CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A

OBMAT (Office-Based Medication Assisted Treatment) coverage criteria

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Governs Medicaid coverage and provider requirements for office-based medication assisted treatment (OBMAT), related counseling/therapy, and alignment with state/federal regulations for West Virginia Medicaid providers.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyOBMAT (Office-Based Medication Assisted Treatment) coverage criteria

Policy CodePolicy N/A

Change TypeOperational revisions clarifying provider enrollment, medication coverage, telehealth, and therapy offering

Effective DateFeb 1, 2025

Last ReviewJan 13, 2025

Next Review DateN/A

Key ActionEnsure OBMAT providers are enrolled/approved by BMS and include NPI and enrollment request when applying for OBMAT reimbursement.

SourceLink

POLICY UPDATE CHANGES

BMS removed the DATA 200 registration requirement and replaced it with broader language requiring OBMAT providers to comply with all applicable state and federal requirements.

Language referencing specific brand names (e.g., Suboxone, Subutex, Vivitrol) is being clarified so that brand names of approved generics for OBMAT medications are covered.

Reference to a DHHR provider registry has been removed from the policy.

Policy text that named Suboxone explicitly in enrollment/reimbursement language will be changed to refer to 'OBMAT' instead.

A bullet referring to the BMS telehealth policy has been added to 519.22.3 to confirm ongoing allowance of telehealth for OBMAT counseling.

Therapy must be offered as part of MAT services but BMS will not mandate therapy as a condition to receive MAT medications.

BMS clarified that Brixadi and other buprenorphine formulations are considered covered under the buprenorphine family.

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CurrentWest Virginia Bureau for Medical Services (Department of Human Services)Policy N/A

OBMAT (Office-Based Medication Assisted Treatment) coverage criteria

Customize your policy alerts

Sign up for all West Virginia Bureau for Medical Services (Department of Human Services) policy alerts

Know when West Virginia Bureau for Medical Services (Department of Human Services) releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerWest Virginia Bureau for Medical Services (Department of Human Services)

PolicyOBMAT (Office-Based Medication Assisted Treatment) coverage criteria

Policy CodePolicy N/A

Change TypeOperational revisions clarifying provider enrollment, medication coverage, telehealth, and therapy offering

Effective DateFeb 1, 2025

Last ReviewJan 13, 2025

Next Review DateN/A

Key ActionEnsure OBMAT providers are enrolled/approved by BMS and include NPI and enrollment request when applying for OBMAT reimbursement.

SourceLink

POLICY UPDATE CHANGES

BMS removed the DATA 200 registration requirement and replaced it with broader language requiring OBMAT providers to comply with all applicable state and federal requirements.

Language referencing specific brand names (e.g., Suboxone, Subutex, Vivitrol) is being clarified so that brand names of approved generics for OBMAT medications are covered.

Reference to a DHHR provider registry has been removed from the policy.

Policy text that named Suboxone explicitly in enrollment/reimbursement language will be changed to refer to 'OBMAT' instead.

A bullet referring to the BMS telehealth policy has been added to 519.22.3 to confirm ongoing allowance of telehealth for OBMAT counseling.

Therapy must be offered as part of MAT services but BMS will not mandate therapy as a condition to receive MAT medications.

BMS clarified that Brixadi and other buprenorphine formulations are considered covered under the buprenorphine family.

Coverage Criteria for OBMAT Services

OBMAT coverage criteria

Covered when services meet the following programmatic requirements and clinical offering:

OBMAT service conditions: 1) Providers must be validly enrolled and approved by BMS for OBMAT; 2) Therapy must be offered per OHFLAC schedule (at least weekly during the first 90 days; at least twice per month during the remainder of the first year; thereafter as indicated in the individualized plan of care); 3) Telehealth is allowed for counseling per BMS telehealth policy and federal DEA telehealth requirements for controlled substances; 4) Providers must comply with all applicable state and federal requirements (previous DATA 200 registration language removed).

Therapy must be offered but BMS will not mandate therapy as a condition for receipt of MAT medications.

Reference to the DHHR provider registry has been removed from this chapter and is no longer a requirement for OBMAT enrollment or reimbursement. The policy will not require providers to be listed on a DHHR registry for OBMAT services.

Managed Care Organizations (MCOs) may deny reimbursement for OBMAT services if the provider has not been approved by BMS. Acceptable grounds for denial include provider history issues, prior disciplinary actions with the West Virginia Board of Medicine or Board of Osteopathic Medicine, and active investigations regarding the provider’s prescribing practices or related conduct.

Provider Enrollment, Documentation, and Compliance

Prior Authorization

Enroll and maintain BMS approval; comply with state/federal requirements

Providers delivering Office-Based Medication Assisted Treatment (OBMAT) must be validly enrolled and approved by the West Virginia Bureau for Medical Services (BMS) to be reimbursed; the prior DATA 200 registration requirement has been removed and OBMAT providers must instead comply with all applicable state and federal requirements.

Step Therapy

Offer therapy on OHFLAC schedule (not mandatory for medication access)

Counseling/therapy must be offered per OHFLAC: at least weekly during the first 90 days, at least twice per month for the remainder of the first year, and thereafter as indicated in the individualized plan; however, therapy may be offered but is not required as a condition of receiving OBMAT medications.

Offer counseling at least weekly for the first 90 days.
Offer counseling at least twice monthly for the remainder of the first year.
After the first year, provide counseling per the patient’s individualized plan.
Document that therapy was offered; therapy is not mandatory for medication access.

Background and Policy Scope

This chapter addresses integration of Office-Based Medication Assisted Treatment (OBMAT) — including buprenorphine formulations and applicable injectable MAT agents — with counseling and service planning for individuals with opioid use disorder. It aligns Medicaid OBMAT requirements with applicable state and federal regulations and OHFLAC therapy expectations, clarifies covered medications, and confirms that counseling may be provided via telehealth in accordance with federal DEA telehealth requirements.

Key Definitions

OBMAT — definition

TermOBMAT (Office-Based Medication Assisted Treatment)

DefinitionPolicy term used in place of specific brand names to describe medication-assisted treatment provided in office settings, covering buprenorphine formulations and applicable injectable MAT medications.

ScopeIncludes buprenorphine family products (e.g., Brixadi) and applicable injectable MAT agents; brand names of approved generics are covered.

Usage noteEnrollment, reimbursement, and enforcement language in the manual will refer to 'OBMAT' rather than individual brand names.

Level of Care — Outpatient / Office-Based Criteria

Medication-Assisted Treatment and Modalities

Medication-Assisted Treatment (buprenorphine and injectable MAT)

Covered medications: Brand names referenced in the manual (e.g., Suboxone, Subutex, Vivitrol) are clarified to include brand names of approved generics and other applicable buprenorphine formulations and injectable MAT (e.g., Brixadi, Sublocade) as covered when provided within OBMAT by an enrolled/approved provider.

Monthly or weekly injectable MAT may be provided in primary care settings; coverage language updated to reflect class coverage of buprenorphine formulations and injectables.

Counseling Visit Frequency and Limits

Counseling schedule (offered)

Initial treatment period (first 90 days)Counseling sessions shall be offered at least weekly during the first 90 days of treatment.

Remainder of first yearCounseling sessions shall be offered at least twice per month during the remainder of the first year of treatment.

After first yearThereafter, counseling sessions shall take place as indicated in the patient’s individualized plan of care or treatment strategy.

TelehealthCounseling sessions may be conducted via telehealth; BMS confirms ongoing allowance and alignment with federal DEA telehealth prescribing requirements.

Counseling schedule (offered) — follow-up period

Frequency (remainder of first year)Counseling sessions shall be offered at least twice per month during the remainder of the first year of treatment.