Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care

Abstract

ImportanceMedicaid is a key policy lever to improve opioid use disorder treatment, covering approximately 40% of Americans with opioid use disorder. Although approximately 70% of Medicaid beneficiaries are enrolled in comprehensive managed care organization (MCO) plans, little is known about coverage and prior authorization (PA) policies for medications for opioid use disorder (MOUD) in these plans.ObjectiveTo compare coverage and PA policies for buprenorphine, methadone, and injectable naltrexone across Medicaid MCO plans and fee-for-service (FFS) programs and across states.Design, Setting, and ParticipantsThis cross-sectional study analyzed MOUD data from 266 Medicaid MCO plans and FFS programs in 38 states and the District of Columbia in 2018.Main Outcomes and MeasuresFor each medication, the percentages of MCO plans and FFS programs that covered the medication without PA, covered the medication with PA, and did not cover the medication were calculated, as were the percentages of MCO, FFS, and all (MCO and FFS) beneficiaries who were covered with no PA, covered with PA, and not covered. In addition, MCO plan coverage and PA policies were mapped by state. Analyses were conducted from January 1 through May 31, 2022.ResultsCoverage and PA policies were compared for MOUD in 266 MCO plans and 39 FFS programs, representing approximately 70 million Medicaid beneficiaries. Overall, FFS programs had more generous MOUD coverage than MCO plans. However, a higher percentage of FFS programs imposed PA for the 3 medications (47.0%) than did MCOs (35.9%). Furthermore, although most Medicaid beneficiaries were enrolled in a plan that covered MOUD, 53.2% of all MCO- and FFS-enrolled beneficiaries were subject to PA. Results also showed wide state variation in MCO plan coverage and PA policies for MOUD and the percentage of Medicaid beneficiaries subject to PA.Conclusions and RelevanceThis cross-sectional study found variation in MOUD coverage and PA policies across Medicaid MCO plans and FFS programs and across states. Thus, Medicaid beneficiaries’ access to MOUD may be heavily influenced by their state of residency and the Medicaid plan in which they are enrolled. Left unaddressed, PA policies are likely to remain a barrier to MOUD access in the nation’s Medicaid programs.

Tailoring dissemination strategies to increase evidence-informed policymaking for opioid use disorder treatment: study protocol

“…Most Medicaid/CHIP agencies contract MCOs to administer benefits; nearly 70% of all Medicaid members across the USA are enrolled in MCOs [34]. MCOs can impose their own utilization management restrictions that differ from those of the state agency and are not evidence-based [16,35]. For example, some MCOs have denied MOUD for members who return to substance use [36].…”

“…For example, some MCOs have denied MOUD for members who return to substance use [36]. A recent national survey of Medicaid plan coverage found that nearly 36% of MCOs surveyed require prior authorization for MOUD, with MCOs differentially imposing these policies on access to buprenorphine, methadone, and naltrexone [35].…”

Buprenorphine Utilization and Prescribing Among New Jersey Medicaid Beneficiaries After Adoption of Initiatives Designed to Improve Treatment Access

“…In 2019, New Jersey Medicaid implemented the MATrx model, which included initiatives designed to reduce barriers to buprenorphine prescribing in the Medicaid program and support clinicians in establishing or expanding capacity to deliver office-based addiction treatment. Under this model, Medicaid prohibited managed care organizations from requiring prior authorizations for MOUDs, to which most New Jersey Medicaid enrollees were subject before 2019 . Medicaid also implemented the Office Based Addiction Treatment (OBAT) program, enhancing reimbursement for office-based MOUD visits in clinics offering patient navigation .…”

“…Under this model, Medicaid prohibited managed care organizations from requiring prior authorizations for MOUDs, 18 to which most New Jersey Medicaid enrollees were subject before 2019. 19 Medicaid also implemented the Office Based Addiction Treatment (OBAT) program, enhancing reimbursement for office-based MOUD visits in clinics offering patient navigation. 18 The program further created new reimbursement codes for patient navigation in OBATs, which could be provided by nurses, social workers, medical assistants, or others who meet training and experiential requirements.…”

Error in Figure Titles

“…In the Original Investigation titled “Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care,” published November 4, 2022, the titles for Figures 3 and 5 have been corrected to include mention of fee-for-service programs; the titles had originally only mentioned managed care organization plans, when these figures in fact report on both. This article has been corrected …”