DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
SMD # 18-006 
RE: Leveraging Medicaid 
Technology to Address the 
Opioid Crisis 
June 11, 2018 
Dear State Medicaid Director: 
On November 1, 2017, the Presidents Commission on Combating Drug Addiction and the 
Opioid Crisis released its final report1 with specific health information technology references. 
This report, as well as the October 26, 2017 announcement2 of the Acting Secretary of Health 
and Human Services declaration of a nationwide public health emergency3 to address the opioid 
crisis, singles out telemedicine and prescription monitoring tools as useful in the effort to combat 
the opioid crisis. Also, the Department of Health and Human Services 5-Point Strategy to 
Combat the Opioid Crisis4 emphasizes the importance of improving access to prevention, 
treatment, and recovery services, including the full range of medication-assisted treatments, and 
strengthening our understanding of the crisis through better public health data and reporting. All 
applicable federal and state regulations relevant to information sharing, patient privacy, or 
consent requirements must be carefully considered in developing such technologies. 
This State Medicaid Director letter (SMD) provides guidance to the States on which funding 
authorities might support these health information technology efforts, with an emphasis on 
leveraging existing authority contained in the final rule entitled Mechanized Claims Processing 
and Information Retrieval Systems (90/10)5 and in the Health Information Technology for 
Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and 
Reinvestment Act of 2009 (Pub. L. 111-5). In the case of systems supporting Medicaid 
Information Technology Architecture (MITA) business processes two concurrent match rates 
may be available for states to utlize; a 90 percent enhanced funding to design, develop and 
implement systems might be available with a  75 percent enhanced match available for the 
1 The Presidents Commission on Combating Drug Addiction and the Opioid Crisis, final report, 
November 1, 2017: 
https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Meeting%20Draft%20of%20Final%2
0Report%20-%20November%201%2C%202017.pdf 
2 HHS Acting Secretary Declares Public Health Emergency to Address National Opioid Crisis, October 
26, 2017: https://www.hhs.gov/about/news/2017/10/26/hhs-acting-secretary-declares-public-health-
emergency-address-national-opioid-crisis.html 
3 https://www.hhs.gov/sites/default/files/opioid%20PHE%20Declaration-no-sig.pdf 
4 https://www.hhs.gov/opioids 
5 80 FR 75817 (Dec. 4, 2015).  Page 2  State Medicaid Director 
maintenance and operation of such systems. The HITECH Act makes available a 90 percent 
enhanced funding match for state expenditures on activities to promote health information 
exchange and encourage the adoption of certified Electronic Health Record (EHR) technology by 
certain Medicaid providers until 2021, if certain criteria are met, as discussed in SMD 16-003.6 
States should discuss with their CMS contacts as to whether HITECH funding or MITA funding 
might be more appropriate for the proposed activities, or a combination of both. As described 
below, there are several ways these enhanced federal funding opportunities for health 
information technology can be leveraged by states to support their ongoing efforts to address the 
opioid crisis. 
 
CMS issued a State Medicaid Director letter, Strategies to Address the Opioid Epidemic (SMD 
17-003)7 on November 1, 2017, to describe state flexibility in addressing the opioid crisis via 
demonstration projects under section 1115 of the Social Security Act. There are a number of 
ways technology might support those efforts, but a state need not be participating in an section 
1115 demonstration project to take advantage of the enhanced federal funding opportunities 
described in this SMD. The enhanced federal match for MITA and the HITECH Act applies to 
all states and territories irrespective of participation in a section 1115 demonstration project.  
 
Prescription Drug Monitoring Programs 
The Presidents Commission is aligned with public health experts8, the recent SMD letter on 
Strategies to Address the Opioid Epidemic9, Overdose Prevention in States (OPIS) effort by 
the Centers for Disease Control and Prevention (CDC), and previous CMS guidance10 in 
emphasizing the importance of enhancing prescription drug monitoring programs (PDMPs) to 
help improve appropriate and safer prescribing of prescription opioid medications, and 
integrating connections to PDMP data into EHRs to limit provider burden and improve interstate 
Health Information Exchange (HIE). This integration removes the requirement for providers to 
log in to a separate system, manage a separate log in, and disrupt their workflow to query the 
PDMP. Single sign-on interoperability between EHR and PDMP such that PDMP results are 
displayed when the EHR indicates a controlled substance is prescribed could be supported, as an 
example. States may consider integrating PDMPs into HIEs, where further integration with 
pharmacy data, shared care plans, drug utilization review (DUR) programs, Emergency Medical 
Services (EMS) data, Medication Assisted Therapy (MAT) data, advanced directives, and other 
EHR data might assist clinical decision making. Similarly, states may develop or leverage 
                                                           
6 Availability of HITECH Administrative Matching Funds to Help Professionals and Hospitals Eligible 
for Medicaid EHR Incentive Payments Connect to Other Medicaid Providers (Feb. 29, 2016).  
https://www.medicaid.gov/federal-policy-guidance/downloads/SMD16003.pdf 
7 https://www.medicaid.gov/federal-policy-guidance/downloads/SMD17003.pdf 
8 States With Prescription Drug Monitoring Mandates Saw A Reduction In Opioids Prescribed To 
Medicaid Enrollees, Health Affairs Vol 36, No. 4: 
https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.1141 
9 https://www.medicaid.gov/federal-policy-guidance/downloads/SMD17003.pdf 
10 Centers for Medicare and Medicaid Services (CMS) Opioid Misuse Strategy 2016, = January 5, 2017: 
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/CMS-Opioid-
Misuse-Strategy-2016.pdf  Page 3  State Medicaid Director 
technology which might incorporate the CDCs Prescribing Guidelines11 into workflows, or 
facilitates the ability of a prescriber to review previous prescriptions. For the purposes of 
administering the Medicaid EHR Incentive Program under the HITECH Act, a PDMP that 
declares itself a specialized registry ready to accept data can be considered, per previous 
guidance,12 a specialized registry for purposes of the meaningful use requirements under 42 CFR 
 495.22 and 495.24. 
 
Accordingly, a state can receive enhanced federal funding to build a PDMP or enhance PDMP 
functionality, as discussed in SMD 16-003.  States may claim the 90 percent HITECH match for 
costs related to the design, development, and implementation of PDMPs and connections to 
PDMPs so long as the cost controls described in SMD 16-003 are met and so long as these costs 
help Eligible Providers meet Meaningful Use measures focused on public health reporting and 
the exchange of public health data described in 42 CFR 495.22 and 495.24. However, Medicaid 
Management Information System (MMIS) matching funds may be a more appropriate source of 
federal funding for costs related to developing a PDMP in some cases, and states should not 
claim 90 percent HITECH match for costs that could otherwise be matched with MMIS 
matching funds. 
 
In addition to the enhanced federal funding opportunities for PDMP development made available 
through the Medicaid EHR Incentive Program, a state may also consider developing or 
enhancing PDMPs in support of the Manage Registry13 business process in MITA, which 
allows states to support specialized registries that receive an individuals health outcome 
information, prepare updates for a specific registry (like the PDMP), and supply information in 
response to inquiries. In the context of MITA, the registry must consolidate related records from 
multiple sources (e.g., intrastate, interstate, or federal agencies) into one comprehensive data 
store, which may or may not reside within the states Medicaid information system. States may 
wish to enhance PDMPs that do not currently meet MITA requirements to comply with these 
standards, such as by incorporating industry standards as required under 42 CFR 433.112(b)(12), 
or by further integrating outside data (such as pharmacy data).  To better capture interstate data, 
states may also consider connecting to multi-state data hubs such as RxCheck developed by the 
US Bureau of Justice Assistance or the PDMP Interconnect, developed by the National 
Association of Boards of Pharmacy. Consistent with the recommendations of the Presidents 
Commission, integrating pharmacy and other data in PDMPs could help facilitate the provision 
of non-opioid pharmaceutical treatments for acute and chronic pain management. In considering 
which industry standards are applicable when integrating PDMPs with EHRs, states should refer 
to the Interoperability Standards Advisory (ISA) published by the Office of the National 
Coordinator for Health IT. Specifically, the section describing, A Prescribers Ability to Obtain 
                                                           
11 https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm 
12 FAQ# 13413: https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Downloads/FAQs.pdf  
13 Guidance regarding MITA 3.0 and the Manage Registry business process are contained in .zip files 
located at https://www.medicaid.gov/medicaid/data-and-systems/mita/mita-30/index.html. See page 
26 of the file named, MITA 3.0 Part 1 for a description of the Manage Registry business process. 
PDMPs may also be relevant to supporting other businesses processes, as well.  Page 4  State Medicaid Director 
a Patients Medication History from a Prescription Drug Monitoring Program14, speaks to the 
standards for PDMP and EHR integration. States are reminded they are required to adhere to 
industry standards in designing such interfaces and the states should coordinate with their 
regional CMS lead or the Office of the National Coordinator for Health IT if they are unsure 
which standard or standards in the ISA might be appropriate for their efforts. States are also 
reminded of 42 CFR 433.112(b)(10) which requires the use of open interfaces and exposed 
application programming interfaces as appropriate. 
 
States are encouraged to minimize provider burden by integrating PDMP data into EHRs, as may 
be practicable, and to consider complementing PDMPs with provider onboarding and training, as 
discussed in SMD 16-003; some evidence suggests15 that a PDMP alone is not as effective as a 
PDMP deployed in conjunction with thoughtfully designed clinical workflows with the 
prescribers participation. States have the opportunity to design programs where the state-
supported PDMP practices are developed in conjunction with business process modeling to help 
minimize provider burden related to implementing new workflows, and to further make 
investments in systems with appropriate linkages to provider delegates such as case managers or 
social workers. State law varies with respect to which entities are allowed access to a PDMP, but 
some states might find value in also connecting law enforcement, licensing and regulatory 
boards, state medical examiners, and/or research organizations, consistent with applicable federal 
and state law. 
 
Finally, States should ensure PDMP integration activities supported by Medicaid resources do 
not duplicate activities funded under CDC, SAMHSA, and DOJ authorities.  
 
Advanced Analytics and Public Health Data 
 
The Presidents Commission, as well as the strategy described in the October 27, 2017 
declaration of a nationwide public health emergency to address the opioid crisis, emphasizes the 
importance of data-driven approaches to both prevention and treatment of negative opioid 
outcomes. States are encouraged to consider linking screening data from risk assessment tools 
such as the Opioid Risk Tool16 into EHRs and/or HIEs to facilitate targeted case management or 
to deploy other resources or follow up interventions. Such integration might be incorporated into 
Certified Electronic Health Record Technology (CEHRT) in a manner consistent with Objective 
6, Measure 317 of the Stage 3 meaningful use objectives and measures under 42 CFR  495.24,  
and thus potentially be supported by a 90 percent federal match, as discussed in SMD 10-016, 
Federal Funding for Medicaid HIT Activities (Aug. 17, 2010).18. Also, MITA design, 
development and implementation at an enhanced 90 percent match, and maintenance and 
                                                           
14 https://www.healthit.gov/isa/a-prescribers-ability-obtain-a-patients-medication-history-a-
prescription-drug-monitoring-program 
15 State Legal Restrictions and Prescription-Opioid Use among Disabled Adults (Meara, Horwitz, Powell, 
McClelland, Zhou, OMalley, Morden, 2016)  http://www.nejm.org/doi/full/10.1056/NEJMsa1514387 
16 https://www.drugabuse.gov/sites/default/files/files/OpioidRiskTool.pdf 
17 https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Downloads/MedicaidEPStage3_Obj6.pdf 
18 https://downloads.cms.gov/cmsgov/archived-downloads/smdl/downloads/smd10016.pdf  Page 5  State Medicaid Director 
operational support at 75 percent match, might be available, such as with respect to a data-
populated prediction model or risk profile to support the MITA business processes described in 
the MITA Business Architecture Supplement, Appendix C, Establish Case for Case 
Management.19 This document  directs states to support systems that leverage data and 
interoperability across Medicaid and non-Medicaid data sources to: 
 
  Identify target members for specific programs   
  Assign a care manager   
  Assess member needs   
  Select a program   
  Establish a treatment plan   
  Identify and confirm provider 
 
In considering data sources for case management, states should consider the interoperability 
standards under 42 CFR  433.112(b)(16), which requires MITA systems to support seamless 
coordination and integration with the Health Insurance Marketplace and the Federal Data 
Services Hub, and to allow interoperability with HIE, public health agencies, human services 
programs, and community organizations. Connecting these various data sources could leverage 
technology to help close referral loops, enable appropriate follow up, and leverage existing data 
and services elsewhere in a state. Adding data sources to the Medicaid system, such as human 
services programs, community organizations, EMS providers, Medicare, or justice-related 
systems, may be helpful and eligible for support related to the implementation of interoperability 
as required under 42 CFR 433.112(b)(16), per previous guidance.20  
 
Technologies for Coordinating Care and Increasing Access to Care 
 
Access to substance use disorder (SUD) treatment providers remains a challenge for states and, 
appropriately, the Presidents Commission supports leveraging telemedicine and telepsychiatry 
to facilitate more coordinated care. States are reminded that they need not necessarily submit a 
state plan amendment to begin delivering covered Medicaid services through telehealth 
modalities. State plan amendments are only required if a state decides to reimburse for 
telemedicine services differently than they pay for face-to-face services, visits, and consultations. 
States should also consider telehealth optimized Medication Assisted Treatment21 given access 
considerations. Virtual treatment centers or remote counseling options integrated into care 
coordination technology might help with addressing provider shortages, particularly in rural 
areas. Many behavioral health providers lack access to EHRs; states may consider reviewing 
what app-based technologies might be appropriate as described in the Office of the National 
Coordinator for Health ITs Health IT Playbook in the module addressing  Behavioral Health 
Providers.22 Under MITA, a state might consider developing telehealth-enabling technology, 
                                                           
19Guidance regarding the Case Management business process are located in .zip files located at 
https://www.medicaid.gov/medicaid/data-and-systems/mita/mita-30/index.html. See page 18 of the 
file named, MITA 3.0 Part 1 for the details on Establish Case. 
20 https://www.gpo.gov/fdsys/pkg/FR-2015-12-04/pdf/2015-30591.pdf 
21 https://www.samhsa.gov/medication-assisted-treatment 
22 https://www.healthit.gov/playbook/pdf/educational-module-Behavioral-Health-Providers.pdf  Page 6  State Medicaid Director 
including patient facing technology, to be used by Medicaid service providers for coordinating 
the care of Medicaid beneficiaries, which might support the Managing Case Information23 
business process, which includes activities in connecting providers to patients and facilitating 
services. Specifically, the Managing Case Information business process might include activities 
such as:   
  Service planning and coordination   
  Facilitation of services (e.g., finding providers or establishing limits or maximums) 
  Advocating for the member 
  Monitoring and reassessment of services for need and cost effectiveness   
  This includes assessing and taking necessary action to ensure that services and 
o
placement are appropriate to meet the programs needs 
 
Similarly, states might also leverage this or other business processes to facilitate shared 
electronic care plans used to coordinate care between providers, with an emphasis on connecting 
to SUD treatment providers. Similarly, enhanced federal funding under the HITECH Act might 
also be leveraged to support the design, development, and implementation of interoperable 
systems and HIEs that facilitate the exchange of electronic care plans between Medicaid 
providers, as discussed in SMD 16-003.  
 
States might also consider using Medicaid support to add systems supporting the Electronic 
Prescribing of Controlled Substances (EPCS). These systems might be integrated into other 
pharmacy systems or health information exchange architecture and complement broader state 
initiatives around securing prescribing processes. Workflow analysis and thoughtful on-boarding 
of Medicaid providers as described in SMD# 16-003 could help reduce the burden which might 
be associated with adopting the two-factor authentication in EPCS as well. 
 
Enhanced Statewide Interoperability 
 
States are reminded that some portion of the costs of the systems outside of the Medicaid 
enterprise that perform a MITA business process may be eligible for enhanced match24.  
Medicaid may pay for the proportion of costs related to its access and use of such systems 
consistent with an approved cost allocation methodology. This might include public health 
systems, such as a birth data registry that could support case management or treatment for 
pregnant women with opioid use disorder who are at increased risk of delivering a newborn with 
neonatal abstinence syndrome (NAS). NAS was highlighted by the Presidents Commission and 
is a condition likely to disproportionately affect the Medicaid population.  
 
States might also consider linking care coordination platforms, PDMPs, or electronic care plans 
with other data sources to support the Case Management business process in MITA. Specifically, 
business process steps described in, Manage Population Health Outreach, or, Manage 
                                                           
23 Guidance regarding the Case Management business processes is located in .zip files located at 
https://www.medicaid.gov/medicaid/data-and-systems/mita/mita-30/index.html. See page 18-23 of 
the file named, MITA 3.0 Part 1 for the full details of supported business processes. 
24 https://www.gpo.gov/fdsys/pkg/CFR-2012-title2-vol1/pdf/CFR-2012-title2-vol1-part225.pdf  Page 7  State Medicaid Director 
Registry, might support such targeted efforts25. For example, emergency management systems 
with structured data could be integrated with PDMPs or pharmacy benefit management systems 
(PBMs), e-prescribing systems, other pharmacy systems providing first-responders access to 
medication history, including pain management regimens, with compliance history. These types 
of data integration and others can provide the states better technical tools to provide Medication-
Assisted Treatment26. As states leverage technology to improve care coordination for justice-
involved individuals, linking correctional health systems to care coordination platforms, PDMPs, 
HIEs, or electronic care plans becomes increasingly valuable as such connections allow 
providers to appropriately manage prescription opioid medication, improve pain management 
and patient safety,  and provide treatment for substance use disorders, including opioid use 
disorder, as the patients move between care settings. 
 
States interested in developing prediction models or deploying advanced analytical approaches to 
data-driven interventions might also look to complement Medicaid data with data from human 
services programs, consistent with the above discussion of interoperability under 42 CFR  
433.112(b)(16). Certain social determinants of health can be partially predictive of potential 
negative outcomes from pain management regimens, and states are encouraged to appropriately 
leverage available data, consistent with applicable law. Factors such as poor housing, 
unemployment or underemployment, poverty, and certain occupations might contribute to 
negative opioid outcomes, and states should consider integrating such data for purposes of 
refining approaches to opioid risk profiling, prevention strategies, and targeted care 
management27. 
 
As state Medicaid agencies design systems with greater focus on value-based payment, Medicaid 
systems will continue to have more modules and processes tied to HIE. States are reminded of 
SMD # 18-005 published on April 18, 2018, which specifically states can achieve reuse, and add 
functionality to systems supported by enhanced funding association with the HITECH Act as 
appropriate28.  
 
CMS hopes states will use this information to improve the technological capacity of state 
Medicaid agencies, providers, and partners to address the opioid crisis and improve the health 
outcomes for Medicaid beneficiaries. CMS is available to provide technical assistance to states 
on the matters described in this letter.  States should err on the side of reaching out to CMS with 
questions about support for technologies which might assist with the prevention and management 
of acute and chronic nonmalignant pain, which includes non-pharmacologic approaches to pain 
prevention and management. Questions regarding this guidance may be directed to the 
appropriate regional CMS office. 
 
                                                           
25 Guidance regarding the Case Management business processes is located in .zip files located at 
https://www.medicaid.gov/medicaid/data-and-systems/mita/mita-30/index.html. See page 24-31 of 
the file named, MITA 3.0 Part 1 for the full details of  the business processes, Manage Population 
Health, and, Manage Registry 
26 https://www.samhsa.gov/medication-assisted-treatment  
27 Opioid Crisis: No Easy Fix to Its Social and Economic Determinants, AJPH February 2018, Vol 108, 
No. 2:  https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2017.304187 
28 https://www.medicaid.gov/federal-policy-guidance/downloads/smd18005.pdf  Page 8  State Medicaid Director 
Sincerely, 
  /S/ 
Tim Hill 
Acting Director 
  
cc:  
National Association of Medicaid Directors  
National Academy for State Health Policy  
National Governors Association  
American Public Human Services Association  
Association of State Territorial Health Officials  
Council of State Governments  
National Conference of State Legislatures  
Academy Health 
National Council for Behavioral Health 
National Association of County Behavioral Health & Developmental Disabilities Directors 
National Association of Boards of Pharmacy 
Federation of State Medical Boards 
American Medical Association 
Pharmacy Care Management Association 
National Council for Prescription Drug Programs 
High Intensity Drug Trafficking Areas National HIDTA Assistance Center 
National Association of State Alcohol and Drug Abuse Directors