Access to Care

Only about 5% of people who need SUD treatment services are being served by the system. The remaining 95% either don’t perceive they need it or don’t want it. The Reaching the 95% initiative is designed to ensure SAPC’s specialty SUD system not only serves those already seeking help, but also actively engages the 95% who aren’t.

This year, while specific R95 activities continue under Value-Based Incentives (VBI), R95 is expanding beyond VBI and becoming a broader system priority. That said, the principles of R95 are embedded throughout SAPC’s VBI, especially the activities within the Access to Care focus area. Like the R95 initiative, this focus area is centered on reducing barriers to care across the SUD System - through words, policies, and actions.

• MAT Education/Services for Opioid Use Disorder (OUD) in Non-OTP Settings- (3-A)

  Description	This incentive is designed to promote clinical quality and access to evidence-based care by ensuring that at least 60% of clients with OUD in non-OTP (opioid treatment program) settings receive MAT education and/or medication services that include MAT.
  Eligibility	Open to all contracted treatment provider agencies.
  Calculation	Numerator: Applicable MAT / Medication Service Code and/or H2010M (MAT Education). Denominator: Clients with OUD (F11.*) diagnosis. *Applicable MAT / Medication Service Codes are, for non-OTP settings: 90792, 99202 through 99205, 99212 through 99215, H0034, H0033, and H2010M.
  Invoicing/Submission Guidelines	Consult the monthly Data Quality Report (DQR) provided by SAPC’s HODA Division on the 15th of each month, which reflects the % of metrics for the prior month’s records. Required Documents: Invoice Form Applicable HODA DQR incentive page Deadlines: Submission 1: Q1 (July to September 2025) - Due 10/20/25 Submission 2: Q2 (October to December 2025) - Due 1/20/26 Submission 3: Q3 (January to March 2026) - Due 4/20/26
  Payment	Submission 1: Q1 $20,000 Submission 2: Q2 $20,000 Submission 3: Q3 $20,000
• MAT Education/Services for Alcohol Use Disorder (AUD)- (3-B)

  Description	This incentive advances clinical quality and access to evidence-based care by ensuring that at least 50% of clients with AUD agency-wide receive MAT education and/or medication services that include MAT. *NOTE: Claims from OTP settings must ensure that at least 50% of patients with AUD either receive education about medications for AUD or treatment with medications for AUD in order to meet this incentive benchmark.
  Eligibility	Open to all contracted treatment provider agencies.
  Calculation	Numerator: Applicable MAT / Medication Service Code1 and/or H2010M (MAT Education). Denominator: Patients with AUD (F10.*) diagnosis. ¹1Applicable MAT / Medication Service Codes are, for non-OTP settings: 90792, 99202 through 99205, 99212 through 99215, H0034, H0033, and H2010M. Applicable codes for OTP settings are H2010M and S5001AB, S5001C, S5000C, and S5001C specific to AUD medications.
  Invoicing/Submission Guidelines	Consult the monthly Data Quality Report (DQR) provided by SAPC’s HODA Division on the 15th of each month, which reflects the % of metrics for the prior month’s records. Required Documents: Invoice Form Applicable HODA DQR Incentive Page Submit all required documents quarterly within 5 days of DQR release, according to the following schedule: Submission 1: Q1 (July 2025 to September 2025) - Due 10/20/25 Submission 2: Q2 (October 2025 to December 2025) - Due 1/20/26 Submission 3: Q3 (January 2026 to March 2026) - Due 4/20/26
  Payment	Submission 1: Q1 $20,000 Submission 2: Q2 $20,000 Submission 3: Q3 $20,000
• MAT: Agency-wide Naloxone Distribution- (3-C)

  Description	This incentive enhances client safety and overdose prevention efforts by ensuring that at least 60% of clients agency-wide receive naloxone through prescription or distribution, as documented in the client record.
  Eligibility	Open to all contracted treatment provider agencies.
  Calculation	Numerator: The number of clients who received naloxone (by prescription or via distribution documented in the record) at a given provider agency. Denominator: The total number of clients served.
  Invoicing/Submission Guidelines	Consult the monthly Data Quality Report (DQR) provided by SAPC’s HODA Division on the 15th of each month, which reflects the % of metrics for the prior month’s records. Required Documents: Invoice Form Applicable HODA DQR Incentive page Submit all required documents quarterly within 5 days of DQR release, according to the following schedule: Submission 1: Q1 (July 2025 to September 2025) - Due 10/20/25 Submission 2: Q2 (October 2025 to December 2025) - Due 1/20/26 Submission 3: Q3 (January 2026 to March 2026) - Due 4/20/26
  Payment	Submission 1: Q1 $20,000 Submission 2: Q2 $20,000 Submission 3: Q3 $20,000
• Clients Referred/Admitted to Another SUD Level of Care- (3-D)

  Description	This incentive strengthens continuity of care by ensuring that at least 30% of clients are referred and admitted to another level of SUD care within 30 days of discharge.
  Eligibility	Open to all contracted treatment provider agencies.
  Calculation	Numerator: Number of clients referred and admitted to another level of SUD care within 30 days of discharge. Denominator: Total number of patients discharged.
  Invoicing/Submission Guidelines	Refer to the Data Quality Report (DQR) provided by SAPC’s HODA Division for the FY 2024-25, Q1-Q3 summary, which is scheduled for release on 4/15/26. Required Documents: Invoice Form Applicable HODA DQR Incentive page Submit all required documents quarterly within 5 days of DQR release, according to the following schedule: Submission 1: Q1 (July 2025 to September 2025) - Due 10/20/25 Submission 2: Q2 (October 2025 to December 2025) - Due 1/20/26 Submission 3: Q3 (January 2026 to March 2026) - Due 4/20/26
  Payment	Submission 1: Q1 $20,000 Submission 2: Q2 $20,000 Submission 3: Q3 $20,000
• Mental and Physical Health Referrals/Care Coordination- (3-E)

  Description	This incentive supports integrated care by ensuring that at least 25% of clients with mental or physical health conditions are referred and connected to appropriate services.
  Eligibility	Open to all contracted treatment provider agencies.
  Calculation	Numerator: The number of clients with a mental or physical health condition who are referred and connected to mental or physical health services. Denominator: Total number of clients with a mental or physical health condition.
  Invoicing/Submission Guidelines	Refer to the Data Quality Report (DQR) provided by SAPC’s HODA Division for the FY 2024-25, Q1-Q3 summary, which is scheduled for release on 4/15/26. Required Documents: Invoice form Applicable HODA DQR incentive page Submit all required documents quarterly within 5 days of DQR release, according to the following schedule: Q1 (July to September 2025): Due 10/20/25 Q2 (October to December 2025): Due 1/20/26 Q3 (January to March 2026): Due 4/20/26
  Payment	Submission 1: Q1 $20,000 Submission 2: Q2 $20,000 Submission 3: Q3 $20,000
• R95 Champion- (3-F)

  Description	This incentive supports provider agencies implement specified Reaching the 95% (R95) initiatives, demonstrating a commitment to redesigning specialty SUD treatment systems by lowering barriers to care and building policies and systems around the needs of our clients. Participation in 1) R95’s policy and agreement activity and 2) at least one MAT activity demonstrates commitment to redesigning specialty SUD treatment systems by lowering barriers to care and building policies and systems around the needs of SUD clients.
  Eligibility	Open to all contracted treatment provider agencies. Treatment provider agencies that previously completed admission AND toxicology policies are eligible if they complete at least one MAT component in FY 2025-26. Eligible MAT activities: MAT Education/Services for OUD in Non-OTP settings (3-A) MAT Education/Services for AUD (3-B) MAT Agency-wide Naloxone Distribution (3-C)
  Invoicing/Submission Guidelines	SAPC will confirm acceptance/invoice records of at least two eligible activities and notify agencies with the pre-populated verification form. Guidance Documents: R95 Champion Guide Submit required documents by 4/25/26: Invoice Form Signed pre-populated verification form
  Payment Rates	$40,000 one-time payment
• R95 Client-Facing Agreements- (3-G)

  Description	This incentive fosters a client-centered approach by ensuring participating treatment provider agencies update their policies and patient-facing agreements to recognize SUD as a chronic medical condition that will be treated with compassion.
  Eligibility	Open to all contracted treatment provider agencies. Treatment providers who previously completed admission, discharge, and/or toxicology policies will not have to repeat activities from previous years.
  Invoicing/Submission Guidelines	Guidance Documents: R95 Policies and Client-Facing Agreements Guide PDF versions of the Admission Agreements and Policies are available below for your convenience. R95 Admission Agreement (pdf) R95 Toxicology Agreement (pdf) R95 Admission Policy (pdf) R95 Discharge Policy (pdf) R95 Toxicology Policy (pdf) For provider agencies that have not previously completed any of the below documents, submit all five by 12/31/25. Invoice form R95 Admission Agreement (word) R95 Toxicology Agreement (word) R95 Admission Policy (word) R95 Discharge Policy (word) R95 Toxicology Policy (word) For provider agencies that previously completed any of the above policies and agreements, short of all five (5) items, submit all remaining items by 12/31/2025. For example, if a provider agency completed the Admission Policy and Discharge Policy in previous fiscal years, for FY 25-26 completion, the provider agency would only need to complete the Admission Agreement, Toxicology Policy, and Toxicology Agreement. Invoice Form R95 Admission Agreement (word) R95 Toxicology Agreement (word) R95 Admission Policy (word) (if not previously completed) R95 Discharge Policy (word) (if not previously completed) R95 Toxicology Policy (word) (if not previously completed)
  Payment Rates	$40,000 for provider agencies that have not previously completed any of the five documents. $20,000 for provider agencies that have previously completed some of the documents and complete the rest this year.
• Service Design Follow Up Implementation Plan- (3-H)

  Description	This incentive supports provider agencies in adapting program services to align with the treatment needs of individuals who want to participate in services but are not yet ready to maintain abstinence.
  Eligibility	Provider agencies with an approved FY 2023-24 Implementation/Investment Plan; OR Provider agencies with an approved FY 2024-25 Implementation/Investment Plan and who did not participate in the FY 2024-25 Follow-Up Implementation Plan.
  Invoicing/Submission Guidelines	Treatment provider agencies are required to participate in and complete the following: Attend Orientation Attend a two-day Change Leader Academy Participate in three (3) of the four (4) coaching calls Complete a change project plan Develop and present a 5x5 PowerPoint slide deck reflecting the change project plan Invoice Submission Due Date: 3/31/26 Required Documents: Invoice Form Required Documentation Change Project Plan 5x5 PowerPoint Presentation
  Payment Rates	$30,000 one-time payment