Substance Use Disorders Remain a Public Health Emergency
Opioid addiction and overdose death rates have captured the nation’s attention on the need to better support individuals with opioid use disorder (OUD) and other substance use disorders (SUD). Because Medicaid is the primary funder for high-risk populations who are eligible for treatment, the Centers for Medicaid and Medicare Services (CMS) and states are at the forefront of dramatic new efforts to address the opioid crisis.
CMS, state Medicaid agencies, and other partners are navigating local and statewide challenges and developing strategic efforts to address them. Increasingly, these efforts include OUD treatment as well as broader social service coordination. Services designed to increase access for eligible beneficiaries to OUD treatment include providing medication-assisted treatment (MAT), treatment planning, counseling, care management, and care coordination services.
Increasingly, CMS offers valuable resources for combating the opioid epidemic by improving patient-centered service delivery, integrating highly coordinated OUD treatment services, and providing resources and flexibility to address barriers to medication-assisted treatment.
Now, a second public health emergency—the novel coronavirus pandemic—has led states to expand medically necessary services for OUD treatment via telehealth through live audio and video communications to examine, monitor, and treat patients. The current situation creates new challenges to safety and patient access to opioid treatment medication and services.
Providers and policymakers are rapidly implementing programs to continue providing life-saving interventions for individuals in need of care amidst the COVID-19 pandemic.
CMS’ Increasing Role in Responding to the Opioid Crisis
In recent years, two critical pieces of legislation enabled CMS to address the opioid crisis through Medicaid, and for the first time, through Medicare. The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act of 2018, among many other provisions, authorized two demonstrations to aid individuals with an OUD or SUD. Additionally, Section 1115A under the Social Security Act (SSA) created CMS’ Centers of Medicare and Medicaid Innovation (CMMI) to test innovative payment and service delivery models to reduce cost and improve quality, coordination, and efficiency of healthcare services delivered to beneficiaries.
Learn the specifics of these initiatives and legislation below.
The SUPPORT Act Authorizes Two OUD and SUD Demonstrations
SUPPORT Act Section 1003, which authorizes the Demonstration Project to Increase Substance Use Provider Capacity, began September 30, 2019 and provides federal funding for 15 states with flexible-purpose planning grants for 18 months and a 36-month demonstration if selected. States are focusing on recruitment, training, treatment assessment, and technical assistance for SUD and recovery service providers for Medicaid beneficiaries and other prioritized populations.
SUPPORT Act Section 6042 authorizes a four-year demonstration program for a maximum of 20,000 Medicare beneficiaries to increase access to OUD treatment services. The initiative is called the Opioids Use Disorder Treatment Demonstration Program (OUDTDP), and it is scheduled to start on January 1, 2021. This demonstration is a federally funded program providing payments to opioid care teams who provide or arrange for MAT, counseling, social support, and care coordination through outpatient settings serving Medicare beneficiaries.
Under Section 1115A of the Social Security Act, CMS is Testing Three SUD-Related Demonstration Efforts
Integrated Care for Kids Model
The Integrated Care for Kids Model (InCK) is a seven-year, Medicaid local-service delivery and state alternative payment model. InCK is CMS’ first model focusing on Medicaid beneficiaries from birth through age 21, Children’s Health Insurance Program (CHIP) awardees, and pregnant Medicaid beneficiaries over 21 years of age. Seven states were awarded cooperative agreements to implement services to their model service areas, beginning at the time of model launch on January 1, 2020. The states and their service provider partners are identifying approaches for integrating care coordination and care management, improving the child’s overall health, and determining how they will contribute to the assessment of the child’s health and reduction of costs for care.
Maternal Opioid Misuse Model
The Maternal Opioid Misuse Model (MOM) is a five-year, state-designed coverage and payment strategy coordinating clinical care and support services for pregnant and postpartum Medicaid beneficiaries with OUD and their newborns. Since the model launched January 1, 2020, ten states are working toward completing the model goals, which are to strengthen care coordination by transforming sectors of behavioral and physical health, as well as recovery support assisting this vulnerable population. Addressing mothers’ diverse health needs will promote complete and flexible standards of care specific to the treatment of the individual, and ultimately reduce costs for these Medicaid beneficiaries.
Section 1115 Substance Use Disorder Demonstration Programs
Section 1115 Substance Use Disorder demonstration programs involve state-designed and independently evaluated innovations to support Medicaid beneficiaries struggling with SUD and OUD by improving the continuum of care. For example, states may apply to receive Medicaid matching funds for treatment in facilities that meet the definition of an institution for mental diseases (IMD). In parallel, Medicaid’s objectives for the demonstrations are to reduce opioid-related deaths and hospital visits (inpatient settings and emergency department), and lower readmission rates for preventable or medically inappropriate cases within the same treatment or higher levels of care. These demonstrations allow states greater flexibility to test innovative and rigorous approaches to implementing, monitoring, and evaluating the program’s performance. CMS will review and approve or deny the state’s application for an 1115 SUD waiver if it does not meet the demonstration’s goal.
State Medicaid Initiatives Provide Flexible Solutions for OUD and SUD Treatment
As the four Medicaid OUD and SUD initiatives aim to offer treatment services to key state-focused populations, the intervention will vary depending on the nature of the initiative the state is awarded. Thirteen states are not currently implementing any of the specific OUD or SUD-related initiatives discussed above. The graphic below shows a state-by-state view of the states that are implementing one or more of the 1115 SUD demonstration, InCK, MOM, or Medicaid SUD Planning Grant initiatives focused on helping Medicaid beneficiaries receive treatment services.
The Patchwork of State-Level OUD and SUD Initiatives
The graphic shows that the OUD and SUD initiatives vary drastically by state, with the most multifaceted programs occurring in a cluster of states in central eastern regions of the country. Information in this figure was updated as of April 28, 2020 and is based on www.medicaid.gov.
The states shown implementing 1115 SUD demonstrations include the following states with pending 1115 SUD waivers: California, Colorado, Indiana, Kansas, Maine, Massachusetts, New Jersey, Utah, Virginia. For more information, refer to this state-level data table [Excel - 20KB].
Several states are implementing more than one CMS OUD/SUD initiative and combinations can vary widely. For example:
- Illinois was awarded two InCK awards to help rural communities increase training and expand medication-assisted treatment services, enhance the state’s helpline with accurate, up-to-date information, and examine payment models for support services for Medicaid beneficiaries. Illinois is also implementing a 1115 SUD waiver and Medicaid SUD Planning Grant.
- West Virginia is implementing three Medicaid initiatives: a 1115 waiver, MOM demonstration, and Medicaid SUD Planning Grant.
- Connecticut is the only state with an InCK award and Medicaid SUD Planning grant, but no pending or approved applications for a 1115 SUD waiver.
CMS Efforts Escalate to Serve OUD Patients During COVID-19
With common goals of state-designed coverage, provider capacity enhancement, and payment strategy improvement, these CMS initiatives set the stage to expand access to MAT and other treatment services for eligible beneficiaries. Now that the COVID-19 emergency has become our new reality, these new systems are even more critical.
In the COVID-19 pandemic, individuals with OUD are at an especially high risk. According to the National Institute on Drug Abuse, individuals prescribed high doses of opioids or who have OUD may be more susceptible to hypoxemia if they contract COVID-19. Substance use treatment provider offices have been closed, which affects patients’ ability to receive treatment in person.
Socially, people with OUD may be more likely to experience cases of incarceration and homelessness. Individuals facing addiction are often stigmatized and underserved, leading to a greater challenge in treatment. The National Institute on Drug Abuse encourages hospitals and clinics to care for this vulnerable population, as the number of COVID-19 cases rise among those with OUD. In turn, state SUD prevention and treatment efforts will need to build on and adapt their prior capacity-building efforts.
New Telehealth Guidance Permits Take-Home Medications, Reimbursement, and Expansion of Telecommunications
Health professionals and policymakers are working to deliver new approaches to treatment for individuals with opioid use disorder. As COVID-19 affects the nation, forcing shelter-in-place orders and closing business, telehealth services and benefits have rapidly expanded for private payers, state oversight bodies, and Medicare beneficiaries under CMS waiver authority. During the public health emergency, states still have the opportunity to provide care to beneficiaries in need of OUD and SUD treatment. Telehealth will serve as the main avenue for providers to prescribe medications and monitor beneficiaries, since entry to healthcare facilities should be limited and many needs can be met remotely.
States have introduced a few solutions to help individuals access behavioral health services, which include relaxing some of the regulatory restrictions on treatment facilities, waiving regulations on certain SUD treatments, and increasing harm reduction services. Additionally, CMS released a new toolkit to support the implementation of telehealth in states needing direction and further guidance during the coronavirus pandemic. The toolkit discusses state considerations for determining eligible patient populations (including pediatric beneficiaries) and providers. Furthermore, the toolkit helps states assess coverage, reimbursement, and telecommunications options to accelerate the development and execution of telehealth.
The new Medicare telehealth regulations allow for audio-telephone calls for counseling and therapeutic services for beneficiaries with OUD, eliminating the requirement of interactive audio-video communication technology to receive care. Usually an in-person medical evaluation is required for a prescription for a controlled substance such as buprenorphine or methadone. However, due the pandemic, live video or audio is considered sufficient patient-provider communication, and certain provisions under the the HIPAA privacy rule are waived under the good faith rule under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).
Recent CMS guidance on Medicaid SUD treatments and the application of telehealth strengthens states’ responses on rural health and Medicaid telehealth flexibilities during the pandemic. States can increase Medicaid services and federal reimbursements for services delivered via telehealth. The Substance Abuse and Mental Health Services Administration (SAMHSA) issued a directive for all states to allow all stable patients in Opioid Treatment Programs (OTP) to receive a 28-day supply of medications, and for patients who are less stable, but can take the medication safely, a 14-day supply of take-home medications like buprenorphine and methadone.
Patients and Providers Face Challenges to Established Treatment Regimens Due to COVID-19
The repercussions of COVID-19 include changes to established SUD treatment regimens. Healthcare providers must make difficult decisions about the best way to support patients at risk of developing SUDs or relapsing due to added stress, medication changes, out-of-routine care, or limited treatment capacity. Additionally, states’ implementation of their MOM, InCK and SUD demonstration and capacity-building awards may dramatically change during the pandemic. States have submitted Medicaid state plan amendments to add or revise reimbursement methodologies, amend services to comply with Medicaid Drug Utilization Review (DUR) under SUPPORT Act Section 1004, and other state-specific reasons.
States now face daunting challenges to continue implementing their efforts to improve care quality for Medicaid and Medicare beneficiaries with OUD/SUD, while also addressing the challenges of the COVID-19 crisis. As states make progress, CMS should prioritize these initiatives and the evaluation of these programs to avoid suffering due to limited or no access to treatment.
CMS’s ongoing data collection efforts, such as Transformed Medical Statistical Information System (T-MSIS) data improvements, are an example of how to support the collection of vital statistics such as frequency and treatment rate for beneficiaries with SUD, to ensure program efforts assist those in need.
As Treatment Policies Evolve, Continuity of Care Remains Top Priority
IMPAQ commends all of the health professionals working so hard to provide continuity of care for clients with SUD during this challenging time. As the opioid crisis continues during the coronavirus pandemic, it is vital for patients and communities to remember that help is still available to support SUD prevention, treatment and recovery.
The CMS initiatives above remain active and still aim to increase quality of care and access to OUD treatment, and telehealth has strengthened patient-provider relationships. Life-saving interventions such as MAT, treatment planning, counseling, care management, and care coordination services, are valuable services to combat the opioid epidemic. IMPAQ Health experts are closely watching the outcomes of ongoing changes to mental health and substance use legislation and guidance, including a $508 billion bill aimed at stabilizing community mental health centers and expanding the behavioral health workforce.
For more information on substance abuse and behavioral health during the coronavirus pandemic, visit SAMHSA’s Resources and Information page.
Lovely Davilmar, Analyst, IMPAQ Health
Karin Johnson, Principal Research Associate, IMPAQ Health
Graphic by Diana Rafanello, Data Analyst Intern, IMPAQ Health