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Q&A: How West Virginia Uses Partnerships to Increase Opioid Use Disorder Treatment

The National Academy for State Health Policy (NASHP) recently spoke to Robert Hansen, executive director of West Virginia’s Office of Drug Control Policy, to learn how the state is expanding opioid use disorder (OUD) treatment access and capacity through strategic partnerships that support its Substance Use Response Plan’s goals.

West Virginia has made expanding access to medications for opioid use disorder (MOUD) a priority. How are you doing this?

In an experiment, conducted by the West Virginia Drug Intervention Institute at the University of Charleston, to locate a treatment provider willing to accept a new patient immediately, we found that access was dismal – no messages or voicemail and no appointments available until seven to ten days, or three weeks, or a month down the road. If you look at a listing in Kanawha County, you’ll see a lot of providers and you might assume that means a lot of treatment. But can you get in when you need help? West Virginia has had a growth in medically assisted treatment availability throughout the state. At last look, we have had a 59 percent increase in the number of waivered providers, but access is still an issue. Our state is very rural and most providers are available 9 to 5, Monday through Friday.

If we know anything about substance use disorder (SUD), we know people need access to treatment as quickly as possible. So, how do you do that in a state with many transportation challenges? West Virginia is tackling access issues by working with Bright Heart Health, which is helping the state expand MOUD availability. This national, for-profit organization specializes in using telehealth to provide round-the-clock treatment as well as rapid access to virtual assessment, enrollment, and crisis intervention. Through this partnership, people living in West Virginia can access care and treatment when they need it and regardless of where they are located, so long as they have access to a phone, tablet, or computer, and a reliable internet connection.

You’ve indicated that West Virginia’s expansion of Medicaid has been crucial in facilitating access to treatment in the state, how is Medicaid supporting this particular partnership?

Medicaid is very central to paying for ongoing services. We have three managed care companies that were just re-awarded contracts to work with our bureau of medical services. All three of them were able to fast track BHH’s application and enrollment, ensuring that these services could be implemented for Medicaid coverage quickly. Sometimes credentialing gets very bogged down, but I think all three companies in West Virginia have embraced this concept and this company.”

How have the state’s emergency departments supported access to OUD treatment? Is COVID-19 a factor?

Increasing access to treatment has to be a goal for addressing not only the COVID pandemic, but the opioid epidemic. We have several emergency rooms in our state that were [providing buprenorphine] before COVID, and that’s why we’ve made it a big initiative and worked with Mosaic to build out assessment, identification, and linkage to SUD services. Mosaic’s approach is multifaceted and involves working with ERs to screen all patients for SUD and develop clinical pathways to address individuals’ treatment needs, including incorporating peer recovery coaches into ER settings in order to fast-track people into treatment. There’s still stigma within the medical community, as there is in the community at large. I think that we lost momentum in [some of our initiatives] since mid-March, and now we’ve got to pick it back up.

How will West Virginia ensure that individuals remain engaged in treatment once they have been linked to treatment?

We are working on measuring [treatment] retention and continuous engagement, and I think we’re making strides – but, we have a long way to go. [Soon], as part of the Shatterproof ATLAS pilot initiative, we plan to go live with a webpage about West Virginia’s providers and how well they’re doing in delivering services according to Shatterproof’s National Principles of Care for addiction treatment. Through this pilot, West Virginia will be working with Shatterproof’s data partner to review Medicaid claims data and determine how providers are performing on a variety of key indicators, including treatment retention. These data will be available to state officials, as well as to managed care companies and individual providers.

How will West Virginia measure the effectiveness of these initiatives?

There are two big benchmarks that I live and die by – one is the number of overdose fatalities and two is the number of suspected overdose incidents. If you look at the national CDC (Centers for Disease Control and Prevention Centers) data on West Virginia fatalities, our rate per 100,000 is so much higher than the national average. [These projects] are just starting to hit the ground in West Virginia, and it’s going to be an evolutionary process, but the more individuals [we] engage, the better.

This blog is funded through a two-year grant awarded by the Foundation for Opioid Response Efforts (FORE). NASHP would like to thank Catherine Dunne, court accounts and special projects manager with Bright Heart Health, for her valuable contributions.

Strengthening Workforce Capacity: State Actions to Address Opioid Use Disorder during COVID-19

May 18, 2020/in COVID-19 State Action Center Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Coverage and Access, Health Equity, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health, Workforce Capacity /by Kristina Long and Jodi Manz

During the COVID-19 pandemic, the opioid epidemic has quietly raged on, requiring states to fight a costly, two-front war. While states have rallied to ensure that opioid use disorder (OUD) treatment remains accessible, organizational and workforce challenges persist and the resources and revenue needed to address them are rapidly changing.

Gaps in treatment infrastructure and behavioral health workforce shortages have historically challenged states’ OUD treatment delivery. In the midst of the pandemic, states are optimizing current flexibility and supports for their behavioral health workforces to help maintain treatment access during the COVID-19 pandemic, while also monitoring how or whether these new strategies will be maintained in the future.

Here are some approaches states are taking to increase access to treatment and address workforce shortages by expanding job descriptions, offering flexible training, and changing licensing requirements:

Modifying licensure requirements. Licensing requirements for providers vary significantly by state, creating barriers for out-of-state practitioners to providing services across state lines. Expanding out-of-state license recognition and preventing licensure lapses can help ensure and expand access to treatment, promote adoption of telehealth services, and address provider shortages.

New Hampshire, New York, and Pennsylvania have all expanded the ability of out-of-state providers to deliver services within their states through executive orders. New Hampshire allows out-of-state providers to deliver medically necessary services both in person and via telehealth. Similarly, Pennsylvania has issued temporary licenses for out-of-state medical providers and has expedited issuance of temporary licensing. New York has allowed providers licensed in other states and Canada to practice in the state without penalty due to lack of licensure.
States may also consider delaying the expiration of provider licenses during the pandemic to remove any potential barriers providers may have to delivering services. Following an executive order that extended license expiration dates across provider types, Maryland’s Behavioral Health Administration (BHA) released guidance on licensure extension and new licensure processing specific to behavioral health providers. Professional licenses that would have expired during the period of the current emergency will be extended for 30 days after the emergency order is lifted, though the BHA continues to process licensure and re-licensure applications that are mailed or submitted electronically.

Leveraging licensed providers. As states face workforce shortages that are amplified by COVID-19, officials may find opportunities to leverage licensed providers in unique capacities, particularly in the provision of OUD treatments.

In Massachusetts, under order of the commissioner of public health, pharmacists may now administer medications for opioid use disorder (MOUD) in clinical settings, a policy shift designed to allow nursing staff who ordinarily handle such responsibilities to be reassigned to treat COVID-19 patients.
The Ohio’s Board of Pharmacy has adopted temporary regulatory guidance to allow authorized prescribers in opioid treatment programs (OTP) to delegate buprenorphine administration to registered nurses (RNs) and licensed practical nurses (LPNs).

Providing buprenorphine waiver trainings. States have been working to encourage and train providers to become “waivered” or licensed to prescribe buprenorphine long before this pandemic began, and several organizations are now taking advantage of increased flexibility in provider schedules to provide training. Anticipating that overdoses may increase during the pandemic, states can encourage provider engagement with these and similar programs to grow their waivered workforce.

California Bridge, a program supported in part by the California Department of Health Care Services (DHCS), is offering free online buprenorphine trainings that emphasize the immediate needs of vulnerable individuals during COVID-19.
Get Waivered, a non-profit program promoting and providing emergency department (ED) provider training, is offering a “Get Waivered Remote” training aimed at ED providers and medical students, recognizing that with clinics operating at limited capacity during the COVID-19 pandemic, EDs may become a more necessary point of care for people with OUD. This training is free and fully remote.

Supporting behavioral health workforces. As with other frontline workers, behavioral health staff working in residential care, institutional settings, and in direct contact with patients are experiencing significant stress working during the pandemic. To support staff without creating new programs and resulting budget demands, states may consider developing resources to support the mental health needs of both licensed and unlicensed workforces.

The Interim COVID-19 Guidance to Providers and Stakeholders for Behavioral Health and Homelessness Services from the Hawaii Department of Health includes specific burnout prevention and self-care strategies for providers to reduce secondary trauma and help monitor workload and stress.
Through support provided by the Washington State Health Care Authority and the Division of Behavioral Health and Recovery, the Washington Council for Behavioral Health has developed BH Providers Connect, a listserv for behavioral health providers to connect and support one another through the COVID-19 pandemic.
As part of their COVID-19 response, Michigan has released “Supporting Emotional Health of the Behavioral Health Care Workforce during COVID-19,” a guide that outlines self-care strategies, resources for providers and their families, and stress management techniques. Additionally, in response to the heightened stresses on long-term substance use disorder recovery, Michigan has also developed guidance on supporting peers during this pandemic.

While these steps in response to COVID-19 are designed to address concerns about treatment access during the pandemic – sometimes, explicitly – policymakers are also considering the long-term service and budget implications of these changes. In a time of historically reduced state revenues, leaders will be considering how policy shifts and adjustments made during this pandemic can or should be adapted for the post-pandemic treatment of OUD, with likely fewer resources to do so.

Federal Funding Change that Includes Stimulants Allows States to Expand their Substance Use Disorder Initiatives

February 3, 2020/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Health Equity, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health /by Jodi Manz

Since 2017, the federal government has awarded $2 billion to states specifically for opioid prevention, treatment, and recovery. But a new spending package passed last month allows states to use federal funds to address the growing use of stimulants, including cocaine and methamphetamine, that are emerging as the newest wave of drugs fueling the overdose crisis in many states.

The addition of stimulants to federal funding presents both challenges and opportunities for states. They will need to develop initiatives that also address stimulant use, though currently there are few evidence-based treatment guidelines for this. On the plus side, the new funding flexibility allows states to address the social factors that contribute to all substance use disorders (SUD), instead of focusing on a single class of drugs.

Background

To date, federal funding to address the opioid epidemic has flowed from the Substance Abuse and Mental Health Services Administration (SAMHSA) through State Targeted Response (STR) and State Opioid Response (SOR) grants. The latest spending package includes a seemingly minor language addition that poses a potentially major shift in how states use the funding.

What is the fourth wave of the overdose crisis?

Stimulants, including methamphetamine and cocaine, are increasingly prevalent and play a role in overdoses in certain states, mostly west of the Mississippi River.

Prevalence is growing, however, in eastern and Appalachian states already hit hard by opioids as well.

The federal decision to broaden substance categories is a direct response to the quickly-developing threat of stimulants like cocaine and methamphetamine reported in provisional federal overdose data for drug deaths though July 2019. Distinct regional patterns show that stimulants are increasingly prevalent in overdoses primarily west of the Mississippi River, but are growing in eastern and Appalachian states hit hard by opioids. While opioids remain the most frequent killer of Americans who die of drug overdose, the increasing presence of stimulants in this data suggests an emerging “fourth wave” of a drug overdose epidemic that began with prescription opioids and quickly escalated, propelled by heroin and then fentanyl.

Previous iterations of STR and SOR grant funding have given states the opportunity to target funds toward the factors that fueled those waves of opioids. This included prevention initiatives around reducing unnecessary prescribing and diversion of opioids and clinical engagement that was focused on medication-assisted treatment (MAT) for opioid use disorder (OUD). Funds were used to support the development of waivered providers to prescribe buprenorphine, or training for peers with lived opioid experience. The opioid focus was unequivocal.

How States Can Address Stimulant Use

The addition of stimulants to the federal language poses a new set of challenges and welcome opportunities for states. The most pressing issue for both policymakers and clinicians will be treatment – while treatment for OUD can include MAT, often in conjunction with psycho-social supports, treatment for stimulant use currently has no evidence-based medical options, limiting opportunities for clinical intervention to just behavioral mediation.

There is some evidence, however, to suggest that in addition to cognitive-behavioral therapy, contingency management approaches in which individuals are provided with small, tangible rewards for negative urine drug screens can be effective treatment for stimulant use.

Notwithstanding these differences in treatment protocols, states can leverage previous opioid work in their response:

Care models: Integrated care models emphasizing and reimbursing for team-based care can be adapted to these treatment approaches.
Reimbursement: States can use 1115 Demonstration waivers to support financing these models and address the Medicaid Institutions for Mental Diseases (IMD) exclusion to expand inpatient opportunities. (The IMD exclusion prohibits use of Medicaid funds for mental health care provided in residential treatment facilities larger than 16 beds.)
Workforce: States can invest in training and continuing education focusing on stimulant treatment modes for licensed behavioral health providers and non-licensed workforce.

Another major opportunity with this change is that states can explicitly tailor efforts to poly-substance use. Even as opioid overdose deaths have dominated in data reports, media attention, and policy activity in recent years, the majority of opioid overdose deaths reviewed in one recent report from the Centers for Disease Control and Prevention involved at least one other drug. Poly-substance use has been self-reported as near universal by individuals entering treatment specifically for OUD.

States Can Now Address What Fosters All SUD

This federal funding change allows states to use federal grant funds to address the factors that foster SUD, instead of focusing on the effects of a specific substance. For example, given the well-documented link between childhood trauma and SUD, states can invest in prevention efforts that protect children and support resiliency, like reimbursement policies and programs that allow parents with SUD to stay with their children in residential treatment or utilizing models of family-centered treatment. Being mindful of the 2015 study that linked deaths of despair (including those from drug overdose) to economic struggle, states can continue investing in strategies that addressing social determinants of health, including recovery housing, job training, and recovery workplaces.

One of the major challenges of developing state SUD policies is that SUD is not itself substance-specific. This language change aligns federal resources to help states address that discrepancy. Specific state guidance from SAMHSA on this change has not been released, but state policymakers will be able to build on their foundational initiatives developed with the support of earlier federal grants and establish new pathways to innovation.

Virginia Advances Integrated Care for Pregnant and Parenting Women with Substance Use Disorder

December 16, 2019/in Medicaid Managed Care Virginia Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Special Populations and Services /by Melissa Caminiti and Ashley Harrell

To tackle the opioid epidemic, which has been the leading cause of unnatural deaths since 2013, Virginia recently developed an integrated physical and behavioral health continuum of care, which spans multiple treatment settings and includes case management and peer recovery support. The initiative, combined with increased access to naloxone and other efforts, has helped reduce fatal overdoses by 3.3 percent between 2017 and 2018.

In March 2016, with support from Virginia Gov. Terry McAuliffe, the Virginia General Assembly passed appropriations mandating transformation of the SUD Medicaid benefit entitled the Addiction and Recovery Treatment Services program or ARTS, which was implemented on April 1, 2017. Early results from Virginia’s ARTS program indicate success in increasing access to care for Medicaid-eligible pregnant women with SUD and opioid use disorder (OUD).

Data obtained from pre-ARTS implementation (covering April 2016-March 2017) compared to post-ARTS implementation (April 2017-March 2018) indicate that the percent of Medicaid-enrolled pregnant women with SUD who received treatment increased from 2 percent to 21 percent, while the rate of pregnant women with OUD who received treatment increased from 4 percent to 31 percent. In addition to increasing treatment rates, the number and types of treatment providers and treatment programs available to pregnant women with SUD and OUD also increased significantly in the post-ARTS implementation period.

Ashley Harrell, senior program advisor with Virginia’s Department of Medical Assistance Services (DMAS), recently shared the goals and highlights of the program with the Maternal and Child Health Policy Innovation Program (MCH PIP) Policy Academy, hosted by the National Academy for State Health Policy (NASHP). The academy, made up of eight cross-sector state teams, focuses on the mental health needs of pregnant and parenting women, particularly those with or at risk of substance use disorder (SUD). The ARTS program has six major goals:

Expand the short-term SUD inpatient detox benefit to all Medicaid/FAMIS enrollees (FAMIS is Virginia’s health insurance program for uninsured children);
Expand short-term SUD residential treatment to all Medicaid enrollees;
Increase reimbursement for existing Medicaid/FAMIS SUD treatment services;
Add peer support services for individuals with SUD and/or mental health conditions;
Require SUD care coordinators for DMAS-contracted managed care plans; and
Organize provider education, training, and recruitment activities.

The Virginia state Medicaid agency has made additional policy changes to improve access to care for pregnant enrollees with SUD. Some of these changes include:

Allowing and encouraging same-day billing of medical and behavioral health services;
Requiring access to medication-assisted treatment (MAT) along the addiction care continuum; and
Removal of prior authorization requirements for up to 24 mg/day of Suboxone film for in-network buprenorphine-waivered practitioners.

Additionally, the Virginia Medicaid MEDALLION 4.0 has an embedded High-Risk Maternity Program that includes comprehensive care management and family planning services to women with SUD. MEDALLION 4.0 is a statewide, fully capitated, risk-based, mandatory managed care program for Medicaid and Family Access to Medical Insurance Security (FAMIS) members that operates under the authority of a §1915(b) waiver. MEDALLION 4.0 covers pregnant women, infants and children and provides acute and primary health care services, prescription drug coverage, and behavioral health services for their members.

Harrell’s presentation spurred much discussion among academy participants, who quickly shared their concerns about access to care, integration of services, health equity, and the long-term health outcomes of women, children, and families affected by SUD.

Over the next two years, NASHP academy participants will continue to learn from each other and from subject matter policy experts as they strive to develop, support, and advance state-level policy innovations for pregnant and parenting women with or at risk for SUD and/or mental health conditions. Understanding state innovations is key to identifying new strategies to leverage change. As one policy academy participant observed during the meeting, “No one [state] has all the answers, but we have a lot of resources in each other.”

For more information on the academy, read NASHP’s blog, New Eight-State Policy Academy Advances Access to Care for Pregnant/Parenting Women with SUD. For more information about the Virginia ARTS program, visit the Virginia DMAS ARTS website or email questions about the ARTS program to sud@dmas.virginia.gov.

50-State Scan: How Medicaid Agencies Leverage their Non-Licensed Substance Use Disorder Workforce

November 21, 2019/in Policy Featured News Home, Reports Behavioral/Mental Health and SUD, Chronic and Complex Populations, Workforce Capacity /by Eliza Mette, Charles Townley and Kitty Purington

Nearly one in every eight adults enrolled in Medicaid has a substance abuse disorder (SUD),[1] and a significant barrier to treatment is a shortage of SUD professionals[2] in every state. In response, state Medicaid agencies are developing and deploying a growing workforce of non-licensed, non-master’s-level treatment and support providers – such as peers, counselors, and other qualified staff – to provide a range of services to supplement licensed SUD provider capacity.[3] To help states address SUD workforce challenges and identify cutting-edge solutions, the National Academy for State Health Policy (NASHP) conducted a comprehensive review of how each state Medicaid program was paying for and overseeing non-licensed SUD staff. This brief summarizes what steps states are taking to reduce workforce shortages and provides resources to help states develop new approaches to expanding their SUD workforce.

How Medicaid Agencies Leverage their Non-Licensed SUD Workforce

To help states address SUD workforce challenges and identify cutting-edge solutions, NASHP conducted a comprehensive review of how each state Medicaid program was paying for and overseeing non-licensed SUD staff.

Background

NASHP analyzed publicly available materials to identify:

How Medicaid agencies reimburse for SUD services provided by non-licensed, non-master’s-level workforce;
What services they provide and in what settings; and
State education, training, and supervision requirements for non-licensed staff.

NASHP used the most recently available Medicaid provider and billing manuals, state regulations, and other public policy documents (including state plans and waivers) for all 50 states and Washington, DC. Findings were grouped and coded to allow for easier cross-state analysis. The data collected was shared with Medicaid and other state leaders.

States’ non-licensed workforce was categorized as:

Peers: Individuals with lived experience providing Medicaid-billable SUD services.

Counselors: Individuals providing Medicaid-billable SUD counseling or therapy services without a state license.

Other Qualified Staff: Other non-licensed professionals providing Medicaid-billable SUD services who did not meet the definition of a “peer” or “counselor.”

Services funded by resources other than Medicaid (e.g., state grant funding) were considered outside the scope of this research.

The majority of state Medicaid agencies (42) reimburse for SUD treatment services provided by non-licensed, non-master’s-level SUD staff. NASHP’s scan identified 45 types of peers in 39 states, 52 types of counselors in 31 states, and 43 types of other qualified staff in 24 states. The services these staff may provide, where they provide the service and how they are reimbursed, as well as education, training, and supervision requirements all varied to some degree across states. Key findings are summarized below.

Service Delivery

State Medicaid programs pay for a range of services and supports delivered by non-licensed staff. These services were grouped in the following categories:

Peer services;
Screening, assessment, and evaluation;
Brief intervention;
Community and rehabilitative supports (e.g., education, skills training, and family support);
Case management/care coordination; and
Crisis intervention.

States reimburse counselors for a broad range of SUD services. In addition to counseling/therapy services, more than half of non-licensed counselors can be reimbursed by state Medicaid programs for screening, evaluation, assessment, community and rehabilitative support, case management/care coordination, and/or crisis intervention services. Most state Medicaid agencies pay peers to provide peer support services-only, although approximately one-quarter of peers may also be reimbursed to provide rehabilitative or supportive services. Other qualified staff generally fell into one of two groupings: individuals primarily providing case management or care coordination services or unlicensed staff providing rehabilitative or supportive services who did not meet state qualifications to provide counseling services.

States vary in the types of counseling/therapy services that may be provided by non-master’s-level counselors. For example, every state permits their non-master’s-level counselors to provide individual and/or group counseling services, but only two-thirds of states reimburse certified counselors for family counseling services. Florida only reimburses its bachelor’s-level counselors for group services, limiting reimbursement for individual and family services to those with a master’s degree.

Setting and Reimbursement

Non-licensed staff deliver services in licensed behavioral health agencies or facilities, typically working within a multidisciplinary care team. Although employed by licensed agencies or facilities, services may often be provided in home and/or community settings to meet the needs of individuals receiving treatment.

How services delivered by this workforce can vary, depending on whether services are provided in outpatient or residential settings. State Medicaid agencies commonly pay licensed behavioral health clinics for services delivered by non-licensed staff on a fee-for-service basis, through Current Procedural Technology or Healthcare Common Procedure Coding System codes that may include modifiers to designate provider type. In contrast, services delivered by non-licensed staff in intensive outpatient programs (including day treatment and partial hospitalization) or residential treatment programs tend to be reimbursed as part of a bundled, per-diem rate. States may also include these types of staff in bundled rates for specialty opioid treatment programs. For example, Maine, Michigan, and Rhode Island all include peers in their opioid health home programs.

Education, Training, and Supervision

Training for peers tends to be more individualized and state-specific. Most states require peers to complete an in-person training program (typically one to two weeks), often offered through a state health agency. Counselors, on the other hand, may receive training though approved courses offered by community colleges or other professional development programs. States generally rely on national exams for counselors but were more likely to use state-developed training and exams for peers. Whether the state’s board membership was with the National Association for Alcoholism and Drug Abuse Counselors (NAADAC) or the International Certification & Reciprocity Consortium (IC&RC) determined which national exam the state required for certification. Some states, particularly those with multiple credentialing boards, allow either exam.

Most states require that non-licensed, non-master’s-level SUD treatment staff be supervised by certified or licensed SUD providers, who often held a master’s degree. In many cases, state regulations identify multiple eligible providers who could supervise staff rather than requiring one specific provider type. For example, a bachelor’s-level counselor might be supervised by a psychiatrist, an advanced practice nurse with specialized addictions training, or a master’s-level counselor with supervisory training. It is also common for individuals, particularly for those without a counseling certification, to be supervised by a more experienced colleague holding a similar credential – for example, a peer with two years of experience would supervise another peer. States also routinely set minimum standards for the supervisory relationship, such as defining frequency of meetings and on-call availability. Positions requiring less training and experience typically required closer supervision. Clinical oversight requirements were generally less specific than supervisory requirements and sometimes vary by type of service. State Medicaid agencies generally require assessments and treatment plans to be signed/authorized by a physician, master’s-level provider, or nurse care manager.

Some state Medicaid programs offer and reimburse for trainee positions. Several states noted the importance of trainee programs in expanding their non-licensed staff capacity. Louisiana reimburses services provided by counselors-in-training, who are permitted to provide screening/evaluation/assessment services, counseling, and crisis intervention services under the supervision of a licensed mental health provider. Similarly, Washington State reimburses a chemical dependency professional trainee, who can provide screening/evaluation/assessment services, counseling, and case management/care coordination under the supervision of a certified individual who has completed some college.

Looking Forward

The number of state Medicaid agencies utilizing non-licensed, non-master’s-level SUD treatment staff is expected to increase in the coming years. Since 2015, the number of states using Section 1115 Medicaid Demonstration Waivers to augment or entirely transform their SUD treatment systems has grown significantly,[5] and many of these states now pay for services delivered by non-licensed staff.[4] The use of these and other relevant Medicaid authorities (e.g., the Medicaid rehabilitative services option or health home state plan option) to increase access to peers and other non-licensed SUD treatment professionals presents both opportunities and challenges for states.

How to support best practices while recognizing state variability. Given the wide range of definitions and standards currently used by states, resources are needed for policymakers to better understand best practices, including where and how these non-licensed staff add the most value. While most non-licensed counselors need to pass a nationally recognized exam for certification, the roles permitted within diverse state Medicaid programs can be quite different. Similarly, training and examination requirements for peers and other qualified staff vary significantly from state to state. Sharing state resources on how non-licensed staff can support best clinical practices for SUD treatment and recovery may be helpful for future policy development.
Ensuring cross-system collaboration to address co-occurring needs in integrated care Given the significant correlation between SUD diagnoses and co-occurring mental health and physical health conditions, appropriate training and use of non-licensed staff offers another opportunity for states to promote integrated care for high-cost, high-needs individuals. Moreover, as states increasingly look to health clinics and primary care providers to provide SUD and opioid use disorder (OUD) treatment, defining how these non-licensed staff can and should operate within those settings raises additional issues (and potential opportunities) for state policymakers to promote access to treatment and better integrate care.
Supporting managed care: In states with managed care systems, important questions remain as to how plan-employed staff (particularly peer supports and care coordination/case management staff) can best work with their provider-level counterparts to efficiently and effectively meet the needs of individuals needing or receiving SUD treatment.
How to integrate non-licensed staff in larger inpatient and residential facilities: Historically, the “Institutions for Mental Disease exclusion” has prevented states from paying for Medicaid services provided to adults ages 21 to 64 in behavioral health facilities with more than 16 beds. Recent federal guidance and programmatic changes have enabled state Medicaid agencies to pay for services for adults in these settings using Section 1115 waiver authority.[6] While models exist, how to incorporate non-licensed staff into these settings will likely be of significant interest for state policymakers going forward.

Conclusion

State Medicaid agencies are increasingly using non-licensed workforce – including counselors, peers, and other qualified staff – to meet the growing need for SUD treatment and recovery services by their Medicaid-enrolled populations. NASHP’s review of how states oversee and pay for these services highlights opportunities. Understanding key trends in oversight and payment for this staff will provide a baseline for states as they seek to leverage and expand this workforce. Additionally, the significant variability in how states use these staff, what services they provide, and the kinds of training, education, and supervision they receive speak to a larger need for additional resources for state policymakers to effectively utilize this valuable part of the SUD workforce.

Other Resources

State Medicaid agencies are increasingly leveraging non-licensed workforce, including peers, to meet the growing need for SUD treatment and recovery services by their Medicaid-enrolled populations. For an overview of cross-cutting themes and additional analyses of how states are paying for other non-licensed workforce, please refer to the following companion documents in this series:

Key Findings from a 50-State Scan of State Medicaid Requirements for Non-Licensed SUD Workforce: Peers
Key Findings from a 50-State Scan of Medicaid Requirements for Non-Licensed SUD Workforce: Counselors
Key Findings from a 50-State Scan of Medicaid Requirements for Non-Licensed SUD Workforce:
Other Qualified Providers
Medicaid Reimbursement Categories Key for Non-Licensed SUD Workforce

State Medicaid Requirements for Peers

The National Academy for State Health Policy (NASHP) analyzed reports and regulations from all 50 states to identify how their Medicaid programs reimbursed for non-licensed, non-master’s-level substance use disorder (SUD) staff – including counselors, peers, and other qualified staff – who typically deliver services within licensed behavioral health agencies or facilities.

Peers are individuals with lived experience who provide Medicaid-billable SUD peer support services. NASHP identified 39 states that reimburse for 45 different types of non-licensed peers through their state Medicaid programs. No state requires more than a high school diploma (or equivalent) to become a peer, but training and supervision requirements for peers vary across states.

Key Findings

The majority of states require peers to have a high school diploma or equivalent. Thirty-two states require peers to have a high school diploma or equivalent, while six states do not specify a minimum educational requirement.

Lived experience is a universal prerequisite to working as a peer. Other peer eligibility requirements (e.g., minimum age and minimum time in recovery) vary. Some states also certify parents or other family members to provide peer services to other parents or families. Kentucky, for example, has distinct certification processes for parent, family, and youth peer support specialists serving SUD populations.

Most states require peers to participate in training or education, document their continuing education, and pass a certification exam.

State Medicaid Certification Requirements for Peers

Delaware, for example, requires peers to complete a nine-day training program in addition to passing a national exam, while Ohio requires peers to complete 56 hours of training – 16 hours online, 40 hours in-person – in addition to passing a state exam.

Twenty-seven states require peers to participate in training or education in addition to passing an exam. The exam may be a state-specific test, either the National Association of Alcoholism and Drug Abuse Counselors (NAADC) exam or the International Certification & Reciprocity Consortium (IC&RC) exam. Within these states, there are variations in the number and type of training/education and work-related experience required, and in the need for supervised practicum and continuing education;
Five states require peers to participate in training or education, and to complete continuing education requirements;
Four states require peers to participate in training or education; and
One state requires passing an exam as its single requirement for peers.

The majority of states require peers to be supervised by certified or licensed SUD providers who hold at least a master’s degree. NASHP examined how states take different approaches to imposing minimum educational requirements on those who supervise non-licensed peers:

Fifteen states require supervisors to have a master’s degree and/or certification or license;
Seven states do not have specified requirements for supervisors;
Six states require supervisors to have a bachelor’s degree and be certified or licensed;
Six states require supervisors to have completed high school and be certified;
Four states require supervisors to have completed other requirements; and
Three states require supervisors to have an associate’s degree and be certified or licensed.

Many states identify multiple eligible providers who can supervise staff, rather than requiring one specific provider type. For example, Nebraska permits its peers to be supervised by psychiatrists, licensed psychologists, provisionally licensed psychologists, advanced practice registered nurses, or nurse practitioners, in addition to numerous licensed mental health providers.

While 36 states reimburse for peer services, states often pay for additional services delivered by peers.

Nine states reimburse for community/rehabilitative supports;
Seven states reimburse for crisis intervention;
Four states reimburse for screening, evaluation, and assessment;
Three states reimburse for case management/care coordination; and
Two states reimburse for counseling services.

State Medicaid programs reimburse for a variety of peer services. Peer services may include activities such as recovery support specialist services, individual peer support services, and group peer support services. For more information about the types of services included in each of these service categories, please refer to the Medicaid Reimbursement Categories Key.

Reference Data – Peers: Education, Examination, and Minimum Supervision Requirements

This chart describes the education, training, supervision, and other state requirements for non-licensed peers to deliver and be paid for Medicaid-reimbursable substance use disorder services. Reimbursements are made to licensed specialty behavioral health organizations and facilities – not to the individual provider. This data was collected from state Medicaid regulations, provider manuals, and policy guidance, state professional board websites, and other resources.

State Medicaid Requirements for Counselors

The National Academy for State Health Policy (NASHP) analyzed reports and regulations from all 50 states to identify how their state Medicaid programs reimbursed for non-licensed, non-master’s-level substance use disorder (SUD) staff – including counselors, peers, and other qualified staff – who typically deliver services within licensed behavioral health agencies or facilities.

Counselors provide Medicaid-billable SUD counseling or therapy services without a master’s degree or a state license. Based on these definitions, NASHP identified 31 states that reimburse for services delivered by 52 different types of counselors through their state Medicaid programs. Requirements related to the education, training, and supervision for these counselors vary significantly across states.

Key Findings

State Medicaid educational requirements for counselors range from no specified minimum education to a bachelor’s degree.

Seventeen states require counselors to have a bachelor’s degree;
Sixteen require counselors to have a high school diploma or equivalent;
Five states require counselors to have an associate’s degree;
Two states require counselors to have some college; and
Two states do not specify minimum educational requirements for counselors.

Some states, such as Georgia and Oregon, rank these counselors by education level (e.g., those with a high school diploma are a Counselor I and those with a college degree are a Counselor II). States vary as to whether counselors with an associate’s degree had a different designation, and whether those counselors were grouped with high school- or bachelor’s-level staff.

The majority of states require counselors to complete some training or education, acquire and document work experience and supervised practice hours, and take an exam. However, there is still significant diversity in state approaches to overseeing this SUD workforce.

State Medicaid Certification Requirements for Counselors

For example, Florida requires its counselors to be certified and pass its state-based exam, while Vermont requires counselors to complete at least 40 hours of substance use disorder education. New York, alternatively, requires counselors to complete both a national exam and additional training to provide administrative and clinical supervision. State Medicaid programs may also permit reimbursement for more than one level or type of counselor, each with its own requirements.

Twenty-nine states require counselors to pass an exam in addition to completing some combination of training/education, work or volunteer experience, supervised practice, and participation in continuing education;
Eighteen states require counselors to pass an exam, complete some training or education, and have some level of experience, but may not require additional elements such as a supervised practicum or continuing education;
Six states do not require counselors to take an exam, but do require some combination of training/education, experience, and supervision; and
Three states require passing an exam as its single requirement for counselors, which may be a state-specific test, the National Association of Alcoholism and Drug Abuse Counselors exam, or the International Certification & Reciprocity Consortium exam.

The majority of state Medicaid programs require non-licensed counselors to be supervised by certified or licensed SUD providers holding at least a master’s degree. NASHP examined states’ approaches with respect to the minimum educational requirements for those who supervise non-licensed counselors.

Fourteen states require supervisors to have a master’s degree and/or certification or license;
Eight states do not have specified requirements for supervisors;
Six states require supervisors to have a bachelor’s degree and be certified or licensed;
Five states require supervisors to have a high school diploma and be certified;
Three states require supervisors to have an associate’s degree and be certified or licensed; and
One state requires supervisors to have completed some college and be certified.

States reimburse for a wide variety of services delivered by counselors within licensed behavioral health settings. NASHP found that states use this non-licensed workforce to deliver a number of services across their state Medicaid SUD service array.

Twenty-eight states reimburse for counseling services;
Twenty-three states reimburse for screening, assessment, and evaluation;
Eighteen states reimburse for community/rehabilitative support services;
Fourteen states reimburse for case management/care coordination;
Thirteen states reimburse for crisis intervention; and
Six states reimburse for brief intervention.

Within the counseling services category, most states reimburse for individual and group behavioral health therapy and counseling services. Other reimbursed services within this category include individual, family, and counseling/psychotherapy; psychoanalysis; psychotherapy for crisis; and counseling. For more information about the types of services included in each of these categories, explore the Medicaid Reimbursement Categories Key.

Reference Data – Counselor: Education, Examination, and Minimum Supervision Requirements

This chart describes the education, training, supervision, and other state requirements for non-licensed counselors to deliver and be paid for Medicaid-reimbursable substance use disorder services. Reimbursements are made to licensed specialty behavioral health organizations and facilities – not to the individual provider. The data comes from state Medicaid regulations, provider manuals, and policy guidance, state professional board websites, and other resources.

State Medicaid Requirements for Other Qualified Providers

Other qualified staff are non-licensed professionals who provide Medicaid-billable SUD services who do not meet the definition of a peer or counselor. NASHP identified 24 states that reimburse for 43 different types of other qualified staff through their state Medicaid programs. Requirements related to the education, training, and supervision of the other qualified staff workforce sector vary significantly across states.

Key Findings

Of the state Medicaid programs that reimburse for this workforce, approximately one-third require other qualified staff to have a high school diploma or equivalent. The minimum educational requirements for other qualified staff vary across states.

Fifteen states require other qualified staff to have a high school diploma or equivalent;
Eight states require other qualified staff to have a bachelor’s degree;
Six states do not specify minimum educational requirements for other qualified staff; and
One state requires other qualified staff to have completed some college.

Of states that require a high school diploma as the minimum educational level for other qualified staff, most require some additional training and experience. Delaware, for example, requires its non-licensed credentialed behavioral health technicians to have a high school diploma and training in topics such as basic first aid, principles of recovery-oriented services, and American Society of Addiction Medicine (ASAM) criteria. States that require a bachelor’s or associate’s degree often require coursework in pertinent fields or relevant training and experience.

While the majority of states do not require this workforce to pass an exam, state approaches to certifying other qualified staff vary greatly across the country.

State Medicaid Certification Requirements for Other Qualified Staff

Seven states require other qualified staff to participate in training or education;
Six states require other qualified staff to have work-related experience;
Three states require passing an exam as the single requirement for other qualified staff. The exam may be a state-specific test, the National Association of Alcoholism and Drug Abuse Counselors (NAADC) exam, or the International Certification & Reciprocity Consortium exam;
Eight states require other qualified staff to meet some combination of training/education, experience, supervision, and continuing education requirements; and
Seven states require other qualified staff to complete a combination of passing an exam and training/education, experience, and supervision requirements.

In some cases, other qualified staff may substitute education for certification or other requirements. For example, Virginia allows some other qualified staff categories to substitute a bachelor’s degree for the certification requirement. Similarly, Minnesota permits its treatment coordinators to substitute a bachelor’s degree for state certification.

The majority of states require other qualified staff to be supervised by certified or licensed SUD providers holding at least a master’s degree. NASHP examined how states take different approaches to ongoing supervision.

Eleven states require supervisors to have a master’s degree and/or certification or licensure;
Seven states require supervisors to have a bachelor’s degree and be certified or licensed;
Seven states do not specify requirements for supervisors;
Two states require supervisors to have an associate’s degree and be certified or licensed;
One state requires supervisors to have completed high school and be certified; and
One state requires supervisors to be licensed physicians.

Many states identify multiple eligible providers – or categories of providers – who can supervise staff, rather than requiring one specific provider type. Nebraska takes a common approach, permitting its other qualified staff to be supervised by a licensed professional, including licensed physicians, licensed psychologists, licensed clinical social workers, licensed mental health counselors, licensed marriage and family therapists, licensed clinical addiction counselors, and other qualified behavioral health professionals.

States reimburse other qualified staff for a wide variety of services. Among the 25 states that reimburse for services delivered by other qualified staff, states pay for the following kinds of services –note that states may pay for multiple services.

Twenty states reimburse for community/rehabilitative support;
Fourteen states reimburse for case management and care coordination;
Ten states reimburse for crisis intervention;
Nine states reimburse for screening, assessment, and evaluation;
Four states reimburse for brief intervention;
Three states reimburse for counseling services; and
Two states reimburse for peer services.

Other qualified staff perform a range of care coordination and case management functions. Services reimbursed by state Medicaid agencies include service plan development, SUD case management, ongoing case management, targeted case management, and targeted plan development. For more information regarding these service categories, view the Medicaid Reimbursement Categories Key.

Reference Data – Other Qualified Staff: Education, Examination, and Minimum Supervision Requirements

This chart describes the education, training, supervision, and other state requirements for non-licensed staff to deliver and be paid for Medicaid-reimbursable substance use disorder services. Reimbursements are made to licensed specialty behavioral health organizations and facilities – not to the individual provider. The data comes from state Medicaid regulations, provider manuals, and policy guidance, state professional board websites, and similar resources.

Medicaid Reimbursement Categories Key

Peer Services

H0038 – Peer Support Services
H2015 – Recovery Support Specialist Service
H2016 – Comprehensive Community Support Services (Peer), per diem
S9445 – Group Peer Support Services
T1012 – Individual Peer Support Services

Screening/Evaluation/Assessment

90791 – Psychiatric Diagnostic Evaluation/Intake Interview
96127 – Brief Assessment
99408 – SBIRT/Screening (15-30 mins)
99409 – SBIRT/Screening (30+ mins)
H0001 – Alcohol and/or Drug Assessment
H0002 – Behavioral Health Screening to Determine Admission Eligibility; Extended Assessment (75+ mins); Screening and Referral
H0031 – Behavioral/Mental Health Assessment by Non-Physician
H0049 – Screening
H2000 – Comprehensive Assessment
T1011 – Evaluation/Determination of Placement
T1023 – Program Intake Assessment; Brief Assessment

Brief Intervention

99408 – SBIRT
H0004 – Brief Treatment
H0022 – Alcohol and/or Drug Intervention Services; Early Intervention
H0049 – Screening and Intervention (less than 15 mins)
H0050 – Brief Intervention

Counseling Services

90832 – Individual Counseling/Psychotherapy, 30 mins (16-37 mins)
90834 – Individual Counseling/Psychotherapy, 45 mins (38-52 mins)
90837 – Individual Counseling/Psychotherapy, 60 mins (53+ mins)
90839 – Psychotherapy for Crisis, first 60 mins
90840 – Psychotherapy for Crisis, additional 30 mins
90485 – Psychoanalysis
90846 – Family Counseling/Psychotherapy (without client)
90847 – Family Counseling/Psychotherapy (with client)
90849 – Multiple Family Counseling/Psychotherapy
90853 – Group (non-family) Counseling/Psychotherapy
90877 – Collateral Therapy/Family Consultation
96153 – Group Therapy
96154 – Family Therapy (with client)
96155 – Family Therapy (without client)
99354 – Prolonged Individual Counseling/Psychotherapy Service (additional 30-60 mins)
99355 – Additional Prolonged Individual Counseling/Psychotherapy Service (per 15-30 mins)
H0004 – Individual Behavioral Health Therapy and Counseling
H0005 – Group/Family Counseling
H2019 – Individual/Group Therapy
G0396 – Substance Use Disorder Counseling (25-45 mins)
G0397 – Substance Use Disorder Counseling (45+ mins)
T1006 – Family/Couple Counseling

Community/Rehabilitative Supports

H0025 – Behavioral Health Prevention Education
H0034 – Medication Monitoring/Training/Support
H0036 – Basic Living Skills Training
H0043 – Supported Housing
H2014 – Individual/Family Skills Training and Development; Behavioral Modification
H2015 – Comprehensive Community Support Services; Addictive Diseases Support Services
H2017 – Individual/Group Psychosocial Rehabilitative Services; Living Skills Training
H2019 – Individual/Family Therapeutic Behavioral Services
H2022 – Intensive In-Home Services
H2025 – Supported Employment
H2026 – Supported Employment (per diem)
H2027 – Psychoeducational Services; Didactic Counseling
S5110 – Family Support (Home Care Training)
S5111 – Family Support and Training
S9482 – Family Support
T1012 – (Non-Peer) Recovery Support; Family Education
T1019 – Personal Care Services
T1020 – Personal Care Services (per diem)

Case Management/Care Coordination

H0006 – Substance Use Disorder Case Management
H0032 – Service Plan Development
H2036 – Recovery Navigation Support
G9012 – Substance Use Care Coordination; Ongoing Case Management
T1007 – Treatment Plan Development
T1016 – Case Management; Treatment Coordination
T1017 – Case Management; Targeted Case Management
T2023 – Targeted Case Management

Crisis Intervention

90791 – Crisis Evaluation
90839 – 24 Hour Access to Crisis Response, first 60 mins
90840 – 24 Hour Access to Crisis Response, additional 30 mins
99510 – Mobile Crisis Response
H2011 – Crisis Intervention/Management/Follow-up; Mobile Crisis Management
H2018 – Crisis Residential Services
S9484 – Crisis Stabilization/Intervention; Crisis Service Center; Mobile Crisis Service
S9485 – Crisis Stabilization (per diem)

Bundles

H0010 – Subacute Detoxification (Residential Setting) (ASAM 3.2-WM); High Intensity Residential Treatment; Clinically Managed Residential Treatment (ASAM 3.3; 3.5)
H0011 – Acute Detoxification (Residential Setting) (ASAM 3.7-WM); Medically-Managed Residential Treatment (ASAM 4)
H0012 – Subacute Detoxification (Outpatient Setting) (ASAM 2-WM); Non-Medical Community Residential Treatment (ASAM 3.5)
H0013 – Outpatient Detoxification (Residential Setting) (ASAM 2-WM); Medically Monitored Community Residential Treatment (ASAM 3.7)
H0014 – Outpatient Detoxification (Ambulatory Setting) (ASAM 2-WM)
H0015 – Intensive Outpatient Program (ASAM 2)
H0018 – Short-Term Residential Services; Medically Monitored Intensive Residential Treatment (ASAM 3.7); Residential Treatment Program with 17+ beds
H0019 – Long-Term Residential Services; Clinically Managed High-Intensity Residential Treatment (ASAM 3.5)
H0035 – Partial Hospitalization (ASAM 2.5)
H0043 – Residential Alcohol and Drug Services (ASAM 3)
H2001 – Outpatient Rehabilitation (2-4 hours)
H2012 – Day Treatment (≤5 hours) (ASAM 2.1)
H2015 – Day Treatment (after 5 hours) (ASAM 2.5)
H0020 – Opioid Treatment Program
H2034 – Low-Intensity Residential Treatment/Halfway House (ASAM 3.1)
H2035 – Outpatient Alcohol and/or Drug Treatment Services
H2036 – High-Intensity Residential Treatment (ASAM 3.3/3.5/3.7); Outpatient Alcohol and/or Drug Treatment Service, per diem/>4 hours; Medically Supervised Detoxification Crisis Stabilization (ASAM 3.7-WM); Residential Treatment Program with <16 beds; Residential Treatment Program (ASAM 3.1/3.3/3.5/3.7)
S0201 – Partial Hospitalization Services in Acute Care or Psychiatric Hospital; Partial Hospitalization Services (ASAM 2.5)
S2080 – Health Home initial Recovery Action Plan
S2081 – Health Home Ongoing Care Management
S9480 – Intensive Outpatient Program

Download PDF version

Notes

[1] “Medicaid Works for People with Substance Use Disorders,” Center on Budget and Policy Priorities, January 19, 2018, https://www.cbpp.org/sites/default/files/atoms/files/1-19-18health-factsheet-suds.pdf.

[2] Ellen Bouchery, and Judith Dey, “ASPE Issue Brief: Substance Use Disorder Workforce,” HHS Office of the Assistant Secretary for Planning and Evaluation, June, 2018, https://aspe.hhs.gov/system/files/pdf/259346/ExamSUDib.pdf.

[3] Angela J. Bech, Cory Page, Jessica Buche, Danielle Rittman, and Maria Gaiser, “Scopes of Practice and Reimbursement Patterns of Addiction Counselors, Community Health Workers, and Peer Recovery Specialists in the Behavioral Health Workforce,” Behavioral Health Workforce Research Center, University of Michigan School of Public Health, http://www.behavioralhealthworkforce.org/wp-content/uploads/2019/06/Y3-FA3-P1-SOP-Full-Report-Updated-6.5.19.pdf.

[4] Elizabeth Hinton, MaryBeth Musumeci, Robin Rudowitz, Larisa Antonisse, and Cornelia Hall, “Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers,” Kaiser Family Foundation, February 12, 2019, https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/.

[5] Angela J. Bech, Cory Page, Jessica Buche, Danielle Rittman, and Maria Gaiser, “Scopes of Practice and Reimbursement Patterns of Addiction Counselors, Community Health Workers, and Peer Recovery Specialists in the Behavioral Health Workforce,” Behavioral Health Workforce Research Center, University of Michigan School of Public Health, http://www.behavioralhealthworkforce.org/wp-content/uploads/2019/06/Y3-FA3-P1-SOP-Full-Report-Updated-6.5.19.pdf.

[6] Elizabeth Hinton, MaryBeth Musumeci, Robin Rudowitz, Larisa Antonisse, and Cornelia Hall, “Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers,” Kaiser Family Foundation, February 12, 2019, https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/.

Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank state officials who generously shared their time and insights in reviewing this material. The authors also thank Trish Riley and Jodi Manz of NASHP, as well as Lynnette Araki and her colleagues at the Health Resources and Services Administration for their guidance and helpful feedback.

This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. The information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.

Medicaid and CHIP Levers to Promote Lead Screening and Treatment: Indiana’s Experience

August 15, 2019/in Policy Indiana, Maryland Reports Care Coordination, Chronic and Complex Populations, Health Coverage and Access, Health Equity, Housing and Health, Lead Screening and Treatment, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health /by NASHP Staff

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Addressing lead hazards today generates future economic benefits and improved health outcomes for children. In partnership with the Health Resources and Services Administration, NASHP is publishing a series of case studies highlighting state initiatives to promote lead screening and treatment. This study explores Indiana’s efforts to address this issue within its Medicaid and Children’s Health Insurance Program.

View or download: State Levers to Promote Lead Screening and Treatment: Maryland’s Strategies
View or download: Medicaid and Children’s Health Insurance Program Levers to Promote Lead Screening and Treatment: Indiana’s Experience
To learn about other state initiatives, read NASHP’s 50-State Scan of State Health Care Delivery Policies Promoting Lead Screening and Treatment.

States May Soon Have to Provide Medication-Assisted Treatment to Inmates, Here’s How to Fund It

July 23, 2019/in Policy Blogs Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health /by Kitty Purington and Chris Kukka

State policymakers on the frontlines of the opioid epidemic understand that treating justice-involved individuals with opioid use disorder (OUD) offers a critical opportunity to expand access to treatment. While there is strong evidence that medication-assisted treatment (MAT) promotes recovery, saves lives, and reduces re-incarceration, states must surmount significant policy and financial challenges to provide MAT in correctional settings.

Does MAT in jails curb costly recidivism and drug use?

Without MAT, 77 percent of inmates with OUD relapse within three months of their release, even if they receive counseling in jail.According to a SAMSHA report, MAT has been found to “reduce criminal activity, arrests, as well as probation revocations and re-incarcerations.”

• A Sacramento County Jail MAT program with 174 inmates found only 31% were arrested for new offenses.

• A study of 370 individuals who completed a MAT program in Middlesex County, MA, found only 19% were rearrested.

• A MAT study of 200 in Louisville, KY, jails found 47% remained arrest-free.

Source: Jail-Based MAT: Promising Practices, Guidelines and Resources, National Commission on Correctional Health Care and the National Sheriffs’ Association

A recent federal court decision indicates that states may need to take a close look at how to overcome barriers to expand access to FDA-approved MAT — methadone, buprenorphine, and naltrexone — in jails. In that decision – which could have nationwide implications – the court ruled that preventing access to MAT is a violation of the Americans with Disabilities Act and the 8th Amendment.

A growing number of state legislatures and governors, through executive orders, have mandated MAT in their correctional facilities. Last month, Maryland passed legislation that requires facilities to assess inmates’ substance use status, treat those with OUD with MAT, and provide follow-up treatment and care coordination after release.

Erek L. Barron, a member of Maryland’s General Assembly and a cosponsor of the new law, suggests the treatment could eventually pay for itself in avoided costs from reduced incarceration rates. “States need to understand that there is a high return on investment in MAT,” he told NASHP. “Addressing this high-risk population will enhance states’ response to the opioid crisis and crimes by reducing overdoses and recidivism rates. The key is understanding that substance abuse is a health care problem, not a crime problem.”

Initially, Maryland’s new treatment requirement will be phased into correctional facilities. The program begins in four counties and will cover the entire state and the Baltimore Pre-trial Complex within two years. The screening and treatment program is funded by the state’s initial allocation of $2 million. A report on the initiative’s impact on recidivism, treatment uptake, and crime will be submitted annually to the state’s General Assembly so lawmakers can assess MAT’s impact and its return on investment.

Barron and bill supporters faced challenges from the state’s various political subdivisions that ran local jails and the state prison system, so they took a “health-focused” approach when negotiating with correctional officials. “My primary partners were the county and local health officers,” he explained, “There was also media attention that helped educate the public about this gap in our response to the opioid crisis. I also learned that states are getting substantial amounts of federal funding from the State Opioid Response Grants that can be directed towards MAT in correction facilities.”

But funding MAT implementation in county and state facilities and after inmates are released remains a challenge for many states, particularly in states that did not expand Medicaid, according to states working with the National Academy for State Health Policy (NASHP) and reports from the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Commission on Correctional Health Care, and the National Sheriffs’ Association.

To start or sustain MAT during incarceration and after, states may want to consider the following strategies:

Tap state block grants and the federal grant funds recently allocated to states for OUD and substance abuse disorder (SUD) treatment by the SUPPORT for Patients and Communities Act and other federal programs.
Encourage criminal justice agencies to participate in group purchasing organizations in order to negotiate more affordable rates for MAT medications on their formulary. (Read Cross-Agency Strategies to Curb Health Care Costs: Leveraging State Purchasing Power for more information.)
Medicaid agencies that do not provide coverage for all three medications approved for MAT may consider including them on their formularies.
States can consider the use of Medicaid options and funding vehicles – such as 1115 waivers – to cover reentry support services, peer services, outreach services, and wraparound case management services for people with opioid use disorders.
Review Medicaid suspension/termination rules. These rules may present barriers for individuals to re-activate their Medicaid coverage and obtain MAT following release from jail. Read NASHP’s report, Opportunities for Enrolling Justice-Involved Individuals in Medicaid.
Despite the passage of the Mental Health Parity and Addiction Equity Act of 2008, the essential health benefits of many health plans do not cover OUD/SUD treatments the same way that other chronic diseases are covered. Oversight of private insurance plans can help to ensure coverage of MAT so that individuals reentering the community from jail or prison can access medication in a timely manner.
To obtain lower-cost drugs, agencies can also participate in the federal 340B Drug Discount Program, which allows certain entities that serve large numbers of uninsured patients to obtain drugs from pharmaceutical suppliers at the same discounted rates that Medicaid pays (about 25 to 50 percent less).

In the months ahead, NASHP will be publishing additional reports detailing effective strategies that states are employing to address the opioid epidemic.

Eliminating Hepatitis C: New State Payment Models for Treatment and Emerging Evidence

June 3, 2019/in Policy Louisiana, Washington Blogs Administrative Actions, Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health IT/Data, Health System Costs, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Prescription Drug Pricing, Value-Based Purchasing /by Maureen Hensley-Quinn

With hepatitis C infections on the rise and curative, but expensive, prescription drugs now available, state leaders across the country are compelled to address this public health crisis, and Louisiana and Washington are developing innovative drug-purchasing strategies within their efforts. At the same time, the Patient-Centered Outcomes Research Institute (PCORI) is investing in patient-focused studies into hepatitis C treatment to help fill gaps in our knowledge with a patient focus to help guide future state efforts to combating this deadly liver disease.

During this National Academy for State Health Policy (NASHP) webinar, officials from Louisiana and Washington share their approaches to using negotiated fixed price payments to ensure unlimited access to hepatitis C drugs for individuals with public health coverage.

Since 2010, the number of new infections has tripled, which experts attribute to the opioid crisis and an increase of people who inject drugs. A growing number of states are committing to eliminating hepatitis C as the World Health Organization, the US Centers for Disease Control and Prevention, and others are advocating. Such a commitment is possible due to drugs introduced in 2011 that can achieve cure rates above 95 percent when the 12-week treatment regimen is followed. However, the costs of these drugs in the United States remains high even though prices have dropped since their introduction. Although prescription drugs are just one component of states’ comprehensive public health hepatitis C elimination campaigns, the high cost of these drugs is the one of the biggest challenges facing states as they address this growing public health crisis.
Although their payment strategies are slightly different, Louisiana and Washington are exploring agreements with drug manufacturers to pay a flat fee over a contracted time period to gain unlimited access to hepatitis C drugs, rather than pay on a per unit basis, which is how most drugs are purchased. In Louisiana, corrections system populations and individuals enrolled in Medicaid and will have access to the drugs. In Washington , incarcerated individuals, Medicaid enrollees, public and school employees, individuals covered by workers compensation, and those in state hospitals will have access to the drugs as needed.
During this National Academy for State Health Policy (NASHP) webinar, officials from Louisiana and Washington share their approaches to using negotiated fixed price payments to ensure unlimited access to hepatitis C drugs for individuals with public health coverage.
As states forge ahead to design and implement strategies to eliminate hepatitis C and find ways to ensure access to treatment while working to contain costs, PCORI research is seeking to learn more about:

Effective screening to identify more cases;
What harm results, compared to no treatment;
Direct comparison of treatments in the real world; and
Effectiveness of care delivery models.

As results from these ongoing patient-centered research studies become available, they will help inform evolving state efforts to address the hepatitis C crisis. The introduction of the effective drug treatment has changed states’ public health approaches and incentivized Louisiana and Washington’s innovative purchasing strategies.
According to an overview of PCORI’s hepatitis C research highlighted during the webinar, researchers are hoping to learn how to most effectively engage people living with hepatitis C who use injection drugs to provide treatment that works. Patient-centered research is also seeking to learn more about the prevalence of re-infection. The evidence from these studies will help with clinical interventions, but could also be taken into consideration as states design, implement, and review their public health campaigns and treatment payment strategies.
Emerging issues, such as public health crises, require immediate attention and innovative cost-effective solutions from state officials. States’ call to action to address the rise in hepatitis C infections is an example of how they must react quickly using the information, appropriate lessons learned, and resources they have to address current crises. State officials are designing their drug contracts and plans to be as flexible as possible so they are able to adjust their approaches as new information becomes available, such as new PCOR evidence. As Louisiana and Washington learn from their prescription payment model and evidence becomes available from PCORI about treatment outcomes and approaches, state efforts will continue to evolve.

Tackling the Opioid Crisis: What State Strategies Are Working?

February 4, 2019/in Policy Blogs Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Coverage and Access, Population Health, Safety Net Providers and Rural Health /by Kitty Purington

Among the many issues confronting new state governors and their administrations, the opioid crisis may be one of the most urgent and complex, and may leave the most devastating legacy. Opioids kill 130 Americans every day. For state policy makers, the ripple effect of the crisis reaches beyond health care systems to impact public safety and corrections, child protective services, and other state agencies and functions.

What state strategies to combat the opioid crisis show promise?

Tracking opioid prescribing
Expanding access to Naloxone
Increasing medication-assisted treatment
Engaging corrections
Ensuring treatment in rural areas
Expanding Medicaid

As part of National Academy for State Health Policy’s (NASHP) work under a National Organizations of State and Local Officials cooperative agreement with the Health Resources and Services Administration, NASHP officials met with policy makers from a dozen states to talk about their challenges and most promising policy strategies to tackle the opioid crisis.
The group discussed and evaluated a range of policy approaches involving Medicaid, behavioral and public health departments, and governors’ offices. State leaders are on the front lines of the opioid crisis, and while the challenges and complexity of this work can be staggering, states generally share a few common goals: prevent addiction, stop people from dying, and get people into treatment.
With those common goals in mind, NASHP identified a few key strategies from the field that are showing results:

Track opioid prescribing: While the majority of states now have prescription drug monitoring programs (PDMPs), Florida was one of the first states to establish a PDMP. Since establishing its program in 2009 (and continuously refining it over the last decade), Florida has achieved a 69.3 percent decrease in the number of individuals having “multiple prescriber episodes” – doctor-shopping for multiple opioid prescriptions. Florida also recently implemented one of the country’s strictest limits on opioid prescribing. Legislation passed in 2018 restricts opioid prescriptions to no more than a three-day supply, with certain exceptions, such as for palliative care.
Invest in harm reduction: In Massachusetts, the Department of Health launched an Overdose Education and Naloxone Distribution (OEND) program. The program has trained more than 64,000 people to administer naloxone, invested in training for first responders, provided naloxone doses to community health centers, and participated in a bulk-purchasing program allowing communities to purchase naloxone at a significant discount. The program reports that close to 11,922 overdose reversals had occurred through the use of OEND naloxone kits.
Build capacity for medication-assisted treatment (MAT). MAT– an approach that includes both medication, counseling, and other supports — is an effective and evidence-based treatment for opioid addiction. However, states have struggled to build sufficient capacity for MAT to address the enormous need created by the opioid crisis. Virginia is addressing this challenge and is starting to see results: the state implemented its Addiction, Recovery, and Treatment Services program through an 1115 waiver. The state is investing in a comprehensive continuum of care that supports primary care practices and a range of other community providers to deliver office-based MAT. Since implementing these wide-ranging delivery system reforms in 2017, the state has seen treatment rates for individuals with opioid disorders increase by more than 70 percent.
Engage corrections: The first two weeks after release from a corrections facility can be one of the most lethal periods of time for individuals with opioid use disorder (OUD). States can take a number of steps to target and assist this high-risk population:
- Rhode Island offers MAT to inmates statewide. The program, which also includes linkages to continued treatment following release, has shown promising results. A recent study in the Journal of the American Medical Association reported a 60 percent reduction in post-incarceration, opioid-related deaths after the program was implemented.
- Although individuals are not permitted to receive Medicaid benefits while incarcerated, the Medicaid enrollment process can get started before their release. NASHP’s State Strategies to Enroll Justice-Involved Individuals in Health Coverage provides examples and resources for states to maximize Medicaid enrollment and link people to services as they leave corrections settings.
Ensure access in rural areas: Access to addiction treatment in hard-hit, rural areas is especially challenging. Overcoming transportation barriers, attracting and supporting specialists, and combatting the stigma associated with accessing (and delivering) services, such as methadone treatment in smaller, more rural communities can be difficult. States are seeing success using the Project Echo model to help providers develop the capacity to deliver treatment. This model links clinical specialists with practitioners in rural areas, facilitating long-distance learning and peer-to-peer mentoring. New Mexico has used the Project Echo model for substance use disorder (SUD) since 2005, and ranks fourth in the country in the number of providers able to deliver MAT services, in spite of its ranking as one of the most rural states in the country.
Expand Medicaid: States that have not expanded Medicaid may be missing an important policy lever to support access to SUD treatment. Recent research found that states that expanded Medicaid saw a significant increase in prescriptions used to treat opioid disorders. Prescriptions for opioids themselves experienced only a modest increase compared to other medications in those .

These strategies represent just a few of the many state innovations happening across the country as health policy makers confront the opioid epidemic. NASHP is continuing to work closely with states to support their opioid epidemic responses and will share other lessons learned in the months ahead.

For New Governors: Snapshot of Major Federal Opioid Funding by State

December 18, 2018/in Policy Charts Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Equity, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by NASHP Writers

There has been significant federal investment made in recent years to address the opioid crisis in every state. This chart summarizes the key federal funding that has flowed to each state’s government agencies and other stakeholders to address the opioid crisis. Data featured in these charts represent grants from multiple federal agencies provided through specific initiatives aimed at supporting state efforts to prevent and treat addiction by addressing behavioral and mental health workforce shortages, promoting evidence-based research, making justice system innovations, and more.
The funding summary chart below shows the total federal grant amounts each state received in FY 2018. To see a more detailed breakdown of the targeted federal initiatives in recent years, click the tabs along the top of the chart. Individual agency funding charts feature grants awarded since FY 2017.

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