Guidelines for Pain Management Alternatives to Opiate Products; Issued 8/29/2019

[LOGO] CHARLES D. BAKER GOVERNOR KARYN E. POLITO LIEUTENANT GOVERNOR COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation DIVISION OF INSURANCE 1000 Washington Street, Suite 810 • Boston, MA 02118-6200 (617) 521-7794 • Toll-free (877) 563-4467 http://www.mass.gov/doi MIKE KENNEALY SECRETARY OF HOUSING AND ECONOMIC DEVELOPMENT EDWARD A. PALLESCHI UNDERSECRETARY OF CONSUMER AFFAIRS AND BUSINESS REGULATION GARY D. ANDERSON COMMISSIONER OF INSURANCE # BULLETIN 2019-06 To: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations From: Gary D. Anderson, Commissioner of Insurance Date: August 29, 2019 Re: Guidelines for Pain Management Alternatives to Opiate Products The Division of Insurance (“Division”) issues this Bulletin to Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations offering insured health benefit plans in Massachusetts (collectively, hereinafter, referred to as “Carriers”) to establish guidelines for the coverage availability of alternatives to opiate pain products for treating the pain of covered persons. The Division expects Carriers to take all appropriate steps to ensure that insured health benefit plans make coverage for methods other than opiate treatment available to covered persons to manage pain, such that there must be at least two (2) alternative medication treatment options and at least three (3) alternative non-medication treatment modalities. Such alternatives may include other types of prescriptions, supplies, services, or treatments that the Carrier may determine are appropriate for the persons covered in its insured health benefit plan. ## Prescription Drug Formularies and Provider Networks As Carriers establish alternatives to opiate products for pain management, they are to update all formulary materials and provider directories to identify the ways for covered persons to obtain the alternative health services from participating pharmacy formularies or provider networks. Carriers who identify an alternative method that involves coverage for services provided by specific types of providers, e.g., massage therapists, acupuncturists, and/or chiropractors, will be required to contract with a sufficient number of providers to have the alternative health services available throughout the Carrier’s service area. Carriers will be required to follow the contract and network requirements that are identified within 211 CMR 52.11 and 52.12 to ensure adequate access to the covered alternate care. If a Carrier identifies that a certain service is covered but does Bulletin 2019-06 August 29, 2019 Page 2 of 3 not establish an adequate network, the service is to be covered at the in-network benefit level until such time as the Division finds that the Carrier has established an adequate network of providers for the covered alternative health service. ## Medical Necessity Reviews As with all covered services, Carriers may establish utilization management systems that review the medical necessity and appropriateness of any alternative prescription, supply, service or treatments offered pursuant to this Bulletin. Under M.G.L. c. 176O, insured health plans may develop medical necessity criteria to determine whether certain services are medically necessary and appropriate to treat a person's condition. As noted in M.G.L. c. 176O, §16(b): A carrier may develop guidelines to be used in applying the standard of medical necessity, as defined in this subsection. Any such medical necessity guidelines utilized by a carrier in making coverage determinations shall be: (i) developed with input from practicing physicians and participating providers in the carrier's or utilization review organization's service area; (ii) developed under the standards adopted by national accreditation organizations; (iii) updated at least biennially or more often as new treatments, applications and technologies are adopted as generally accepted professional medical practice; and (iv) evidence-based, if practicable. In applying such guidelines, a carrier shall consider the individual health care needs of the insured. Any such medical necessity guidelines criteria shall be applied consistently by a carrier or a utilization review organization and made easily accessible and up-to-date on a carrier or utilization review organization's website to subscribers, health care providers and the general public. If a carrier or utilization review organization intends either to implement a new medical necessity guideline or amend an existing requirement or restriction, the carrier or utilization review organization shall ensure that the new or amended requirement or restriction shall not be implemented unless the carrier's or utilization review organization's website has been updated to reflect the new or amended requirement or restriction. If a carrier establishes medical necessity criteria for the alternatives to opiate pain management, the Division expects Carriers to establish criteria according to M.G.L. c. 176O, §16(b) and to make the criteria available according to M.G.L. c. 176O, §12 and Bulletin 2014-10. ## Materials to Explain Alternatives to Opiate Products to Manage Pain Carriers are expected to update all existing Evidence of Coverage materials to describe the methods that the Carrier has identified as medication treatment and non-medication treatment alternatives to the use of opiate products for pain management. Carriers should be prepared to provide information to members about locations/providers to obtain those services, as well as any steps that covered persons must follow in order to obtain any required prior approval for the noted services. ## Implementation The Division expects that Carriers will send a plan by no later than October 31, 2019 that will Bulletin 2019-06 August 29, 2019 Page 3 of 3 outline how the Carrier will have at least two (2) non-opiate medication treatment options and at least three (3) non-medication treatment modalities available to covered persons as their coverage renews in 2020. For insured health plans renewing on or after January 1, 2020, the plan shall identify the alternatives that the Carrier intends to make available and identify the steps that the Carrier will take to make sure that it contracts with necessary providers to develop appropriate networks and make consumer materials available for plan members. If you have any questions about this bulletin, please contact Kevin Beagan, Division of Insurance at (617) 521-7323 or kevin.beagan@mass.gov.