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INTotal Health An Inova Health Plan

ARTS Benefit - Beginning 4/1/17

ARTS Benefit

Addiction Recovery Treatment Services • Reasons For the new Benefit

• What the Benefit Includes

• DMAS Goals for ARTS

• Treatment Services Provided

• Reimbursement Structure

• How to Become an Arts Provider

• DMAS Draft Provider Manual

• Authorization Requirements

• Intotal Health internal Auth Workflow

• Pharmacy Changes

• Possible Member FAQs

• Communication to Members and Providers

ARTS Benefit

Addiction Recovery Treatment Services

REASONS FOR THE BENEFIT

Virginia is experiencing a substance use crisis in overwhelming proportion

More Virginians died from drug overdoses than car accidents or homicides in 2013. Nearly 80% of those deaths involved prescription opioids or heroin.

Governor McAulffie’s Task Force on Prescription Drug and Heroin Addiction recommended an increase to access to treatment for opioid (and other substances) addiction for Virginia’s Medicaid members by increasing Medicaid reimbursement rates

ARTS Benefit


Benefit Includes: Expansion of Substance Abuse (SA) covered services to

include community-based addiction and recovery treatment services to all INTotal Health Members

Revised Pharmacy requirements related to Opioids

To make sure prescribers are aware of medications their patients are taking.

To make sure prescribers have a plan in place for managing patients medications

To prevent patients who are newly prescribed Opioids from receiving high doses.

ARTS Benefit

Addiction Recovery Treatment Services DMAS OBJECTIVES

ARTS Benefit


Service type Setting

Inpatient acute detox Acute medical hospital

Inpatient subacute detox Psychiatric hospital or residential facility

SA residential treatment Facility

SA partial day treatment Outpatient facility

SA Intensive Outpatient Outpatient facility or professional provider

Methadone Professional provider

Medication-assisted treatment (opioid treatment)

DBHDS licensed OTP clinic or professional provider setting (MDs only Suboxone)

SA case management Outpatient facility or professional provider

SA peer support Outpatient facility or professional provider

Treatment Services Offered Under the ARTS Program

ARTS Benefit


General overview of ASAM levels

Level of care Type of service

1.0 Outpatient services

2.1 Intensive outpatient services

2.5 Partial hospitalization/outpatient managed withdrawal

3.1 Clinically managed, low-intensity residential services

3.3 Clinically managed, population-specific, high-intensity residential services for those with cognitive impairments

3.5 Clinically managed, population-specific, high-intensity residential services — 24-hour care

3.7 Medically monitored intensive inpatient services — 24-hour nursing care with physician availability

4.0 Medically managed intensive inpatient services — 24-hour nursing care and daily physician care, counseling available, severe unstable withdrawal

Providers must meet ASAM requirements to provide services at a particular level of care. The American Society of Addiction Medicine (ASAM) criteria is a widely used and comprehensive set of guidelines used for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions.

ARTS Benefit

ARTS Benefit


ARTS REIMBURSEMENT STRUCTURE – FINAL

http://www.dmas.virginia.gov/Content_atchs/bh/ARTS%20Reimbursement%20Structure%2002

242017.pdf

http://www.dmas.virginia.gov/Content_atchs/bh/ARTS Reimbursement Structure 02242017.pdf




ARTS Benefit


How does a provider become an ARTS provider? The provider must have the correct state license whether

through Virginia Department of Health (VDH), VA Dept of Behavioral Health and Developmental Services (DBHDS), and the Department of Health Professions (DHP)

Determine what substance use disorder related service (or ASAM Level of Care) the provider provides or wants to provide for Medicaid Reimbursement

ARTS Benefit


How does a provider become an ARTS provider? Contract and complete credentialing process with INTotal

Health

Complete ASAM attestation form and Organizational Staff Roster

Attestation forms can be found on the DMAS Website http://www.dmas.virginia.gov/Content_Pgs/bh-sud.aspx

Call INTotal Health Provider Relations 1.800.231.8076 for more information

ARTS Benefit


DMAS Requirements for ARTS Credentialing

ASAM LOC Placement VDH/DBHDS/DHP License Required ARTS Attestation and Other Documents for

Credentialing

4 Medically Managed Intensive

Inpatient

Acute Care General Hospital (12VAC5-410)

ARTS Attestation Form 2.1 to 4.0 ARTS Staff Roster of Licensed Providers who do not require

supervision Copy of VDH license

3.7 Medically Monitored Intensive

Inpatient Services (Adult)

Medically Monitored High-Intensity Inpatient Services (Adolescent)

Inpatient Psychiatric Unit Freestanding Psychiatric Hospital Substance Abuse (SA) Residential

Treatment Service (RTS) for Adults/Children

Residential Crisis Stabilization Unit Substance Abuse RTS for Women with

Children Mental Health Residential Children with

a SA Residential license Managed Withdrawal-Medical Detox

Adult Residential Treatment Service Medical Detox License required for all


supervision Copy of DBHDS license listed to the right. Providers may be

in process of submitting service modification to DBHDS and should have approval by DBHDS before fully credentialing.

Westat Inc., Certification with specified ASAM Level

ARTS Benefit

Addiction Recovery Treatment Services DMAS Requirements for ARTS Credentialing

3.5

Clinically Managed High-Intensity Residential Services (Adults) /

Medium Intensity (Adolescent)

3.3 Clinically Managed Population-

Specific High-Intensity Residential Services (Adults)

Substance Abuse Residential Treatment Services (RTS) for Adults or Children;

Freestanding Psychiatric Hospital or Inpatient Psychiatric Unit that have substance abuse on their license or within the “licensed as statements”;

RTS for Women with Children; Substance Abuse and Mental Health

Residential Treatment Services (RTS) for Adults that have substance abuse on their license or within the “licensed as statements.”; or

Level C or Mental Health Residential Children that have substance abuse on their license or within the “licensed as statements”.

Medical Detox License required for 3.2 WM





3.1 Clinically Managed Low-Intensity

Residential Services

MH & SA Group Home Service for Adults and Children (Required for co-occurring enhanced programs)

Supervised Residential Treatment Services for Adults.





ARTS Benefit


DMAS Requirements for ARTS Credentialing

2.5

Partial Hospitalization Services

2.1 Intensive Outpatient Services

Substance Abuse or SA/Mental Health Partial Hospitalization (2.5)

Substance Abuse Intensive Outpatient for Adults, Children and Adolescents (2.1)

Outpatient Managed Withdrawal Service Licensed required for 2WM




1 Outpatient Services

Outpatient Services (Agency Option) Individual or Groups of Licensed

Clinicians

No specific forms, credential directly with health plans and/or BHSA

0.5 Early Intervention

N/A; All Licensed Providers No specific forms, credential directly with health plans and/or BHSA

Opioid Treatment Program (OTP) Medication Assisted Treatment/Opioid Treatment Services

ARTS Attestation Form for OTP ARTS Staff Roster of Licensed Providers who do not require

supervision Copy of DBHDS license

Office-Based Opioid Treatment (OBOT)

Physician Offices with Individual or Groups of Licensed Clinicians

ARTS Attestation Form for OBOT ARTS OBOT Credentialing Checklist ARTS OBOT Staff Roster DMAS approval of the OBOT status (on excel list share with

health plans)

ARTS Benefit

Addiction Recovery Treatment Services DMAS DRAFT PROVIDER MANUAL

ARTS Provider Requirements: http://www.dmas.virginia.gov/content_atchs/bh/ARTS%20Provider%20Manual%20CHAPTER%20II%20%20DRAFT%2003022017.pdf ARTS Covered Services: http://www.dmas.virginia.gov/content_atchs/bh/ARTS%20Provider%20Manual%20Chapter%20IV%20DRAFT%2003022017.pdf ARTS Billing Instructions: http://www.dmas.virginia.gov/content_atchs/bh/ARTS%20MANUAL%20CHAPTER%20V%20DRAFT%2003022017.pdf ARTS Utilization Review: http://www.dmas.virginia.gov/content_atchs/bh/ARTS%20Provider%20Manual%20Chapter%20VI%20DRAFT%2003022017.pdf

http://www.dmas.virginia.gov/content_atchs/bh/ARTS Provider Manual CHAPTER II DRAFT 03022017.pdf



http://www.dmas.virginia.gov/content_atchs/bh/ARTS Provider Manual Chapter IV DRAFT 03022017.pdf



http://www.dmas.virginia.gov/content_atchs/bh/ARTS MANUAL CHAPTER V DRAFT 03022017.pdf



http://www.dmas.virginia.gov/content_atchs/bh/ARTS Provider Manual Chapter VI DRAFT 03022017.pdf



ARTS Benefit


ASAM Levels Requiring Auth: Notification Provided Within:

Level 2.1 (IOP) 72 Hours

Level 2.5 (PHP) 72 Hours

Level 3.1 (low intensity Residential)

72 Hours

Level 3.3 (population specific Residential)

72 Hours

3.5 (high intensity Residential) 72 Hours

3.7 (Medically Monitored Intensive Residential)

72 Hours

4.0 (Medically Managed Detox)

24 Hours

ARTS Benefit


Providers must complete the Prior Authorization Form and FAX to INTotal Health 855.323.5588

Call 888.393.8978 for any questions about Prior Authorizations

ARTS Benefit

Addiction Recovery Treatment Services DMAS Guidelines for Units/Timeframes for the Initial ARTS Service Authorization

Service Authorizations are based on medical necessity for services.

Service ASAM LOC Procedure Code(s) AVERAGE*

Initial Service Authorization

SUD IOP 2.1 H0015 or Rev 0906 15 days

SUD Partial

Hospitalization 2.5 S0201 or Rev 0913 10 days

SUD Group

Home/Halfway House 3.1 H2034 14 days

Clinically Managed

Population with Cognitive

Impairments – High

Intensity - RTS

3.3 H0010 & Rev 1002 12 days

Clinically Managed All

Population – High

Intensity - RTS

3.5

(RTS) H0010 & Rev 1002 12 days

Clinically Managed All

Population – High

Intensity – Inpatient

Psychiatric Unit

3.5

(Inpt Psych Unit) H0010 & Rev 1002 12 days

ARTS Benefit


DMAS Guidelines for Units/Timeframes for the Initial ARTS Service Authorization

Service Authorizations are based on medical necessity for services.

Service ASAM LOC Procedure Code(s)

AVERAGE*

Initial Service Authorization

Medically Monitored

Intensive Inpt

3.7

(RTS) H2036 & Rev 1002 5 days

Medically Monitored

Intensive Inpt

3.7

(Inpt Psych Unit) H2036 & Rev 1002 5 days

Medically Monitored

Intensive Inpt

3.7

(Freestanding Psych) H2036 & Rev 1002 5 days

Medically Managed Inpt

(acute detox)

4.0

(Acute Care Hospital) H0011 & Rev 1002 3 days

*This is the DMAS recommended guidelines for the average length that will approved by all Medicaid

Managed Care Organizations (MCOs) and Magellan for the initial ARTS service authorization. The length of subsequent ARTS service authorizations will be based on medical necessity according to ASAM patient placement criteria.

ARTS Benefit

Addiction Recovery Treatment Services (Pharmacy)

OPIOID/BENZODIAZEPINE CHANGES New Opioid restrictions 12/1/2016 for NEW utilizers (<14 days of utilization 10/1/16-11/30/16)

ANY opioid therapy that exceeds a total of 14 days within a 60-day period requires prior authorization to be completed by prescriber Members will not be permitted to receive opioid therapy AND benzodiazepine (Ativan, Xanax, lorazepam, diazepam…) during overlapping dates of service. Prescribers may request a one-time prior authorization for up to a 14-day supply once annually for extenuating circumstances.

Members with >14 days of opioid therapy between 10/1/2016-11/30/2016 May continue to receive opioid prescriptions with no NEW restrictions through 4/30/17

Previous (prior to 12/1/16) quantity/formulary restriction still apply Prior authorizations have been added for the identified members Caremark may enter additional edits for these members to include other formulary opioids If member has a previously approved PA for opioids, those PA limitations may continue to be permitted through 4/1/17 extended to 4/30/17

Members identified as having both opioid and benzodiazepine therapies between 10/1/2016-11/30/2016 will be permitted to continue to receive concomitant therapy through 4/30/17 Members previously established on either an opioid or benzodiazepine alone will require prior authorization through Caremark to begin concomitant therapy and will be subject to the 14 day limitation Prior authorizations for members previously established on opioid therapy or opioid-benzo therapy should be managed through the Caremark Pharmacy Help Desk (800-364-6331) and/or the prior authorization team at Caremark

Pharmacies should be instructed to call Caremark for assistance If the pharmacy has contacted Caremark and been informed that the member does not meet the necessary requirements for approval and there is documented evidence in COS (the CVS system) showing that the member received opioids (or concomitant benzo therapy) during the window of 10/1/16-11/30/16, please refer the case internally to pharmacy for review. If the member does not meet these requirements, they should be instructed to request that their provider complete the prior authorization process through Caremark

ARTS Benefit

Addiction Recovery Treatment Services (Pharmacy) Requirements for Opioid Therapy Short-Acting Opioids Prior Authorization (PA). Prior Authorization is required for Short Acting Opioids over the limit of TWO 14-day supply per fill and that exceed 28 days in 60 days. Quantity limits apply to each drug. Long-Acting Opioids Prior Authorization (PA). Indicated for patients with chronic, moderate to severe pain who require daily, around-the-clock, chronic opioid treatment. Patients with a history of substance use disorder should be considered for Buprenorphine analgesic treatment with either topical patch or buccal film. These products have a ceiling effect with less risk of respiratory depression than other opioids. Members with active cancer will require that prescriber complete PA every 6 months, but will automatically be approved for formulary opioids. Short-Acting Opioids – will review that member has tried and failed non-opioid therapy options such as baclofen, NSAIDs, Gabapentin, Duloxetine/Tricyclic Antidepressants, Carbamazepine, or Capsaicin Gel/Lidocaine 5% Patch Long-Acting Opioids – will review that member has tried and failed 2 weeks of short-acting opioids or buprenorphine pain patch or film

ARTS Benefit


PA*, QL buprenorphine buccal film BELBUCA

PA*, QL codeine/acetaminophen TYLENOL w/CODEINE

PA*, QL fentanyl transdermal 12 mcg/hr, 25 mcg/hr, 50 mcg/hr,

75 mcg/hr, 100 mcg/hr

DURAGESIC

PA*, QL hydrocodone/acetaminophen NORCO

PA*, QL hydrocodone/acetaminophen soln 7.5 mg/325 mg/15 mL

PA*, QL hydromorphone tabs DILAUDID

PA*, QL methadone tabs 5 mg, 10 mg DOLOPHINE

PA*, QL morphine

PA*, QL morphine ext-rel MS CONTIN

PA*, QL morphine supp

PA*, QL oxycodone soln

PA*, QL oxycodone tabs 5 mg, 10 mg, 15 mg

PA*, QL oxycodone/acetaminophen PERCOCET

PA*, QL oxycodone/aspirin PERCODAN

PA*, QL tramadol ULTRAM

PA*, QL tramadol ext-rel ULTRAM ER

PA*, QL tramadol/acetaminophen ULTRACET

•INTotal Preferred Products are required to be trialed before non-formulary products are approved:

ARTS Benefit


Prescriber is REQUIRED to check the PMP (Prescription Monitoring Program) – https://virginia.pmpaware.net/login - this website provides ALL controlled substance dispense history as submitted by retail pharmacies within 24 hours of dispense regardless of payer source. Prescriber must provide:

Patient’s active MED (morphine equivalent dose per day) Date of patient’s last opioid and benzodiazepine prescription

IF MED is ≥120 the prescriber must attest that he/she will be managing the patient’s opioid therapy long term in accordance with the Virginia Board of Medicine Regulations Prescriber will establish a SIGNED AGREEMENT with the patient addressing the goals of treatment, potential harms of treatment, including addiction, and include a urine drug screen if therapy lasts longer than 60 days. Prescriber should provide counseling on overdose management and provide prescription for naloxone for MED >50

https://virginia.pmpaware.net/login

ARTS Benefit


Key Pharmacy Take-Aways • Members new to opioid therapy will be able to get up to 2 short-acting opioid

prescriptions with a quantity of 14 day supply or less within a 60-day time frame without a prior authorization

• Members with a CANCER diagnosis will require a Prior Authorization, but will be approved for formulary opioids without additional restrictions. PAs are approved for 6 months at a time.

• Opioids for post-surgical procedure should NOT be prescribed for more than 14 consecutive days unless there are extenuating circumstances. Prior authorizations for post-surgical procedures are approved for a period of 60-days

• Prescribers should have access to the Virginia PMP and be checking this database prior to prescribing controlled substances containing an opioid or a benzodiazepine

• Prescribers should consider also prescribing NALOXONE (antidote to opioids) for doses above 50 MED, BOM regulations will require naloxone is dosing exceeds 120 MED