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On October 24, 2018, President Trump signed the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. The SUPPORT Act is federal law that will change aspects of Washington Apple Health (Medicaid) – specifically clinical pharmacy policy and prescription drug monitoring requirements
Medicaid Drug Utilization Review (DUR) requirements
The SUPPORT Act created new requirements for all state Medicaid programs. These requirements are known as Drug Utilization Review (DUR). Apple Health updated clinical policies to conform with these requirements which include:
- Safety edits for subsequent fills for opioids and an automated claims review process that indicates when an Apple Health enrollee is prescribed a subsequent fill
- Safety edits on the maximum daily morphine equivalent that can be prescribed to an Apple Health enrollee for treatment of chronic pain and an automated claims review process that indicates when an indicates when an individual is prescribed in excess of that limitation
- An automated claims review process that identifies when an Apple Health enrollee is concurrently prescribed opioids and benzodiazepines or antipsychotics
In addition to new DUR requirements, Apple Health also updated program and reporting requirements that include:
- A program to monitor and manage the appropriate use of antipsychotic medications by Apple Health enrolled children under age 18 and “children in foster care specifically”
- A process to identify potential fraud or abuse of controlled substances by Apple Health enrollees, health care providers prescribing drugs to Apple Health enrollees, and pharmacies dispensing drugs to Apple Health enrollees
- A report to the Secretary annually on state Drug Utilization Review Board (DUR) activities
Prescription Drug Monitoring Program (PDMP)
The SUPPORT Act establishes the Medicaid Providers Are Required to Note Experiences in Record Systems to Help In-need Patients Act (Medicaid PARTNERSHIP Act).
The Medicaid PARTNERSHIP Act requires Apple Health providers to make a “good faith effort” to check a prescription drug monitoring program before prescribing a controlled substance (Schedule II through Schedule IV), beginning October 1, 2021. The qualified prescription drug monitoring program must allow covered providers to access:
- Information regarding the prescription drug history of a covered individual with respect to controlled substances,
- The number and type of controlled substances prescribed to and filled for the covered individual during at least the most recent 12-month period; and
- The name, location, and contact information (or other identifying number selected by the State) of each covered provider who prescribed a controlled substance the covered individual during at least the most recent 12-month period.
This information must be “as real time as possible.”
Apple Health providers will be required to check relevant PDMPs before prescribing a Schedule II through Schedule IV controlled substance. The policy also encourages Apple Health providers to integrate PDMP usage into an Apple Health provider’s clinical workflow and establishes standard criteria that a PDMP must meet to be counted as a qualified PDMP.
- PMP rules slide deck (updated July 19, 2021)
- Apple Health Prescription Monitoring Program check for outpatient prescriptions - FAQ (updated September 16, 2021)
Better data sharing to combat the opioid crisis
The SUPPORT Act gives HCA reasonable access, if permitted by state law, to prescription drug monitoring program databases administered or accessed by other state agencies, and may facilitate reasonable access to those databases for any Apple Health enrolled provider or any managed care organization (MCO). The act also permits HCA to share information from the databases with providers and managed care entities to the same extent that the State agency is permitted under State law. In other words, this provision clarifies states’ ability to access and share data from prescription drug program databases, consistent with the parameters established in state law, including with providers and MCOs, and in adherence to applicable security and privacy protections and laws.
Changes to HCA opioid policy
On November 1, 2019, Apple Health (Medicaid) began using an updated clinical policy for opioid prescriptions. The Health Care Authority (HCA) has updated the clinical policy to include new criteria related to morphine milligram equivalents (MME). Forms pertaining to opioid prescriptions have also been updated. This opioid policy will affect all clients served through Apple Health, including both fee-for-service and managed care. HCA’s opioid clinical policy is a patient safety tool that will help ensure appropriate use of opioids and reduce the risk of clients from developing opioid use disorder. Read more about the policy.
Opioid policy frequently asked questions (FAQ)
Why is Apple Health (Medicaid) implementing more changes? Didn’t we just go through this?
- HCA is implementing these changes as required by the SUPPORT Act – a federal mandate. The SUPPORT Act affects all states and their respective Medicaid programs.
What are the specific changes to prescribing policy due to the SUPPORT Act?
- HCA is currently working to analyze and summarize the changes. We will have more specific information by September 1, 2019. Please check back regularly for updates. HCA will also send out provider alert updates as needed. You can sign up for alerts if you have not already.
Does the SUPPORT Act apply to skilled nursing facility and home care patients?
- Yes. The new policy applies to all opioid prescriptions that are billed through pharmacy claims systems.
Does the SUPPORT Act apply to inpatient facilities?
- No. Opioids administered in an inpatient facility will not be impacted by the SUPPORT Act.
Roadmap to Recovery
In September of 2019 the Centers for Medicare and Medicaid Services (CMS) awarded Washington state $3.8 million to develop a policy framework over the next 18 months. This framework will guide future activities to advance statewide whole-person, integrated care. Read more about the planning grant.
For opioid policy questions
Email: Apple Health Pharmacy Policy
For Road to Recovery questions
Megan Fowler, program director