Form CMS-10398 #68 CMS-10398 #68 SPA Coverage Template for Limitations (Supplement to Att

Enclosure ___

Supplement to Attachment 3.1‑A

Page _____

State of ______________

1905(a)(29) Medication-Assisted Treatment (MAT)

Citation: 3.1(a)(1) Amount, Duration, and Scope of Services: Categorically Needy (Continued)

1905(a)(29) ­­­­_____MAT as described and limited in Supplement ____ to Attachment 3.1‑A.

ATTACHMENT 3.1‑A identifies the medical and remedial services provided to the categorically needy.

Enclosure ___

Supplement to Attachment 3.1‑A

Page _____

State of ______________

1905(a)(29) Medication-Assisted Treatment (MAT)

Amount, Duration, and Scope of Medical and Remedial Care Services Provided to the Categorically Needy (continued)

1. General Assurance

MAT is covered under the Medicaid state plan for all Medicaid beneficiaries who meet the medical necessity criteria for receipt of the service for the period beginning October 1, 2020, and ending September 30, 2025.

2. Assurances

1. The state assures coverage of Naltrexone, Buprenorphine, and Methadone and all of the forms of these drugs for MAT that are approved under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) and all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262).

2. The state assures that Methadone for MAT is provided by Opioid Treatment Programs that meet the requirements in 42 C.F.R. Part 8.

3. Service Package

The state covers the following counseling services and behavioral health therapies as part of MAT.

1. Please set forth each service and components of each service (if applicable), along with a description of each service and component service.

2. Please include each practitioner and provider entity that furnishes each service and component service.

3. Please include a brief summary of the qualifications for each practitioner or provider entity that the state requires. Include any licensure, certification, registration, education, experience, training and supervisory arrangements that the state requires.

Enclosure ___

Supplement to Attachment 3.1‑A

Page _____

State of ______________

1905(a)(29) Medication-Assisted Treatment (MAT)

Amount, Duration, and Scope of Medical and Remedial Care Services Provided to the Categorically Needy (continued)

4. Utilization Controls

_____ The state has drug utilization controls in place. (Check each of the following that apply)

_____ Generic first policy

_____ Preferred drug lists

_____ Clinical criteria

_____ Quantity limits

_____ The state does not have drug utilization controls in place.

5. Limitations

Describe the state’s limitations on amount, duration, and scope of MAT drugs, biologicals, and counseling and behavioral therapies related to MAT.

Enclosure ___

Supplement to Attachment 3.1‑A

Page _____

State of ______________

1905(a)(29) Medication-Assisted Treatment (MAT)

Amount, Duration, and Scope of Medical and Remedial Care Services Provided to the Categorically Needy (continued)

PRA Disclosure Statement - This information is being collected to assist the Centers for Medicare & Medicaid Services in implementing section 1006(b) of the SUPPORT for Patients and Communities Act (P.L. 115-271) enacted on 10/24/2018. Section 1006(b) requires state Medicaid plans to provide coverage of Medication-Assisted Treatment (MAT) for all Medicaid enrollees as a mandatory Medicaid state plan benefit for the period beginning October 1, 2020, and ending September 30, 2025. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0938-1148 (CMS-10398 # 68). Public burden for all of the collection of information requirements under this control number is estimated to take about 80 hours per response. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.