The Centers for Medicare and Medicaid Services (CMS) requires each State Medicaid Program to submit to CMS an annual report on the operation of its Medicaid Drug Utilization Review (DUR) fee-for-service (FFS) program, including information on prescribing patterns, cost savings generated by the state’s DUR program, and the state’s DUR program’s overall operations, including any new or innovative practices.
The recently-enacted Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act includes measures to combat the opioid crisis in part by reducing opioid abuse and misuse by advancing treatment and recovery initiatives, improving prevention, protecting communities, and bolstering efforts to fight deadly illicit synthetic drugs. There are several Medicaid-related DUR provisions contained within the SUPPORT for Patients and Communities Act with respect to FFS and Managed Care Organization (MCO) pharmacy programs. These provisions establish drug review and utilization standards to supplement existing requirements to reduce opioid-related fraud, abuse and misuse.
On August 5, 2019, the CMS Center for Medicaid and CHIP Services (CMCS) released an Informational Bulletin for states on how to implement the Medicaid DUR provisions under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act). Many of the new requirements use a prospective review, as opposed to reviewing past claims, to encourage proper use of opioid analgesics.
Prospective review includes alerts that tell pharmacists when a patient is exceeding certain limits on opioid prescriptions or if fraud, abuse, or misuse is indicated. Prospective reviews can result in restrictions on early refills, duplicate refills, and prescribed quantities deemed too large. They may also lead to restrictions on daily morphine milligram equivalent (MME) dispensation and warnings on prescriptions made concurrently with another drug with which it could have an adverse drug interaction. The guidance directs states to make such changes the top priority in developing a State Plan Amendment (SPA) to submit to CMS.
CMS further notes that education and training for providers will be necessary to ensure a smooth rollout of, and ongoing compliance with, the provisions. CMS also addresses patients with prescriptions that exceed limits, noting that prior authorization may be necessary to ensure that they do not undergo forced tapers. Additionally, the bulletin notes that patients using medication-assisted therapy (MAT) drugs for substance use disorder treatment should not have their treatment disrupted and that states may use their discretion as to whether to include MAT drugs in their DUR programs. CMCS encourages state Medicaid agencies to reach out to providers to help ensure a smooth transition and ensure that beneficiaries have access to necessary medications.
In addition to the requirements for opioids, states must also implement a program to manage the use of antipsychotic medications by child beneficiaries, including submitting information to CMS on the management of antipsychotic medications by children in foster care as part of usual DUR reporting.
State Plan Amendments
States have until December 31, 2019 to submit their SPA to CMS describing how they address the requirements. States must also have plans in place to ensure that MCOs serving their beneficiaries comply with the same requirements as fee-for-service Medicaid; MCO contracts must include these newly mandated DUR requirements no later than October 1, 2019.
CMS directs states to address the following areas in their SPA: (1) claims review limitations, (2) a program to monitor antipsychotic medication use by children, (3) fraud and abuse identification, and (4) requirements for MCOs.
CMCS also encourages states to adopt the Centers for Disease Control’s 2016 opioid prescription guideline in their DUR programs, in spite of reported widespread misuse of the guideline and criticism from patient advocates. The changes required by the SUPPORT Act will require changes in the information systems used to run Medicaid programs and process claims. CMS reminded states that they may be eligible for enhanced federal funding for such changes, amounting to 90 percent of the cost.