Medicaid and Vivitrol Strategies in Colorado

1. Medicaid and Vivitrol Strategies in Colorado Bill Wendt, JD, CAC III Chief Executive Officer/General Counsel

2. 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.

3. 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

4. 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

5. 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.

6. 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.

7. 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)

8. 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

9. 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.