ADDICTION AND RECOVERY OPIOID CRISIS

Transcription

1 ADDICTION AND RECOVERY OPIOID CRISIS Ke Shawn Harper, MS Substance Use Disorder Analyst Virginia Department of Medical Assistance Services

2 The Opioid Addiction Emergency In Virginia: October 2017 Information provided by Office of the Chief Medical Examiner with the Virginia Department of Health

3 CURRENT ISSUES Fatal drug overdose has been the leading method of unnatural death in Virginia since 2013 and the leading method of accidental death since 2014 Opioids have been the driving force behind the large increases in fatal overdoses since 2013 In 2015 statewide, the number of illicit opioids deaths surpassed Rx opioid deaths. This trend continued at a greater magnitude in 2016 There has not been a significant increase or decrease in fatal Rx opioid overdoses over the 10 year time span ( ) Fatal fentanyl overdoses (Rx, illicit, and analogs) increased by 176.4% from 2015 to 2016 (225 and 622 deaths, respectively) Rural areas of Virginia have the highest mortality rates due to Rx opioids while urban areas have the highest mortality rates due to illicit opioids The number of fatal cocaine overdoses began increasing in In 2016, 54% of fatal cocaine overdoses also had fentanyl causing death

4 Number of Fatalities TOP 3 METHODS OF UNNATURAL DEATH The leading methods of unnatural death in Virginia since 2007 have been motor vehicle collisions, gun-related deaths, and fatal drug overdoses (these methods of death include all manners of death: accident, homicide, suicide, and undetermined). In 2013, fatal drug overdose became the leading method of unnatural death in the Commonwealth. This trend has continued to worsen at a greater magnitude due mainly to illicit opioids (heroin, illicit fentanyl, and fentanyl analogs). Total Number of Motor Vehicle, Gun, and Drug Related Fatalities by Year of Death, (Data for 2017 is a Predicted Total for the Entire Year) * Motor Vehicle Related Gun Related Fatal Drug Overdose Top 3 methods of death (motor vehicles, guns, and drugs) include all manners of death (accident, homicide, suicide, and undetermined)

5 Number of Fatalities ALL DRUGS The total number of fatal drug overdoses statewide has increased each year. In 2013, fatal drug overdose became the number one method of unnatural death in the Commonwealth, surpassing both motor vehicle-related fatalities and gunrelated fatalities. In 2014, fatal drug overdose became the leading cause of accidental death in Virginia. The number of all fatal overdoses in 2016 compared to 2015 increased by 38.9%. Total Number of Fatal Drug Overdoses by Quarter and Year of Death, ( Total Fatalities for 2017 is a Predicted Total for the Entire Year) * Q Q Q Q Total Fatalities At the time of this analysis, approximately 30 cases from Q were open and awaiting toxicology results and were therefore not included in the calculated total of Q

6 Number of Fatalities ALL OPIOIDS Total Number of Fatal Opioid Overdoses by Quarter and Year of Death, % * Q Q Q Q Total Fatalities

7 Number of Fatalities OPIOIDS- A DIFFERENT PERSPECTIVE Prescription opioids are a group of drugs that are commercially made by pharmaceutical companies in certified laboratories that act upon the opioid receptors in the brain. Historically, fentanyl has been one of these drugs. However, in late 2013, early 2014, illicitly made fentanyl began showing up in Virginia and by 2016, most fatal fentanyl overdoses were of illicit production of the drug. Separating fentanyl from the grouping of prescription opioids for this reason demonstrates a slight decrease in fatal prescription opioid overdoses in 2015 and a dramatic increase in the number of fatal fentanyl and/or heroin overdoses. This has caused the significant rise in all fatal opioid overdoses in the Commonwealth since Total Number of Prescription Opioid (Excluding Fentanyl), Fentanyl and/or Heroin, and All Opioid Overdoses by Year of Death, ( Total Fatalities for 2017 is a Predicted Total for the Entire Year) * All Opioids Prescription Opioids (excluding fentanyl) Fentanyl and/or Heroin All Opioids include all versions of fentanyl, heroin, prescription opioids, and opioids unspecified 2 Illicit and pharmaceutically produced fatal fentanyl overdoses are represented in this analysis. This includes all different types of fentanyl analogs (acetyl fentanyl, furanyl fentanyl, etc.) 3 Prescription Opioids (excluding fentanyl) calculates all deaths in which one or more prescription opioids caused or contributed to death, but excludes fentanyl from the required list of prescription opioid drugs used to calculate the numbers. However, given that some of these deaths have multiple drugs on board, some deaths may have fentanyl in addition to other prescriptions opioids, and are therefore counted in the total number. Analysis must be done this way because by excluding all deaths in which fentanyl caused or contributed to death, the calculation would also exclude other prescription opioid deaths (oxycodone, methadone, etc.) from the analysis and would thereby undercount the actual number of fatalities due to these true prescription opioids.

8 Number of Fatalities FENTANYL AND/OR HEROIN The total number of fatal fentanyl and/or heroin overdoses have significantly increased since late It is important to look at these two drugs together because as heroin became more popular in 2010, fentanyl occasionally began showing up as an additive to the heroin. By late 2013 and early 2014, some heroin being sold on the street was actually completely fentanyl, unbeknownst to the user. It is essential to look at these fentanyl (no heroin), heroin (no fentanyl), and fentanyl and heroin combination deaths together because users never know exactly what is in the illegal drugs purchased off the streets. Fatal fentanyl and/or heroin overdoses increased by 72.6% in 2016when compared to Total Number of Fatal Fentanyl and/or Heroin Overdoses by Year of Death, ( Total Fatalities for 2017 is a Predicted Total for the Entire Year) * Fentanyl (No Heroin) Heroin (No Fentanyl) Fentanyl and Heroin Total Fatalities Illicit and pharmaceutically produced fatal fentanyl overdoses are represented in this analysis. This includes all different types of fentanyl analogs (acetyl fentanyl, furanyl fentanyl, etc.)

9 Medicaid Members with Substance Use Disorder Diagnosis Source: Department of Medical Assistance Services claims/encounter data (CY2017). Circles # of Medicaid recipients whose claims/encounter data included an addiction related diagnosis.

10 Medicaid Members who are Pregnant by Substance Use Disorder Diagnosis Source: Department of Medical Assistance Services claims/encounter data (CY2017). Top row are all female recipients whose claims/encounter data included an addiction related diagnosis. Bottom row identifies recipients who are pregnant.

11 Prescription Prescription Opioid Opioid Overdoses Overdoses ( ) ( )

12 Heroin/Fentanyl Overdoses ( )

13 CONTACT INFORMATION This report is compiled by the Virginia Department of Health, Office of the Chief Medical Examiner. For additional information regarding these or other statistics, please contact: Kathrin "Rosie" Hobron, MPH Statewide Forensic Epidemiologist Virginia Department of Health Office of the Chief Medical Examiner

14 Agenda Medicaid Overview Overview of DMAS s Addiction and Recovery Treatment Services (ARTS) Program Transformation American Society of Addiction Medicine (ASAM) Levels of Care ARTS Covered Services ARTS Provider Qualifications Medication Assisted Treatment (MAT): Covered Medications, Reimbursement, and Preferred Provider Network Peers Services Questions

15 OVERVIEW OF VIRGINIA MEDICAID

16 Virginia Medicaid Key Facts 1 Million + Virginians covered by Medicaid/CHIP 1in8 Virginians rely on Medicaid 50% Medicaid beneficiaries are children 1in3 Births covered in Virginia 2in3 Residents in nursing facilities supported by Medicaid - Primary payer for LTSS 62% Long-Term Services & Supports spending is in the community Behavioral Health Medicaid is primary payer for services 16

17 Medicaid Members with Substance Use Disorder Diagnosis Source: Department of Medical Assistance Services claims/encounter data (November 3, 2016). Circles # of Medicaid recipients whose claims/encounter data included an addiction related diagnosis. 18

18 Communities Impacted by Addiction Source: Department of Medical Assistance Services claims/encounter data (November 3, 2016) and 2010 U.S. Census Bureau Population. Circles % of Medicaid recipients whose claims/encounter data included an addiction related diagnosis respective to the total population in that zip code. 19

19 DMAS ADDICTION AND RECOVERY TREATMENT SERVICES How Virginia Medicaid is addressing the Opioid Crisis?

20 Coverage Prior to the Implementation of ARTS on 4/1/17 Incomplete Care Continuum Limited Coverage Residential treatment not covered for non-pregnant adults. Utilizing more expensive inpatient detox. Pregnant women lose eligibility and coverage for treatment 60 days after delivery. Fragmented System: Substance use disorder treatment is separated from mental and physical health services Lack of Providers Rates for substance use disorder treatment have not been increased since 2007 Providers not getting reimbursed for the actual cost of providing care. System severely limits number of providers willing to provide services to Medicaid members. Providers also struggle to understand who to bill for services. Consumers do not know where to seek services. Limited Access to Services

21 Addiction and Recovery Treatment Services (ARTS) Benefit Changes to DMAS s Substance Use Disorder (SUD) Services for Medicaid and FAMIS Members 1 Expand short-term SUD inpatient detox to all Medicaid /FAMIS members 2 Expand short-term SUD residential treatment to all Medicaid members 3 Increase rates for existing Medicaid/FAMIS SUD treatment services 4 Add Peer Support services for individuals with SUD and/or mental health conditions 5 Require SUD Care Coordinators at DMAS contracted Managed Care Plans 6 Provide Provider Education, Training, and Recruitment Activities

22 Reforming the Current Delivery System for Community-Based Services Partial Hospitalization Intensive Outpatient Programs Opioid Treatment Case Management Magellan will continue to cover community-based substance use disorder treatment services for feefor-service members Residential Treatment Inpatient Detox Effective April 1, 2017 Addiction and Recovery Treatment Services (ARTS) Peer Recovery Supports effective July 1, 2017 MAT - Pharmacy Peer Recovery Supports All Community- Based SUD Services will be Covered by Managed Care Plans A fully integrated Physical and Behavioral Health Continuum of Care

23 DMAS ADDICTION AND RECOVERY TREATMENT SERVICES Overview of ASAM Levels of Care

24 ASAM Assessment Criteria

25 ASAM Continuum of Care

26 ASAM LOC Placement VDH/DBHDS/DHP License 4 Medically Managed Intensive Inpatient 3.7 Medically Monitored Intensive Inpatient Services (Adult) Medically Monitored High-Intensity Inpatient Services (Adolescent) 3.5 Clinically Managed High-Intensity Residential Services (Adults) / Medium Intensity (Adolescent) 3.3 Clinically Managed Population-Specific High-Intensity Residential Services (Adults) 3.1 Clinically Managed Low-Intensity Residential Services 2.5 Partial Hospitalization Services 2.1 Intensive Outpatient Services Acute Care General Hospital (12VAC5-410) Inpatient Psychiatric Unit Acute Freestanding Psychiatric Hospital Substance Abuse (SA) Residential Treatment Service (RTS) for Adults/Children Residential Crisis Stabilization Unit SA RTS for Women with Children Medical Detox License required for all Inpatient Psychiatric Unit (3.5) )/Required for co-occurring enhanced programs SA RTS for Adults (3.3 or 3.5) and Children (3.5) SA and MH RTS for Adults and Children (3.3 or 3.5)/Required for co-occurring enhanced programs SA RTS for Women with Children (3.3 or 3.5) Supervised RTS for Adults (3.3) Medical Detox License required for 3.2 WM MH & SA Group Home Service for Adults and Children (Required for co-occurring enhanced programs) SA Halfway House for Adults SA or SA/Mental Health Partial Hospitalization (2.5) SA Intensive Outpatient for Adults, Children and Adolescents (2.1) Outpatient Managed Withdrawal Service Licensed required for 2WM 1 Outpatient Services 0.5 Early Intervention Outpatient Services N/A; All Licensed Providers Opioid Treatment Program (OTP) Opioid Treatment Program

27 Benefits of ASAM for Providers Uniform Credentialing Checklist All health plans and Magellan will use uniform credentialing checklist based on ASAM to credential providers at all ASAM Levels of Care Providers can use this checklist to determine if they meet criteria for specific ASAM Level of Care Uniform Patient Assessment/ Service Authorization One uniform form based on ASAM for providers to request service authorization for all ASAM Levels 2.1 to 4.0 All health plans and Magellan will recognize uniform service authorization for ASAM Levels 2.1 to 4.0 No service authorization for ASAM Level 1.0 outpatient or ASAM Level 0.5 Health plans and Magellan will review service authorization within 72 hours with retroactive authorization to facilitate immediate access to care Level 4.0 inpatient detox services authorized within 24 hours

28 DMAS ADDICTION AND RECOVERY TREATMENT SERVICES ARTS Provider Qualifications

29 Provider Qualifications for ARTS Covered Services Addiction Credential Physicians have achieved professional recognition in the treatment of addiction and have been certified for their expertise in treating addiction by one of the following three pathways: any physician who has completed an addiction medicine fellowship or met other eligibility criteria and then by examination, received certification and diplomate status from the American Board of Addiction Medicine; or a psychiatrist who completed a fellowship in addiction psychiatry and then by examination, became certified by the American Board of Psychiatry and Neurology; or a doctor of osteopathy (DO) who received certification in addiction medicine through examination and certification by the American Osteopathic Association. In situations where a certified addiction physician is not available, physicians treating addiction should have some specialty training and/or experience in addiction medicine or addiction psychiatry. If treating adolescents, they should have experience with adolescent medicine. Physician Extenders are licensed nurse practitioners and physician assistants.

30 Provider Qualifications for ARTS Covered Services Credentialed Addiction Treatment Professionals Addiction-credentialed physicians or physicians with experience in addiction medicine Licensed psychiatrists Licensed clinical psychologists Licensed clinical social workers Licensed professional counselors Licensed psychiatric clinical nurse specialists Licensed psychiatric nurse practitioner Licensed marriage and family therapist Licensed substance abuse treatment practitioner

31 Provider Qualifications for ARTS Covered Services Credentialed Addiction Treatment Professionals cont. Residents under supervision of licensed professional counselor, licensed marriage and family therapist or licensed substance abuse treatment practitioner approved by the Virginia Board of Counseling Residents in psychology under supervision of a licensed clinical psychologist approved by the Virginia Board of Psychology Supervisees in social work under the supervision of a licensed clinical social worker approved by the Virginia Board of Social Work An individual with certification as a substance abuse counselor (CSAC) or certified substance abuse counselor-assistant (CSAC-A) under supervision of licensed provider and within scope of practice

32 Certified Substance Abuse Counselor Provider Requirements Providers need to ensure their staff meet the Board of Counseling certification requirements for CSAC and CSAC Assistants by April 1, 2017 in order to receive Medicaid/FAMIS reimbursement for all ARTS services. CSAC and CSAC-A need to practice within their scope of practice as define by the Board of Counseling ( and ) Certifications approved by the Board of Counseling for Certification as a Substance Abuse Counselor by Endorsement The National Certified Addiction Counselor Level II (NCAC II) accreditation from the National Certification Commission for Addiction Professionals (NCC AP)/NAADAC, the Association of Addiction Professionals; The Master Addiction Counselor (MAC) accreditation from the National Certification Commission for Addiction Professionals (NCC AP)/NAADAC, the Association of Addiction Professionals; or The Advanced Alcohol & Drug Counselor (AADC) accreditation from the International Certification & Reciprocity Consortium (IC&RC)

33 DMAS ADDICTION AND RECOVERY TREATMENT SERVICES OBOT Providers

34 Preferred Office-Based Opioid Treatment (OBOT) Settings and Care Model CSBs, FQHCs, outpatient clinics psychiatry practices, primary care clinics Provide Medication Assisted Treatment (MAT) - use of medications in combination with counseling and behavioral therapies that results in successful recovery rates of 40-60% for opioid use disorder compared to 5-20% with abstinence-only models Supports integrated behavioral health - buprenorphine waivered practitioner with on site behavioral health provider (e.g., psychologist, LCSW, LPC, psych NP, etc.) providing counseling to patients receiving MAT Payment Incentives Buprenorphine-waivered practitioner in the OBOT can bill all Medicaid health plans for substance use care coordination for members with moderate to severe opioid use disorder receiving MAT Can bill higher rates for individual and group opioid counseling Can bill for Certified Peer Recovery Support specialists 35

35 Preferred OBOT Providers Recognized by DMAS and Credentialed by Health Plans Care Team Requirements Buprenorphine-waivered practitioner (physician, NP, or PA who has completed 8 hour SAMHSA training) may practice in settings such as CSBs, FQHCs, primary care clinics, outpatient psychiatry clinics Co-located credentialed addiction treatment professional (licensed psychiatrist, licensed clinical psychologist, licensed clinical social worker, licensed professional counselor, licensed psychiatric clinical nurse specialist, licensed psychiatric NP) providing counseling on-site MAT Requirements Buprenorphine monoproduct prescribed only to pregnant women.. Maximum daily buprenorphine dose 16 mg unless documentation of ongoing compelling clinical rationale for higher dose up to max of 24 mg. No tolerance to other opioids, soma, sedative hypnotics, or benzodiazepines except for patients already on benzos for 3 months during a tapering plan

36 Preferred OBOT Providers Recognized by DMAS and Credentialed by Health Plans Risk Management and Adherence Monitoring Random urine drug screens, a minimum of 8 times per year. Virginia Prescription Monitoring Program checked at least quarterly. Opioid overdose prevention education including the prescribing of naloxone. Patients seen at least weekly when initiating treatment. Utilization of unused medication and opened medication wrapper counts Benefits to Preferred OBOT Providers No Prior Authorizations required for buprenorphine products. Can bill all Medicaid health plans for substance use care coordination for members with moderate to severe opioid use disorder receiving MAT. Can bill higher rates for individual and group opioid counseling. Can bill for Certified Peer Recovery Support specialists.

37 OBOT Providers will be Credentialed by Health Plans Care Team Requirements Buprenorphine-waivered physician may practice in a variety of practice settings including primary care clinics, outpatient health system clinics, psychiatry clinics, FQHCs, CSBs, Local Health Departments, and physician s offices On site licensed behavioral health provider (licensed clinical psychologist, licensed clinical social worker, licensed professional counselor, licensed psychiatric clinical nurse specialist, a licensed psychiatric nurse practitioner, a licensed marriage and family therapist, a licensed substance abuse treatment practitioner, or CSAC) providing counseling to patients receiving buprenorphine MAT Requirements Buprenorphine monoproduct prescribed only to pregnant women. All other patients receive buprenorphine/naloxone or naltrexone products Maximum daily buprenorphine/naloxone dose 16 mg unless documentation of ongoing compelling clinical rationale for higher dose up to maximum of 24 mg. No tolerance to other opioids, soma, stimulants, or benzodiazepines except for patients already on benzodiazepines for 3 months during a relapse or tapering plan

38 OBOT Providers will be Credentialed by Health Plans Risk Management and Adherence Monitoring Requirements Random urine drug screens, a minimum of 8 times per year for all patients. Virginia Prescription Monitoring Program checked at least quarterly for all patients. Opioid overdose prevention education including the prescribing of naloxone. Patients seen at least weekly when initiating treatment. Patient must have been seen for at least 3 months with documented clinical stability before spacing out to a minimum of monthly visits with physician or licensed behavioral health provider. Periodic utilization of unused medication and opened medication wrapper counts when clinically indicated. Benefits No Prior Authorizations required for buprenorphine or buprenorphine/naloxone Buprenorphine-waivered physician in the OBOT can bill all Medicaid health plans for substance abuse care coordination code (monthly per member payment) for members with moderate to severe opioid use disorder receiving MAT. Can bill for Certified Peer Recovery Support specialists Buprenorphine waivered residents can complete structured moonlighting experiences under the supervision of a credentialed attending physician Public recognition (if desired) as a Gold-Card OBOT clinic who is a preferred provider.

39 OBOT: Possible Models for Integrated Behavioral Health + Waivered Physician Waivered Physician + Behavioral Health Professional Employed by Same Site FQHC, public or private behavioral health provider, primary care physician, outpatient clinic, etc. employs buprenorphine-waivered physician AND behavioral health professional to offer MAT for opioid use disorder Services would be billed through the physician Waivered Physician On-site at Behavioral Health Provider Waivered physician goes on-site to private or public behavioral health provider 2-3x per week to provide MAT Services would be billed through the physician Behavioral Health Professional On-Site at Health Department, Physician s Office, or FQHC Behavioral health professional (LCSW, LPC, psychologist, etc.) goes on-site to FQHC, health department, PCP office, or outpatient clinic 2-3x per week to provide MAT Services would be billed through the physician Attend the Addiction Disease Management Training Attend the Virginia Department of Health Addiction Disease Management Trainings to earn free CMEs, physicians receive 8 hours needed to apply for the waiver to prescribe buprenorphine for treatment of opioid addiction, and learn how to successful bill for and be reimbursed for MAT.

40 Buprenorphine Prior Authorization Requirements Uniform Requirements Adopted by FFS and Managed Care Plans Diagnosis of Opioid Use Disorder, and > 16 years of age; and Prescriber s personal DEA and XDEA numbers are required; and Individual is participating is psychosocial counseling Maximum of 16 mg per day Initial authorization for 3 months; subsequent authorizations for 6 months No set time limit or duration of treatment Buprenorphine only products for pregnant women Patient is locked-in to prescribing physician and dispensing pharmacy No concurrent use with benzodiazepines, tramadol, carisoprodol, other opiates or stimulants Urine drug testing at least 4 times per 6 months

41 Medication Medications Available for Medication Assisted Therapy for all SUDs Buprenorphine/Naloxone and Buprenorphine (for pregnant women only) Methadone Prior Authorization Required Induction (7 days) no Maintenance - yes No (for opioid use disorder) Naltrexone Long-Acting Injection Naltrexone (oral) Naloxone Disulfiram Acamprosate No No No No No Note: Prior Authorizations are not required for buprenoprhine/naloxone or buprenorphine provided by OBOTs or OTPs credentialed by health plans.

42 Opioid Overdose Fatality Prevention Increase Access to Naloxone FFS and Managed Care Plans Expand Naloxone Coverage Prior Authorization not required for Naloxone injection Naloxone (Narcan )nasal spray

43 Rate Structure for Preferred OBOTs: New Codes Code Service Description Unit Rate/ Unit H0014 Medication Assisted Treatment (MAT) induction Ambulatory detoxification Withdrawal Management- Induction Per encounter $140 H0004 H0005 Opioid Treatment Services Opioid Treatment Services Opioid Treatment individual and family therapy Opioid Treatment group therapy 1 unit= 15 min 1 unit = 15 min (per patient) $24 $7.25 G9012 Substance Use Care Coordination Substance Use Care Coordination 1 unit = 1 month $243 T1012 Peer Support Peer Recovery Support Specialist 1 unit = 15 minutes $6.50

44 Rate Structure for OBOTs: Existing Codes Code Service Description CPT E/M Code CPT Codes for Labs Established Patient Visit Urine Drug Screens Labs Follow-Up Visits by Physician/NP after Induction Urine Drug Screen for Opioids and Illicit Drugs Examples: Hepatitis B Test (86704), Hepatitis C test (86803), HIV Test (86703), Syphilis Test (86593), Treponema Pallidum (86780), Syphilis Test Non-Treponema (86592), Pregnancy Test (81025), Skin Test- Tuberculin (86585), EKG (93000, 93005, 93010), Alcohol-Breathalyzer (82075)

45 Higher Rates for Opioid Counseling Service Description Psychosocial Treatment for Opioid Use Disorder that includes at a minimum the following components: Assessment of psychosocial needs Supportive individual and/or group counseling Linkages to existing family support systems Referrals to community-based services Care coordination, medical/prescription monitoring, and coordination of on-site and off-site treatment services Provider Requirements Credentialed Addiction Treatment Professionals

46 NEW Substance Use Care Coordination Service Description Integrates behavioral health into primary care and specialty medical settings through interdisciplinary care planning and monitoring patient progress and tracking patient outcomes. Supports interdisciplinary team meetings with medical and behavioral health staff to develop and monitor individualized treatment plans. Links patients community resources (including NA, AA, peer recovery supports, etc.) to facilitate referrals and respond to social service needs. Tracks and supports patients when they obtain medical, behavioral health, or social services outside the practice. Provider Requirements At least a bachelor's degree in one of the following fields (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling) and has at least one year of substance abuse related clinical experience; or An individual with certification as a substance abuse counselor (CSAC)

47 PEER SUPPORT SERVICES Integrating Recovery Focused Peer Supports into Virginia s Medicaid Program

48 Effective July 1, 2017 Peer Support Services A Peer Recovery Specialist (PRS) is a self-identified individual with lived experience with mental health or substance use disorders, or co-occurring mental health and substance use disorders who is trained to offer support and assistance in helping others in the recovery and community-integration process. Available to individuals who have mental health conditions and/or substance use disorders Supported by The Centers for Medicare & Medicaid Services (CMS) as an important component in the State s delivery of effective treatment. Supported by the Governor s Task Force on Prescription Drug and Heroin Addiction Established in response to a legislative mandate 49

49 RECOVERY Recovery is not limited to substance use disorder treatment. The provision of Peer Services facilitates recovery from both serious mental health conditions and substance use disorders. Recovery is a process in which people are able to live, work, learn and fully participate in their communities. 50

50 Peer Support: Targeted Populations ADULTS* Over 21 Peer Support Services YOUTH Under 21 Family Support Partners ARTS ARTS Mental Health Mental Health *Allowance for year olds *Individuals years old who meet the eligibility criteria for Peer Support Services in ARTS or MH, who would benefit from receiving peer supports directly, and who choose to receive Peer Support Services directly instead of through their family are permitted to receive Peer Support Services by an appropriate Peer Recovery Specialist. 51

51 TARGETED SETTINGS ARTS Acute Care General Hospital ASAM 4.0 licensed by Virginia Department of Health. Freestanding Psychiatric Hospital or Inpatient Psychiatric Unit ASAM Levels 3.7 and 3.5 licensed by Department of Behavioral Health and Developmental Services Residential Placements ASAM Levels 3.7, 3.5, 3.3, and 3.1 licensed by Department of Behavioral Health and Developmental Services Partial Hospitalization and Intensive Outpatient ASAM Levels 2.5 & 2.1 Outpatient Services ASAM Level 1 Opioid Treatment Program (OTP) Office Based Opioid Treatment (OBOT) Hospital Emergency Department Services licensed by Virginia Department of Health. Pharmacy Services licensed by Virginia Department of Health. MENTAL HEALTH Acute Care General and Emergency Department Hospital Services licensed by Virginia Department of Health. Freestanding Psychiatric Hospital and Inpatient Psychiatric Unit licensed by Department of Behavioral Health and Developmental Services. Psychiatric Residential Treatment Facility licensed by Department of Behavioral Health and Developmental Services. Therapeutic Group Home licensed by Department of Behavioral Health and Developmental Services. Outpatient mental health clinic services licensed by Department of Behavioral Health and Developmental Services. Outpatient psychiatric services provider CMHRS provider licensed by the Department of Behavioral Health and Developmental Services 52

52 Covered Services Peer Support Services shall be rendered on an individual basis or in a group. PEER SUPPORT SERVICES & FAMILY SUPPORT PARTNERS ARTS Individual ARTS Group Mental Health Individual Mental Health Group UNIT VALUE 1 unit=15 minutes PROCEDURE CODE T1012 S9445 H0024 H0025 RATE $6.50 per 15 minute unit $2.70 per 15 minute unit per member $6.50 per 15 minute unit $2.70 per 15 minute unit per member DAILY LIMITS 4 hours/16 units per calendar day ANNUAL LIMITS Up to 900 hours/3600 units per calendar year Up to 900 hours/3600 units per calendar year 53 AH

53 GOVERNOR S ACCESS PLAN FOR THE SERIOUSLY MENTAL ILL (GAP)

54 The Mental Health Coverage GAP in VA Serious Mental Illness (SMI) and co-occurring disorders and conditions are HIGHLY treatable. We believe that establishing a benefit plan that targets individuals with SMI will enable them to access behavioral and primary health services in order to help them recover, live, work, parent, learn, and participate in their communities. Help for Individuals with SMI 55

55 Bridging the Mental Health Coverage GAP Eligibility & Enrollment Ages 21 through 64 U.S. Citizen or lawfully residing immigrant Requirements Not eligible for any existing entitlement program Resident of VA Income below 80%* of Federal Poverty Level (FPL) (*80% + 5% disregard) Effective 10/1/2017, Income below 100%* of FPL (*100% + 5% disregard) Uninsured Does not reside in long term care facility, mental health facility or penal institution Screened and meet GAP SMI criteria GAP application is a two step process: Financial/non-financial determination with Cover Virginia GAP SMI determination with Magellan 56

56 2 Step Application Process SMI Screening Financial Application Having a GAP SMI Screening done at your local Community Services Board (CSB) or a participating Federally Qualified Health Center (FQHC). Find the nearest SMI screening provider by calling GAP9 To start the application process contact Cover Virginia #

57 Bridging the Mental Health Coverage GAP Integrating care coordination, primary care, specialty care, pharmacy and behavioral health services Outpatient Medical GAP Benefits Outpatient Behavioral Health Magellan Only Services Primary & Specialty Care GAP Case Management Care Coordination; Community Wellness/Community Connection Substance Abuse Services Screening Brief Intervention and Referral to Treatment Intensive Outpatient Outpatient Laboratory Psychiatric Evaluation, Management and Treatment Crisis Line available 24/7 Opioid Treatment Programs Pharmacy Crisis Intervention and Stabilization Recovery Navigation Office Based Opioid Treatment Diagnostic Services Physician s office Outpatient hospital coverage limited to: diagnostic ultrasound, diagnostic radiology (including MRI and CAT) and EKG including stress Psychosocial Rehabilitation Effective 7/1/2017 MH and ARTS Peer Supports Effective 10/1/2017 Partial Hospitalization, Residential and Inpatient Psychiatric Services Diabetic Supplies Outpatient Psych 58

58 COVERAGE AFTER THE IMPLEMENTATION OF ARTS DMAS Addiction and Recovery Treatment Services

59 Preliminary Findings from VCU Evaluation First Quarter of ARTS Implementation Treatment rates among Medicaid members with substance use disorders (SUD) increased by 50% The number of practitioners providing outpatient psychotherapy or counseling to Medicaid members more than doubled: Treating Opioid Use Disorder (OUD) to 691 practitioners Treating SUD to 1,603 practitioners 60

60 Number of Outpatient Providers Treating OUD More than Doubled During the first three months, ARTS has reduced the treatment gap for SUD by increasing th number of practitioners providing services for SUD across all regions in Virginia 61

61 ARTS Narrows the Treatment Gap Prevalence of members with SUD is likely higher than the estimates in this report because they include only those who have been diagnosed or treated for SUD. 62

62 ARTS Narrows the Treatment Gap Prevalence of members with SUD is likely higher than the estimates in this report because they include only those who have been diagnosed or treated for SUD. 63

63 Pharmacotherapy for OUD Increasing ARTS significantly increased the number of Medicaid members receiving pharmacotherapy for OUD in all regions in Virginia. 64

64 QUESTIONS For more information, please contact: