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How Does Medicaid Managed Care Address the Needs of Beneficiaries with Opioid Use Disorders? A Deep Dive into Contract Design
Published online by Cambridge University Press: 12 February 2024
Abstract
Many people who experience opioid use disorder rely on Medicaid. The high penetration of managed care systems into Medicaid raises the importance of understanding states’ expectations regarding coverage, access to care, and health system performance and effectively elevates agreements between states and plans into blueprints for coverage and care. Federal law broadly regulates these structured agreements while leaving a high degree of discretion to states and plans. In this study, researchers reviewed the provisions of 15 state Medicaid managed care contract related to substance use disorder (SUD) treatment to identify whether certain elements of SUD treatment were a stated expectation and the extent to which the details of those expectations varied across states in ways that ultimately could affect evaluation of performance and health outcomes. We found that while all states include SUD treatment as a stated contract expectation, discussions around coverage of specific services and nationally recognized guidelines varied. These variations reflect key state choices regarding how much deference to afford their plans in coverage design and plan administration and reveal important differences in purchasing expectations that could carry implications for efforts to examine similarities and differences in access, quality, and health outcomes within managed care across the states.
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Footnotes
The authors wish to thank Josemiguel Rodriguez, GW Law, J.D. (expected) 2024, for his indispensable research support and Morgan Handley, Eyman Associates, J.D., for her contract review work.
References
1 U.S. Dep’t Health & Hum. Servs., Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health 30 (2021), https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf.
2 Compare Overdose Death Rates, Nat’l Insts. Health (Jan. 20, 2022), https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates (92,000 drug-overdose deaths) [https://perma.cc/R8VF-6BX5] with All Injuries, Ctrs. for Disease Control & Prevention (Sept. 6, 2022), https://www.cdc.gov/nchs/fastats/injury.htm (40,698 traffic fatalities) [https://perma.cc/UR92-MGUE].
3 U.S. Overdose Deaths in 2021 Increased Half as Much as in 2020 – But Are Still Up 15%, Ctrs. for Disease Control & Prevention (May 11, 2022), https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/202205.htm [https://perma.cc/X7DX-WPNB].
4 Feijun Luo et al., State-Level Economic Costs of Opioid Use Disorder and Fatal Opioid Overdose — United States, 2017, 70 Morbidity & Mortality Wkly. Rep. 541, 543 (2021).
5 See, e.g., Carlos Blanco & Nora D. Volkow, Management of Opioid Use Disorder in the USA: Present Status and Future Directions, 393 Lancet 1760, 1762, 66 (2019).
6 See, e.g., Pia M. Mauro et al., Use of Medication for Opioid Use Disorder among US Adolescents and Adults with Need for Opioid Treatment, 2019, 5 JAMA Network Open 1, 1–14 (2022).
7 See, e.g., Matthew A. Davis et al., Prescription Opioid Use among Adults with Mental Health Disorders in the United States, 30 J. Am. Bd. Fam. Med. 407, 412 (2017), https://www.jabfm.org/content/30/4/407 [https://perma.cc/X7AR-LJ5E]; Opioid Addiction with Psychiatric Comorbidities, Providers Clinical Support Sys. (Sept. 19, 2021), https://pcssnow.org/resource/opioid-addiction-psychiatric-comorbidities/ [https://perma.cc/9WN5-M33P].
8 Optimizing Care for People with Opioid Use Disorder and Mental Health Conditions, Nat’l Insts. Health (Sept. 30, 2022), https://heal.nih.gov/research/new-strategies/optimizing-care [https://perma.cc/3X4M-28GX].
9 Kendal Orgera & Jennifer Tolbert, The Opioid Epidemic and Medicaid’s Role in Facilitating Access to Treatment, Kaiser Fam. Found. (May 24, 2019), https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-facilitating-access-to-treatment/ [https://perma.cc/Y6VN-K589].
10 Opioid Overdose Deaths by Age Group, Kaiser Fam. Found., https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-age-group/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D (last visited Dec. 27, 2022); 2020 NSDUH Detailed Tables – Table 1.16A, Substance Abuse & Mental Health Servs. Admin. (Jan. 11, 2022), https://www.samhsa.gov/data/report/2020-nsduh-detailed-tables [https://perma.cc/7CHA-BMV4].
11 Ryan M. McKenna, Treatment Use, Sources of Payment, and Financial Barriers to Treatment among Individuals with Opioid Use Disorder Following the National Implementation of the ACA, 179 Drug & Alcohol Dependence 87 (2017).
12 Orgera et al., supra note 9.
13 Id.
14 Id.
15 Tami. L. Mark et al., Spending on Mental and Substance Use Disorders Projected to Grow More Slowly than all Health Spending through 2020, 33 Health Affs. 1407, 1413 (2014); see also 42 U.S.C. § 300x–7 (outlining formula by which U.S. HHS Secretary shall determine block grant to states for mental health services).
16 See generally Agata Dabrowska et al., Cong. Rsch. Serv., R45405, The SUPPORT for Patients and Communities Act (P.L. 115-271): Food and Drug Administration and Controlled Substance Provisions 12-13 (2018) (discussing SUPPORT Act waiver from annual Drug Enforcement Administration registration for practitioners who dispense controlled substances approved for “maintenance or detoxification” treatment of OUD).
17 See, e.g., Colleen M. Grogan et al., Survey Highlights Differences in Medicaid Coverage for Substance Use Treatment and Opioid Use Disorder Medications, 35 Health Affs. 2289, 2294 (2016); Christina M. Andrews et al., Medicaid Benefits for addiction treatment expanded after implementation of the Affordable Care Act, 37 Health Affs. 1216, 1216 (2018).
18 Erika L. Crable et al., Translating Medicaid Policy into Practice: Policy Implementation Strategies from Three US States’ Experiences Enhancing Substance Use Disorder Treatment, 17 Implementation Sci. 1, 7 (2022); Andrea Kermack et al., Buprenorphine Prescribing Practice Trends and Attitudes among New York Providers, 74 J. Substance Abuse Treatment 1, 2 (2017).
19 Shailina Keshwani et al., Buprenorphine Use Trends Following Removal of Prior Authorization Policies for the Treatment of Opioid Use Disorder in Two State Medicaid Programs, 3 JAMA Health F. 1, 2, 4-5 (2022); Tami L. Mark et al., Association of Formulary Prior Authorization Policies with Buprenorphine-Naloxone Prescriptions and Hospital and Emergency Department Use among Medicare Beneficiaries, 3 JAMA Network Open 1, 8 (2020).
20 MaryBeth Musumeci & Jennifer Tolbert, Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act, Kaiser Fam. Found. (Oct. 5, 2018), https://www.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/ [https://perma.cc/65HP-M4P7]; Dispensing and Administering Controlled Substances for Medication-Assisted Treatment, 85 Fed. Reg. 69,153, 69,161 (Nov. 2, 2020) (to be codified at 21 C.F.R. pts. 1301, 1306) (interim final rule with request for comments).
21 Elizabeth Hinton & Lina Stolyar, 10 Things to Know About Medicaid Managed Care, Kaiser Fam. Found. (Feb. 23, 2022), https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid-managed-care/ [https://perma.cc/J9W2-8666]; Total Medicaid MCO Enrollment – Timeframe: 2020, Kaiser Fam. Found., https://www.kff.org/other/state-indicator/total-medicaid-mco-enrollment/?currentTimeframe=0&sortModel=%7B“colId”:"Location","sort":"asc"%7D [https://perma.cc/WK5R-DBLG] (last visited Dec. 27, 2022).
22 Medicaid & CHIP Payment & Access Comm’n, supra note 1.
23 See 42 C.F.R. § 441.50–.55 (requiring that state plans cover EPSDT, defined below).
24 42 C.F.R. § 440.230(b). For children under 21, however, Medicaid sets a national coverage standard through its early and periodic screening, diagnosis and treatment (EPSDT) benefit that entitles children to exceptionally comprehensive benefits and that establishes a nationwide medical necessity standard, the purpose of which is to ensure that all treatments necessary to “ameliorate” physical and mental health conditions are made available. See generally Sara Rosenbaum & Paul Wise, Crossing the Medicaid-Private Insurance Divide: The Case of EPSDT, 26 Health Affs. 382 (2007) (discussing implications of 2005 Deficit Reduction Act for child health and developmental principles of EPSDT). Over the years, beneficiaries have sued states to force coverage that their plans denied, and courts have consistently recognized state officials’ legal obligations for the actions of their contractors. See R.K. ex rel. J.K. v. Dillenberg, 836 F.Supp. 694, 698–700 (D. Ariz. 1993) (D. Ariz. 1993) (health authority discharging treatment center residents state action because state delegated entire responsibility when legislation “conceived [health authority] as [a vehicle] for execution of evolving public policy on [state’s] mental health needs”); see also Quinones v. UnitedHealth Grp., No. 14-00497 LEK-RLP, 2015 U.S. Dist. LEXIS 97166 at *7 (D. Hawaii July 24, 2015) (“The court is not persuaded that there is a per se rule precluding a finding of state action [by a managed-care organization].”); Reed ex rel. C.R. v. Noggle, 559 F. Supp. 3d 1323, 1333 (N.D. Ga. 2021) (ruling private healthcare provider charged under state’s contract with reviewing prior authorization requests a state actor for purposes of 42 U.S.C. Section 1983).
25 42 U.S.C. § 1396a(z)(bb)(5)(A).
26 Tiffany Stecker, California Plans Deny Mental Health Claims Despite New Law, Bloomberg Law (Dec. 22, 2022), https://news.bloomberglaw.com/health-law-and-business/california-plans-deny-mental-health-claims-despite-new-law [https://perma.cc/GJE7-8EBK].
27 See, e.g., Wit v. United Behav. Health, No. 14-cv-02346-JCS, 2019 WL 1033730 (N.D. Cal. Mar. 5, 2019) (ruling provider guidelines abused discretion because unreasonable and contrary to generally accepted standards of care), rev’d, Wit v. United Behav. Health, No. 20-17363, 2022 WL 850647 (9th Cir. Mar. 22, 2022) (ruling abuse-of-discretion review standard misapplied by lower court because provider guidelines were not unreasonable when guidelines excluded coverage for treatment inconsistent with generally accepted standards of care); Mondry v. Am. Fam. Mut. Ins. Co., 557 F.3d 781, 809 (7th Cir.) (fiduciary duty to furnish plan documents extended to agent health insurer but not principal health insurer).
28 See, e.g., Erika Crable et al., How Do Medicaid Agencies Improve Substance Use Treatment Benefits? Lessons from Three States’ 1115 Waiver Experiences, 47 J. Health Pols., Pol’y, & L. 497, 507 (2022).
29 About the ASAM Criteria, Am. Soc’y Addiction Med., https://www.asam.org/asam-criteria/about-the-asam-criteria [https://perma.cc/SA92-RBYL] (last visited Dec. 28, 2022).
30 Letter from Brian Neale, Dir., Ctrs. for Medicare & Medicaid Services, to State Medicaid Dir. (Nov. 1, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf.
31 Id.
32 Information about Medication-Assisted Treatment (MAT), U.S. Food & Drug Admin., https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat [https://perma.cc/7JB6-V4FD] (last visited Dec. 28, 2022).
33 W.Va. Dep’t Health Hum. Res., West Virginia Medicaid Section 1115 Waiver Demonstration: Evolving West Virginia Medicaid’s Behavioral Health Continuum of Care 75 (2022), https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/wv-creating-continuum-care-medicaid-enrollees-sud-ext-req-06012022.pdf.
34 Mich. Dep’t Health & Hum. Servs., Comprehensive Health Care Program app. 8, at 208 (2021).
35 Health Center Program Uniform Data System (UDS) Data Overview, Health Res. & Servs. Admin., data.hrsa.gov/tools/data-reporting/program-data?grantNum=H80CS00006 [https://perma.cc/MB73-BSV6] (last visited Dec. 28, 2022).
36 Md. Dep’t Health, HealthChoice Managed Care Organization Agreement app. O, at 235–36 (2022).
37 Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability, 81 Fed. Reg. 27,498, 27,537 (May 6, 2016) (to be codified at 42 C.F.R. pts. 431, 433, 438, 440, 457, and 495) (final rule); see also Julia Paradise & MaryBeth Musumeci, CMS Final Rule on Medicaid Managed Care: A Summary of Major Provisions, Kaiser Fam. Found. (June 9, 2016), https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/ [https://perma.cc/H63D-LLC6] (explaining that “in lieu of” regulatory provision allows states to receive federal matching funds for capitation payments for adults undergoing short-term institutionalization to treat psychiatric or substance use disorder).
38 N.H. Dept’ Health & Hum. Servs., Requested Action ex. A, amend. VII, at 234 (2022).
39 Commonwealth of Ky, Master Agreement Modification app. H at 279 (2022).
40 N.Y. Dep’t Health, Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan/Health and Recovery Plan Model Contract app. K, at 43 (2019).
41 Mich. Dep’t Health & Hum. Servs., Comprehensive Health Care Program app. 7, at 203–04 (2021).
42 Substance Abuse & Mental Health Servs. Admin., 2018–2019 National Surveys on Drug Use and Health: Model-Based Estimated Tools (in Thousands) (50 States and the District of Columbia) 19-21, 42-43 (2020), https://www.samhsa.gov/data/report/2018-2019-nsduh-state-prevalence-estimates [https://perma.cc/6L44-EBAR].
/sites/default/files/reports/rpt32879/NSDUHsaeTotal2019/2019NSDUHsaeTotal.pdf.
43 Id.; see, e.g., Substance Abuse & Mental Health Servs. Admin, 2020 N-SSATS State Profiles (2020).
44 Substance Abuse & Mental Health Servs. Admin., Results from the 2021 National Survey on Drug Use and Health: Detailed Tables 823, 857 (2022), https://www.samhsa.gov/data/report/2021-nsduh-detailed-tables [https://perma.cc/7UWB-EPAN].
45 See generally Grogan et al., supra note 17 (“Among states that limited [Medicaid] coverage, it was most common to restrict level 3 residential treatment.”).
46 Jennifer Tolbert et al., Key Facts about the Uninsured Population, Kaiser Fam. Found. (Dec. 19, 2022), https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/ [https://perma.cc/8J98-MTZJ].
Morris et al. supplementary material
Appendix A
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