CMS Actions to Address the Opioid Crisis Objectives

CMS Actions to Address the Opioid Crisis Objectives

CMS Actions to Address the Opioid Crisis Objectives This session should help you Review facts about the opioid crisis Describe CMS actions to address the opioid crisis Explain opioid-related services and prescription drug coverage under Medicare, Medicaid and the Marketplace Locate opioid information resources July 2019 CMS' Actions to Address the Opioid Crisis

2 Opioids Overview Prescription opioids can be prescribed to treat moderate to severe pain, but can also have serious risks and side effects. Examples include Oxycodone (OxyContin) Hydrocodone (Vicodin) Morphine Codeine

Methadone Fentanyl is a synthetic opioid pain reliever that is many times more powerful than other opioids and is approved for treating severe pain, like advanced cancer pain. Its also illegally made and distributed. Heroin is an illegal opioid. July 2019 CMS' Actions to Address the Opioid Crisis 3 Opioids and Older Adults Pain is one of the most common health problems for people older than 65 and is linked to less mobility, avoiding activity, falls, depression, anxiety, sleep

disruption, and isolation Opioids can help some older adults remain independenta key predictor of healthand can effectively treat some debilitating pain that impacts function and quality of life Opioid use can pose certain health risks for older adults, including constipation, breathing issues, confusion, drug interactions, and increased fall risk Prescribers play a key role in weighing the benefits and risks of opioid use in their older patients July 2019 CMS' Actions to Address the Opioid Crisis 4

Opioid Crisis 1 CDC: CDC.gov/drugoverdose/data/index.html July 2019 CMS' Actions to Address the Opioid Crisis 5 CMS Roadmap Fighting the Opioid CrisisOverview Scope of the problem

Key areas of focus Successes so far Moving forward To view the entire CMS Opioids Roadmap, go to CMS.gov/About-CMS/Agency-Information/Emergency/Downloads/Opioid-epidemi c-roadmap.pdf July 2019

CMS' Actions to Address the Opioid Crisis 6 Scope of the Problem Source: HHS: HHS.gov/opioids/about-the-epidemic/index.html 3 Source: SAMHSA: SAMHSA.gov/sites/default/files/aatod_2018_final.pdf 2 July 2019 CMS' Actions to Address the Opioid Crisis 7

Key Areas of CMS Focus July 2019 CMS' Actions to Address the Opioid Crisis 8 CMS Successes So Far July 2019 CMS' Actions to Address the Opioid Crisis 9

Moving Forward July 2019 CMS' Actions to Address the Opioid Crisis 10 Opioid-Related Services and Coverage Role of payers Medication-assisted treatment (MAT) Medicare Medicaid Marketplace/Exchanges

July 2019 CMS' Actions to Address the Opioid Crisis 11 Role of Payers in Responding to the Opioid Crisis Cover opioid use disorder treatment Monitor prescription opioid trends and address outliers Ensure coverage of treatments for pain that rely less on opioids July 2019 CMS' Actions to Address the Opioid Crisis

12 HHSs Efforts to Improve the Treatment of Pain Department of Health and Human Services (HHS) Established a comprehensive high-level strategy for pain IPRCC.nih.gov/sites/default/files/HHSNationalPainStrategy_5 08C.pdf Leads the Pain Management Best Practices Inter-Agency Task Force Proposed updates to best practices and issued recommendations that address gaps or inconsistencies for managing chronic and acute pain

HHS.gov/ash/advisory-committees/pain/reports/2018-12draft-report-on-updates-gaps-inconsistencies-recommend ations/index.html July 2019 CMS' Actions to Address the Opioid Crisis 13 What is is Medication-Assisted Medication-Assisted Treatment Treatment (MAT) (MAT) What MAT, including opioid treatment programs (OTPs), combines

behavioral therapy and medications to treat substance use disorders. Can be prescribed only by certain providers Can be prescribed by any health professional with prescribing authority Examples: Example: Methadone administered at a clinic Vivitrol (Naltrexone injection) is that meets certain federal opioid administered in a physicians office. treatment program standards Used for outpatient maintenance therapy and requires a prescription

Suboxone(Buprenorphine/Naloxone combined) prescribed or dispensed at a doctors office/by a physician or practitioner meeting specific standards July 2019 CMS' Actions to Address the Opioid Crisis 14 Medicare and Opioids Medicare coverage of drug treatment services Medicare coverage of prescription drugs for drug treatment Medicare Part D (prescription drug coverage)

medication coverage rules CMS final rule to address the opioid crisis through prevention Medicare Part D Opioid Prescribing Mapping Tool July 2019 CMS' Actions to Address the Opioid Crisis 15 Medicare CoverageDrug Treatment Services Medicare will cover drug treatment services if Services are from a Medicare-participating facility, other provider, or physician/practitioner Services are reasonable and necessary

Covered services include Psychotherapy Individual and group counseling Patient education regarding diagnosis and treatment Post-hospitalization follow-up Screening, Brief Intervention, and Referral to Treatment (SBIRT) services Alcohol misuse screening and counseling Screening for depression July 2019

CMS' Actions to Address the Opioid Crisis 16 Medicare CoveragePrescription Drugs for Drug Treatment Medicare covers prescription drugs for drug treatment. They are covered by Part A when administered during a hospital stay Part B when the drug is injectable or implantable and administered by a physician/practitioner in a physicians office or hospital outpatient department Part D when dispensed from a pharmacy when prescribed for medication-assisted treatment (MAT)

July 2019 CMS' Actions to Address the Opioid Crisis 17 Medicare Part D Medication Coverage Rules Medicare Part D drug plans may apply certain coverage rules to Part D drugs on their formularies Prior authorizationrequires the patient or their prescriber to get approval from the plan before the plan will agree to cover the drug Quantity limitsare limits on how much medication can be obtained at a time

Step therapyrequires the patient to try one or more similar, lower cost drugs before the plan will cover the prescribed drug Patient or the prescriber can request an exception if they believe that a coverage rule should be waived July 2019 CMS' Actions to Address the Opioid Crisis 18 CMS Final Rule to Address the Opioid Crisis through Prevention Starts in plan year 2019 Part D plans may adopt drug management programs to limit an atrisk persons access to opioids and benzodiazepines to a selected

network pharmacy/doctor Includes Medicare Advantage Prescription Drug Plans (MA-PDs) and stand-alone Medicare Prescription Drug Plans (PDPs) Person must meet certain criteria showing opioid use with multiple doctors and pharmacies Doesnt apply to people with Medicare who have cancer, get palliative care or are in hospice or long-term care At-risk person may generally select the pharmacy/doctor Limits the availability of the Special Enrollment Period (SEP) for people with Medicare who are dually-eligible for Medicare and Medicaid or have a lowincome subsidy (LIS) July 2019 CMS' Actions to Address the Opioid Crisis

19 Medicare Part D Drug Safety Alerts As of January 1, 2019, Medicare Part D drug plans may send a persons pharmacy a safety alert before a prescription is filled for Possible unsafe amounts of opioids First prescription fills for opioids Use of opioids and benzodiazepines at the same time If a persons prescription cant be filled as written, the pharmacist will give them a notice explaining how they or their doctor can obtain a coverage determination July 2019

CMS' Actions to Address the Opioid Crisis 20 Medicare Part D Opioid Prescribing Mapping Tool Allows providers, local health officials, and others to Learn about their communitys Medicare opioid prescription rate Make geographic comparisons of Medicare Part D opioid prescription claims so they can better target prevention and treatment efforts Go.CMS.gov/opioidheatmap July 2019

CMS' Actions to Address the Opioid Crisis 21 Medicaid and Opioids Coverage of drug treatment Pharmacy program drug use management strategies Drug utilization review Opportunities for states to address mental health and substance use disorders July 2019 CMS' Actions to Address the Opioid Crisis

22 Medicaid Coverage of Drug Treatment States have the option to cover substance use disorder (SUD) treatment services States offer pharmacy benefits Varies by state and the drug In most cases, providers are permitted to prescribe covered, preferred drugs without prior authorization July 2019 CMS' Actions to Address the Opioid Crisis 23

Medicaid Pharmacy Program Drug Use Management Strategies Preferred drug list Clinical criteria Step therapy Prior authorization Quantity limits Drug utilization review State Prescription Drug Monitoring Program (PDMP) July 2019 CMS' Actions to Address the Opioid Crisis 24

Medicaid Drug Utilization Review Annual Report State Medicaid agencies must report drug utilization review (DUR) program activities and processes to Centers for Medicare & Medicaid Services (CMS) every year Ensures appropriate drug utilization policies, including appropriate opioid utilization CMS compiles DUR information for the CMS Medicaid DUR State Comparison/Summary Report at Medicaid.gov/Medicaid/prescription-drugs/drug-utilizatio n-review/index.html July 2019 CMS' Actions to Address the Opioid Crisis

25 Medicaid Opportunities for States to Address Mental Health and Substance Use Disorders (SUDs) Final Mental Health and SUD parity rule Strengthens access to mental health and SUD benefits Plans must disclose information on mental and SUD benefits information States must disclose reasons for denying reimbursement or payment CMS/federal partners work with states to improve SUD and behavioral health services Innovation Accelerator Program (IAP) Health Homes Certified Community Behavioral Health Centers Section 1115 SUD demonstrations July 2019

CMS' Actions to Address the Opioid Crisis 26 The Marketplace and Opioids Mental health coverage and substance use disorder (SUD) coverage July 2019 CMS' Actions to Address the Opioid Crisis 27 The MarketplaceMental Health and

Substance Use Disorder (SUD) Coverage Essential health benefits (EHB) rules require coverage for key categories of benefits Specific benefits depend on your state, but the health plan but must include coverage for Mental health and SUD benefits (including behavioral health treatment) Prescription drugs July 2019 CMS' Actions to Address the Opioid Crisis 28 The MarketplaceMental Health and

Substance Use Disorder (SUD) Coverage (continued) Other protections for Marketplace plans include Cost sharing for EHB benefits must count towards the plans annual limitation No yearly or lifetime dollar limits Must comply with parity" protections Must not discriminate July 2019 CMS' Actions to Address the Opioid Crisis 29 Additional Information and Resources

July 2019 CMS' Actions to Address the Opioid Crisis 30 CMS Opioid Resources CMS.gov/about-cms/story-page/reducing-opioid-misuse.html July 2019 CMS' Actions to Address the Opioid Crisis 31 CMS Collaboration With Federal and Private Partners

Informational Bulletin on Medication-Assisted Treatment (MAT) for Substance Use Disorders Surgeon Generals letter campaign on the prescription drug crisis Centers for Disease Control and Preventions (CDC) Guideline for Prescribing Opioids for Chronic Pain Discussions about expanding the evidence base to inform coverage determinations for alternative therapies Healthcare Fraud Prevention Partnership (HFPP) July 2019 CMS' Actions to Address the Opioid Crisis 32

U.S. Department of Health and Human Services (HHS) Opioid Resources HHS Opioids Initiative HHS.gov/opioids Substance Abuse & Mental Health Services Administration SAMHSA.gov Centers for Disease Control and Prevention CDC.gov/drugoverdose/opioids/index.html U.S. Food and Drug Administration FDA.gov/drugs/drugsafety/informationbydrugclass/ucm337066.htm National Institute on Drug Abuse Drugabuse.gov/publications/research-reports/prescription-drugs/opioids Health Resources & Services Administration HRSA.gov/opioids Administration for Community Living (ACL) ACL.gov/search/node?keys=opioids&=Search Agency for Healthcare Research and Quality AHRQ.gov/topics/opioids.html July 2019

CMS' Actions to Address the Opioid Crisis 33 NEWU.S. Department of Health and Human Services (HHS) Combatting the Opioids Crisis Fact sheet HHS.gov/sites/default/files/opioids-fact-sheet-april-2019.pdf Infographic HHS.gov/sites/default/files/opioids-infographic-april-2019.pdf Watch HHS Secretary Azar explain the HHS 5-point plan for combating the opioid crisis July 2019 CMS' Actions to Address the Opioid Crisis 34

Substance Abuse & Mental Health Services Administration (SAMHSA) Resources Behavioral Treatment Services Locator SAMHSA National Helpline Treatment program locators (buprenorphine and methadone) for opioid addiction July 2019 CMS' Actions to Address the Opioid Crisis

35 Centers for Disease Control and Prevention (CDC) Resources for Providers CDC.gov/drugoverdose/pr escribing/clinical-tools.ht ml July 2019 CMS' Actions to Address the Opioid Crisis 36 This Training is Provided by the

CMS National Training Program (NTP) To view all available NTP training materials, or to subscribe to our email list, visit CMSnationaltrainingprogram.cms.gov. Stay connected. Contact us at [email protected], or follow us @CMSGov #CMSNTP July 2019 CMS' Actions to Address the Opioid Crisis 37

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