New State Opioid Abuse Law: Compliance Implications for Providers

This summer, New York enacted a comprehensive law to combat the heroin, opioid and prescription drug abuse epidemic. The epidemic has impacted New York on a large scale, with 118,875 admissions to New York State certified treatment programs involving opiate abuse during 2014. To address this issue, the new law is intended to attack the epidemic on multiple fronts, the most significant of which is new legal requirements for health care providers. There have already been some requirements implemented, while others become effective this fall through January 1, 2017. Here are some of the major changes affecting providers:

• Provider Education Requirements (Effective June 22, 2016) – Providers that prescribe opioids must receive 3 hours of educational training on pain management, palliative care and addiction every 3 years. This requirement is not limited to prescribing physicians, as it requires any provider that prescribes opioids, such as dentists, physician's assistants and nurse practitioners, to fulfill this obligation.

• Limits on the Length of Opioid Prescriptions (Effective July 22, 2016) – During an initial consultation, providers can now only prescribe opioid medications for acute pain for up to 7 days, absent an exception (e.g., chronic pain). This is a shorter timeframe than the previous rule, which permitted opioid prescriptions for acute pain for up to 30 days. In addition, any refill or new prescription requires a subsequent consultation with the health care provider. Providers that routinely treat acute pain, such as emergency department clinicians and dentists will be significantly impacted by this shorter timeframe. The law also places limits on patients' copayments for initial and subsequent prescriptions for the same opioid medications.

• Requirements for Pharmacists (Effective October 22, 2016) – When an individual is prescribed an opioid, pharmacists must provide educational materials on opioids, including information on the risks of addiction and local treatment services. 

• Requirements for Hospitals: Staff Training and Discharge Planning (Effective December 22, 2016) – Hospitals are required to provide follow-up treatment services through discharge planning to connect patients to treatment options. This requires providers to distribute state Department of Health (DOH) and Office of Alcoholism and Substance Abuse Services (OASAS) educational materials to patients who appear to have a substance use disorder. The law also requires hospitals to have policies and procedures related to dealing with substance use disorders, as well as training staff on these policies and procedures. This may require building relationships with substance use disorder treatment programs in order to refer and coordinate care for patients who have such disorders.

Additional Services for Patients (Effective June 22, 2016)

For providers seeking to expand capacity in response to the growing demand for treatment services, the law seeks to support these providers by investing in expanding access to treatment. In total, the law will provide an additional 270 treatment beds and 2,335 opioid treatment program spaces.

Insurance Reforms (Effective January 1, 2017)

One of the law's most significant provisions prohibits prior insurance authorization for medically necessary treatment services. In addition, the law prohibits insurers from conducting utilization review for the first 14 days of treatment. To determine whether services are medically necessary, insurers must use an OASAS designated level of care tool. Once a program admits a patient, the provider must notify the insurer of the admission and the initial treatment plan within 48 hours. Although the law prohibits utilization review for 14 days, this should not be construed as permission for providers to treat patients for 14 days. A patient should only remain in treatment for 14 days when it is medically necessary as determined by the patient's health care provider.

The comprehensive legislation builds on existing laws in New York that seek to combat the opiate epidemic. Further, the law places New York in the company of the Federal government and several other States that have recently passed similar legislation.