Medicaid Coverage for the Treatment of Opioid Use Disorder

As the focus of South Carolina’s healthcare system has turned toward coronavirus disease 2019 (COVID-19), the South Carolina Department of Health and Human Services (SCDHHS) remains committed to ensuring access for Medicaid beneficiaries suffering from opioid use disorder (OUD). This bulletin highlights specific provisions of existing policy that are especially relevant during the state’s response to COVID-19, and details modifications to further ensure access to treatment for OUD.

Management of Medication-Assisted Treatment (MAT) via Telehealth

As a part of the state’s preparation and response to COVID-19, SCDHHS has announced several modifications to policies related to telehealth coverage. Details related to those modifications are available at www.scdhhs.gov/covid19. Expanded coverage of telephonic check-in and evaluation and management services, as described in Medicaid bulletins 20-004 and 20-005, are available to reimburse providers for managing MAT via telehealth. Expanded coverage of telehealth will remain in effect for the duration of the current declared public health emergency, unless SCDHHS determines they should sunset at an earlier date.

Additionally, the South Carolina Board of Medical Examiners has issued an order regarding the use of telemedicine for providing MAT. SCDHHS will reimburse for MAT provided pursuant to the provisions of this order.

MAT Prior Authorization Guidelines

SCDHHS, along with the managed care organizations (MCOs) in the South Carolina Medicaid market, provides coverage for all Food and Drug Administration-approved MAT options. MAT coverage criteria are available here. These criteria apply to the fee-for-service Medicaid benefit, as well as to each of the MCOs.

Billing for Services Provided by an Opioid Treatment Program (OTP)

SCDHHS added coverage for OTPs in January 2019, effectively providing access to all formulations of MAT to Medicaid beneficiaries in South Carolina. Since then, the Centers for Medicare and Medicaid Services (CMS) has introduced a series of Healthcare Common Procedure Coding System (HCPCS) codes to designate services provided by an OTP. Effective July 1, 2020, SCDHHS will transition to the CMS code set.

The following codes will be reimbursed by SCDHHS:

The fee schedule for the services listed above will be available at www.scdhhs.gov.

Long-acting Injectable Reimbursement for Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Outpatient Hospital Providers

Effective for services provided on or after July 1, 2020, SCDHHS will reimburse for long-acting injectable medications indicated for the treatment of OUD, including naltrexone for extended-release injectable suspension and buprenorphine extended-release, outside of the encounter rate for FQHCs and RHCs. These medications should be submitted for payment and will be reimbursed as “bill-above” services.

Long-acting injectable medications will also be reimbursed as “add-on” services for reimbursement type 1 and reimbursement type 5 claims for outpatient hospital providers.

Timely Information for Providers in South Carolina (tipSC)

SCDHHS has engaged in an aggressive provider education campaign to promote opioid risk reduction strategies and expand access to MAT, named tipSC. Working with physicians, pharmacists and other experts from the Medical University of South Carolina, tipSC develops and disseminates targeted, practical information to help prescribers make safer prescribing decisions. These educational programs offer continuing education credit for providers. These materials are available at https://msp.scdhhs.gov/tipsc/.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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