What happens in an assessment, and who decides the level of care?

What the assessment is for

The assessment is how a service works out what you actually need rather than offering everyone the same package. ASAM describes its Criteria as the most widely used standards for deciding where people start treatment, whether they continue and when they move. It says recommendations should come from an assessment of a person's medical, psychological and social needs, together with their strengths and the support around them.

That is why the questions go beyond how much you drink or use. A service needs to know whether withdrawal could be risky, whether another health or mental health condition needs attention, what would make a return to use more likely and whether home is a place where recovery can happen.

A short phone screening is not the same thing. It may decide whether you are booked for an assessment, or whether you need urgent medical help first. Ask which one you are having.

What you are likely to be asked

ASAM's patient guide on opioid treatment describes common assessment questions. They include how long you have been using, other medicines you take, family history, other mental or physical health problems and social or financial circumstances. It says a physical examination and a drug test, most often a urine test, may follow.

You may also be asked about past treatment, legal matters, work, housing, the people you live with, and what you want from treatment. Some questions may feel intrusive. You can ask why a question matters. You can also say when you do not know or do not remember, rather than guessing.

Try to include anything that would make a plan unworkable for you: shift work, children at home, no car, a pet with no one to care for it. Those details belong in the assessment, not only in a later conversation about logistics.

How a level of care is chosen

ASAM's Criteria group adult care into broad levels, from outpatient appointments through intensive outpatient programs and residential care to hospital inpatient care. The name matters less than what each level provides: how many hours of care, whether you stay overnight and how much medical staffing is available.

ASAM's Criteria FAQ explains that the criteria aim to find the least intensive level of care where a person can be treated safely and effectively. The clinician looks first at clinical risks, such as withdrawal, health conditions and the chance of returning to use. Then, ASAM says, the clinician should use shared decision-making to consider the person's preferences, barriers to care and where they are willing and able to take part.

So the answer to “who decides?” has more than one part. A clinician makes the recommendation. You have a say in how and where it happens. And if insurance is paying, the insurer decides what it will cover.

Where your insurer comes in

ASAM says payers and managed care organizations should use the same criteria as clinicians to decide which level of care they will cover. In practice, the program may send the assessment to your insurer and wait for approval before admitting you or before continuing care.

That means a clinical recommendation and an insurance approval can differ. If they do, ask the program to explain what the insurer decided and why, and what your options are. Ask the insurer for its decision in writing. A difference is not always final; there may be a review or appeal process to ask about.

Assessment does not happen only once

ASAM expects people to be reassessed as treatment goes on. Its FAQ says programs at several levels should carry out formal reassessments monthly, that treatment planning should be continuous and that states can set their own rules on how often.

A reassessment can lead to moving to less intensive care, staying where you are or moving to more support. Tell the team when something changes, such as new symptoms, a return to use or a change at home, so the plan can be reviewed rather than carried on unchanged.

When you disagree with the recommendation

You may have hoped for outpatient care and been told residential care is safer, or the other way round. Ask the clinician to explain which risks or needs led to the recommendation and what would need to be different for another setting to be appropriate.

If the recommendation is not possible for practical reasons, say exactly why. “I cannot leave my children for thirty days” gives the team something concrete to work with. Ask what alternatives could meet the same need.

If you are still unsure, you can ask for the recommendation in writing and seek another clinical opinion. ASAM's Criteria are guidance used by clinicians and payers; the FAQ notes that ASAM is not a regulator.

Before the assessment ends

Before you leave, ask for the level of care being recommended, in plain words, and the main reasons for it. Ask what happens next and who contacts whom. Ask whether insurance approval is needed and who is requesting it, and when care would start.

A clear summary lets you check that you have understood, and helps if you need to explain the plan to someone helping you.