Getting help for a substance use disorder

A substance use disorder is a medical condition that causes physical and mental changes in your brain and impacts your ability to control the use of legal or illegal drugs or medications. Willpower alone is not enough to cut down or quit.

As you consider next steps, it may be helpful to reflect on whether your relationship with alcohol or drugs are impacting your life and health. If you find your health is declining, you are withdrawing from friends and family who care, noticing changes in your mood and behavior, or engaging in behaviors with consequences, it may be time to talk with a professional. You may find that you need more of the substance to feel the effects or are experiencing what you feel could be withdrawal symptoms. If that is the case, please seek medical attention at your local ER.

Michigan Department of Health and Human Services (MDHHS) manages your Medicaid health plan substance use disorder benefits in partnership with your local Community Mental Health (CMH) agency and Priority Health. We recommend you first reach out to your local CMH agency for substance use disorder treatment access by clicking here to find your local CMH office contact information. You may also contact Priority Health Behavioral Health Department during business hours by calling 800.673.8043 (TTY 771).

Prior authorization (PA) is a term that communicates to your provider the need to submit a request for your treatment. PA is needed for some outpatient treatment and all partial hospital, residential, and detox services. The provider you choose for treatment will request prior authorization on your behalf – you do not need to do this. Our Utilization Review Team will review the request to ensure that the treatment is medically necessary. If there are questions, concerns, or more information needed – we will work directly with your provider to coordinate.

The initial prior authorization is based on a review of your presenting symptoms that is sent to Priority Health by your provider. A certain number of days are authorized up front based on that review. Regular reviews will be completed throughout your treatment stay to determine whether additional days are needed. We authorize ongoing treatment days based on medical necessity which considers the following:

• Are you participating, attending groups, and making progress?
• Are you requiring regular medical check-ins?
• Have there been medication changes that require a doctor’s monitoring?
• Do you have a positive support system in your community?
• Are there safety concerns that may indicate a need for a more intensive level of care?
• And other factors

If you have an out-of-network benefit, you may be able to see a provider or receive treatment from an out of network facility. Be aware that out of pocket costs may be higher when the provider does not hold a contract with Priority Health. You may end up paying more out of pocket and/or paying for services that Priority Health does not cover. This is referred to as balanced billing (see below question for more information).

Another advantage of staying in-network is that your health plan works with participating treatment centers to ensure that they are providing evidence-based treatment.

Our Find a Doctor tool is a great way to search online for individual behavioral health providers that are in network in your area. This information is also available over the phone by calling the Behavioral Health Department at 800.673.8043 (TTY 711).

When you go out-of-network, you run the risk of being charged more than the reasonable and customary guidelines followed by Priority Health. The out-of-network provider/facility is not held to a contract and can bill you for the difference between what the treatment cost at their office/facility and what the insurance company paid. Staying in-network can help you avoid those additional costs. If you have more questions about balance billing, call 800.673.8043 (TTY 711) to speak with a behavioral health specialist.

Recognizing the need for education, support, and/or professional intervention involving substance use for your child or adolescent can be overwhelming and have implications for the entire family system. While services and treatment options for young people are limited, help is available. Contact our Behavioral Health Department at 800.673.8043 to speak with a clinical staff about treatment options.

What is it?

This service provides a therapeutic space to process thoughts, feelings, and behaviors while gaining skills for healthy coping. Outpatient therapy allows you to receive treatment while remaining at home or in the community. Sessions can occur weekly, bi-weekly, or monthly and focus on an array of concerns including coping with symptoms of a substance use disorder, understanding the disorder, relapse prevention, building self-esteem, gaining insight into relationships, dealing with strong emotions, or coping with a traumatic or life altering event(s). Many providers offer this service virtually as well as in person.

What types of clinicians provide this service?

• Licensed Professional Counselor
• Psychiatrist
• Clinical Social Worker
• Psychologist
• Licensed Marriage and Family Therapist.

For more information about how these providers differ in treatment, expertise, and training – click here: National Alliance on Mental Illness - Types of Providers

How long will I be in outpatient therapy?
The length of time spent in outpatient therapy will depend on the severity of your symptoms, whether there are other barriers, and how quickly goals are met. You are encouraged to have regular conversations with your provider about how the process is going and what next steps may look like.

This service is like outpatient therapy however more intensive and frequent. Often the treatment is five days per week up to three hours a day, however, some programs are more flexible.

What types of clinicians provide this service?

This level of care is provided by an outpatient group practice or outpatient clinic which can be staffed with several different types of clinicians.

How long will I be in intensive outpatient therapy?

Treatment in this level of care can last five to eight weeks – and could be longer depending on your clinical needs.

Priority Health partners with several outpatient providers who offer intensive, community-based outpatient mental health treatment. The program is known as Community Care Management and gives you access to a therapist, medication management, and care coordination. The program allows you to see a therapist more frequently (up to 3 times weekly) at home, in the community, office, or virtually. There are some program restrictions based on plan and location. For more information and to speak with someone about whether you are eligible, contact our Behavioral Health Department at 800.673.8043 (TTY 711).

Download our Community Care Management flyer here for more information.

What is it?

Partial Hospital (PHP) is a service that is often referred to as “day treatment” and is the most intensive service that is offered on an outpatient basis. Treatment includes individual therapy, group therapy, and access to a clinician who can manage psychiatric medications if needed. Treatment will occur five days a week for six hours each day.

What types of programs provide this service?

This level of care can often be found embedded within an inpatient hospital or is offered at an outpatient clinic.

How long will I be in partial hospital programming?

The length of treatment will depend on individual needs.

What is it?

Medication for Opioid Use Disorder (MOUD) is sometimes called Medication Assisted Treatment (MAT). This is an evidence-based form of treatment that is most often used to treat people diagnosed with Opioid Use Disorder (OUD) and Alcohol Use Disorder. MAT can reduce cravings and help prevent relapse for individuals with Alcohol Use Disorder. Although MOUD has been stigmatized as replacing one drug with another, MOUD functions to stabilize brain chemistry, relieve cravings, and, in some cases, block the effects of other drugs—making it another form of opioid overdose prevention. MOUD may be used temporarily to stabilize someone after stopping the use of a particular drug, or it may be a long-term form of recovery.

What types of providers can prescribe this treatment?

Any of these medical providers who hold a medical license and can prescribe controlled substances are able to prescribe MAT/MOUD:

• Medical Doctor (MD)
• Doctor of Osteopathic Medicine (DO)
• Psychiatrist
• Physician Assistant (PA)
• Nurse Practitioner (NP)

For more information about how these providers differ in treatment, expertise, and training – click here: National Alliance on Mental Illness - Types of Providers

You can also use our Find a Doctor tool in your member account to search for a MAT/MOUD provider.

What is it?

This service provides a supportive living environment alongside an intensive treatment program with access to individual and group therapy, psychiatric medication management, and other supports. Residential programs are often separated by whether they treat primary mental health or substance use concerns.

What types of programs provide this service?

Most substance use disorder residential programs are not connected to a hospital system, and access is through the program’s intake process. Other substance use residential programs are connected to a hospital system and may require going to the ER for admission.

How long will I be in a residential program?

Your health plan may cover short term substance use residential treatment which is based on individual treatment needs. Length of stay is determined by intensity of symptoms that are reported by the provider. Most substance use residential programs cover 10 - 14 days. Length of stay reviews are done regularly and consider what physical and psychological symptoms you are experiencing. These reviews also consider if there are interpersonal stressors, whether you have complex medical and psychological needs, whether you are at a high risk of relapse, how much progress you are making towards learning new coping skills, and how committed you are to your recovery plan if you were to be discharged.

If you are not satisfied with the coverage decision made for your treatment, you or the provider can file an appeal. Learn how here.

What is it?

This service often occurs in an inpatient setting and focuses on helping you safely withdraw from a substance. It is not intended to treat and address the longstanding patterns and need for additional support. Some detox services can occur on an outpatient basis with a provider who specializes in this, however, it is particularly important to be evaluated and follow treatment recommendations due to dangerous medical complications that can present when the body is withdrawing from substances. Please call 911 or seek medical care at your local ER if you are experiencing withdrawal symptoms.

What types of programs provide this service?

Some hospitals have a detox unit within their larger hospital system. There are some programs that are separate from a large hospital system.

How long will I be in detox?Trea

ment length depends on severity of withdrawal symptoms and your medical need to have access to nursing care 24 hours a day.

Goals around substance use can vary from abstinence to finding ways to reduce the health risks associated with your use. Your provider may recommend a form of harm reduction in your treatment plan.

To find out more about harm reduction and lifesaving interventions like Naloxone, please visit https://www.samhsa.gov/find-help/harm-reduction.

Naloxone is a medicine that can be life saving for someone who is overdosing on an opioid. Naloxone can reverse the effects of an overdose from heroin, morphine, oxycodone, methadone, hydrocodone, codeine, hydromorphone, or fentanyl.

Naloxone can be administered by bystanders and is available in nasal spray or as an injectable. Consider talking to your provider to see if this would be a good option for you or your loved one. For coverage questions, please call our Customer Service Line at 800.942.0954 and follow the prompts to speak with a staff member in the Pharmacy Department.

The term co-occurring disorders (COD) refers to co-occurring substance-related and mental disorders. If you have a co-occurring disorder, it means you have one or more substance-related disorders and mental disorders. Mental health conditions that commonly co-occur with substance use disorders include depressive disorders, anxiety disorders, attention deficit hyperactivity disorder, bipolar disorder, schizophrenia, and personality disorders. The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends an integrated treatment approach meaning that it is important that you have access to treatment that addresses both experiences by way of different therapeutic modalities, medication management, psychoeducation, and relapse prevention.

Centers for Disease Control & Prevention

Substance Abuse and Mental Health Services Administration (SAMHSA)

Alcoholics Anonymous

Narcotics Anonymous

Al-Anon Family Groups

Alateen

Suicide Prevention 

SMART Recovery

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