1. 2016 National Training Program Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders July 2016

2. Session Objectives  This session should help you Identify the prevalence of substance use disorders (SUDs) Describe the opioid crisis and the new recommendations in place to reduce the misuse of opioids Explain SUD services and prescription drugs covered by Medicare, Medicaid, and the Marketplace Use resources to help with questions July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 2

3. Substance Use Disorder (SUD)  SUDs can refer to substance use or substance dependence Can refer to alcohol, tobacco, cannabis, stimulants, hallucinogens, opioids  Symptoms of SUDs may include: Behavioral changes Physical changes Social changes  Diagnosis of SUD is based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders3

4. Co-Occurring Disorder—Mental Illness and SUDs  Mental illness and SUDs often occur together  Share some underlying causes (changes in brain composition, genetic vulnerabilities, and early exposure to stress or trauma)  Drugs can cause people with an addiction to experience one or more symptoms of a mental health problem  Mental health problems can lead to alcohol or drug use, as a form of self-medication  Less than 10% of individuals with co-occurring disorders receive treatment Source: SAMHSA / National Survey of Drug Use and Health (NSDUH 2014) July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders4

5. 2014 Substance Use Disorders and Mental Illness Among Adults Aged 18 or Older Source: National Survey on Drug Use and Health (NSDUH 2014) July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 5

6. Opioids July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 6

7. About Opioids  A type of pain medication that comes from opium plants Common prescription opioids include oxycodone, hydrocodone, fentanyl, and morphine Sometimes called narcotics  Addiction to prescription opioids is the strongest predictor for heroin addiction July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders7

8. Opioid Crisis Facts and Figures  In 2014, more than 28,000 people in the U.S. died from overdoses from all types of opioids combined  About 14,000 out of the 28,000 deaths were prescription opioids  Heroin-related deaths have tripled since 2010  The most commonly diverted drugs are opioids  Nearly 80% of individuals with an opioid use disorder don’t receive treatment Source: CDC, SAMHSA July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 8

9. Individuals at High Risk for Overdose  You may be at high risk for an overdose if you Take high daily doses of opioids “Doctor shop” Use of a combination of drugs like opioids, benzodiazepines, central nervous system depressants, and/or other legal/illicit drugs Have a history of substance use disorders or other mental health issues  Medicaid, low-income, and rural populations have a higher risk for overdose Source: CDC’s Primary Care and Public Health Initiative July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 9

10. Medication Assisted Treatment (MAT) for Opioid Addiction Combines behavioral therapy and medications to treat opioid addictions Controlled SubstancesNon-Controlled Substances Requires a prescription Regulated by state and federal government Sometimes requires a prescription Prescribing limit depends on state and insurance plan Examples: Methadone – only obtained at a clinic Suboxone (Buprenorphine/Naloxone combined) – prescribed or dispensed in doctor’s offices / used for outpatient maintenance therapy Examples: Naloxone – often used for heroin overdose in an emergency situation to block or reverse the effect of the opioid July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 10

11. Department of Health and Human Services Opioid Initiatives July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 11  March 2015 – DHHS Secretary’s opioid abuse initiative to decrease overdose and prevalence of opioid use disorder  October 2015 – Presidential Memorandum Reduce opioid deaths, promote appropriate and effective pain medication prescribing, and improve treatment access Active partners in opioid initiative  Substance Abuse and Mental Health Services Administration (SAMHSA)  Food and Drug Administration (FDA)  National Institutes of Health-National Institute on Drug Abuse (NIH-NIDA)  Centers for Medicare & Medicaid Services (CMS)  Office of the Assistant Secretary for Health (OASH)  Centers for Disease Control and Prevention (CDC)

12. 2016 CDC Guidelines for Prescribing Opioids for Chronic Pain in the U.S.  Provides recommendations for doctors who are prescribing opioids for conditions other than cancer treatment, palliative care, and end-of-life care and addresses When to initiate or continue opioids for chronic pain Choosing the appropriate opioid, dosage, duration, follow-up, and discontinuation Assessing risk and addressing harms of opioid use cdc.gov/drugoverdose/prescribing/guideline July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 12

13. Medicare and SUDs July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 13

14. Medicare Coverage of SUD Treatment  Medicare will cover alcohol and drug treatment if: Services are from Medicare-participating provider or facility Doctor states that services are medically necessary Doctor sets up a plan of treatment  Medicare Part A pays for hospitalization  Medicare Part B pays for clinic or hospital outpatient Psychotherapy Patient education regarding diagnosis and treatment Post-hospitalization follow-up Structured Assessment and Brief Intervention (SBIRT) services Alcohol misuse screening and counseling July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 14

15. Medicare Alcohol Misuse Screening and Counseling  Annual screening Up to 4 face-to-face counseling sessions if you  Misuse alcohol but don’t meet criteria for alcohol dependence  Are competent and alert when counseled Counseling must be furnished  By a qualified primary care provider  In a primary care setting  Medicare doesn't identify specific screening tool  No copayment or deductible if provider accepts assignment July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 15

16. Prescription Drug Coverage—SUD Treatment  Medicare Part A covers prescription drugs administered during an hospital stay or injected at a doctor’s office  Part D covers outpatient prescription drugs needed for treatment Medication-Assisted Treatment Examples Part A Methadone for inpatient detox Naloxone is limited when administered inpatient Part B Naloxone injection after detox Part C Methadone for inpatient detox Naloxone injection after detox Part D Suboxone Methadone (pain only) Naloxone, if not covered under Part B July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 16

17. Medicare Part D Overutilization Monitoring System (OMS)  January 2013: Medicare initiated the OMS to prevent overutilization of certain prescribed medications  July 2013: Began providing reports to Part D plans about persons with Medicare who were noted as high opioid users  February 2014: CMS enhanced the Medicare Advantage Prescription System (MARx) which identifies high opioid users MARx system alerts a new Part D plan when a flagged person with Medicare enrolls in a new Part D plan Person with Medicare can be denied a prescription at the pharmacy July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 17

18. Medicare Part D Opioid Drug Mapping Tool Allows providers, local health officials, and others to:  Learn about their community’s Medicare opioid prescription rate  Make geographic comparisons of Medicare Part D opioid prescription claims go.cms.gov/opioidheatmap July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 18

19. Improving Mental Health and SUD—Medicaid July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 19

20. Mental Health SUD Treatment Services— Medicaid  States have the option to cover SUD treatment services like counseling, psychosocial and behavioral health therapies  States may choose to offer pharmacy benefits It’s optional for adults Varies by state and by the drug  SUD services are required for Individuals under age 21 The newly eligible adult group (aged 19-64 with income at or under 133 percent of the FPL) in states that have expanded Medicaid July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 20

21. Medicaid Opportunities for States to Address Mental Health and SUDs  Final Mental Health and Substance Use Disorder parity rule for Medicaid and CHIP Strengthens access to mental health and SUD benefits for low-income Americans Plans must disclose information on mental and SUD benefits upon request State must disclose reasons for denying reimbursement or payment for services  CMS and federal partners work with states to improve their SUD services Innovation Accelerator Program for better SUD, primary care, and mental health integration Health Homes that focus on mental health Certified Community Behavioral Health Centers July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 21

22. Medicaid Pharmacy Program Drug Use Management Strategies  Preferred drug list  Clinical criteria  Step therapy  Prior authorization  Quantity limits  Drug utilization review  Prescription Drug Monitoring Program 22 July 2016Medicare, Medicaid, and Marketplace and Substance Use Disorders

23. The Health Insurance Marketplace July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 23

24. The Marketplace—Mental Health and Substance Use Coverage All Marketplace plans cover mental health and substance use disorders services as essential health benefits  Behavioral health treatment, such as psychotherapy and counseling  Mental and behavioral health inpatient services  Substance use disorder treatment  Specific behavioral health benefits depend on your state and the health plan  Pre-existing mental and behavioral health conditions are covered  “Parity" protections between mental health and substance use disorders benefits July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 24

25. Resources July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 25

26. Substance Abuse & Mental Health Services Administration (SAMHSA) Resources samhsa.gov/find-help July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 26

27. Other Resources for Providers July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 27

28. HHS Opioid Resources  HHS Opioids Initiative hhs.gov/opioids/ hhs.gov/opioids/  Centers for Disease Control and Prevention cdc.gov/primarycare/materials/opoidabuse/index.html cdc.gov/primarycare/materials/opoidabuse/index.html  U.S. Food and Drug Administration fda.gov/drugs/drugsafety/informationbydrugclass/ucm337066.htm\ fda.gov/drugs/drugsafety/informationbydrugclass/ucm337066.htm\  National Institute on Drug Abuse drugabuse.gov/publications/research-reports/prescription- drugs/opioids drugabuse.gov/publications/research-reports/prescription- drugs/opioids July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 28

29. This Training Provided by the CMS National Training Program (NTP) For questions about training products, email training@cms.hhs.gov. training@cms.hhs.gov To view all available NTP training materials, or to subscribe to our email list, visit CMS.gov/outreach-and- education/training/CMSNationalTrainingProgram July 2016 Medicare, Medicaid, and Marketplace Coverage for Substance Use Disorders 29