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QUEST Integration – Payment Policy Medication Assisted Treatment (MAT)

Effective Date: December 2022

Last Reviewed: June 2025

Policy Number: UM 20

Line(s) of Business: QUEST Integration

  1. Scope

    Medication Assisted Treatment (MAT) uses FDA-approved pharmacological agents in combination with behavioral and psychosocial therapies to provide a comprehensive approach to the treatment of opioid use disorders. Medication Assisted Treatment for Opioid Dependence is limited to behavioral health and medical providers or programs that have the appropriate DEA certifications and meet all legally mandated requirements.

  2. Purpose

    To ensure HMSA QUEST Integration Plan members have access to safe and effective Medication Assisted Treatment (MAT) in accordance with the Centers for Medicare & Medicaid Services (CMS) guidance.

  3. Definitions

    1. Medication-assisted treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a “whole-person” approach to the treatment of substance use disorders (SUD). Medications used in MAT are approved by the Food and Drug Administration (FDA) and are clinically driven and tailored to meet each patient’s needs.
    2. The Collaborative Care Model is a specific model for behavioral health integration that typically is provided by a primary care team consisting of a primary care provider and a care manager who works in collaboration with a psychiatric consultant, such as a psychiatrist.
    3. Ambulatory Mental Health Services means to provide coverage for ambulatory mental health services, which includes twenty-four (24) hour access line, mobile crisis response, crisis stabilization, crisis management, and crisis residential services.

  4. Background

    1. SUPPORT Act (Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities)

      1. To increase access to medication-assisted treatment (MAT) for opioid use disorders (OUD), section 1006(b) of the SUPPORT Act requires states to provide Medicaid coverage for certain drugs and biological products, and related counseling services and behavioral therapy.
      2. Section 1006(b) of the SUPPORT Act, signed into law on October 24, 2018, amends section 1902(a)(10)(A) of the Social Security Act (the Act) to require state Medicaid plans to include coverage of MAT for all eligible to enroll in the state plan or waiver of state plan.
      3. Section 1006(b) of the SUPPORT Act requires states to begin implementing MAT as a mandatory Medicaid state plan benefit for categorically needy populations for the 5-year period beginning October 1, 2020. Under the definition of the new mandatory benefit at section 1905 (ee)(1) of the Act, states are required to cover all drugs approved under section 505 of the Federal Food, Drug and Cosmetic Act (21 U.S.C. 355), including methadone, and all biological products licensed under section 351 of the Public Health Service Act (42 U.S.C. 262) to treat opioid use disorders (OUD). CMS interprets the statute to require coverage of all forms of the drugs and biologicals that the FDA has approved or licensed for the treatment of OUD. States are also required to cover counseling services and behavioral therapy associated with provision of the required drug and biological coverage.
      4. Section 2601 of the Continuing Appropriations Act, 2021 and other Extensions Act, Pub. L. No. 116-159, amended that SUPPORT Act to specify that the rebate requirements in section 1927 shall apply to any MAT drug or biological described under the mandatory benefit to the extent that the MAT drug or biological is a covered outpatient drug.

    2. Medication-Assisted Treatment (MAT) – Additional Statutes

      1. Federal statutes, regulations, and guidelines govern medication-assisted treatment (MAT) for opioid addiction.
      2. SAMHSA’s Division of Pharmacologic Therapies (DPT), part of SAMHSA’s Center for Substance Abuse Treatment (CSAT), manages the day-to-day oversight activates required to implement federal regulations surrounding the use medications approved by the Food and Drug Administration (FDA) such as methadone and buprenorphine for the treatment of opioid use disorder (OUD) for practitioners and opioid treatment programs (OTPs).
      3. Some medications used in medication-assisted treatment (MAT) are controlled substances governed by the Controlled Substances Act. The Act contains federal drug policy for regulating the manufacture, importation, possession, use, and distribution of controlled substances.
      4. The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities or SUPPORT for Patients and Communities Act of 2018 (SUPPORT Act).

  5. Utilization Management Requirements

    1. Medications

      1. Opioid Dependency Medications

        1. Buprenorphine, methadone, and naltrexone are used to treat opioid use disorders to short-acting opioids such as heroin, morphine, and codeine, as well as semi-synthetic opioids like oxycodone and hydrocodone. These MAT medications are safe to use for months, years, or even a lifetime.
        2. Buprenorphine – suppresses and reduces cravings for opioids.
        3. Buprenorphine extended release (subdermal and injectable) – Partial-opioid agonist—attaches to opioid receptors but produces only a limited opioid-like effect while competitively inhibiting other opioids from attaching to and fully activating the receptor. These properties allow it to relieve withdrawal and reduce cravings while blocking other opioids up to one to six months.
        4. Buprenorphine-naloxone – blocks the effects of opioid medication, including pain relief or feelings of well-being that can lead to opioid use. Buprenorphine and naloxone are a combination medicine used to treat narcotic (opiate) addiction.
        5. Methadone – reduces opioid cravings and withdrawal and blunts or blocks the effects of opioids.
        6. Naltrexone (oral and extended release injectable) – blocks opioid receptors that are involved in alcohol and opioid cravings.

      2. Opioid Overdose Prevention Medication

        1. Naloxone – is used to prevent opioid overdose by reversing the toxic effects of the overdose. Naloxone is one of a number of medications considered essential to a functioning health care system.

      Following is a list of MAT medications on HMSA’s Formulary for QUEST Integration Plan.

      Generic Name Brand Name Dosage Form Strengths
      Buprenorphine/naloxone Bunavail Film, Buccal 6.3/1, 2.1/0.3, 4.2/0.7
      Buprenorphine/naloxone Suboxone Film, Sublingual 4/1, 8/2, 12/3, 2/0.5
      Buprenorphine/naloxone Generic Film, Sublingual 12/3, 2/0.5, 4/1, 8/2
      Buprenorphine/naloxone Zubsolv Tablet, Sublingual 5.7/1.4, 8.6/2.1, 0.7/0.18, 1.4/0.36, 11.4/2.9, 2.9/0.71
      Buprenorphine/naloxone Generic Tablet, Sublingual 2/0.5, 8/2
      Buprenorphine Generic Tablet Sublingual, Sublingual 2, 8
      Naltrexone Generic Tablet, Oral 50

      There are no prior authorization requirements for methadone maintenance treatment provided by Opioid Treatment Programs. Providers can also prescribe any MAT medications on the formulary without prior approvals. In addition, a minimum 30-day supply of MAT is available during the 90-day period prior to release for eligible justice-involved individuals in facilities operated by Department of Public Safety (DPS), including State prisons and county jails, as well as Youth Correctional Facilities operated by the Hawaiʻi Department of Human Services.

    2. Therapy

      1. For many people, the most effective behavioral health approach involves a combination of counseling and medication. Early treatment is best. A trained professional should do a full evaluation to make the diagnosis. No single treatment works best. Treatments must address each person’s needs and symptoms. There is a variety of therapies that use MAT. Each option targets and focuses on various substance use. Medically Assisted Treatment can work with this substance use disorders in a unique way.
      2. Counselling therapy in conjunction with MAT is a standard benefit for HMSA QUEST Integration Plan members. No prior authorization is required for therapy sessions. Counselling and therapy services do not require prior authorization and there are no limits on the number of treatment sessions a member can receive. The following list includes but not limited to various outpatient counselling and therapy services available to QUEST Integration Plan members.
      CPT/HCPCS codes Service Description
      90791 Psychiatric diagnostic evaluation
      90792 Psychiatric diagnostic evaluation with medical services
      90832 Psychotherapy, 30 minutes with patient
      90833 Psychotherapy, 30 minutes with patient when performed with an evaluation and management service
      90834 Psychotherapy, 45 minutes with patient
      90836 Psychotherapy, 45 minutes with patient when performed with an evaluation and management service
      90837 Psychotherapy, 60 minutes with patient
      90838 Psychotherapy, 60 minutes with patient when performed with an evaluation and management service
      90839 Psychotherapy for crisis; first 60 minutes
      90840 Psychotherapy for crisis; each additional 30 minutes
      90853 Group psychotherapy (other than of a multiple-family group)
      90863 Pharmacologic management, including prescription and review of medication, when performed with psychotherapy
      G0396 Alcohol and/or substance (other than tobacco) misuse structured assessment and brief intervention 15 to 30 minutes
      G0397 Alcohol and/or substance (other than tobacco) misuse structured assessment and intervention, greater than 30 minutes
      G0410 Group psychotherapy other than of a multiple-family group, in a partial hospitalization setting, approximately 45 to 50 minutes
      G0411 Interactive group psychotherapy, in a partial hospitalization setting, approximately 45 to 50 minutes
      G2067 Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment program)
      G2068 Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program)
      G2069 Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program)
      G2070 Medication assisted treatment, buprenorphine (implant insertion); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program)
      G2071 Medication assisted treatment, buprenorphine (implant removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program)
      G2072 Medication assisted treatment, buprenorphine (implant insertion and removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program)
      G2073 Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program)
      G2074 Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled opioid treatment program)
      G2075 Medication assisted treatment, medication not otherwise specified; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment program)
      G2078 Take home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare-enrolled opioid treatment program
      G2079 Take home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a Medicare-enrolled opioid treatment program
      G2080 Each additional 30 minutes of counseling in a week of medication assisted treatment, (provision of the services by a Medicare-enrolled opioid treatment program
      G2086 Office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month
      G2087 Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month
      G2088 Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes
      G2172 All-inclusive payment for services related to highly coordinated and integrated opioid use disorder (OUD) treatment services furnished for the demonstration project
      G2215 Take home supply of nasal naloxone (provision of the services by a Medicare enrolled opioid treatment program
      G2216 Take home supply of injectable naloxone (provision of the services by a Medicare-enrolled opioid treatment program
      H0001 Alcohol and/or drug assessment
      H0015 Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education
      H0049 Alcohol and/or drug screening
      H0050 Alcohol and/or drug services, brief intervention, per 15 minutes
      S9480 Intensive outpatient psychiatric services, per diem
      S9484 Crisis intervention mental health services, per hour
      S9485 Crisis intervention mental health services, per diem

  6. Guidelines/Procedures

    1. Medication-Assisted Treatment (MAT)

      1. Opioid Treatment Programs administering MAT medications must have a current, valid certification from the Substance Abuse and Mental Health Services Administration (SAMHSA) and be accredited by an independent, SAMHSA-approved accrediting body.
    2. The SUPPORT Act affords practitioners greater flexibility in the provision of medication-assisted treatment (MAT) and extends the privilege of prescribing buprenorphine in office-based settings to qualifying other practitioners (Nurse Practitioners (NPs), Physician Assistants (PAs), Clinical Nurse Specialists (CNSs), Certified Registered Nurse Anesthetist (CRNAs), and Certified Nurse-Midwifes (CNMs)) until October 1, 2023.

    3. The SUPPORT Act expands the ability to treat up to 100 patients in the first year of waiver receipt if practitioners satisfy one of the following two conditions:

      1. The physician holds a board certification in addiction medicine or addiction psychiatry by the American Board of Preventive Medicine or the American Board of Psychiatry and Neurology.

      2. The practitioner provides medication-assisted treatment (MAT) in a “qualified practice setting”. A qualified practice setting is a practice setting that:

        1. provides professional coverage for patient medical emergencies during hours when the practitioner’s practice is closed
        2. provides access to case-management services for patients including referral and follow-up services for programs that provide, or financially support, the provision of services such as medical, behavioral, social, housing, employment, educational, or other related services;
        3. uses health information technology systems such as electronic health records;
        4. is registered for their state prescription drug monitoring program (PDMP) where operational and in accordance with Federal and State law; and
        5. accepts third-party payment for costs in providing health services, including written billing, credit, and collection policies and procedures, or Federal health benefits.
      3. After one year at the 100-patient limit, physicians and qualifying other practitioners who meet the above criteria can apply to increase their patient limit to 275.

    4. Provider Requirements

      In order to ensure safety and quality of services provided to members, HMSA has set credentialing standards and professional requirements. Credentialing standards are developed in accordance with the National Committee for Quality Assurance (NCQA) standards and any business line specific requirements. Once a practitioner has been initially credentialed and approved by the HMSA Credentialing Committee, the practitioner becomes eligible to participate with the various plans throughout the next three years. Similarly, treatment facilities go through HMSA’s credentialing process initially as well as every three years once credentialed. A detailed process is described in HMSA’s credentialing policies.

      1. For Opioid Treatment Program (OTP)

        Must meet all of the following:

        1. The provider holds a board certification in addiction medicine or addiction psychiatry by the American Board of Preventive Medicine or the American Board of Psychiatry and Neurology. For out of state providers, appropriate state licensure in the state they are located and prescribe is required.
        2. Complies with all expectations of the federal opioid treatment standards found in Title 42 of the Code of Federal Regulations Part 8 (42 CFR 8);
        3. Has Substance Abuse and Mental Health Services Administration (SAMHSA) certification;
        4. Is registered with the Drug Enforcement Administration (DEA), through a local DEA office;
        5. Policies are in place for physicians who are waivered under The Drug Addiction Treatment Act of 2000 (DATA 2000), to assure compliance with the Controlled Substances ACT (CSWQ) 28 USC 802);
        6. Regular review of prescription drug monitoring program (PDMP);
        7. Staff have training and general competency in substance use disorder recognition and management of all aspects of treatment;
        8. Staff have specific training and knowledge about working with individuals with Opioid Use Disorders, including specific expertise in the use of medication assisted treatment. All staff will work within scope of individual licensure;
        9. Knowledge of community substance use disorder providers, capacity to refer and arrange for substance use disorder services as needed;
        10. Ongoing collaborative decision making between MAT providers and psychosocial treatment providers;
        11. Capacity to refer to mental health/ psychiatric services for evaluation and treatment of co-occurring mental illness, if needed.
        12. Prescribers who participate in Office Based Treatment Programs (OBOT) that offer buprenorphine must have a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver. Treatment provided adheres to all applicable Federal and state laws.

      2. For Office-based Opioid Treatment (OBOT)

        Must meet all of the following:

        1. Adheres to the Substance Abuse and Mental Health Services Administration (SAMHSA) regulations for addiction treatment under the provisions of the Drug Addiction Treatment Act of 2000 (DATA 2000);
        2. Prescribers are registered with the Drug Enforcement Administration (DEA) to dispense controlled substances;
        3. Provider maintains a log of all current individuals according to Drug Enforcement Administration guidelines;
        4. Regular review of prescription drug monitoring program (PDMP);
        5. Capacity to monitor adherence using medically necessary and appropriate drug screening and pill counts or both;
        6. An individualized recovery plan including counseling and psychosocial supports is provided in addition to medication management;
        7. Staff have training and general competency in substance use disorder recognition and management of all aspects of treatment;
        8. Staff have specific training and knowledge about working with individuals with Opioid Use Disorders, including specific expertise in the use of medication assisted treatment (MAT). All staff will work within scope of individual licensure;
        9. Knowledge of community substance use disorder providers, capacity to refer and arrange for substance use disorder services as needed;
        10. Ongoing collaborative decision making between MAT providers and psychosocial treatment providers;
        11. Capacity to refer to psychiatric services for evaluation of co-occurring mental illness, if needed.
        12. Prescribers who participate in Office Based Treatment Programs (OBOT) that offer buprenorphine no longer require Drug Addiction Treatment Act of 2000 (DATA 2000) waiver. Section 1262 of the Consolidated Appropriations Act, 2023 allows all practitioners who have a current DEA registration that includes Schedule III authority to prescribe buprenorphine for opioid use disorder in their practice if permitted by applicable state law. The DATA-Waiver registration number is no longer required on opioid use disorder prescriptions. Opioid use disorder prescriptions, like all prescriptions, now only require a standard DEA registration number.

  7. Member Support Services

    The following health plan services are available to HMSA QUEST Integration members to assist them in the treatment and recovery from opioid use disorders.

    1. Health Coordination Services

      1. Health Action Plan (HAP)

        1. A Health Coordinator will work with a team of decision-makers, including the PCP, other providers as appropriate, the member, and others determined by the member including family members, caregivers, and significant others to develop the Health Action Plan (HAP). The HAP for each member in Health Coordination Services will be based on the health and functional assessment of the member. It will be person-centered, describe the medical and social needs of the member, and identify all of the services to be utilized, including but not limited to the amount, frequency, and duration of each service, and the type of provider furnishing the services. The HAP also includes a description of how all clinical and non-clinical healthcare-related needs and services will be coordinated, including coordination with outside entities providing supports for the member. The Health Coordinator works closely with the member’s PCP in updating and making changes to a member’s HAP.
        2. For members not meeting institutional Level of Care (LOC), the plan can extend beyond services provided by the QUEST Integration plan, including community resources.
        3. Health Coordinators, who are Hawaii-licensed behavioral health clinicians, are available via phone call for crisis support services during and after business hours, seven days a week.

      2. Assessments

        1. Health Coordinators will assess a member’s needs in a face-to-face Health and Functional assessments (HFA). This will determine the appropriate strategies and services to best meet the member’s needs, taking into consideration the health status, environment, available supports, medical history, and social history of each member.
        2. Reassessments will be conducted annually for members with Expanded Health Care Needs (EHCN) when there is a significant change in the member's condition, such as, the death of a caregiver, significant change in health status, change in living arrangement, institutionalization, and change in provider if the provider change affects the Health Action Plan.

    2. Transferring members to a different MAT provider

      Members receiving MAT, currently defined by Med-QUEST are monitored at least every three months, at which time the Health Coordinator discusses with the member any concerns or barriers related to a member’s treatment. If clinically appropriate, the Health Coordinator will transfer service to another provider and ensure there is continuity with treatment, as well as continued monitoring and participation in Health Coordination and treatment services.

    3. Screening for co-occurring disorders

      The Health and Functional Assessment includes evaluation of member’s mental, physical health conditions and substance use disorders. Co-morbid disorders are addressed accordingly in the Health Action Plan.

    4. Crisis Intervention Services

      1. 24/7 Nurse Line

        Members experiencing a crisis related to substance use disorders have access to HMSA’s 24-hour nurse line at 1-800-440-0640. A nurse can answer members’ questions and advise whether the member should see their physician or go to the emergency room for further assessment and care.

      2. Behavioral Health Support Line

        In addition to the 24/7 Nurse Line, by contacting HMSA’s behavioral health vendor at 1-855-856-0578, members may speak to a clinician any time during business hours Monday through Friday. For assistance during after-hours and on weekends and holidays, members who need urgent assistance will be connected to a behavior health on-call clinician. For non-urgent matters, requests are responded by the next business day.

    5. Peer Support Services

      The health plan anticipates piloting of peer support specialists to be available to QUEST Integration Plan members undergoing substance addiction treatment for identified subpopulations. Learnings will be applied to scale and standardize service over time.

    6. Travel Assistance

      To support members residing on the neighbor islands with limited MAT providers, HMSA provides travel assistance so that members can access providers on another island. The following services are available to QUEST Integration plan members.

      1. Non-emergency Transportation Services

        1. Transportation is provided when a member’s medical condition requires treatment that is not available in the area where they are.

        2. Travel services include:

          • Transportation
          • Air transportation
          • Taxi services
          • Lodging
          • Meals
        3. Transportation services require prior approval.
        4. If determined medically appropriate, one approved attendant may be allowed to help with any special travel needs that the member may have.
        5. The attendant must be age 18 or older and able to help during travel

    7. Telehealth Services

      In addition to providing travel assistance to members to access MAT providers, HMSA has been expanding capabilities and benefits of telehealth services to all members. HMSA’s telehealth policies and Online Care platform are key components in keeping care accessible to meet the increasing need for behavioral health services. To ensure safe and reliable access to care during the pandemic, HMSA will continue to cover audio-only telephonic therapy sessions for QUEST Integration Plan members through the end of the public health emergency.

    8. Member Appeals and Grievances

      HMSA provides an avenue to receive, identify, assess and resolve issues in a timely and objective manner for all member inquiries, grievances, and appeals in strict conformance with the requirements of the State of Hawaii and 42 CFR Part 438, Subpart F. Dedicated staff in various HMSA departments such as Customer Relations, Member Advocacy & Appeals, Quality Management, Medicaid Program, and Medical Management are involved in addressing members’ inquiries, appeals, and grievances.

  8. References

    1. HMSA Policy on Initial Credentialing and Recredentialing, Policy Number CR 001
    2. HMSA Policy on Facility/Ancillary Credentialing, Policy Number CR 004
    3. HMSA Medicaid Policy on Member Grievance System, Policy Number QMS 014-A
    4. HMSA Medical Policy on Telehealth Services, Policy Number MM.12.027

    5. Centers for Disease Control and Prevention, About CDC’s Opioid Prescribing Guideline, U.S. Department of Health and Human Services. CDC website.

    6. Centers for Medicare & Medicaid Services (CMS), Section 1006(b) of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (herein referred to as the SUPPORT Act) (Pub. L. No. 115-271)

    7. Substance Abuse and Mental Health Services Administration (SAMHSA). Medication-Assisted Treatment. SAMHSA website.

    8. U.S. Food and Drug Administration (FDA). Information about Medication-Assisted Treatment (MAT). FDA web site.

  9. Policy / Procedure History

    Action Date: Action:
    May 2022 Policy drafted for review
    October 2022 Policy revised based on Med-QUEST feedback 
    November 2022 Reviewed and Approved by Med-QUEST
    January 2023 Reviewed and Approved by Medical Management
    July 2024 Policy revised to reflect MAT waiver elimination by the Consolidated Appropriations Act, 2023.
    June 2025 Policy revised to add MAT medications to be made available during the 90-day period prior to release of eligible justice-involved individuals.
CURRENT AS OF 08/03/2026

Revision History

Date Nature of Revision
08/03/2026 Migrated to new platform.