ModifiedNevada Health AuthorityPolicy 3800

Medication-Assisted Treatment for Opioid Use Disorder

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Governs Nevada Medicaid coverage, provider requirements, clinical phases, documentation, and pharmacist requirements for outpatient medication-assisted treatment for eligible recipients diagnosed with opioid use disorder.

Policy Summary

PayerNevada Health Authority

PolicyMedication-Assisted Treatment for Opioid Use Disorder

Policy CodePolicy 3800

Change TypeModified

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionDocument the opioid use disorder diagnosis, comprehensive medical evaluation, suitability for treatment, patient education, and informed consent.

SourceLink

POLICY UPDATE CHANGES

Section 3802 was revised to add naltrexone and recognize pharmacists as eligible providers.

New Section 3808 establishes special requirements for pharmacists who prescribe and dispense treatment for opioid dependence.

Authority references were added or clarified.

5Eligible provider types

NonePrior authorization

12–24 hours

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ModifiedNevada Health AuthorityPolicy 3800

Medication-Assisted Treatment for Opioid Use Disorder

Customize your policy alerts

Sign up for Nevada Health Authority Policy 3800 alerts

Get alerted when Policy 3800 changes without checking for updates manually.

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Policy Summary

PayerNevada Health Authority

PolicyMedication-Assisted Treatment for Opioid Use Disorder

Policy CodePolicy 3800

Change TypeModified

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionDocument the opioid use disorder diagnosis, comprehensive medical evaluation, suitability for treatment, patient education, and informed consent.

SourceLink

POLICY UPDATE CHANGES

Section 3802 was revised to add naltrexone and recognize pharmacists as eligible providers.

New Section 3808 establishes special requirements for pharmacists who prescribe and dispense treatment for opioid dependence.

Authority references were added or clarified.

5Eligible provider types

NonePrior authorization

12–24 hours

Opioid abstinence before induction

Before visit 3Psychosocial assessment deadline

6 monthsPharmacist care coordination review

IndefiniteMaintenance duration

Medication-Assisted Treatment Overview

Medication-assisted treatment (MAT), also called medications for opioid use disorder (MOUD), combines medication with counseling and behavioral therapies to provide a whole-patient approach to substance use disorders. This policy focuses on outpatient, office-based treatment for opioid use disorder and supports medication treatment as part of sustained recovery; buprenorphine maintenance may continue indefinitely when clinically appropriate to help prevent relapse.

Key Terms

Medication-Assisted Treatment (MAT/MOUD)

TermMedication-Assisted Treatment (MAT), also known as medications for opioid use disorder (MOUD)

DefinitionThe use of medications in combination with counseling and behavioral therapies to treat substance use disorders using a whole-patient approach.

Behavioral-health relationshipCounseling and behavioral therapies are combined with medication as part of treatment; patients may be offered or referred to behavioral-health services based on individual need.

Opioid Use Disorder (OUD)

ConditionOpioid use disorder is the condition diagnosed under the current edition of the Diagnostic and Statistical Manual of Mental Disorders or the current edition of the International Classification of Diseases.

Coverage relevanceNevada Medicaid covers medically necessary MAT for eligible Medicaid recipients with a diagnosis of OUD who meet the predetermined criteria.

DocumentationThe provider must assess the patient and diagnose and document OUD before commencing MAT.

Induction Phase

DefinitionThe induction phase is the medically monitored startup of buprenorphine treatment in a qualified physician's office using approved buprenorphine products.

TimingBuprenorphine is administered after the patient has abstained from opioids for 12 to 24 hours and is in the early stages of opioid withdrawal.

MonitoringThe provider titrates the dose to alleviate withdrawal symptoms, completes the Clinical Opiate Withdrawal Scale or another approved tool during each visit until symptoms are absent, and determines whether two or three consecutive days of visits are needed.

Stabilization Phase

Phase beginsStabilization begins after the patient has discontinued or greatly reduced misuse of the problem drug and no longer has cravings.

Clinical statusThe patient experiences few, if any, side effects; the buprenorphine dose may require adjustment.

Follow-upThe stabilization period lasts several weeks after induction, with a limited medication supply and clinically appropriate regular follow-up during the first month.

Maintenance Phase

Clinical statusMaintenance occurs when the patient is doing well on a steady dose of buprenorphine.

DurationThe length of maintenance treatment is tailored to each patient and may be indefinite.

Ongoing careConcurrent psychosocial support, periodic psychosocial assessment, and laboratory testing are indicated throughout treatment.

Harm Reduction

DefinitionHarm reduction consists of practical strategies and ideas intended to reduce the public-health risks associated with drug use.

ApproachServices and resources are provided in a nonjudgmental and noncoercive manner to people who use drugs and the communities in which they live.

Treatment applicationProviders consider incorporating harm-reduction strategies into the patient's treatment and make recommendations to the prescribing provider.

Medical Necessity and Coverage Requirements

General MAT Coverage

MAT is covered when all applicable medical necessity, provider, assessment, and treatment requirements are met.

General MAT coverage

Clinical eligibility: Diagnosis of opioid use disorder and medical necessity for MAT are documented.
Provider eligibility: The provider has a DEA license and complies with provider-type requirements; pharmacists also comply with the special pharmacist requirements.
Required assessment and consent: A comprehensive medical evaluation, appropriate laboratory testing or referral, informed consent, treatment agreement, and required psychosocial assessment are completed and documented.

Assessment and Initial Eligibility

Provider Types and Operational Thresholds

Eligible provider type codesmixed

PT 20	Physician, M.D.
PT 24	Advanced Practice Registered Nurse
PT 77	Physician's Assistant
PT 74	Nurse Midwife
PT 91	Pharmacist

Opioid Abstinence Before Buprenorphine Induction

Typical abstinence period12–24 hours before buprenorphine administration.

Withdrawal statusThe patient should be in the early stages of opioid withdrawal when buprenorphine is administered.

Safety considerationAdministration before early withdrawal, while other opioids remain in the bloodstream, can bring on acute withdrawal.

Psychosocial Assessment Completion

DeadlineBefore the third patient visit to the provider prescribing or dispensing MAT.

Required contentThe assessment must include documentation supporting ASAM criteria, including dimensions and levels of care.

Documentation and Practice Requirements

Documentation Required

Initial Evaluation and OUD Diagnosis

Before commencing MAT, complete and document a comprehensive medical evaluation, assess and diagnose OUD under the current DSM or ICD, and determine the individual's suitability and medical necessity for MAT. Provide education about the MAT process and organize accessible services, minimizing separate patient trips where possible.

Document the OUD diagnosis and the physician's medical-necessity and suitability determination in the patient's record.
Arrange necessary ancillary services, including psychosocial therapy, directly or by referral.

Documentation Required

Assessment, Laboratory, and ASAM Documentation

Before commencing MAT, conduct an intake examination with relevant physical and laboratory testing, or refer the patient to a qualified medical professional for the examination. Address urgent or emergent medical or psychiatric problems first, complete the psychosocial assessment before the third visit, and document ASAM dimensions and levels of care.

Laboratory testing may include urine drug screening, CBC, liver function tests, tuberculosis, hepatitis, HIV, sexually transmitted disease/infection, and pregnancy testing for women of childbearing age.

Outpatient Office-Based Treatment

Outpatient Office-Based Opioid Treatment

Outpatient office-based opioid treatment is covered when the patient can be appropriately assessed, monitored, and treated outside a certified opioid treatment program.

Admission criteria: The patient has OUD and requires MAT; a psychosocial assessment documents ASAM dimensions and levels of care; urgent medical or psychiatric conditions are identified and referred appropriately; and behavioral-health services are offered or arranged according to the individual's needs.Psychosocial assessment before the third patient visit

Continued outpatient MAT: The patient continues to benefit from medication treatment, receives clinically appropriate monitoring and follow-up, and has periodic psychosocial assessment and laboratory testing as indicated. Therapy or behavioral-health referral is provided when clinically appropriate, but counseling refusal alone does not justify discontinuing MAT.

Covered MAT and Behavioral-Health Services

MAT/MOUD for Opioid Use Disorder

MAT/MOUD is covered as a whole-patient treatment for opioid use disorder.

Medication-assisted treatment: Medication is provided with counseling and behavioral therapies or appropriate referrals as part of a whole-patient approach to OUD. Treatment includes assessment, induction, stabilization, and maintenance, with psychosocial support and harm-reduction strategies incorporated according to patient need.

MAT may continue indefinitely when clinically appropriate.

Psychosocial Therapy and Behavioral-Health Referral

Psychosocial therapy and behavioral-health referral are provided according to the patient's clinical needs.

Behavioral-health and therapy support: The MAT provider obtains SBIRT documentation when completed by another provider after obtaining the patient's authorization for release, offers or refers the patient for behavioral-health services based on individual need, and provides individual or group therapy directly or through referral when clinically appropriate.

Behavioral-health providers must follow MSM Chapter 400 requirements. A patient's refusal of counseling alone does not justify denial or discontinuation of MAT; the refusal must be documented in the treatment plan and progress notes.

Assessment and Induction Timing

MAT Psychosocial Assessment

Required deadlineComplete the psychosocial assessment before the patient's third visit to the provider prescribing or dispensing MAT.

Assessment standardDocument ASAM criteria, including dimensions and levels of care.

Referral requirementIf the prescribing provider is not certified in an approved discipline, refer the patient for the psychosocial assessment during the initial visit.

Buprenorphine Induction Monitoring

Visit durationTwo or three consecutive days may be required, based on the provider's clinical judgment.

Follow-up frequencyPatients must be seen frequently at the onset of induction until they are determined to be stable.

Policy Summary

PayerNevada Health Authority

PolicyMedication-Assisted Treatment for Opioid Use Disorder

Policy CodePolicy 3800

Change TypeModified

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionDocument the opioid use disorder diagnosis, comprehensive medical evaluation, suitability for treatment, patient education, and informed consent.

SourceLink

On This Page

Before commencing MAT, all of the following assessment requirements apply.

Assessment stage

Psychosocial assessment provider: The assessment is completed by a psychiatrist, physician certified by the American Board of Addiction Medicine, psychiatric APRN, psychiatric physician assistant, licensed clinical social worker, psychologist, licensed marriage and family therapist, licensed clinical professional counselor, licensed clinical alcohol and drug counselor, licensed alcohol and drug counselor, or certified alcohol and drug counselor.
If the prescribing provider is not qualified in one of these disciplines, referral for psychosocial assessment is required during the initial visit.
Timing and content: The psychosocial assessment includes documentation supporting ASAM dimensions and levels of care and is completed and maintained in the medical record.Before the third patient visit
Medical examination and testing: The provider conducts an intake examination that includes relevant physical and laboratory tests or refers the patient to a medical professional who can perform the examination. Testing may include urine drug screening, complete blood count, liver function tests, tuberculosis, hepatitis, HIV, sexually transmitted disease or infection, and pregnancy testing for women of childbearing age.
Pre-treatment authorization and records: Before buprenorphine treatment, the provider obtains voluntary written informed consent, confirms there is no specific contraindication, obtains a treatment agreement, makes reasonable efforts to obtain applicable releases of information, and includes the current medical evaluation and laboratory results in the medical record prior to or shortly after starting medication.

Induction and Stabilization

Buprenorphine induction and stabilization are covered when clinically monitored and documented.

Induction and stabilization: Buprenorphine is initiated under medical monitoring, titrated to alleviate withdrawal symptoms and support discontinuation of illicit opioid use, and followed with frequent visits until stability is established. During induction, the provider completes the Clinical Opiate Withdrawal Scale or another approved tool at each visit until symptoms are absent. During stabilization, the patient receives clinically appropriate follow-up, a limited medication supply, and therapy or referral when indicated.Induction follows 12–24 hours of opioid abstinence and early withdrawal

The provider determines whether two or three consecutive induction visits are needed, followed by frequent visits until the patient is stable.

Maintenance Therapy

Maintenance treatment is individualized and may continue indefinitely.

Maintenance therapy: The patient is doing well on a steady buprenorphine dose, receives ongoing clinical monitoring, and has periodic psychosocial assessment and laboratory testing as indicated. Concurrent psychosocial support remains an important component of treatment.Duration is individualized and may be indefinite

MAT may not be denied or discontinued solely because the patient declines recommended counseling or behavioral intervention unless the patient is otherwise noncompliant with program expectations. There should be a compelling reason to stop buprenorphine because discontinuation is associated with a high rate of relapse.

Pharmacist Prescribing and Dispensing

Pharmacist prescribing and dispensing is covered only when all pharmacist-specific requirements are met.

Pharmacist MAT requirements: The pharmacist assesses whether treatment is appropriate using available patient history, laboratory and medical records; develops, signs, and maintains a treatment plan; documents referrals as indicated; coordinates treatment with referring or collaborating practitioners; counsels the patient; queries the state prescription drug monitoring program; performs medication reconciliation; maintains records for DHCFP review; holds a DEA license; and is actively registered with the Nevada Board of Pharmacy for controlled-substance dispensing and prescribing as required by Nevada law.Care coordination and periodic treatment reviews documented at least every six months

The pharmacist must comply with the general provider requirements and all applicable state and federal controlled-substance laws.

Buprenorphine prescriptions are non-covered when prescribed for any reason other than opioid use disorder (OUD). Coverage applies only when the prescription is for the treatment of OUD and the applicable medical-necessity and policy requirements are met.

This policy addresses outpatient, office-based opioid treatment for OUD that is not provided in a certified opioid treatment program. Buprenorphine treatment is specifically addressed; medications used to treat other diagnoses must be reviewed under Medicaid Services Manual Chapter 1200, Prescribed Drugs.

MAT services are not supported unless the record establishes medical necessity, an eligible Medicaid recipient's OUD diagnosis under the current DSM or ICD edition, and compliance with the policy's predetermined criteria. The medical record must support the required evaluation, treatment, and documentation; buprenorphine prescribed for a non-OUD indication is non-covered.

RecordkeepingThe completed psychosocial assessment must be documented in the patient's record.

Pharmacist Treatment-Plan Review and Care Coordination

Review frequencyCare coordination and periodic treatment reviews must be documented at least every six months.

CoordinationThe pharmacist must coordinate treatment regularly with the referring or collaborating practitioner and make the treatment plan accessible when applicable.

Treatment planThe pharmacist must develop, sign, and maintain a patient treatment plan based on the assessment and document referrals as indicated.

If the prescribing provider is not qualified to complete the psychosocial assessment, refer the patient during the initial visit to an appropriately qualified behavioral-health professional.

Document the psychosocial assessment in the patient record and offer or refer for behavioral-health services based on the patient's needs.

Documentation Required

Consent and Treatment Agreement Required

Before treating a patient with buprenorphine, obtain voluntary, written, informed consent and confirm that the patient has no specific contraindication to buprenorphine treatment. Obtain a treatment agreement outlining the responsibilities and expectations of both the prescribing provider and the patient.

Make reasonable efforts to obtain HIPAA- and 42 CFR Part 2-compliant releases of information for care coordination.
Include the current medical evaluation and laboratory results in the medical record before or shortly after medication initiation.

Documentation Required

Treatment Agreement Contents

Ensure the treatment agreement documents the patient's decisions and the provider's required education before buprenorphine treatment. Retain the signed agreement in the patient's record.

Patient agrees to refrain from opioid use before induction for the clinician-determined appropriate timeframe.
Patient agrees to participate in all MAT components, attend scheduled appointments, and participate in weekly or clinically appropriate therapy.
Patient agrees to complete random or scheduled laboratory testing and take medications as prescribed.
Document education about alcohol and other drug risks, withdrawal symptoms, buprenorphine for opioid treatment, a 24-hour emergency hotline, and community-resource referrals.

Documentation Required

Ongoing Phase-of-Care Records

Maintain records supporting each phase of care, including monitoring and follow-up. During induction, evaluate and monitor the patient frequently, titrate buprenorphine to control symptoms, and complete the Clinical Opiate Withdrawal Scale or another approved tool at each visit until symptoms are absent.

For stabilization, document reduced or discontinued misuse, craving and side-effect status, dose adjustments, limited medication supplies, clinically appropriate follow-up during the first month, and individual or group therapy or referral.
For maintenance, document the steady dose and individualized duration of treatment; maintenance may continue indefinitely unless there is a compelling reason to stop.
Maintain concurrent psychosocial support and perform periodic psychosocial assessments and laboratory testing throughout treatment.

Documentation Required

Behavioral-Health Refusal and Harm Reduction

Document any patient refusal of counseling, behavioral-health services, or other recommended services in the treatment plan and progress notes. Do not deny or discontinue MAT solely because the patient declines behavioral interventions, unless the patient is otherwise non-compliant with program expectations.

Use nonjudgmental, noncoercive care and consider harm-reduction strategies and resources in the treatment plan.
Continue to offer or refer for behavioral-health services based on the patient's needs.

Documentation Required

Pharmacist Records and Care Coordination

Pharmacists prescribing or dispensing treatment for opioid dependence must maintain complete assessment, treatment-plan, referral, coordination, and review records. Make records available to DHCFP upon request and provide counseling and appropriate evidence-based treatment information.

Assess appropriateness of treatment using patient history, laboratory and medical records and, when applicable, consult the referring or collaborating practitioner.
Develop, sign, and maintain a treatment plan documenting assessment findings and indicated referrals to medical, case-management, psychosocial, counseling, or residential services.
Coordinate regularly with the referring or collaborating practitioner; retain signed care-coordination documentation and periodic treatment reviews at least every six months.
Query the state prescription drug monitoring program and complete necessary medication reconciliation.
Comply with applicable state and federal controlled-substance laws and regulations.

Unsupported block type: denial_risk

Withdrawal monitoringThe Clinical Opiate Withdrawal Scale or another approved tool must be completed during each visit until withdrawal symptoms are absent.