However, in September 2018, Congress agreed to compromise opioid legislation. They did not align 42 CFR Part 2 with the HIPAA Privacy Rule, but instead permits the disclosure of substance abuse treatment on a patient’s medical record with the patient’s consent.

In October 2019, The Partnership to Amend 42 CFR Part 2 is calling on the SAMHSA to align the rule with HIPAA to ensure proper patient data access and protect patient privacy.

Some Momentum, Needs More Results

In May 2019, HHS the creation of a new committee to identify areas for improved coordination related to SUD research, services, supports and prevention activities across all relevant federal agencies. DOE will be part of the committee.

Schools are leary of doing any assessments on kids. They don’t want to be held responsible for knowing something about a child and not addressing it. Assessment in schools by school staff is rare.

However, school districts do not need to wait for the Department of Education to implement SBIRT – there is a free tool available: CRAFFT Screening Tool

Waivers can currently be requested for opioid use disorder but not for broader SUDs. As part of the HHS effort to combat the ongoing opioid crisis, on November 1, 2017, CMS issued guidance describing additional flexibilities to help states improve access to, and quality of, SUD treatment through Medicaid section 1115

The Medicaid Innovation Accelerator Program (IAP) is available to support Medicaid agencies interested in strategic design support to develop their section 1115 SUD demonstration proposals and implementation plans. For more information, visit IAP SUD Individualized Technical Support Opportunities. H.R. 6, SUPPORT for Patients and Communities Act provides the option to cover care in IMDs, which may otherwise not be reimbursed, for treatment of SUD for patients aged 21-64 during fiscal years 2019-2023. However, this is still not a permanent solution.

NGA: Health & Human Services (HHS) should strengthen federal oversight and ensure the Mental Health Parity and Addiction Equity Act (MHPAEA)/parity violations do not limit access to substance use disorder (SUD) treatment. 

Commission #33:  HHS, The Centers for Medicare and Medicaid Services (CMS), the Indian Health Service (IHS), Tricare, the Drug Enforcement Agency (DEA), and the Veterans Administration (VA) should remove reimbursement and policy barriers to SUD treatment, such as patient limits, that limit access to any forms of FDA-approved medication-assisted treatment (MAT), counseling, inpatient/residential treatment, and other treatment modalities, particularly fail-first protocols and frequent prior authorizations. All primary care providers employed by the above-mentioned health systems should screen for alcohol and drug use, and provide treatment within 24 to 48 hours, directly or through referral. 

Commission #35: Because the Department of Labor (DOL) regulates health care coverage provided by many large employers, the Commission recommends that Congress provide DOL increased authority to levy monetary penalties on insurers and funders, and permit DOL to launch investigations of health insurers independently for parity violations. 

Commission #36: Federal and state regulators should use a standardized tool that requires health plans to document and disclose their compliance strategies for non-quantitative treatment limitations (NQTL) parity. HHS, in consultation with DOL and Treasury, should review clinical guidelines and standards to support NQTL parity requirements.

Uncoordinated

NGA: Expand access to evidence-based SUD and mental health services for justice-involved populations. Specifically, medicaid coverage for medicaid-eligible individuals who are incarcerated pending disposition or nearing release. CMS should grant states (under 1115 authority) partial waivers of inmate exclusion otherwise barring states form receiving federal Medicaid funding in these circumstances. 

Commission #37: The Commission recommends the National Institute on Corrections (NIC), the Bureau of Justice Assistance (BJA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and other national, state, local, and tribal stakeholders use medication-assisted treatment (MAT) with pre-trial detainees and continuing treatment upon release. 

STATUS

Needs Funding, Culture and Attitude Change

The move to allow for Medication Assisted Treatment (MAT), also known as pharmacotherapy, for incarcerated individuals has been very slow, mostly due to funding, concerns over diversion of prescription medicine for illicit use within the facilities, and a general misunderstanding of the role of these medications and their effectiveness for longer term treatment of SUD. Even if inmates have access to MAT/pharmacotherapy, those with felony charges are not eligible for medicaid coverage upon release until their probation is complete, creating a dangerous gray area.

Public-Public and Public-Private partnerships must be formed in most cases so the correctional facility can make a warm handoff of medical services to the local managed care organization (MCO/Medicaid provider) or county health department. In 2016 Rhode Island launched a first of its kind program in the country to provide medically assisted substance abuse treatment for incarcerated individuals, as well as transition programs to connect with treatment providers upon release. Rhode Island is currently the only state that mandates the use of all three evidenced-based opioid withdrawal medications (Vivitrol, Suboxone, and Methadone).

All of these systems mentioned are working on incorporating MAT/pharmacotherapy into their programs and making it available to current incarcerated offenders. H.R. 6, Support for Patients and Communities Act requires Health and Human Services to convene a stakeholder group to report on best practices for states on this topic. This is an important, but tiny step in an area critical to impacting this crisis.

NGA:  The Health Resources and Services Administration (HRSA) should expand definition of approved sites where primary care providers can be reimbursed for providing medication assisted treatment (MAT) and other behavioral health interventions to include substance use disorder (SUD) treatment facilities.

Commission #34: Health and Human Services (HHS) review and modify rate-setting (including policies that indirectly impact reimbursement) to better cover the true costs of providing SUD treatment, including inpatient psychiatric facility rates and outpatient provider rates.

Slow Progress

As of November 2019, Some states have used their SUD waivers to formally implement the ASAM Criteria to promote consistency in client placement for SUD treatment

Slow Progress

HRSA has an Opioid Crisis Webpage that incorporates resource, training, and assistance opportunities to address the opioid epidemic

These recovery support services were included in the first piece of legislation called CARA (Comprehensive Addiction Recovery Act), however, they were not funded. Some states have added recovery coaches to their formulary but it is hit and miss. When someone successfully stops misusing, but can’t find employment, or housing, or a community of support, they are more likely to re-engage in misuse. Recovery Support Services are part of treatment.

H.R. 6, SUPPORT for Patients and Communities Act requires HHS to issue best practices for recovery housing, and to identify common indicators in fraudulent recovery housing operators. The Building Communities of Recovery program was reauthorized and modified by the law to include peer support networks and funding for community organizations focused on long-term recovery support services. H.R. 6 also requires HHS to establish a National Peer-Run Training and Technical Assistance Center for Addiction Recovery Support to facilitate expansion of comprehensive recovery support programs in communities, as well as provide a program to support transition to independent living and return to the workforce.

NGA:  Health & Human Services (HHS) should issue guidance encouraging universal screening of pregnant women as part of comprehensive obstetric care. HHS should also issue comprehensive standards for treating neonatal abstinence syndrome.

Commission #47: HHS, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Administration on Children, Youth and Families (ACYF) should disseminate best practices for states regarding interventions and strategies to keep families together, when it can be done safely (e.g., using a relative for kinship care). These practices should include utilizing comprehensive family centered approaches and should ensure families have access to drug screening, substance use treatment, and parental support. Further, federal agencies should research promising models for pregnant and postpartum women with substance use disorders (SUDs) and their newborns, including screenings, treatment interventions, supportive housing, non-pharmacologic interventions for children born with neonatal abstinence syndrome, medication-assisted treatment (MAT) and other recovery supports.

Moving Forward

When screening laws lead to separation of families with a charge of “neglect and abuse,” the safety and health risk increases for mothers and children. The opioid crisis has caused a dramatic increase in the number of children in foster care. Communities and states must ask (if children can be kept safe with their parents); does investment in finding ways to keep families together and healthy make more fiscal and emotional sense than foster care?

H.R. 6, SUPPORT for Patients and Communities Act has several provisions to improve care for infants with neonatal abstinence syndrome and their mothers – an important step in reducing the impact of this crisis to next generations. The law includes a study to identify gaps in Medicaid coverage for pregnant and postpartum mothers, clarification for states on provision of Medicaid to infants with NAS, and provision of support for their mothers. It also provides funding for HHS to test a “recovery coach” program for parents with children in foster care, along with an increase of funding to increase capacity for family-focused residential treatment.

Some Momentum, Needs More Funding

Great idea but there has been no money for this. Technical assistance and services for Collegiate Recovery Programs has not previously been funded by the federal government and there is no current legislation to support it.

In March 2019, the U.S. Department of Education, Office of Safe and Supportive Schools (OSSS) and the National Center on Safe Supportive Learning Environments (NCSSLE) in coordination with the White House ONDCP hosted a webinar to explore the role of Collegiate Recovery Programs (CRPs) and similar initiatives in supporting students in recovery. In this transcript, it is mentioned that the federal government supports the development of CRPs bu hosting webinars, hosting panels with experts, passing policies, and funding preliminary research. However, there are no direct links included in this transcript to point people towards more information on these investments.

There are several organizations that do support the development, creation, and maintenance of CPR, including Transforming Youth Recovery and The Association of Recovery in Higher Education

Consistent Progress