Study Raises Concerns About Access to Substance Abuse Treatments in Medicaid

An analysis of Medicaid coverage for substance abuse treatments revealed that the services and medications covered vary widely by state. The Health Affairs study raised concerns that patients in some states may not have adequate access to necessary treatment.

Under the Affordable Care Act, states that have expanded Medicaid are required to cover substance abuse treatments, and the Mental Health Parity and Addiction Equity Act of 2008 ensured that Medicaid limitations on substance abuse treatment are no more restrictive than those placed on other medical services. However, these laws do not dictate which specific services Medicaid programs must offer, leading to wide disparities in coverage among different states.

The American Society of Addiction Medicine (ASAM) clinical guidelines have identified 7 essential treatments across 4 levels of care for substance abuse disorders:

• Level 1: outpatient services
• Level 2: intensive outpatient services
• Level 3: residential inpatient services
• Level 4: intensive inpatient services.

The FDA has approved 4 medications (methadone, buprenorphine, and oral and injectable naltrexone) for the effective treatment of opioid use disorders in conjunction with psychosocial treatment at the appropriate level of care.

Study authors gathered data on Medicaid programs in all 50 states and the District of Columbia and analyzed their levels of coverage for the treatments and medications. They found that just 13 states and DC covered all 7 services across the 4 levels of care specified by ASAM. Of the 24 states that did not cover at least 1 treatment within each level of care, 15 lacked coverage in at least 1 level of care, 5 lacked coverage in 2 levels, and 4 lacked coverage in 3 levels. Level 3 residential treatment, which was not covered by 21 states, was the most commonly restricted level of care. Recovery support services were covered by Medicaid in just half of the states and DC.

All of the states and DC provided Medicaid coverage for buprenorphine, but only 31 states and DC covered methadone, which the authors called “the most efficacious and rigorously studied medication” of the 4 used to treat opioid use disorder. Furthermore, Medicaid programs in just 17 states and DC provided a comprehensive package of all 4 medications and coverage across the ASAM levels of care.

The study also found that “the vast majority” of Medicaid programs set limits on the services it covered, most commonly by requiring preauthorization or imposing annual maximums on coverage. However, the set maximums varied widely, from as few as 12 visits per year before requiring preauthorization to as many as 365 treatments per year. Some states required cost sharing for certain medications, but copayments and deductibles were uncommon.

The coverage disparities highlighted in this research could be contributing to the substance abuse crisis in the US, according to the study authors.

“Patients without access to the full range of efficacious services or medications are more likely to be mismanaged or treated in inappropriate settings,” they wrote. “Consequently, they are put at higher risk for relapse, which has serious public health implications.”