The CMS on Monday issued new guidance for states and Medicaid managed-care programs to change up their Medicaid drug utilization review programs by the end of this year.
Medicaid programs have been on the front lines fighting the opioid epidemic. The CMS' new mandates, which include setting opioid prescription limits and monitoring Medicaid patients for potential abuse, apply equally to state Medicaid fee-for-service programs and private managed-care companies.
States have until Dec. 31 to outline their state plan amendments to overhaul the way they approach opioid use by their Medicaid populations. They will have to set their own limits on opioid prescriptions and refills while also tracking patients who are at risk of overusing painkillers, or who may be concurrently taking multiple prescribed opioids and benzodiazepines and antipsychotics.
The CMS acknowledged that setting these plans will likely be very complicated. The agency urged states to set up trainings to keep their clinicians on the same page about the new requirements.
The guidance is part of the agency's implementation of an opioid law that Congress passed last year.
It shows how clinicians may have to walk a fine line while they try to follow the new law by keeping prescribed medication coming for Medicaid patients and curbing overprescribing and abuse.
Medicaid programs may need to issue prior authorizations so Medicaid beneficiaries can receive clinical treatment to reduce opioid usage.
The CMS underscored that patients who are already using medication-assisted treatment should continue those therapies "without disruption," but states will decide whether their programs should include that treatment.
The CMS wants states to create prospective and retrospective drug utilization reviews that fall in line with the state's medical practice patterns and hold up the Centers for Disease Control and Prevention's 2016 prescribing guidelines as the standard for outpatients with chronic pain.
States will also have to design and implement a program to track and manage the prescribing of antipsychotic medications for children in Medicaid. They will have to report annually to the CMS about how these programs are functioning, with particular attention on children in foster care.