Medicaid professional fees for treatment of opioid use disorder varied widely across states and were substantially below fees paid by medicare in 2021

Abstract

Background As Medicaid is the largest payer for opioid use disorder (OUD) treatment services in the United States, information about Medicaid provider reimbursement is critical, and Medicaid payment policies influence the structure of OUD treatment services for everyone with OUD treatment needs. Methods We collected Medicaid professional fees for OUD treatment and related services for the District of Columbia and fifty state Medicaid programs and the Medicare program in 2021. We create three fee indexes related to OUD treatment, with an emphasis on services related to first-line medication treatments in outpatient settings. We then create Medicaid fee indexes and Medicaid-to-Medicare fee indexes. Results Weekly Medicaid fee bundles for methadone treatment at OTPs in 2021 varied widely, more than 4-fold across states. The Medicaid-to-Medicare fee index shows that the national average Medicaid fee bundle was 56 percent of Medicare fees for regular methadone treatment at OTPs in 2021. For services related to OUD treatment, Medicaid fees varied up to 5-fold and larger across the components of each of the four services, and Medicaid fees were low relative to Medicare for almost all state services examined. The Medicaid-to-Medicare fee index was 64 percent of Medicare fees in 2021, ranging from 52 percent for evaluation & management to 76 percent for toxicology testing. Conclusions There appears to be little justification for such large variation in Medicaid fees across states. In addition, the generally low fees in Medicaid persist despite recent efforts to increase access to opioid use disorder treatment for Medicaid enrollees, and have important implications for access to life-saving treatment during the current opioid overdose crisis.

National Trends in Buprenorphine Treatment for Opioid Use Disorder From 2007 to 2018

“…21 As coverage expanded, Medicaid became a key payer for buprenorphine treatment—our results indicate that the number of buprenorphine episodes paid for by Medicaid grew 4-fold across the study period, such that Medicaid paid for nearly 4 in 10 episodes by 2016-2018, consistent with prior work. 22,23 Our results indicated relatively limited growth in the number of episodes paid for by commercial insurance—this is consistent with emerging evidence that buprenorphine initiation (per capita) has been declining among the commercially insured population 24 and that changes in the buprenorphine payer mix may have served more to shift costs than to robustly expand treatment access. 25,26 Furthermore, studies have found that growth was primarily in Medicaid expansion states, underscoring important state heterogeneity in treatment access.…”

Differences in Availability and Use of Medications for Opioid Use Disorder in Residential Treatment Settings in the United States

“…By the end of 2017, Medicaid covered buprenorphine and XR-NTX but not methadone in all 50 US states, yet there continue to be many nuances in MOUD coverage within states that might further complicate access to treatment. 44 Prescriber restrictions include prior authorization to prescribe buprenorphine or XR-NTX, the requirement that buprenorphine be distributed by an opioid treatment program, or lifetime limits on doses of buprenorphine greater than 8 mg. 43 In addition, American Society for Addiction Medicine criteria play a large role in assigning levels of care to patients with OUD and determining reimbursement for OUD treatment providers. 45 Both facility-level and admission-level data suggest that MOUD availability and use may be lacking for disadvantaged populations, given that residential facilities that did not offer any MOUDs had higher odds of accepting cash-only payments than those that offered at least 1 MOUD (Table 1), and black patients as well as those who were referred from the criminal justice system had lower odds of receiving MOUDs as part of their treatment plan.…”

Association of Medicaid Expansion With Opioid Overdose Mortality in the United States

“…Expanded Medicaid eligibility has substantially increased access to these services among the low-income population . Recent evidence demonstrates that compared with nonexpansion states, Medicaid expansion states experienced increases in overall prescriptions for, Medicaid-covered prescriptions for, and Medicaid spending on both MOUDs, particularly buprenorphine and naltrexone, and the opioid overdose reversal medication naloxone …”

“…10,29 Recent evidence demonstrates that compared with nonexpansion states, Medicaid expansion states experienced increases in overall prescriptions for, Medicaidcovered prescriptions for, and Medicaid spending on both MOUDs, particularly buprenorphine and naltrexone, and the opioid overdose reversal medication naloxone. [6][7][8]11,14,30,31,35 Two prior studies 12,16 have found associations between income eligibility expansions for Medicaid and reductions in SUD-related deaths, and a recent study 17 assessed changes in opioidrelated deaths in Medicaid expansion vs nonexpansion states. Whereas the last study 17 found that Medicaid expansion was associated with larger increases in opioid overdose mortality, particularly in 2015 and 2016, analyses were conducted only at the state level.…”