Medicaid coverage for substance abuse treatment improved substantially since 2014: study

Access to care for Medicaid fee-for-service beneficiaries with substance use disorder has improved from 2014 until 2021, but much more can be done to improve it further, researchers say.

“The findings of this survey study of Medicaid FFS program coverage suggest that there have been substantial improvements in Medicaid benefits for [substance use disorder—SUD] treatment services and [opioid use disorder—OUD] medications since 2014,” according to a study in JAMA Network.

“Because 10 states only use Medicaid FFS, and state Medicaid FFS programs set the minimum standard for SUD treatment coverage in Medicaid MCO plans, this finding is highly salient. Nonetheless, there is still progress to be made before all Medicaid enrollees have adequate coverage for SUD treatment," the researchers said.

Researchers with the University of Chicago Survey Lab surveyed Medicaid directors in 50 states in 2014, 2017 and 2021. Data were analyzed after each wave of SUDs and OUDs in 2015, 2017 and 2021.

Nine states were not included because 100% of their Medicaid beneficiaries younger than 65 who were not on disability were covered by managed Medicaid health plans. They were Colorado, Hawaii, Idaho, Nebraska, New Jersey, New York, Pennsylvania, Tennessee and Virginia.

The percentage of Medicaid fee-for-service programs that offered outpatient treatment increase to 100% by 2021. In addition, some programs intensified inpatient and outpatient treatment and detoxification, which meant that 90% and 95%, respectively, offered this coverage. Researchers looked at outpatient and inpatient detoxification separately, finding that while 93% covered inpatient detoxification, only 67% covered outpatient detoxification.

“In each wave of the survey, information was collected on coverage for various SUD treatment services such as individual and group outpatient, intensive outpatient, short-term and long-term residential, recovery support, inpatient treatment and detoxification, and outpatient detoxification services,” the study said. “The survey also included data on coverage for FDA-approved medications for treating OUD, including methadone, oral and injectable naltrexone, and buprenorphine.”

In 2014 and 2017, the percentage of Medicaid fee-for-service programs requiring copayments increased, but there seemed to be a dip in 2021. That’s when copayments decreased for individual and group outpatient services from 27% to 24%, and copayments for intensive treatment decreased from 27% in 2017 to 18% in 2021.

On the other hand, copayments increased from 14% to 18% for recovery support and from 20% to 23% for detoxification. Copayment requirements for OUD medications decreased across all programs in 2021.

Prior authorizations needed for treatments and medications were highest in 2014 but then decreased in both 2017 and 2021. From 2017 to 2021, the percentage of Medicaid FFS programs requiring prior authorization for individual outpatient treatment decreased from 34% to 22%.

For group outpatient treatment, the decrease was from 33% to 22%.

“We observed a large increase in coverage for short- and long-term residential treatment for SUD, which had been stagnant at a low level of coverage in 2014 and 2017,” the study said.

“The magnitude of this change may be especially important, given [the Centers for Medicare and Medicaid Services’] option to allow states to waive the institutions for mental disease exclusion, which limited Medicaid coverage to small residential programs providing care to fewer than 16 persons,” the study states. “Prior to the option to waive the exclusion, states’ decision to cover residential treatment may have had a more limited impact on access to care.”