Expanding Services During COVID-19
Individuals with opioid use disorder (OUD) may be especially vulnerable during the pandemic due to the effects of both opioids and COVID-19 on their respiratory health. Additionally, quarantine and social isolation practices designed to reduce COVID-19’s spread may increase the risk of overdose, as people are more likely to use alone. To reduce the risk of overdose and support individuals with OUD, harm reduction services, such as syringe exchanges and naloxone distribution, have emerged as valuable tools to engage and protect vulnerable individuals. States are supporting harm reduction efforts in a number of ways.
How States Implement Telehealth during COVID-19
Before the onset of the COVID-19 pandemic, all 50 states offered at least partial coverage of telehealth services through their Medicaid fee-for-service programs. Medicaid managed care plans had increased their use of telehealth services, but coverage varied significantly across (and sometimes within) states.
Reimbursing telehealth services at in-person rates. Parity in payment for telehealth services and in-person services is also inconsistent across states, though COVID-19 has provided an impetus for states to change this policy.
Recently, California expedited legislation that required payment parity for telehealth services within both Medicaid and commercial insurance. The law requires contracts between health plans and providers to specify that a provider will be reimbursed for diagnosing, treating, or consulting via telehealth on the same basis as the provider would be for providing the same service in-person.
The law was written to go into effect in January 2021, but in light of the pandemic, the state released an All Plan Letter on March 18, 2020, directing all state-regulated health plans, including Medicaid managed care plans, to reimburse providers at the same rate effective immediately, whether a service is provided in-person or through telehealth, including via telephone.
Earlier this year, the Washington state legislature passed SB 5385, which would ensure payment parity beginning in January 2021 by requiring health carriers to reimburse providers for the provision of health care services via telehealth at the same rate as they would for the provision of the same services in-person. In response to the emergency presented by COVID-19, however, Gov. Jay Inslee issued a proclamation implementing the bill in February 2020, establishing payment parity throughout the duration of the state of emergency.
Since the pandemic began, many states have instituted policy changes to incentivize providers to use telehealth, including temporary payment parity for those services. This interactive map and chart illustrates which states have implemented telehealth payment parity during the COVID-19 pandemic, as well as those states that had payment parity previously.
Providing billing guidance. Clear and complete Medicaid telehealth billing and reimbursement guidance has become increasingly important since the pandemic began, especially for services that have historically only been provided in face-to-face settings. While federal agencies have provided parameters for telehealth platforms, privacy provisions, and specific prescribing needs for OUD treatment in response to COVID-19, state Medicaid agencies have worked quickly to ensure that network providers have the information and resources to correctly bill for the services they provide. This 50-state chart – States that Provide Payment Parity for Telehealth and In-Person Care link – highlights the most up-to-date COVID-19 telehealth guidance documents from each state. These documents include information about:
- Which services can be provided via telehealth;
- Which providers can provide these services; and
- How to bill for these services.
Maine has issued comprehensive guidelines that cover all issues relate to telehealth during COVID-19. In addition to offering billing guidance, the document provides direction about prior authorization requirements, the prescription of controlled substances, behavioral health services, and other resources for providers.
Oregon has published a COVID-19 Provider Guide, which includes guidance with respect to fee-for-service telehealth reimbursement, covered services, a coding chart, coverage criteria, security and privacy requirements, and documentation.
Building telehealth infrastructure. Providing appropriate resources can support provider uptake of telehealth. With the increased demand for telehealth services, states are finding innovative ways to support their providers in connecting with their patients to ensure that patients have access to necessary services and supports.
The Washington Health Care Authority purchased Zoom licenses for certain providers to deliver telehealth services. Licenses were apportioned to providers who:
- Provide primary care services;
- Serve a significant Medicaid population
- And/or children, adolescents, pregnant or parenting women, or tribal members;
- Do not have access to legally-compliant video technology; and
- Are OTPs or otherwise prescribe medication-assisted treatment for OUD (MOUD).
NASHP’s April 2020 blog, States Rapidly Build their Telehealth Capacity to Deliver Opioid Use Disorder Treatment, offers additional insight into innovative state efforts to leverage telehealth.
States Provide Payment Parity for Telehealth and In-Person Care
Since the outbreak of COVID-19, many states have instituted policy and reimbursement changes to encourage providers to use telehealth, including mandating temporary payment parity for those services. As states’ public health emergencies have come to an end, several states have enacted legislation that extends or makes permanent some of the COVID-related telehealth reimbursement requirements. This map shows which states mandated telehealth payment parity before and during the COVID-19 pandemic, as well as those that have made changes to this effect that extend beyond the public health emergency period.
How States Are Revising Regulations for More Program Flexibility
During the COVID-19 pandemic, several states have revised guidelines that regulate harm reduction practices and syringe services to increase their reach and effectiveness:
- In March 2020, Maine’s governor signed an executive order temporarily suspending some restrictions on the state’s syringe exchange programs. One-to-one needle exchange requirements were lifted and program limitations on location and hours of operation were suspended during the pandemic.
- The Oregon Health Authority released guidance for harm reduction and syringe services programs to support community-based efforts during the pandemic. Its guidance includes suggestions for creating roles for volunteers to continue to provide services during the pandemic and recommendations for messaging to clients.
- Prevent Overdose Rhode Island – an initiative of Gov. Gina Raimondo’s Overdose Prevention and Intervention Task Force – released pandemic-specific harm reduction resources for individuals with OUD. The resources include information about peer recovery supports and information on how to access naloxone, sterile syringes, and fentanyl testing strips.
How States Are Increasing Access to Naloxone
Many states are actively working to get more naloxone (the overdose reversal drug) out to both patients and community members during the pandemic.
- Maryland is providing free naloxone to patients in opioid treatment programs (OTPs). OTPs are able to request naloxone kits for high-need patients and are encouraged to educate patients about overdose risk.
- Similarly, Ohio is using State Opioid Response (SOR) funds to provide naloxone kits to OTPs, as well as programs operated by Harm Reduction Ohio. Ohio’s distribution of naloxone kits is in support of previously issued guidance approving extended take-home doses for methadone patients. These extended take-home methadone doses are designed to reduce the number of patients visiting OTPs during the pandemic, but Ohio also mandated that patients had to possess naloxone in order to to get the methadone take-home doses.
- New York State’s COVID-19 Guidance for Opioid Overdose Prevention Programs provides information on the administration and provision of naloxone in overdose prevention programs. Its guidance includes recommendations for the assembly of naloxone kits, including mandating that each kit include at least two doses of naloxone, but it allows programs to add more doses at their discretion.
NASHP Blog: Q&A: How Medicaid Expansion Put Naloxone in the Hands of the People Who Needed It Most, August 2019
Additional Harm Reduction Resources
The Harm Reduction Coalition’s COVID-19 Guidance for People Who Use Drugs and Harm Reduction Programs outlines recommendations for safer drug use, including overdose preparedness, and tips for programs to minimize the spread of COVID-19 while continuing to provide services.
The American Medical Association developed policy recommendations to support harm reduction efforts in communities, including increasing access to sterile syringes, designating supplies provided by harm reduction programs as essential services, and campaigns to inform the public of the importance of naloxone.
State Approaches to Supporting Postpartum Women
Some states have worked to extend Medicaid coverage to postpartum women for other conditions.
- Missouri attempted to extend Medicaid coverage for postpartum women seeking opioid treatment services, but the proposed legislation failed to pass.
- South Carolina submitted a Section 1115 waiver seeking to encourage new mothers to return to the workforce by extending Medicaid coverage for pregnant women from 60 days postpartum to one year after birth. Similarly, Illinois is seeking to extend coverage through an 1115 waiver for its new mothers from 60 days postpartum to one year after birth.
- In response to COVID-19, Nebraska is allowing pregnant women to maintain continuous Medicaid eligibility through the post-partum period via a prenatal benefit, regardless of eligibility category at the beginning of pregnancy.
- Throughout the pandemic, all opioid treatment programs (OTPs) in Colorado have continued accepting new patients – in fact, the state has opened an additional four OTPs during this time. Colorado providers have also been providing curbside MOUD dosing for individuals with dependent children or who those are symptomatic.
This continually expanding list of resources are designed to help policymakers design initiatives to support pregnant and parenting women with opioid and substance use disorders.
- Foundation for Opioid Response Efforts webinar: Caring for Pregnant and Parenting Women with OUD during the COVID-19 Pandemic, April 2020. This webinar focuses on both policy and practice elements to ensure the provision of evidence-based treatment for pregnant and parenting women during the pandemic.
- New Jersey developed a COVID-19 webinar series to support providers serving pregnant and parenting women with substance use and mental health disorders. Topics include:
- Maternal Child Health and OUD: Alternative Ways to Manage Patient Care/Ask Our Pediatricians – Q&A on COVID-19 in Infants and Children
- Maternal Child Health and OUD: NJ Perinatal Care during COVID-19
- Maternal Child Health and OUD: Adapting Delivery of Care
Webinars are still ongoing. All presentations have been archived, along with supplementary materials and the contact information of presenters, and are accessible to anyone seeking guidance in providing care to the postpartum population. For more information on New Jersey’s initiative , read NASHP’s recent blog, New Jersey’s Project ECHO Builds Provider Capacity to Support Maternal and Child Health during COVID-19.
New Jersey has also added a COVID-19 field to its prenatal risk assessment forms.
Individuals Experiencing Homelessness
Opioid use disorder (OUD) and homelessness are mutually reinforcing. Underlying risk factors for homelessness can be aggravated by OUD, while people with OUD who lack stable housing have unique barriers to maintaining recovery, including lack of access to transportation to treatment, difficulty receiving and storing medications, and inconsistent social supports.
People with OUD who are experiencing housing instability or homelessness are particularly at risk during the COVID-19 pandemic, leaving states challenged more than ever to identify effective housing strategies that can simultaneously address the complex treatment needs of people with SUD while also curbing the spread of COVID-19 in congregate settings.
NASHP Blog: States Craft Collaborative Approaches to House the Homeless and Curb COVID-19, July 2020. This blog explores the collaborative strategies states are taking during the pandemic to protect and support particularly at-risk individuals.