States Using Coverage and Reimbursement Policy to Address the Opioid Epidemic

October 26, 2017|12:55 p.m.| ASTHO Staff

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) approved West Virginia’s demonstration waiver to create a continuum of care for individuals with substance use disorders (SUD). CMS has promoted the use of such waivers to address the opioid epidemic by implementing state-level delivery system reforms that ensure access to high-quality, evidence-based treatment and recovery services. Under the waiver, West Virginia’s Medicaid plan will cover:

  • Peer recovery support services when provided by an individual with a personal background in recovery and certified by the state’s department of health and human resources.
  • Inpatient treatment and recovery services.
  • Clinically-managed withdrawal management.
  • Opioid treatment programs, such as methadone maintenance treatment.

Per CMS guidance, providers must use the American Society of Addiction Medicine’s treatment criteria to determine the appropriate care setting and individualized services for patients. To increase treatment capacity, West Virginia also waived the Institutions for Mental Diseases exclusion, which prohibits Medicaid payments for residential behavioral health and SUD treatment in facilities with more than 16 beds. In addition to West Virginia, California, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Oregon, and Virginia have received approval for demonstration waivers that impact SUD treatment and recovery options. Other states, including Arizona, Indiana, Illinois, Kentucky, Michigan, and Utah, have waiver applications pending before CMS.

Beyond Medicaid waivers, policymakers can leverage state-level insurance laws and regulations to advance SUD treatment and recovery options. For example, both New Jersey and Maryland (HB 887 [2017], HB 1329 [2017], and SB 967 [2017]) expanded the SUD benefits that health plans must provide while restricting certain utilization controls, such as prior authorizations or retrospective reviews of medical necessity, for SUD treatments. States have also clarified enforcement authority to ensure meaningful consumer access to SUD benefits. For example, Texas enacted a uniform, state-level mental and behavioral health parity law, granted the state insurance commissioner additional enforcement authority, and established an ombudsman for behavioral health in the Texas Department of Insurance. By clarifying the parity requirements and enforcement authority, the department is better positioned to determine health plans’ compliance with state and federal parity laws.

Improving access to and use of effective treatment and recovery support is a key strategy of ASTHO’s framework for Preventing Opioid Misuse in the States and Territories. ASTHO will continue to identify and monitor efforts to ensure timely access to high-quality SUD treatment and recovery services.