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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 services 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 regions. 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 locations. Signal targeted key legislators (Joint Budget Committee, Speaker of House) to submit letters of support. Still waiting for protocol approval from Alkermes--- long process Medicaid - HCPF Signal has no direct relationship with Health Care Policy Financing (HCPF) – the state agency who administers Medicaid. 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 system. Need incentives to identify Medicaid eligible clients. Rates are low and billing is a hassle.
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