Medicaid and Vivitrol Strategies in Colorado by Sm5dWLv


									Medicaid and Vivitrol
Strategies in Colorado

          Bill Wendt, JD, CAC III
          Chief Executive Officer/General Counsel
History of Signal

   A non-profit dedicated to managing a network of providers of
    substance abuse treatment services that are accessible to,
    affordable, and efficacious for consumers of these services
   In 1996, the Colorado Alcohol and Drug Abuse Division
    (ADAD) issued an RFP for managed service organizations
    (MSO) to manage and monitor substance abuse treatment
   In 1997, Signal was awarded contracts for northeast
    Colorado, southeast Colorado, and metro Denver.
   In 2003, Signal was designated as the MSO for the three
Signal Services

   A complex online service management and billing website
    available to providers, counties, and internal Signal staff

   Clinical auditing and oversight of network providers as well as
    performance monitoring

   Management of state, county, and judicial district funds

   Data collection and reporting resource for the state

   Lobbying to obtain monies or effect public policy for
    substance abuse treatment
Advancing Recovery Projects

   Signal chose continuation as the year 1 AR project and
    MAT as the year 2 project. 38% of statewide treatment
    admissions have alcohol as the primary drug of abuse.
    Less than 1% receive any MAT.
   Signal submitted an Investigator Sponsored Study (ISS)
    protocol to Alkermes for 480 clients to receive 4 months
    worth of donated Vivitrol through 3 Signal provider
   Signal targeted key legislators (Joint Budget Committee,
    Speaker of House) to submit letters of support.
   Still waiting for protocol approval from Alkermes--- long
Medicaid - HCPF

   Signal has no direct relationship with Health Care Policy
    Financing (HCPF) – the state agency who administers

   There is limited outpatient substance abuse benefit
    managed by HCPF directly to providers. May be included
    in the mental health capitation contracts beginning 2009.
Medicaid - Vivitrol

   HCPF was invited to an AR MAT team meeting to discuss
    Medicaid reimbursement of Vivitrol.
    –   Medicaid reimburses Vivitrol as part of Medicaid medical
        benefit – not a pharmacy benefit nor part of substance
        abuse treatment benefit.
            HCPCS Code J2315 at $2.52 per mg is used by HCPF.

            CPT Code 90772 for injection is not used.

            Reimbursement for both medication and time for administering
             injection is covered in J2315.

            At 380 mg each – the injection reimbursement rate is $957.60.
Medicaid – Vivitrol

   Signal requested current Vivitrol Medicaid utilization data.
    There are barriers to getting the data – must submit an
    Open Records Request. (Request still pending)

   Signal brought Alkermes reimbursement consultants to the
    MAT team meeting to offer resources to providers.

   Signal lobbyists retained by Alkermes are working with
    Single State Agency, Governor’s Office and Joint Budget
    Committee to submit a decision item to fund MAT through
    MSO’s. (Multi-year process)
Lessons Learned

   Include Medicaid office early in the process.
   Many MSO clients are not Medicaid eligible. Strategies must
    cut across multiples systems, funding streams and various
    policy makers.
   Providers need technical assistance to bill Medicaid.

   FQHC’s get low reimbursement---less than $100 per injection
Lessons Learned

   Number of Medicaid eligible clients not accurately
    captured in current treatment system.

   Vivitrol managed by different part of HCPF system from
    treatment benefit. Need to include both parts of the

   Need incentives to identify Medicaid eligible clients. Rates
    are low and billing is a hassle.

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