Many state Medicaid agencies have enacted coverage requirements and prior authorization bans for the drugs involved in addiction treatment. But according to a new study out of the Boston University School of Public Health, not every Medicaid managed care organization actually follows those guidelines.
The report, published in The Milbank Quarterly, indicated that those seeking alcohol use disorder or opioid use disorder treatment could face barriers, despite state policies trying to limit those barriers.
"Medicaid managed care plans administer health insurance benefits for about 80 percent of Medicaid enrollees across the US," Sage Feltus, lead study author and research associate in the Department of Health Law, Policy & Management at BUSPH, said in a statement.
"Many states require managed care plans to cover alcohol and opioid use disorder treatment medications without limitations such as prior authorizations, but the influence of these requirements is limited if plans do not actually align their policies with state requirements," Feltus continued. "This discrepancy may inhibit patients from having timely access to these drugs."
Medications to treat AUD and OUD are evidence-based and effective, the researchers said. Drugs like methadone, buprenorphine and injectable naltrexone can effectively treat OUD, while oral naltrexone, acamprosate and disulfiram can help treat AUD.
Most states have coverage policies to ensure access to these drugs for those who need them. For example, 82.5% require Medicaid managed care plans to cover acamprosate and disulfiram for AUD treatment, and more than half have banned prior authorization requirements for oral naltrexone, acamprosate and disulfiram.
Meanwhile, 92.5% of states require managed care plans to cover methadone for OUD, while 88.9% require coverage of extended-release buprenorphine, injectable naltrexone and buprenorphine-naloxone. More than half have banned prior authorization for extended-release buprenorphine and injectable naltrexone, while 62.5% have banned it for buprenorphine-naloxone.
On a policy level, state Medicaid programs are creating avenues for individuals in need of AUD or OUD treatment to access it.
But in practice, that isn't happening.
Managed care plans misaligned on state Medicaid policy
Using data on SUD and AUD medication coverage and management from 167 Medicaid managed care plans in 2021, the researchers found significant misalignment.
Plans were better aligned in terms of AUD treatment coverage, with most (93.3%) states covering oral naltrexone. Another 70.2% aligned with requirements to cover disulfiram and 64.9% aligned with requirements to cover acamprosate.
Fewer states complied with prior authorization bans on AUD treatments. For example, 56.4% of managed care plans aligned with state policies for oral naltrexone, 71.7% for disulfiram and 74.1% for acamprosate.
Managed care plan compliance with state Medicaid policy was mixed for OUD treatment coverage. While 85.6% of plans complied with coverage requirements for buprenorphine-naloxone and 72.5% with coverage requirements for injectable naltrexone, only about 60% did so for methadone or extended-release buprenorphine.
The biggest misalignment was with prior authorization requirements for OUD treatments. According to the analysis, 55.4% of managed care plans complied with prior authorization bans for injectable naltrexone, 45.3% for extended-release buprenorphine and 42% for buprenorphine-naloxone.
"Effective implementation and oversight are crucial for policy impact," Maureen Stewart, the study's senior and corresponding author and research associate professor of health law, policy & management at BUSPH, said in the press release. "In this case, policies are in place, but managed care plans aren't adhering to them, and this disconnect has been largely overlooked in substance use treatment policy."
States must conduct better managed care oversight
This misalignment comes with risks, according to Feltus, who noted that medications like methadone and buprenorphine reduce the risk of all-cause mortality by more than 50%.
"Without treatment, people with opioid use disorder are at very high risk for overdose and death," Feltus added. "Alcohol use disorder medications can help people manage their cravings, cut back on drinking or achieve abstinence, in combination with behavioral therapies."
According to Stewart, state Medicaid agencies need to conduct stronger oversight of their contracts with Medicaid managed care plans to ensure access to necessary treatment.
"State Medicaid programs may also consider auditing the plans operating in their state to confirm that these medications are being covered and that plans are not requiring prior authorization where it is banned," Steward concluded.
Sara Heath has reported news related to patient engagement and health equity since 2015.
