New Medicaid Add-on Payment: Emergency Dept. Opioid Treatment

The Illinois Dept. of Healthcare and Family Services (HFS) has issued a Provider Notice updating guidance on coverage and reimbursement for the initiation of medication for the treatment of Opioid Use Disorder (MOUD) in a hospital emergency department (ED) setting, as an add-on payment to standard ED billing. This notice supersedes the previous guidance on this service issued in the May 13, 2022 Provider Notice. 

Effective Jan. 1, 2022, Public Act 102-0598 was successfully amended by IHA to authorize coverage and reimbursement for this service, as well as increase access to opioid use disorder treatment funding for hospitals more broadly. IHA worked closely with HFS to revise the initial notice to better align with hospital service delivery and billing. IHA’s Behavioral Health Advisory Forum and substance use treatment experts working in member hospitals also provided critical expertise during negotiations. 

Coverage Requirements
Based on the new notice, service requirements that hospitals must perform and document when seeking reimbursement for initiation or induction of buprenorphine for the treatment of Opioid Use Disorder (OUD) in the ED are outlined below. Descriptions that include may or should are not required, but recommended based on best practice.

  1. An assessment to determine the individual has an OUD and appropriateness for MOUD; a plan for initiating MOUD if appropriate; and patient education regarding MOUD, treatment services, and overdose prevention. 
  2. Initiation of buprenorphine must occur in the emergency room and under appropriate medical supervision if the individual is in withdrawal or post-overdose. If the individual is not in withdrawal, a clinician may initiate buprenorphine via a home induction with a prescription at discharge. Medication management and prescribing must be aligned with best practices and individuals should be prescribed MOUD until their follow-up appointment.  
  3. Referral for follow-up and ongoing care is a best practice for this service and should occur prior to discharge, consisting of a “warm handoff” to a community-based Substance Use Disorder (SUD) treatment provider for follow-up care or, when a “warm handoff” is not possible, a connection to follow-up care should be arranged through the Medication Assisted Recovery (MAR NOW) program by contacting the Illinois Helpline for Opioids and Other Substances online or by calling 833-234-6343 and asking for an MAR NOW coordinator.  

The negotiations with HFS ensured that new coverage requirements would:

  • Permit the initiation of medication at home following discharge, when appropriate;
  • Remove:
    • A burdensome and medically unnecessary three-step screening process;
    • A notification to the patient’s primary care physician, as hospitals do not always have access to this information;
    • A secondary, duplicative referral that was unnecessary and often unavailable for rural hospitals; and
  • Clarify that a “warm handoff” is suggested, but a follow-up appointment confirmation is not required to be added to documentation in order to bill the service, as the timing of this confirmation is not always provided prior to discharge.

Reimbursement Requirements
Hospitals can bill for initiation of MOUD to HFS or the customer's HealthChoice Illinois managed care organization (MCO) using Procedure Code G2213 as an add-on to the primary procedure codes submitted on the 837I claim format. Reimbursement for G2213 will be made consistent with HFS EAPG pricing or MCO established reimbursement methodologies. 

Educational Resources
For more information and hospital training to implement initiation of MOUD in hospital EDs, the Illinois Helpline has an overview on MAR NOW, free support and toolkits. IHA has also partnered on hospital OUD education with BRIDGE, a national organization that that has a free resource library and trainings.

Hospitals not already participating should also consider enrolling in the state’s Drug Overdose Prevention Program (DOPP), designed to help hospital EDs and inpatient staff provide free naloxone kits to at-risk individuals, like those receiving this service for OUD. For more information about becoming a DOPP enrolled program, naloxone training, and related resources, visit the Illinois Saves Overdose website. For hospital training, IHA will hold a webinar on May 29 from 11 a.m. - 12 p.m. CT on how hospitals can successfully implement a take-home naloxone program within their EDs and inpatient units.

Questions regarding HFS’ Provider Notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 for FFS claims, or to the applicable MCO. Questions or comments regarding this memo can be directed here.