HHS Grants to Fight Opioid Addiction: How Could the Grants Impact Your MSA?

CMS, Medicare Set-Aside Blog, Opioids, Rx/Pharmacy on May 4, 2017
Posted by Jean S. Goldstein, JD, CMSP

Nationwide, states and workers’ compensation boards have been taking measures to curb the overprescribing and misuse of opioids and the crisis that has ensued as a result.  Nonetheless, opioid addiction continues to be a growing concern.  In an effort to help states combat the opioid epidemic, the U.S. Department of Health and Human Services (HHS) announced that $485 million in grants will be disbursed to states.  The grants are authorized by the 21st Century Cures Act which was passed in 2015, and allows funds to be provided for opioid abuse prevention efforts and to increase access to treatment and recovery initiatives.  In announcing disbursement of the funds, the Secretary of the HHS, outlined five specific strategies that will be employed to continue to fight opioid addiction, specifically:

  1. Improving access to addiction treatment and recovery services.
  2. Promoting the use of medications to reverse opioid overdose, such as naloxone.
  3. More closely monitoring opioid-related public health trends.
  4. Supporting research on pain management and opioid addiction.
  5. Rethinking pain management practices.

As these strategies and actions are implemented across the country, it is likely that workers’ compensation claims and Medicare Set Asides (MSAs) will be impacted by these efforts.  Workers’ compensation claimants are often prescribed opioid drugs by treating physicians to treat chronic and acute pain.  As a result, workers’ compensation carriers pay for these prescriptions and often these medications are included in MSAs so that Medicare is not the primary payer for any prescription medication treatment related to the industrial injury.  It is likely that MSA allocations will be impacted as the strategies as outlined by the HHS are implemented nationwide.

Inclusion of Addiction Treatment Programs Are a Possibility

One of the specific strategies to be implemented is improving access to addiction treatment and recovery services. As the awareness of these services grows and the services become more accessible, it is likely prescribers will recommend addiction treatment more frequently.  Medicare provides coverage for addiction treatment under the broad category of Mental Health Services. There are specific criteria for coverage; however, detoxification typically must be provided on an inpatient basis to be covered by Medicare.  If a diagnosis of opioid addiction, due to prescribing of opioids for the industrial injury,  is documented in the medical records, it is possible that MSA allocations will include these types of treatment.  Particularly, if the treatment is recommended by a treating physician.  This is something to keep mind if opioid overuse or concerns of addiction are documented within the medical records.  In addition, should you choose to submit an MSA to CMS, as always be aware that even the mere mention of such a treatment option means that CMS is likely to include at least portions of this type of treatment program.

Tapering/Weaning Program Recommendation

We are hopeful that with the array of actions underway, we also will begin to see implementation of more effective and clear opioid tapering/weaning programs.  However, one thing to consider is how this may affect a CMS submitted MSA.  When a physician recommends a tapering/weaning plan it does not automatically mean that CMS will remove the medication(s).  Typically, before removing medications from a recommended MSA allocation, CMS expects to see evidence that such action has already been initiated and that weaning has successfully occurred.

Costs-Driving Inclusion of Naloxone

As you may recall, last year we began noticing a trend of CMS including Evzio in CMS issued approvals, as we reported.  Evzio is a take home naloxone auto injector which is an antidote for opioid analgesic overdose.  CMS began including this medication over a Claimant’s entire life expectancy, even based upon a mere mention of the medication by a physician.  Similarly, Narcan is a nasal spray preparation of naloxone; however, we are finding that treating providers are most often times prescribing Evzio in conjunction with many opioid prescriptions, and not just to those patients who are at a higher risk for opioid overdose.  With HHS’ announcement, it is extremely likely we will see more recommendations for Evzio, which in turn, means more CMS issued approvals with allocations for this medication.  The cost of this medication is significant, as the AWP package price for the pre-filled syringes is almost $5,000.  Cases where Evzio has been prescribed can be quite problematic and there may be reasons for exclusion of Evzio that have been overlooked by physicians when prescribing the medication in an abundance of caution. There are also specific CDC issued guidelines which should be considered prior to prescribing naloxone, in addition to possible contraindications.  In addition, there may be alternative treatments and changes in medication regimens which could mitigate overdose risks and eliminate the need for naloxone.  However, with this new push to curb the opioid epidemic, we anticipate that guidelines may be overlooked and there may be more recommendations for naloxone.  We expect to continue to see increased prescriptions for naloxone and subsequent increased costs in claims were opioids continue to prescribed.

Recommendations Based Upon HHS’ Announcement and Pending State Grants

We have several recommendations as the HHS strategies are implemented across the country, as these actions may have a significant impact on your claim:

  1. Clarify that treatment or detoxification programs recommended are related to use of any opioid medications for the industrial injury;
  2. Provide all evidence of tapering/weaning; and
  3. Obtain clarification with respect to the necessity of Evzio or Narcan when mentioned or prescribed by a treating physician.


Based upon HHS’ recent announcement, and states’ continued efforts to combat the opioid crisis, it is very likely that the workers’ compensation industry and MSAs will be impacted.  For these reasons, it imperative to have a clinical analysis of all recommended opioid prescription medications. The HHS’ action plans, while extremely necessary may significantly impact your claim and your settlement.

Please feel free to contact us at info@medval.com with any questions or to request a clinical analysis of your claim.