March 2019 HOW TO PAY FOR IT MAT in the Emergency Department: FAQ C alifornia has responded to the opioid over- First, patients with OUD commonly go to the ED, dose epidemic by investing more than $240 seeking more opioids to maintain their addiction, million in federal funds to support medica- help in managing withdrawal symptoms, or as a tion-assisted treatment (MAT) expansion throughout result of an overdose.5 The visit can be an opportu- the medical and behavioral health care system, as nity to bring a patient into treatment at a high-risk, well as in correctional health. Of these funds, the high-motivation moment, especially since people ED-Bridge program has received more than $9 mil- rescued from an overdose have a 1 in 10 chance of lion to support expansion of MAT in emergency dying within the next year.6 Second, evidence sug- departments (EDs) and inpatient hospital settings.1 gests that buprenorphine — a medication common Thirty-one hospitals received grants and joined a in the treatment of OUD — is safe to use in the learning collaborative that launched in February ED, does not promote drug-seeking, and doubles 2019. Plans are in place for another cohort of hos- the chance that a patient will be in treatment after pitals to join a learning collaborative later in 2019. 30 days.7 ED-based clinicians can also administer Funding includes core grants for start-up costs, as buprenorphine without a federal waiver or addi- well as funding for alcohol and drug counselors in tional training, as long as medication administration rural EDs.2 is limited to no more than 72 hours and is used to relieve acute withdrawal symptoms.8 Finally, treating ED visits involving substance use disorders (SUDs) a patient’s underlying OUD, rather than simply man- experienced a cumulative increase of more than 50% aging symptoms associated with withdrawal, may from 2006 through 2013.3 California’s rate of opioid- be more efficient and effective. A 2015 Journal of related ED utilization more than doubled from 2008 the American Medical Association study found that through 2016 (from 76.8 to 183.5 per 100,000 popu- ED-initiated buprenorphine significantly increased lation per quarter).4 engagement in addiction treatment, reduced self- reported illicit opioid use, and decreased use of In addition to the sheer volume of opioid use disor- inpatient addiction treatment services, compared der (OUD) cases that flow through the ED, the ED is with brief intervention and referral for treatment.9 an ideal setting to begin MAT for several reasons. This document provides responses to frequently Patients presenting with a relevant chief complaint asked questions about providing MAT in EDs, focus- Can a patient in the ED (e.g., withdrawal, chronic pain with narcotics) can ing on funding and reimbursement options. receive a buprenorphine be assessed for OUD and, if appropriate, then prescribed buprenorphine to initiate treatment for What is the X-waiver? prescription via withdrawal. Providers and the ED care team may As required by the Drug Addiction Treatment Act of telemedicine? conduct a general health screening and motiva- tional interviewing to identify patient goals as well as 2000 (DATA 2000), clinicians can prescribe buprenor- Buprenorphine and all products containing community-based treatment options. ED-Bridge — phine, a controlled substance, to treat addiction only buprenorphine are Schedule III controlled sub- a program that supports EDs throughout California after receiving training (eight hours for physicians, 24 stances.11 Under the 2008 Ryan Haight Act, an to develop and implement plans for round-the-clock hours for nurse practitioners and physician assistants). X-waivered clinician can prescribe buprenorphine by access to buprenorphine for patients with OUD — Following successful completion of this training, a telemedicine, as long as the patient is in the pres- notes that starting patients on buprenorphine can prescriber’s U.S. Drug Enforcement Agency (DEA) ence of a clinician in a DEA-registered facility, such be efficiently fast-tracked and can take less time license number will include an “X,” which signifies as an ED, while the X-waivered prescriber conducts a than managing someone with untreated withdrawal the capability to prescribe buprenorphine for addic- virtual visit (e.g., via live video).12 The buprenorphine symptoms. More information on treating OUD in the tion. This is known as the X-waiver. provider can then call in or fax a buprenorphine ED can be found on the ED-Bridge website. prescription.13 In October 2018, Congress passed a law to allow prescribing of buprenorphine through What is the three-day telemedicine without an in-person exam, requiring How is buprenorphine rule? the DEA to issue language to support this exception through “special registration.”14 The legislation set a paid for? Under the three-day rule, buprenorphine and metha- one-year deadline for the DEA to issue a final regula- When buprenorphine is administered in the ED, done can be administered (but not prescribed) in the tion that includes the special registration language; reimbursement is treated the same as for other ED for the treatment of pain and acute withdrawal this language has not been released at the time of medications. It is either bundled into a visit rate or without a DEA X-waiver, for no more than 72 hours.10 publication. billed on a fee-for-service basis. Prescriptions for Requirements around the three-day rule also include combination buprenorphine/naloxone medications the limitation that not more than one day’s medica- dispensed through pharmacies are reimbursed tion can be administered or given to a patient at one How is the ED visit through Medi-Cal, and no Treatment Authorization time and that the 72-hour period cannot be renewed or extended. reimbursed? Request (TAR) is required.15 Most insurance compa- nies have removed prior-authorization requirements Payment for ED MAT is based on the same acuity for buprenorphine/naloxone products used for ED clinicians may prescribe buprenorphine if they scale used for other patients seen in the ED. ED addiction treatment. have an X-waiver. Methadone may only be adminis- payments use a five-tier system (CPT codes 99281– tered; it can not be prescribed. 99285), based on severity. While some patients may The exceptions are for buprenorphine-only products fall into lower severity levels, the medical decision- for pain indications, as well as long-acting buprenor- making involved may result in a higher code. phine injections or implants. These formulations California Health Care Foundation 2 require prior authorization in Medi-Cal and usually for other insurance plans as well. Can SBIRT be reimbursed Neither case management nor behavioral health services are required to be in place for patients to when used in ED-based receive buprenorphine in the ED as long as the Although buprenorphine is the most appropriate medication for ED-based MAT for OUD,16 naltrexone MAT in Medi-Cal? ED has arrangements with community providers for ongoing care. However, given limited clinician tablets and injectable naltrexone are both covered Screening, Brief Intervention, and Referral to time, navigators or counselors can present a more under Medi-Cal fee-for-service and could be admin- Treatment (SBIRT) is an evidence-based practice cost-effective way to screen patients, conduct moti- istered and/or prescribed for patients with alcohol used to identify, reduce, and prevent problematic vational interviewing, and offer counseling and use and opioid use disorders.17 use of alcohol and drugs. Medicare reimburses for support. SBIRT as a preventive service in the primary care Most people on Medi-Cal are enrolled in a Medi- setting.21 In California, SBIRT is a billable service for Cal managed care plan, and most medications for Medi-Cal only if the ED has a specific contractual What funds support physical health issues are covered by these plans and not subject to caps on prescriptions per month. agreement with a Medi-Cal managed care health plan to provide this service. clinician training In contrast, all addiction, antipsychotic, and human opportunities? immunodeficiency virus (HIV) medicines are “carved out” and covered by Medi-Cal fee-for-service. What funds can be used Providers may access no-cost X-waiver and other clinical training opportunities through the MAT Medi-Cal fee-for-service will not reimburse provid- ers for more than six prescriptions per month for for patient navigators or Expansion Project website.22 The Providers Clinical medications in the carve-out, or fee-for-service, pro- SUD counselors? Support System also offers no-cost trainings for phy- sicians, nurse practitioners, and physician assistants. gram18; however, TARs for additional refills are easily ED-based navigators or counselors provide education approved by Medi-Cal if frequent prescriptions of and counseling to support ED-based buprenorphine The California Society of Addiction Medicine small doses are required for patient safety.19 The starts. Services provided by ED-based navigators (CSAM) provides medical education opportunities, California Department of Health Care Services notes and counselors are not reimbursable separately and its sister organization, the Medical Education that the turnaround time for the approval of TARs for under Medi-Cal but could be included as part of a and Research Foundation for the Treatment of medications with this limitation is 24 hours.20 bundled visit rate. Some hospitals have worked out Addiction, offers scholarships to CSAM’s annual grant arrangements with Medi-Cal health plans. EDs addiction education conference, which include a can also contract with Medi-Cal plans to get reim- year of mentoring with addiction experts. bursement for SBIRT services, which is a Medi-Cal benefit. How to Pay for It? | MAT in the Emergency Department: FAQ 3 The Author Endnotes Sandra Newman, MPH, LSN Health Strategy 1.This funding will also support the integration of 12.Nathanial M. Lacktman, “Prescribing Controlled paramedics into the continuum of care by making Substances Without an In-Person Exam: The Practice of buprenorphine part of the standard emergency medicine Telemedicine Under the Ryan Haight Act,” Health Care curriculum for all California emergency medicine Law Today, April 17, 2017, www.healthcarelawtoday.com. About the Foundation residency programs. 13. Andrew Herring, Emergency Department Medication- The California Health Care Foundation is dedicated 2.California Department of Health Care Services, California Assisted Treatment of Opioid Addiction, California to advancing meaningful, measurable improvements MAT Expansion Project 2.0: State Overdose Response Health Care Foundation, updated August 2016, in the way the health care delivery system provides (SOR) Funding, accessed October 23, 2018, www.chcf.org (PDF). care to the people of California, particularly those www.dhcs.ca.gov (PDF). 14.H.R.6 - Support for Patients and Communities Act, Public with low incomes and those whose needs are not 3.Audrey Weiss et al., “Statistical Brief #216: Trends in Law No. 115-271, § 7172 (2018), www.congress.gov. well served by the status quo. We work to ensure Emergency Department Visits Involving Mental and 15.California Department of Health Care Services, that people have access to the care they need, when Substance Use Disorders, 2006 – 2013,” Healthcare Cost “Contract Drugs List: Drugs: Contract Drugs List Part 1 and Utilization Project (HCUP), December 2016, – Prescriptions Drugs (A through D) (drugs cdl p1a),” they need it, at a price they can afford. www.hcup-us.ahrq.gov. accessed January 25, 2019, medi-cal.ca.gov. 4.“HCUP Fast Stats - Opiod-Related Hospital Use,” 16.Andrew Herring, “Addiction Treatment Comes to CHCF informs policymakers and industry leaders, Healthcare Cost and Utilization Project (HCUP), the Emergency Department,” California Health Care invests in ideas and innovations, and connects with October 2018, www.hcup-us.ahrq.gov. Foundation, May 17, 2018, www.chcf.org. changemakers to create a more responsive, patient- 5.David Kan and Anna Lembke, Use of Buprenorphine- 17.L.A. County Department of Public Health, centered health care system. Naloxone in the Emergency Department (San Francisco: Reimbursement of Medications for Addiction California Society of Addiction Medicine, 2018). Treatment Through Medi Cal & in FQHCS in For more information, visit www.chcf.org. 6.S.G. Weiner et al., “One-Year Mortality of Opioid Los Angeles County, revised February 27, 2018, Overdose Victims Who Received Naloxone by publichealth.lacounty.gov (PDF). Emergency Medical Services,” Annals of Emergency 18.California Department of Health Care Services, California Medicine 70, no. 4 (October 2017): S158. Medication Assisted Treatment Expansion Project: 7.Kan and Lembke, Use of Buprenorphine-Naloxone in the Billing and Grant Funding [Frequently Asked Questions], About This Series Emergency Department. updated February 27, 2018, www.dhcs.ca.gov (PDF). 8.U.S. Department of Justice, Drug Enforcement 19.Lisa Maiuro, David Coronado, and Barbara Coulter The California Health Care Foundation commis- Administration, Diversion Control Division, “Emergency Edwards, The Medi-Cal Prescription Drug Benefit: sioned How to Pay for It, a series of short papers Narcotic Addiction Treatment,” accessed October 23, An Overview, California HealthCare Foundation, that focuses on reimbursement mechanisms for 2018, www.deadiversion.usdoj.gov. December 2009, www.chcf.org (PDF). strategies that advance integration of behavioral 9.Gail D’Onofrio et al., “Emergency Department-Initiated 20.California Department of Health Care Services, California health and medical care. Buprenorphine/Naloxone Treatment for Opioid Medication Assisted Treatment Expansion Project: Billing Dependence: A Randomized Clinical Trial,” JAMA 313, and Grant Funding [Frequently Asked Questions]. no. 16 (April 28, 2015): 1636 – 44. 21.SAMHSA-HRSA Center for Integrated Health Solutions, 10.U.S. Department of Justice, Drug Enforcement SBIRT: Screening, Brief Intervention, and Referral Administration, Diversion Control Division, “Emergency to Treatment, accessed February 11, 2019, Narcotic Addiction Treatment.” www.integration.samhsa.gov (PDF). 11.U.S. Drug Enforcement Administration, Office of 22.CA Hub and Spoke System: MAT Expansion Project, Diversion Control, Buprenorphine, July 2013, “Calendar of Events,” accessed September 4, 2018, www.deadiversion.usdoj.gov (PDF). www.uclaisap.org. California Health Care Foundation 4