News & Info for NYS Council Members – July 8, 2024

HHS Authorizes Five States to Provide Historic Health Care Coverage for People Transitioning out of Incarceration

Centers for Medicare and Medicaid Services (CMS) | CMS Newsroom | July 2, 2024

Illinois, Kentucky, Oregon, Utah, and Vermont to provide better continuity of Medicaid and CHIP coverage for incarcerated people, whose health care needs — from substance-use disorder treatment to chronic physical health conditions — have historically gone overlooked.

Adults and youth transitioning out of incarceration can experience delays in getting access to Medicaid or CHIP coverage upon return to their communities — harming public health and public safety. Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), approved the latest in a series of groundbreaking Medicaid and Children’s Health Insurance Programs (CHIP) demonstrations that will allow Illinois, Kentucky, Oregon, Utah, and Vermont to provide coverage before release, creating a seamless transition and avoiding gaps in coverage. These states join California, Massachusetts, Montana, and Washington in pursuing an innovative option for expanding access to high-quality, affordable health care.

“The Biden-Harris Administration is working to ensure every American has access to high-quality, affordable health care. This is an essential step for advancing health equity in our nation,” said HHS Secretary Xavier Becerra. “For people involved in the justice system, ensuring a successful transition back into the community includes having the health care supports and services they need. I’m pleased to see more and more states putting resources behind efforts that will ensure these individuals have what they need to thrive.”

“For the first time ever, thousands of incarcerated people in Illinois, Kentucky, Oregon, Utah, and Vermont will have critical supports during their transition out of a carceral setting, thanks to this important health care coverage,” said CMS Administrator Chiquita Brooks-LaSure. “At the heart of that work are Medicaid and CHIP — programs that continue to bring states and the federal government together to meet the needs of our communities. Under the Biden-Harris Administration, that’s meant more innovation than ever before to enhance public health and public safety.”

“Expanding access to life-saving treatment and recovery supports for incarcerated people is a critical part of our bipartisan efforts to beat the overdose epidemic and save lives,” said White House Office of National Drug Control Policy (ONDCP) Director Dr. Rahul Gupta. “President Biden made addressing the overdose epidemic part of his Unity Agenda for the nation because it is an issue that affects every community across the country and requires members of both parties to deliver progress for the American people. Under this important action today, the Biden-Harris Administration is providing a groundbreaking opportunity for these states to increase access to health care, including care for substance use disorder, in jails and prisons, and provide historically underserved and marginalized individuals with the tools and resources they need to succeed upon reentry. I am grateful to these states — red and blue, from coast to coast — for joining our whole-of-society response to strengthen public health, enhance public safety, and save lives.”

The Medicaid Reentry Section 1115 Demonstration Opportunity allows a state to cover certain services not otherwise coverable in Medicaid and CHIP up to 90 days before an eligible person’s expected release from incarceration. This includes coverage of substance-use disorder (SUD) treatment before a Medicaid or CHIP beneficiary is released from jail, prison, or a youth correctional facility. Additionally, states will be able to help connect the person to community-based Medicaid and CHIP providers up to 90 days prior to their release to ensure they can continue their treatment after they return to the community.

For incarcerated people — who often live with higher rates of SUDs, chronic physical health conditions, poor health care coordination, and other health concerns that can impact public health and public safety — these demonstrations mean:

  • Increased coverage, continuity of care, and appropriate service uptake through assessment of eligibility and availability of coverage for benefits in carceral settings just prior to release.
  • Improved access to services prior to release, and improved transitions into the community upon release.
  • Improved coordination and communication among correctional facilities, Medicaid programs and CHIPs, including managed care plans, and community-based providers.
  • Increased investments in health care and related services aimed at improving the quality of care for people in carceral settings.
  • Improved connections between carceral settings and community services to address physical health, behavioral health, and health-related social needs.
  • Better interventions for certain behavioral health conditions and increased use of stabilizing medications like long-acting injectable anti-psychotics and medications targeting SUDs, with the goal of reducing decompensation, suicide-related deaths, overdoses, and overdose-related deaths in the near-term post-release; and
  • Improved use of health care resources post-release, which can reduce unnecessary emergency department visits, inpatient hospitalizations, and all-cause deaths among recently incarcerated people with Medicaid and individuals otherwise eligible for CHIP if not for their incarceration status.

As highlighted in a previously released report from HHS Assistant Secretary for Planning and Evaluation, there are significant health coverage and continuity-of-care needs that justice-involved individuals face when returning to the community. These include disproportionately high rates of SUD, opioid overdose and overdose deaths, serious mental illness, and infectious and other chronic physical health conditions. Opportunities like the Medicaid and CHIP reentry demonstrations have a track record for improving health and health care transitions.

CMS continues to work with a range of other states on Medicaid reentry section 1115 demonstration requests. The agency has developed a standard demonstration application and special terms and conditions to expedite the approval of these requests. CMS continues to review these applications as quickly as possible under this streamlined approach, which balances increased efficiency with the Biden-Harris Administration’s priority to advance high-quality, affordable, person-centered health care coverage wherever possible. CMS hopes to adopt this approach for other section 1115 demonstration initiatives

HHS Authorizes Five States to Provide Historic Health Care Coverage for People Transitioning out of Incarceration | CMS

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More medical transport companies face Medicaid fraud charges

Companies in Orange and Tompkins Counties are accused of stealing more than $3.4 million from Medicaid

By Molly Burke,Capitol BureauJuly 7, 2024

ALBANY — The state attorney general’s office has filed more indictments targeting multiple medical transportation operators accused of stealing millions from Medicaid.

The office said in a release that operators in Orange County are accused of stealing more than $2.3 million from Medicaid through reimbursements for fake medical trips. The operators are also accused of adding fraudulent toll charges to medical transport trips between $15 and $50.

Daler and Damir Yudashev, who operated DYD Universe, Inc., were indicted and arrested last week on charges of grand larceny, health care fraud and other charges that could carry up to 25 years in prison. Nigina Iskandarova was also accused of operating a kickback scheme for Medicaid patients, and faces up to four years in prison.

The attorney general’s office said that between April 2018 and March 2023 the company overbilled Medicaid by more than $2 million.

The office also accused the operators of paying people thousands of dollars to take rides that the company then billed to Medicaid to receive tens of thousands of dollars.

The attorney general’s office also announced the arrest of David Moore, a Tompkins County resident, who was accused of stealing more than $1 million from Medicaid through his medical transport company, ASAP 2, between January 2019 and August.

Moore is accused of billing for fake trips and overinflating the mileage for Medicaid reimbursement. James’s office also said Moore billed trips with multiple passengers as separate trips, increasing the fees paid to the medical transport company.

The arrests followed other arrests last month of five men in Orange and Rensselaer Counties who are accused of stealing more than $4.4 million from Medicaid.

Muhammad Rizwan Khan, Muhammad Usman Khan and Farhan Khan of Orange County operated four companies that contracted with Medicaid to transport patients to and from covered medical services. They are accused of overcharging Medicaid by more than $3.8 million between September 2019 and October, and face up to 25 years in prison if convicted.

The attorney general’s office said that the defendants paid others to use their companies for transport and submitted claims for trips that did not take place. The office also alleged that they charged Medicaid for tolls that were “far above” any toll that could be incurred in the region, adding additional costs of up to $50 per trip.

John Gouzos and Richard Sehl, who operate three medical transport companies in Rensselaer County, are accused of Medicaid fraud by billing for trips originating at addresses further away from where patients really lived, the attorney general’s office alleges. They were charged with grand larceny and money laundering for allegedly overcharging Medicaid by more than $650,000, and face up to 15 years in prison if convicted.

The Khans were arraigned on June 14 in Orange County Court. Farhan Khan remains in custody but Muhammad Rizwan Khan and Muhammad Usman Khan both posted bail and were released. Gouzos and Sehl were arraigned on June 12 in Rensselaer County Court. They were released on their own recognizance.

The attorney general’s office said that the defendants all used kickbacks and shell companies to aid in their overbilling schemes.

“Medical transportation providers are an essential service for New Yorkers who lack the resources to travel to receive care,” state Attorney General Letitia James said in a statement. “These individuals abused our health care system and stole millions of taxpayer dollars meant to provide care for New Yorkers in need. Taking advantage of Medicaid recipients is reprehensible, and my office will always ensure those who attempt to illegally profit from health care fraud face justice.”

The attorney general’s office also claims that some of the defendants participated in money laundering through shell companies to get cash proceeds from the alleged fraud, as well as to pay patients their kickbacks.

A representative from Medi Cab Corp., one of the three Rensselaer County companies operated by Gouzos and Sehl, previously declined comment.

Usman Khan said that the Orange County defendants self-surrendered plan to fight the charges.

“They’re just accusations,” Usman Khan said of the charges at the time.

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Lifting the veil on psychiatric hospital joint ventures

STAT News, 7/8

Nonprofit hospital systems are opening psychiatric hospitals to help the growing number of people suffering from mental health problems. But in many instances, those psychiatric hospitals are actually being run by troubled for-profit companies, and this fast-spreading model is putting unsuspecting patients and workers in dangerous environments, my colleague Tara Bannow reports in a new deeply reported investigation. 

Nonprofits like Ascension, Geisinger, Trinity, and Henry Ford are pursuing joint ventures with Acadia Healthcare and Universal Health Services, the largest psychiatric hospital chains in the country. Acadia and UHS both have checkered histories of understaffing and undertraining workers at their hospitals, which have led to numerous lawsuits and government settlements.

For the nonprofits, the partnerships have been a no-brainer: They are able to transfer patients, alleviating the logjams in their emergency rooms, and get a cut of the profit. Acadia and UHS love it, too: More growth, and they get to slap the name of the respected nonprofit on the hospital, or what one Acadia executive called the “brand halo effect.” But patients and workers have been put at risk — Tara found several instances of rape, assault, and even death at some of these facilities, which are pressured to admit as many people as possible. 

Read Tara’s investigation, which is based on interviews with more than 50 former employees, patients, and industry experts, along with a review of dozens of government investigations and court records.

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Thousands with disabilities subjected to segregation in these three states

USA Today, 

https://www.usatoday.com/story/news/nation/2024/06/24/thousands-with-mental-health-disabilities-segregated-in-missouri-nebraska-utah-doj-investigation/74175601007/

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Most States Allow Medicaid Managed Care Plans Discretion To Restrict Substance Use Disorder Treatment Benefits

PUBLISHED:JULY 2024, HEALTH AFFAIRS

Abstract

Managed care plans, which contract with states to cover three-quarters of Medicaid enrollees, play a crucial role in addressing the drug epidemic in the United States. However, substance use disorder benefits vary across Medicaid managed care plans, and it is unclear what role states play in regulating their activities. To address this question, we surveyed thirty-three states and Washington, D.C., regarding their substance use disorder treatment coverage and utilization management requirements for Medicaid managed care plans in 2021. Most states mandated coverage of common forms of substance use disorder treatment and prohibited annual maximums and enrollee cost sharing in managed care. Fewer than one-third of states forbade managed care plans from imposing prior authorization for each treatment service. For most treatment medications, fewer than two-thirds of states prohibited prior authorization, drug testing, “fail first,” or psychosocial therapy requirements in managed care. Our findings suggest that many states give managed care plans broad discretion to impose requirements on covered substance use disorder treatments, which may affect access to lifesaving care.

The United States remains in the midst of the deadliest drug epidemic in the nation’s history. Unintentional drug mortality reached an all-time high in 2022, exceeding 100,000 deaths.1 Despite the availability of effective, evidence-based substance use disorder (SUD) treatment services and medications, comparatively few people with SUD receive any treatment for their condition.2–5 In 2022, only 4.6 percent of the estimated 48.7 million Americans who experienced SUD in the prior year received care.3 Expanding access to effective SUD treatment remains a national public health priority.

Expanded Medicaid coverage has played a leading role in responding to the epidemic.6 As the largest US payer of SUD treatment services and medications, Medicaid covers a sizable proportion of Americans with SUD, including nearly 40 percent of all people diagnosed with opioid use disorder (OUD).6,7 People covered by Medicaid have a high prevalence of SUD relative to the general population, and they represent a disproportionate share of SUD-related deaths in many states.8,9 The decisions that state Medicaid programs make regarding SUD treatment coverage requirements and utilization management policies thus are highly consequential.10–13

Managed care plans play a major role in administering Medicaid benefits for SUD treatment. As of 2021, close to sixty-eight million people—approximately three-quarters of all Medicaid enrollees—were enrolled in comprehensive managed care plans, which contract with state Medicaid programs to administer benefits.14 Some state Medicaid programs contract with managed care plans to manage all SUD treatment benefits. Other state Medicaid programs may manage all SUD benefits or selected SUD treatments on a fee-for-service basis through traditional state plans and waiver programs. The Centers for Medicare and Medicaid Services (CMS) encourages all state Medicaid programs to cover evidence-based practice care continuums for SUD treatment.4

In a review of Medicaid SUD benefits conducted in 2018, Amanda Abraham and colleagues found that most Medicaid enrollees were covered by a plan that included the three medications that have been approved by the Food and Drug Administration (FDA) for the treatment of OUD (buprenorphine, methadone, and injectable naltrexone), with greater coverage generosity among state fee-for-service plans compared with managed care plans.10 However, the researchers also found widespread use of prior authorization, a common utilization management strategy, affecting approximately half of all Medicaid enrollees in state fee-for-service and managed care plans with OUD coverage requirements. Additional evidence indicates that there is considerable variation in SUD treatment coverage and utilization management policies across state Medicaid programs and managed care plans, which raises concerns that timely access to effective SUD treatments may be influenced by state of residence and managed care plan enrollment.10–13 Importantly, although the utilization management strategies that managed care plans employ can help ensure appropriate clinical care, they may also unnecessarily delay or deter SUD treatment.4

By default, state Medicaid programs that contract with managed care plans to provide SUD treatment afford significant deference to individual plans to determine coverage and utilization management policies. Whereas the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act of 2018 requires all state Medicaid programs and contracted managed care plans to cover the three FDA-approved medications for OUD treatment and related services until 2025,15 few other regulations are in place to ensure adequate coverage for SUD treatment, as defined by the clinical guidelines for management of SUD established by the American Society of Addiction Medicine (ASAM).16 The Affordable Care Act designates SUD treatment as an essential health benefit but does not set any standard to define adequacy of coverage.17

State Medicaid programs have broad authority to limit the discretion afforded to managed care plans to place restrictions on benefits for SUD treatment. First, states can stipulate SUD treatment services and medication coverage requirements in contracts with managed care plans. Second, states can explicitly prohibit managed care plans from using specific utilization management strategies, such as enrollee cost sharing, prior authorization, and annual maximums. However, little is known about whether and how state Medicaid programs exercise this authority.

To address this gap in the literature, we assessed whether state Medicaid programs required contracted managed care plans to provide coverage and prohibited the use of specific utilization management strategies across an array of common SUD treatment services and medications.

Study Data And Methods

Data Sources

Data were collected in 2021 as part of an internet-based survey administered to Medicaid programs from all fifty states plus Washington, D.C., hereafter referred to collectively as the fifty-one “state programs,” regarding SUD treatment benefit requirements and oversight policies. Each state Medicaid director was emailed a packet that contained a study description and an invitation to participate. Follow-up emails and telephone calls were made to state Medicaid directors who did not respond to the survey. Relevant survey questions for this study are listed in online appendix exhibit A1.18

Between October 2020 and February 2022, forty-six of the fifty-one state programs completed the survey, for a response rate of 90 percent. Three additional state programs did not respond to the survey, but the research team was able to use state administrative documents to fill out the survey on their behalf. No data were available for two state programs (Arkansas and Delaware).

Forty state programs contracted with managed care plans to cover some or all Medicaid enrollees in 2021. We excluded six state programs that contracted with managed care plans in 2021 but carved out all SUD treatment benefits to state Medicaid fee-for-service plans, which were beyond the scope of this study. Our final analytic sample included thirty-four state programs that used managed care plans to manage SUD treatment services (seven state programs), medications (two state programs), or both (twenty-five state programs). No survey data were collected on other Medicaid managed care arrangements, such as limited benefit plans, or other state initiatives, such as waivers. State programs’ SUD treatment benefit coverage decisions pertaining to contracted Medicaid managed care plans are depicted in appendix exhibit B1,18 which also includes analyses linking our survey data to 2021 Medicaid managed care enrollment data downloaded from the CMS website.14

The study was approved by an Institutional Review Board at the University of Chicago. The requirement for informed consent was waived because no human participant data were used in this study.

Measures

Data were collected on state program coverage requirements for Medicaid managed care plans for ten SUD treatment services and nine medications for SUD treatment across the continuum of care, as broadly defined by ASAM16 and adopted by the American Medical Association.19 The ten services were group outpatient, individual outpatient, recovery support services, SUD medication monitoring, intensive outpatient, outpatient detoxification, short-term residential, long-term residential, inpatient detoxification, and inpatient treatment. ASAM recommends the provision of all medications and their variant formulations that have been approved by the FDA for OUD (buprenorphine, buprenorphine implants, injectable buprenorphine, methadone [both maintenance and take-home], and injectable naltrexone), as well as for alcohol use disorder (injectable naltrexone, oral naltrexone, acamprosate, and disulfiram) in conjunction with the appropriate SUD treatment services.11,20 All nine of these SUD treatment medications and formulations were included in this study.

For each SUD treatment service and medication, data were collected to assess whether state programs prohibited managed care plans with coverage requirements from imposing three common utilization management strategies: annual maximums, enrollee cost sharing (copays and deductibles), and prior authorization. Data were also collected on three additional utilization management strategies specific to SUD treatment medications: drug testing, “fail first” (or step therapy), and psychosocial therapy requirements. The six utilization management strategies were selected on the basis of a review of the literature, including a Medicaid and CHIP Payment and Access Commission report to Congress on SUD treatment utilization management policies in Medicaid that was commissioned as a requirement of the SUPPORT Act.21 All analyses were performed using Stata, version 17.0.

Limitations

This study had several limitations. First, we were unable to identify variation in SUD treatment benefit coverage and utilization management policies beyond a binary classification based on whether state programs required each SUD treatment service or medication and whether state programs prohibited the use of each common utilization management strategy. As a consequence, we might not have fully captured differences in state program contracts with individual managed care plans and the frequency or extent to which Medicaid managed care plans covered SUD treatment benefits or forbade utilization management strategies for SUD treatment. Second, we relied on one year of data reported by state programs, collected at a single point in time. Information provided by state program staff may have been incorrectly entered or outdated. Some state programs may have amended or updated managed care plan contracts during the study period. Finally, our findings were limited to state program regulation of comprehensive managed care plans, which might not have captured all Medicaid enrollees or all types of SUD treatment available to Medicaid enrollees in some states.

Study Results

SUD Treatment Coverage Requirements

Thirty-four state programs contracted with managed care plans to manage SUD benefits for some or all Medicaid enrollees in 2021. Thirty-two of these programs provided SUD treatment services through managed care. As presented in exhibit 1, most state programs mandated coverage of each service, ranging from 78 percent for long-term residential services to 100 percent for group and individual outpatient SUD treatment. Overall, half of these state programs required managed care plans to cover all ten services measured in our study.

Exhibit 1 Percent of state Medicaid programs with coverage requirements for managed care plans for selected substance use disorder (SUD) treatment services and medications, 2021

SOURCE Authors’ analysis of data for 2021 from an internet-based survey of state Medicaid programs. NOTES Thirty-two of the 34 state programs included in the analytic sample reported contracting with managed care plans to cover SUD treatment services in 2021, and 27 of the 34 programs reported contracting with managed care plans to cover SUD treatment medications in 2021. No data were available on state coverage requirements for buprenorphine implants, injectable naltrexone, acamprosate, and disulfiram in managed care for one of these state programs or for injectable buprenorphine, take-home methadone, acamprosate, and disulfiram in managed care for a second state program.

Twenty-seven of the thirty-four state programs contracted with managed care plans to cover FDA-approved medications for OUD and alcohol use disorder in 2021. As also shown in exhibit 1, most programs required managed care plans to cover each type of medication for SUD, ranging from 81 percent for take-home methadone to 96 percent for buprenorphine and oral naltrexone. Three-quarters of these state programs mandated coverage for all nine medications in managed care. Additional data on state programs that required managed care plans to cover each SUD treatment and the associated 2021 enrollment numbers are in appendix C.18

Prohibitions On Utilization Management Strategies

Among the state programs that contracted with managed care plans to cover SUD treatment services, most restricted annual maximums and enrollee cost sharing (copays and deductibles) in managed care. As presented in exhibit 2, at least 65 percent of state programs prohibited managed care plans from imposing these utilization management strategies for each service, with slightly more programs prohibiting copays or deductibles than annual maximums. In contrast, 20–33 percent of state programs forbade the use of prior authorization for each service in managed care.

Exhibit 2 Percent of state Medicaid programs that prohibited contracted managed care plans from imposing selected utilization management strategies, by type of substance use disorder (SUD) treatment service, 2021

SOURCE Authors’ analysis of data for 2021 from an internet-based survey of state Medicaid programs. NOTES The data shown are for 30 of the 32 state programs that contracted with managed care plans to cover SUD treatment services for some or all Medicaid enrollees in 2021. No data were available regarding state prohibition on imposing prior authorization for group outpatient services and medication monitoring in managed care for one state program or on annual maximums for any services in managed care for two state programs. No data were available on state prohibitions on imposing annual maximums, copays or deductibles, or prior authorization for any services in managed care for two additional state programs, which were excluded from the analysis for exhibit 2.

As depicted in exhibit 3, higher proportions of state programs also prohibited managed care plans from imposing annual maximums, copays, or deductibles for each SUD treatment medication, ranging from approximately 77 percent (annual maximums for methadone maintenance) to 90 percent (copays and deductibles for take-home methadone and buprenorphine implants). The percentage of state programs restricting managed care plans from using prior authorization for each medication ranged from 50 percent for buprenorphine implants to 67 percent for oral naltrexone.

Exhibit 3 Percent of state Medicaid programs that prohibited contracted managed care plans from imposing selected utilization management strategies, by type of substance use disorder (SUD) medication, 2021

SOURCE Authors’ analysis of data for 2021 from an internet-based survey of state Medicaid programs. NOTES The data shown are for 25 of the 27 state programs that contracted with managed care plans to cover SUD treatment medications for some or all Medicaid enrollees in 2021. No data were available on state prohibitions on imposing annual maximums for any medications in managed care for one state program. No data were available on state prohibitions on imposing annual maximums, copays or deductibles, and prior authorization for any medications in managed care for two additional state programs, which were excluded from the analysis for exhibit 3.

Overall, fewer state programs prohibited managed care plans from imposing utilization management strategies specific to SUD medications, as shown in exhibit 4. The percentage of state programs that forbade managed care plans from imposing drug testing requirements ranged from 32 percent for methadone maintenance to 45 percent for injectable and oral naltrexone. In comparison, higher proportions of the state programs prohibited psychosocial therapy requirements for each medication, ranging from 59 percent for methadone maintenance to 71 percent for injectable naltrexone. For most medications, a similar or slightly lower percentage of state programs (range, 55–71 percent) forbade the use of fail-first policies. Data on the number of Medicaid enrollees covered by managed care plans in states with and without prohibitions on these utilization management strategies for each SUD treatment are in appendices D and E.18

Exhibit 4 Percent of state Medicaid programs that prohibited contracted managed care plans from imposing selected utilization management strategies specific to substance use disorder (SUD) treatment, by type of medication, 2021

SOURCE Authors’ analysis of data for 2021 from an internet-based survey of state Medicaid programs. NOTES The data shown are for 24 of the 27 state programs that contracted with managed care plans to cover SUD treatment medications for some or all Medicaid enrollees in 2021. No data were available on state prohibitions on imposing drug testing for buprenorphine, buprenorphine implant, injectable buprenorphine, injectable naltrexone, oral naltrexone, acamprosate, and disulfiram in managed care for one state program. No data were available on state prohibitions on imposing drug testing, fail-first policies (also known as step therapy), or psychosocial therapy requirements for any medications in managed care for three additional state programs, which were excluded from the analysis for exhibit 4.

Additional findings on practices used by most state programs to ensure managed care plans’ compliance with state coverage requirements and utilization management prohibitions, such as random sampling of claims approval and denials, are in appendix F.18

Discussion

High percentages of state programs mandated coverage for each of the SUD treatments and medications, but only half required coverage of all ten treatments recommended by ASAM.

To our knowledge, this was the first national study to investigate state Medicaid program coverage requirements and prohibitions on utilization management strategies for SUD treatment in managed care since the implementation of the SUPPORT Act in 2020.10 Overall, high percentages of state programs mandated coverage for each of the SUD treatments and medications assessed in this study. Our findings reflect a commitment from most state programs to ensure that Medicaid managed care plan enrollees have coverage for at least some forms of SUD treatment, particularly medications for OUD and related services, which are mandated by the SUPPORT Act.15 However, although coverage of individual SUD treatments was high, only 50 percent (sixteen of the thirty-two state programs) that contracted with managed care plans to administer SUD treatment services required coverage of all clinically necessary services, as defined by ASAM, which may lead to gaps in care for millions of Medicaid enrollees, as shown in appendix C.18

Notable numbers of state programs also allow managed care plans discretion to impose prior authorization requirements, as well as drug testing, fail-first, and psychosocial therapy requirements for SUD treatment medications. Although a high percentage of state programs prohibited managed care plans from imposing annual maximums, copays, or deductibles on individual SUD treatment services and medications, these tools remained available to Medicaid managed care plans in several states.

Utilization management strategies can be used to control costs and limit inappropriate or unnecessary use of some medical services and medications. However, such strategies can also limit appropriate and necessary SUD treatment.21 Given the urgency of the current epidemic of drug-related overdose and mortality, it is imperative that more research be conducted to provide guidance for state programs. However, robust research is currently extremely difficult to conduct because data on Medicaid managed care plan benefits are not publicly available. As a result, it may be important, moving forward, for policy makers to require public disclosure from all Medicaid managed care plans on exactly which SUD treatment services and medications are covered and what utilization management strategies are used for each treatment or medication in actual practice.

Notable numbers of state programs also allow managed care plans discretion to impose prior authorization requirements.

There are at least five possible reasons behind the variation in state program requirements observed in this study. First, state programs may have a policy preference for maximizing managed care plans’ discretion, with the perspective that plans know best how to manage care. A second reason may be provider-driven factors—for example, shortages of residential facilities and other SUD treatment providers may limit the ability of state programs and Medicaid managed care plans to ensure access, which may affect benefit design decisions. Ultimately, a benefit design regulatory policy mandating coverage in the absence of a concurrent strategy to ensure adequate provider capacity would not be helpful. Third, some states may suffer from limited availability of Medicaid managed care plans (and therefore reduced competition), which could make it difficult for states to have sufficient bargaining leverage to impose mandates or hold plans accountable. Fourth, Medicaid managed care plans are incentivized to control costs; publicly traded plans have a profit motive and may insist on discretion in SUD treatment coverage decisions or utilization management policies during contract negotiations with state programs.22 Fifth, it is possible that state programs simply have not considered the need for more stringent regulation of SUD treatment coverage and utilization management strategies, in which case evidence-based research would again be helpful.

Further guidance regarding federal priorities from CMS could prove useful in guiding state program decision making. For example, the agency has issued guidance on the use of prior authorization and fail-first arrangements for Medicare Advantage plans to ensure that they do not delay or discourage appropriate treatment,23 but it has yet to issue any such guidance for state Medicaid programs on the regulation and oversight of utilization management policies in Medicaid managed care plans.

Conclusion

Our study indicates that many state Medicaid programs require contracted managed care plans to cover the most common SUD treatment services and medications, particularly those medications for OUD and related services mandated by the SUPPORT Act. However, limits on comprehensive coverage remain, and many state programs defer to managed care plans regarding decisions around prior authorization and requirements specific to SUD treatment, such as drug testing. Allowing managed care plans such broad discretion in employing utilization management strategies may be cost-effective and limit unnecessary care, as intended, or it may restrict access to lifesaving SUD treatment services and medications. Given the severity of the opioid epidemic in the United States and the reach of Medicaid managed care plans—which conservative estimates suggest now cover approximately 2.2 million Medicaid managed care plan enrollees diagnosed with OUD and nearly five million enrollees diagnosed with SUD7,14—our findings indicate that the utmost priority should be given to determining whether the discretion given to managed care plans is ultimately helpful in avoiding unnecessary care or harmful by restricting access to necessary lifesaving care, and to providing appropriate guidance.

ACKNOWLEDGMENTS

Preliminary findings were presented at the Annual Agency for Healthcare Research and Quality National Research Service Award Trainees Research Conference (virtual), April 13, 2023, and the 2023 Addiction Health Services Research Conference in New York City, October 19, 2023. This study was funded by the National Institute on Drug Abuse, National Institutes of Health (NIH) (Grant No. R01DA052425; Christina Andrews, Amanda Abraham, and Colleen Grogan); the National Institute on Alcohol Abuse and Alcoholism, NIH (Grant No. R01AA029097; Andrews, Abraham, and Grogan); and the Agency for Healthcare Research and Quality (Grant No. T32 HS000084, Lauren Peterson; principal investigator, R. Tamara Konetzka). The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, or the Agency for Healthcare Research and Quality. To access the authors’ disclosures, click on the Details tab of the article online.

NOTES