(Withdrawn) Coverage for Opioid Use Disorder Treatment Medications in Medicaid Managed Care

Background and Purpose: Opioid-related mortality reached an all-time high in 2021, exceeding 75,000 deaths. Medicaid covers approximately 40% of Americans with opioid use disorder (OUD), and roughly 70% of all Medicaid beneficiaries are enrolled in managed care organization (MCO) plans. While Medicaid is the largest payer of addiction treatment in the United States, very little is known about coverage policies for medications for opioid use disorder (MOUD) in MCO plans. Given that these medications have been found to be an important concurrent treatment alongside psychosocial interventions commonly employed by social workers, it is critically important for the profession to be aware of barriers to treatment access presented by insurance policies.

Methods: Data on benefits and prior authorization policies for three FDA-approved MOUD (buprenorphine, methadone, injectable naltrexone) was collected for 266 Medicaid MCO plans in 38 states and DC in 2018 via content analysis of publicly available documentation, including member handbooks, provider manuals, and prescription-drug formularies. Data on the same policies among Medicaid fee-for-service (FFS) programs was taken from a survey of state Medicaid agencies conducted in 2017. For each medication, we calculated and compared percentages of (1) MCO plans and FFS Medicaid programs; and (2) Medicaid beneficiaries enrolled in MCO plans, state FFS programs, and in total (MCO and FFS) that included the medication as a covered benefit with no prior authorization requirement, included the medication as a covered benefit with a prior authorization requirement, or did not cover the medication at all.

Results: While most Medicaid beneficiaries were enrolled in a plan that included coverage benefits for MOUD, about half were enrolled in a plan that also required prior authorization. A lower percentage of MCO plans included benefits for methadone (69.5%) and injectable naltrexone (71.2%) compared to FFS programs (82.1% and 94.9%, respectively). However, a higher percentage of FFS programs than MCOs required prior authorization for buprenorphine and injectable naltrexone (64.1% vs. 42.3% and 46.2% vs. 29.9%, respectively). Similarly, a higher percentage of FFS beneficiaries faced prior authorization requirements for buprenorphine (60.5% FFS vs. 41.7% MCO) and injectable naltrexone (64.2% FFS vs. 41.5% MCO). Prior authorization requirements for Methadone were more common in MCO plans (35.6%) than FFS (30.8%). The percentage of enrollees in FFS and MCO plans subject to prior authorization for methadone was similar (37.5% and 38.5% respectively).

Conclusions and Implications: FFS and MCO plans vary dramatically in their coverage of MOUD. Overall, more Medicaid FFS programs include benefits for MOUD, however only 24.7% of beneficiaries are enrolled in Medicaid FFS. Overall, findings suggest that Medicaid beneficiaries’ access to MOUD may be heavily influenced by the specific Medicaid plan in which they are enrolled. Given the escalating opioid epidemic, it is critical that social workers find ways to assist patients with OUD in navigating and enrolling in insurance plans that provide benefits without these restrictions whenever possible and support advocacy efforts that call for the removal of prior authorization and similar policies that impede access to care.