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Perspectives

President signs opioid crisis legislation

The president addresses substance use disorders

President Trump signed the SUPPORT Act, a new law which makes numerous changes to Medicaid, Medicare, the Food and Drug Administration, and adds many new provisions to federal public health and prescription monitoring programs.

October 24, 2018 | Health care

President signs law increasing funding, providing greater flexibility in government programs to address opioid use disorders

On October 24, 2018, President Trump signed the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, or the SUPPORT Act. The law passed with broad bipartisan support in the Senate and House of Representatives.

The new law provides additional funding for Medicaid and Medicare for treatment of substance use disorders (SUDs) in various care settings, while also creating new requirements for Medicare Advantage (MA) and Part D prescription drug plans aimed at reducing opioid abuse. In addition, a provision of the law creates stronger incentives for states to adopt medical loss ratios (MLR) for Medicaid managed care plans of at least 85 percent. The MLR provision was included to help offset the cost to the federal government of increased spending via other provisions.

Highlights of select key provisions of the law dealing with health care payment and delivery are provided below.

Medication-assisted treatment (MAT)

The law will expand the clinicians permitted to prescribe or dispense medication-assisted treatment (MAT) in an effort to make MAT more widely available. Specifically, the law would authorize clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists to prescribe MAT in fiscal year (FY) 2019 through FY 2023. The authority for physician assistants and nurse practitioners to prescribe MAT is made permanent under the law.

In addition, the law will permit clinicians board-certified in addiction medicine or who provide the treatment in a qualified practice setting immediately to provide MAT to as many as 100 patients. The law also codifies regulations that permit physicians to provide MAT to as many as 275 patients.1

Currently, clinicians can provide MAT to 30 patients, although the cap increases to 100 patients after one year of obtaining a waiver from registration requirements. After another year, the cap can increase to 275 patients.

The Congressional Budget Office (CBO) projects that the provision will increase federal spending by $395 million from 2019 through 2028.2

Medicaid

The law requires state Medicaid programs for FY 2021 through 2025 to cover medication-assisted treatment, including methadone and counseling services. The same provision also extends an enhanced federal match rate for treatment of substance use disorders for Medicaid beneficiaries in Medicaid health homes from eight quarters to 10 quarters.3 The CBO projects that the provision will increase federal spending by the $509 million from 2019 through 2028.4

The SUPPORT Act will allow states to file state plan amendments (SPAs) to cover care in certain institutes of mental disease (IMDs), including IMDs with more than 16 beds for which federal funding historically has been restricted. To have their SPAs approved, state Medicaid programs will be required to meet certain requirements, including:

  • Covering certain outpatient and inpatient levels of care
  • Maintaining certain state spending requirements
  • Fulfilling other reporting and notification rules

The provision provides for state Medicaid programs to receive federal reimbursement for up to 30 days of care in an IMD during a 12-month period for eligible individuals.5 The CBO projects that the provision will increase federal spending by more than $1 billion from 2019 through 2028.6

The Act also codifies existing regulations that provide for managed care organizations to receive federal matching funds for patients in IMDs for 15 days or less per month.

States will also be required to maintain opioid drug review and use programs to find instances of overutilization and other high-risk prescribing patterns and will be required to report on behavioral health quality as part of their core set of adult health quality measures.

The law directs CMS to issue guidance to states on options to provide telehealth services for treatment of SUDs under Medicaid. Under the law, the guidance is required to address state options for services addressing high-risk individuals, provider education through a hub-and-spoke model, and options for providing telehealth services to students in school-based health centers.

In an effort to encourage states to adopt medical loss ratios (MLRs) of at least 85 percent for Medicaid managed care organizations (MCOs), the law will allow them to retain a higher percentage of remittances paid as a result of the MLR for a limited period of time. Current regulations require an MLR of at least 85 percent only if states establish an MLR.7 The CBO projects that greater adoption of an 85 percent MLR by state Medicaid programs would reduce federal spending by the $2.7 billion from 2019 through 2028.8

Medicare

Beginning July 1, 2019, the law will eliminate statutory originating site requirements for telehealth services provided to Medicare beneficiaries for treatment of SUDs and co-occurring mental health disorders. Medicare reimbursement will be available at originating sites, including a beneficiary’s home, regardless of geographic location. If the originating site is a beneficiary’s home, Medicare will not provide a separate facility fee.9 The CBO projects that the provision will increase federal spending by the $18 million from 2019 through 2028.10

Beginning January 1, 2021, prescriptions for a Schedule II, III, IV, or V Controlled Substance covered under a Part D prescription drug plan or MA prescription drug plan must be transmitted via an electronic prescribing program.

Part D prescription drug plans will be required to include drug management programs for beneficiaries at risk of SUDs beginning by the plan year 2022.

Under the SUPPORT Act, Medicare coverage will expand to include Opioid Treatment Programs (OTPs) for purposes of delivering MAT to expand treatment options for Medicare beneficiaries. Medicare payments for OTPs will be made via bundled payments, including necessary medications, counseling, and testing.11 The CBO projects that the provision will increase federal spending by the $250 million from 2019 through 2028.12

The SUPPORT Act directs the Centers for Medicare and Medicaid Innovation (CMMI) to pilot an incentive payment program for behavioral health providers aimed at facilitating greater adoption of certified electronic health record technology (CEHRT).

In an effort to improve compliance with Medicare secondary payer requirements, the law will extend mandatory requirements for group health plans to include prescription drug coverage. Such information will be transmitted to HHS and Part D sponsors to more effectively coordinate benefits related to Medicare Part D.13

Endnotes

1 SUPPORT for Patients and Communities Act (H.R. 6), September 28, 2018.

2 Estimated Direct Spending and Revenue Effects of H.R. 6, Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. September 27, 2018.

3 SUPPORT for Patients and Communities Act (H.R. 6), September 28, 2018.

4 Estimated Direct Spending and Revenue Effects of H.R. 6, Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. September 27, 2018.

5 SUPPORT for Patients and Communities Act (H.R. 6), September 28, 2018.

6 Estimated Direct Spending and Revenue Effects of H.R. 6, Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. September 27, 2018.

7 SUPPORT for Patients and Communities Act (H.R. 6), September 28, 2018.

8 Estimated Direct Spending and Revenue Effects of H.R. 6, Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. September 27, 2018.

9 SUPPORT for Patients and Communities Act (H.R. 6), September 28, 2018.

10 Estimated Direct Spending and Revenue Effects of H.R. 6, Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. September 27, 2018.

11 SUPPORT for Patients and Communities Act (H.R. 6), September 28, 2018.

12 Estimated Direct Spending and Revenue Effects of H.R. 6, Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. September 27, 2018.

13 SUPPORT for Patients and Communities Act (H.R. 6), September 28, 2018.

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Deloitte Risk and Financial Advisory
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