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ASAM Joins OHSAM Urging ODM to Require Medicaid Managed Care Plans to Use Nationally Recognized Clinical Standards for Determining Coverage for SUD

October 18, 2017



Ohio’s substance use treatment providers are dedicated to increasing access to and improving the quality of addiction treatment.  Treatment providers working within community behavioral health care agencies, community health centers, hospitals, and physician practices are fighting Ohio’s opioid epidemic from the front lines as they help individuals battling the disease of addiction.  Our community of treatment providers, represented by the undersigned organizations, write today to respectfully urge the Ohio Department of Medicaid (ODM) to require its contracted Managed Care Organizations (MCOs) to set operational, utilization management, and reimbursement policy for addiction treatment services according to nationally recognized clinical standards. 


Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction treatment efforts aim to prevent substance abuse, treat symptoms of withdrawal, manage co-occurring medical and mental health disorders, provide rehabilitative services, and continue care to support individuals in recovery. In recent decades, significant and rapid progress has been made in both the scientific understanding of the disease of addiction and the medical interventions available to treat it. Throughout this evolution, robust efforts have been made to develop evidence-based clinical practices to treat addiction. Through both primary research and systematic consensus reviews, national organizations regularly produce and update comprehensive evidence-based guidelines for treating the disease of addiction in all its phases, from prevention to drug treatment and recovery. 


Treatment providers in Ohio are using all available evidence and guidance to treat substance use disorders and prevent overdose deaths. In serving individuals with addiction, providers use national guidelines and standards to implement high-quality assessments and evidence-informed clinical protocols within their practices.  For example, all treatment providers certified by the Ohio Department of Mental Health and Addiction Services (ODMHAS) must follow Ohio Administrative Code Rule 5122-27-07, which requires providers to assess client admission, continued stay, discharge, or referral to services based on one such national publication by the American Society of Addiction Medicine (ASAM) called the ASAM criteria. The ASAM Criteria is a clinical guide designed to standardize and improve assessment and outcomes-driven treatment and recovery services for individuals with substance use disorders. Ohio providers are held to ASAM standards by the rule cited above, and by other ODMHAS rules that were written to follow ASAM guidance without explicitly citing the national standard. 


Many treatment providers go well beyond the ODMHAS rule cited above and develop their assessments and treatment protocols by combining information from the ASAM criteria with other nationally recognized guidelines and standards. Providers frequently look to ASAM and the U.S. Department of Substance Abuse and Mental Health Services Administration (SAMHSA), the American Academy of Addiction Psychiatry (AAAP), the American Psychological Association (APA), and the National Institute on Drug Abuse (NIDA) as they seek improve the quality and outcomes of their services.  Most treatment providers are using the opportunities presented by the state’s Behavioral Health Redesign to transform their operational and clinical practices using evidence-based protocols to raise quality, improve outcomes, and better meet the needs of their clients.


It is universally accepted that with the worsening opiate epidemic, every effort is necessary to address the need for opiate-dependent patients to receive effective treatment. Despite addiction treatment providers’ best efforts to incorporate evidence-based guidelines into their practices, many in the field regularly experience barriers to providing evidence-based care when health insurers’ reimbursement and utilization management policies are not grounded in sound clinical guidance.


While most of the addiction treatment services provided to individuals with Medicaid are “carved-out” of Medicaid’s managed care benefit today (the State plans to transition these services into the managed care benefit on July 1, 2018), some addiction treatment services, including many physician services, laboratory services, and prescription drugs, are already part of Medicaid’s managed care benefit.  Treatment providers’ experiences with the services that are already “carved-in” inform our request for Medicaid to require the MCOs to follow national addiction treatment guidelines and standards.  The following examples highlight a few of the types of barriers to providing the evidence-based services that are “carved-in” today:


• Some Medicaid MCO’s have established generic MAT policies that don’t allow for clinically appropriate latitude when choosing medications.  Choices of medications for addiction treatment can often be very complicated and individual to each patient.  This decision should be between the provider and the patient and based on a thorough history, physical, and the experience of both parties.  Generic medications can often have significant variance in concentration that affects stability in patients with opioid use disorders specifically.  In addition, sublingual MAT forms actually have widely variable adherence by patients depending on the delivery mechanism and tolerance of the medication.


• Some Medicaid MCOs recently implemented arbitrary limits on the number and type of urine toxicology tests that will be reimbursed within a given timeframe.  These limits were not based on published clinical standards and make it very difficult – and often impossible – for providers to appropriately treat complex opioid use disorder patients with medication assisted treatment (MAT). If MCOs were required to follow published clinical standards, such as ASAM’s consensus statement on Appropriate Use of Drug Testing in Clinical Addiction Medicine, they would need to base reimbursement and utilization management policies on the extensive clinical experience supporting the use of drug testing to improve patient outcomes. Some of the limits of these tests result in providers’ inability to comply with the Ohio OBOT rules (OAC 4731-11-12) and HHS guidance on qualified practice settings and diversion strategies, and can result in medical liability issues.


With these examples in mind, we strongly urge ODM to amend the next revision (effective date 1/1/18) of its provider agreement with the MCOs to require use of evidence-based criteria published by ASAM, SAMHSA, AAAP, APA, and NIDA when setting operational, utilization management, and reimbursement policies for addiction treatment services.  Placing this requirement in the 1/1/18 version of the agreement will ensure MCOs have time to use evidence-based information as they initially design their operations and protocols to prepare for “carving in” community-based treatment services on 7/1/18.  Moreover, adding this requirement to the contract will ensure (1) MCOs will use well-established evidence-based criteria  to operationalize the PA requirements and limits on services set by the state (those that are in place for the first 12 months of managed care), and (2) MCOs will use strict evidence-based criteria to develop their future individualized PA, service limitation, and reimbursement policies that will go into effect on/after July 1, 2019.


We thank you for your consideration of our recommendations for improving access to high-quality addiction treatment services in Ohio and would welcome the chance to discuss the content of this letter with you at any time.  Questions and comments can be directed to Marisa Weisel at mpweisel@voryshcadvisors.com or 614464-5419.