Substance Use Disorder Treatment Benefits in Medicaid Managed Care

Background and Objective: The Patient Protection and Affordable Care Act (ACA) of 2010 included two major reforms: expanded coverage under Medicaid and establishment of essential health benefits (EHB) requirements. Together, these reforms have expanded access to substance use disorder (SUD) treatment for people newly-eligible for Medicaid. However, while state Medicaid programs are required to set coverage policies that comply with the EHB requirements, they do not always apply to managed care organizations (MCOs) that contract with Medicaid. However, little is known about what SUD treatment benefits MCOs provide.  Given that evidence suggests that coverage improves treatment access,  it is important to document what MCOs cover and what limitation policies, such as pre authorizations and annual maximums, they have in place.

Methods: We reviewed online documentation of benefit plans for all Medicaid MCOs in all states (39) that have Medicaid MCO contracts (n = 280). We collected data regarding  11 SUD treatment service types (e.g., individual outpatient, detoxification, short-term) and four evidence-based medications for treatment of SUD (e.g. methadone, naltrexone). We assessed whether each MCO plan (1) covered the service; (2) required cost sharing; (3) required prior authorization; and (4) imposed service quantity limits such as annual maximum restrictions. We performed descriptive analyses and used t-tests and ANOVA to test for statistical significance of differences across plans and across states where relevant. In addition, we conducted a content analyses. We used an iterative process to identify key themes in plans’ to defining and implementing service utilization limits for SUD treatment.

Results: Just over one-third of MCO plans had explicit exclusions for behavioral health, including SUD treatment.  The proportion of plans explicitly covering each SUD treatment service and medication varied dramatically among plans within states and across states. The use of prior authorization and annual limitations is quite common across MCO plans—rates of  87% and 73% respectively, across plans—but varied by service type and across states. Additionally, the qualitative analysis suggests that plans claim authority to set limits on service utilization without a clear explanation of the clinical guidelines used to determine eligibility for treatment services. Moreover, few details are provided for how such limitations are imposed.

Conclusions and Implications: We found evidence of significant differences in SUD treatment benefits and service limits  across MCO plans and across states. These findings suggest that, despite ACA provisions intended to ensure adequate benefits for SUD treatment, MCO plans that are not required to provide benefits for SUD treatment are not doing so. This is particularly problematic in light of the fact that the majority of the Medicaid population is enrolled in a managed care plan.  The extent of restrictions imposed by plans, without clear explanation as to how limitations are imposed or why raises questions for access to needed services and also about how consumers can make knowledgeable choices among plans.