing a higher level of care (residential).
- Sober living home costs are NOT covered by insurance!
There are RARE instances in some states where a sober living home is licensed in a special way that some policies will cover, but this is not the norm. It’s often called “PHP with housing” benefits. To find out if you’re dealing with ethical sober living homes who claim to bill insurance, you should check with your provider first.
There is something that has been coined “The Florida Model” that creates some slippery ethics pathways. It was created with good intentions, but it is often plagued by fraudulent billing and activities. Here is a great article about it.
In the Florida Model, a patient is billed and placed into outpatient services but the patient lives in sober living home, often unaffiliated. But some treatment program have affiliated sober living homes and they deeply discount their “rent” to those who attend their treatment programs and they sometimes give free rent (absorbing the costs by billing insurance). To the end-user this appears to be residential treatment, but it is NOT, nor is it licensed as such.
This creates a number of challenges because sober living homes are not permitted to dispense, monitor, or hold medications. They are not permitted to have clinical services IN the homes. And many of those homes are not licensed, certified, or regulated in any way.
Also, insurance companies don’t pay for sober living services, and this Florida Model is a shady way to attempt (via “bed vouchers”) to offer what looks like residential treatment without any money out of the client’s pocket. There are attempts to work this out, because an ethically provided Florida model (with good regulations) makes sense when it comes to helping the patient who often has limited financial resources.