North Carolina Opioid Spotlight Highlights State Progress

Manatt on Health: Medicaid Edition

North Carolina has fought the opioid epidemic with an array of public and private sector initiatives. A new spotlight analysis, developed by Manatt in partnership with the American Medical Association (AMA) and the North Carolina Medical Society, highlights the work of two agencies—North Carolina (NC) Medicaid and the North Carolina Department of Insurance (DOI)—to expand substance use disorder (SUD) treatment, improve pain management and increase access to naloxone. It mobilized multiple state agencies to implement new strategies for reducing opioid prescriptions and expanding access to treatment and recovery-oriented systems of care. As part of the plan, the state established the North Carolina Payers Council to bring Medicaid, Medicare and commercial insurers together to collaborate on responses to the epidemic. While there has been a 12% reduction in opioid prescriptions since 2013, the death rate has not yet plateaued.

The report reviews the state’s progress in Medicaid and the commercial insurance market in these areas and identifies options for further building on these gains, drawing on emerging strategies from around the country. (Results of the full spotlight analyses series were shared in a recent webinar from Manatt and the AMA. Click here to view the program on demand.)

Key Actions Taken in North Carolina

  • Increasing access to medication-assisted treatment. The state has eliminated prior authorization for leading forms of medication-assisted treatment (MAT) in Medicaid and used federal grants to fund treatment, linkages to MAT, and training and support for MAT providers.
  • Providing the full continuum of care required for SUD treatment. As a key feature of its Section 1115 waiver, NC Medicaid will provide the full set of benefits comprising the American Society for Addiction Medicine (ASAM) continuum of care. The waiver lifts the federal ban on Medicaid reimbursement for SUD treatment provided to individuals residing in institutions for mental diseases (i.e., “the IMD exclusion”).
  • Focusing on “whole person” care in Medicaid managed care implementation. As part of the state’s transition to Medicaid managed care in November 2019, the state established requirements for Medicaid managed care plans to provide integrated care that considers an individual’s physical health, behavioral health and unmet health-related resource needs. This focus on whole-person care is particularly important for individuals with SUD, who often face challenges across all these domains and can benefit significantly from integrated care.
  • Promoting access to comprehensive pain care. NC Medicaid has taken steps to increase access to non-opioid pain management alternatives. It has added or expanded coverage for some non-opioid pharmaceuticals and topical analgesics, as well as non-pharmaceutical alternatives, such as physical therapy and chiropractor services. Even as it promotes non-opioid pain treatments, NC Medicaid recognizes that some beneficiaries with chronic pain require opioids and has created clinical guidelines that promote individualized patient care plans.
  • Expanding naloxone access and promoting harm reduction. The state has expanded the availability of naloxone throughout the state, building on its early adoption of a naloxone standing order and Good Samaritan law. Its efforts to promote the distribution of naloxone kits to first responders, law enforcement and community coalitions have reversed more than 10,000 overdoses. As part of its commitment to harm reduction, the state legalized and publicized syringe exchange programs to reduce the spread of infectious diseases and link individuals with SUD to services.

Where North Carolina Can Build on Its Accomplishments

  • Expand Medicaid. The state has not expanded Medicaid to low-income adults as allowed under the Affordable Care Act, leaving approximately 150,000 North Carolinians with an SUD without coverage. Without a solid base of coverage for its citizens, the state cannot ensure that its residents are systematically screened for and treated for SUDs. Governor Roy Cooper has called for expansion, and the legislature is debating this issue during the current legislative session.
  • Partner with Medicaid managed care plans to ensure implementation of key SUD-related policies. The state has established strong requirements for Medicaid managed care plans to provide whole-person care, offer an adequate network of SUD providers and cover key forms of MAT without prior authorization. Following managed care implementation, it will be critical to ensure plans are complying with these requirements and partnering with the state to end the epidemic.
  • Adopt cross-sector approaches to combating the epidemic. The Council developed concrete recommendations for health insurance payers to respond to the opioid epidemic through pain treatment, naloxone access, SUD treatment, data analytics, and patient and provider education. The state’s largest insurer, Blue Cross Blue Shield of North Carolina, has eliminated prior authorization for all of its preferred buprenorphine products. Many large insurers in North Carolina have also expressed support for removing prior authorization.
  • Partner with commercial insurers to strengthen network adequacy and parity compliance standards. The network adequacy standards established for Medicaid managed care plans provide clear guidance to those plans and could be used to strengthen DOI guidelines for ensuring that commercial insurers have adequate networks as well. The DOI also could clarify mental health and SUD parity standards and use targeted market conduct exams to identify and remedy gaps in commercial insurance services.
  • Further increase access to opioid alternatives. NC Medicaid could build on its efforts to cover important forms of evidence-based non-opioid and non-pharmacological alternatives for pain management by continuing to review whether all appropriate alternatives are covered. The DOI should work with commercial insurers to ensure commercially insured patients have access to timely and affordable, comprehensive, multidisciplinary, multimodal pain care.
  • Continue efforts to systematically measure the impact of opioid-related interventions. The state has recognized the importance of evaluating its progress on combating the opioid epidemic, and has developed key metrics that are monitored and published quarterly on an opioid data dashboard. It will be important for the state to continue evaluating the effectiveness of interventions and work with the medical community, patient advocates, researchers and universities to identify programs that are working well and how to effectively target resources based on surveillance data.


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