The opioid use disorder (OUD) epidemic extends beyond the boundaries of traditional state health systems, requiring evidence-based treatment and coordination between state agencies and leaders. To optimize all potential avenues to treatment and reduce overdoses, the National Academy for State Health Policy (NASHP) is working with states to develop a “no-wrong-door” approach to treatment that prioritizes cross-systems policies. NASHP is providing tools and resources with support from the Foundation for Opioid Response Efforts (FORE) and its steering committee. Read our newest blog, State Harm Reduction Services Get Creative in the COVID-19 Era.
State Telehealth Policies to Support Treatment
While telehealth to provide medications for opioid use disorder (MOUD) treatment has been an emerging practice in recent years, the COVID-19 pandemic has forced many states to quickly expand their capacity. Because of social distancing, states are quickly innovating to support telehealth service delivery and reimbursement and are leveraging federal policy shifts that allow more flexibility. As states turn to telehealth to maintain access to OUD treatment, they have confronted long-standing barriers to telehealth, including achieving payment parity for telehealth services and accompanying technological and confidentiality challenges.
How States Implement Telehealth during COVID-19 to Treat Opioid Use Disorder
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 that Provide Payment Parity for Telehealth and In-Person Care
Since COVID-19s outbreak, many states have instituted policy and reimbursement changes to encourage providers to use telehealth, including mandating temporary payment parity for those services. This map and chart show which states mandated telehealth payment parity before and during the COVID-19 pandemic.
Legend:
Purple – State requires telehealth payment parity from all insurers.
Green- State Medicaid program requires telehealth payment parity.
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.
- NASHP Q&A: How West Virginia Uses Partnerships to Increase Opioid Use Disorder Treatment, August 2020
- NASHP Blog: Federal Rule Change Allowing Providers to Share Data Poised to Improve Substance Use Disorder Treatment, August 2020
- NASHP Blog: States Rapidly Build their Telehealth Capacity to Deliver Opioid Use Disorder Treatment, April, 2020. Offers additional insight into innovative state efforts to leverage telehealth.
Expanding Harm Reduction 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 respiratory health. Additionally, quarantine and social isolation practices designed to reduce COVID-19s 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 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.
NASHP Blog: State Harm Reduction Services Get Creative in the COVID-19 Era, October 2020. Despite COVID-19 workarounds, such as telehealth and virtual recovery programs, drug overdoses are rising during the pandemic, underscoring the importance of keeping critical harm reduction services accessible. States have replaced these traditionally in-person services, including needle exchanges and naloxone distribution, with curbside, mailed, and peer-delivered delivery and COVID-19 prevention education.
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
NASHP Q&A: A Deep Dive into New York’s Drug User Health Hubs with New York’s Allan Clear, May, 2020
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.
NASHP Report: Tackling the Trifecta: State Approaches to Addressing Co-Occurring Substance Use Disorders, HIV, and Hepatitis C, April 2020
Treatment for Underserved Populations
States are taking steps to provide additional prevention, treatment, and recovery services to higher-risk populations with opioid use disorder (OUD). Before and during the COVID-19 pandemic, these populations often require specialty services, intensive care coordination, or other interventions that go beyond traditional OUD services.
- NASHP Report: Three State Approaches to Opioid Use Disorder Treatment in State Departments of Corrections, September 2020
Individuals Re-entering the Community
People with opioid use disorder (OUD) who are incarcerated are often abstinent from substances upon their release, though without evidence-based treatment, they are over 12-times more likely to die of an overdose within two weeks of release than the general population. Re-entry, from this lens, is itself a risk factor for people with OUD and many jails and prisons are releasing individuals early due to the pandemic, increasing the urgency for people to receive evidence-based treatment while incarcerated.
Criminal justice leaders are increasingly embracing models of treatment that include the provision of medications for opioid use disorder (MOUD) in incarceration settings, recognizing that treatment for individuals with OUD is effective and contributes to reductions in overdose deaths.
Additional Resources:
Foundation for Opioid Response Efforts and NASHP webinar: Correctional Facilities and MOUD During the COVID-19 Pandemic, April 2020. This webinar provides a look at the challenges of providing MOUD in incarcerated settings, as well as how the pandemic has affected incarceration-based programs and how state Medicaid programs can support them.
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.