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Millions of Americans who rely on Medicaid rehab coverage for addiction treatment may not be getting the benefits their states require, according to new research from Boston University School of Public Health.
If you’re on Medicaid and struggling to access medications for alcohol or opioid use disorder, the gap may not be your fault, it may be your insurance plan’s.
What the Study Found
A new study found a substantial discrepancy between states’ Medicaid requirements for substance use disorder (SUD) treatments and the actual policies of Medicaid managed care plans regarding these medications.
Many plans did not align with their states’ requirements to cover specific medications for alcohol use disorder (AUD) and opioid use disorder (OUD).
Published in The Milbank Quarterly, the study found that many managed care plans required prior authorization for these medications, even in states where such requirements were prohibited.
These administrative hurdles can delay treatment and increase the risk of coverage denials for essential SUD medications.
In practical terms, this means a Medicaid enrollee could be legally entitled to medication-assisted treatment but still face obstacles when they try to fill a prescription.
Which Medications Are Affected
The medications at issue are proven, often generic and widely recommended by medical professionals:
For opioid use disorder (OUD): methadone, buprenorphine and injectable naltrexone
For alcohol use disorder (AUD): oral naltrexone, acamprosate and disulfiram
Methadone and buprenorphine reduce the risk of all-cause mortality by more than 50 percent for people with opioid use disorder. Medications for alcohol use disorder can help individuals reduce cravings, decrease alcohol consumption, or maintain abstinence when used alongside behavioral therapies.
Despite that evidence, about 93 percent of managed care plans were aligned with state requirements to cover the AUD medication oral naltrexone, but only 57 percent were aligned with prior authorization bans for this drug. Similarly, 86 percent of plans were aligned with requirements to cover buprenorphine-naloxone, but only 42 percent were aligned with prior authorization bans.
Who Is Most Affected
Expanding access to SUD treatment can significantly improve health outcomes for individuals with alcohol and opioid use disorders.
Because alcohol and opioid use disorders disproportionately affect Medicaid beneficiaries, nearly 80% of state Medicaid programs require managed care plans to cover all approved medications for AUD and OUD.
The study also found that managed care plans in Republican-leaning states were considerably less likely to follow coverage requirements when they were in place.
Misalignment with state coverage and prior authorization policies was particularly evident among nonprofit managed care plans operating in Republican-leaning states. The researchers noted more investigation is needed to understand why this pattern exists.
It is worth noting that the data reflects 2021 plan policies, and some states have since strengthened enforcement. The study does not examine why individual plans fall out of compliance, whether due to administrative error, resource limitations or deliberate policy, and the authors call for more research on the causes.
What States and Plans Should Do
The researchers lay out clear recommendations for closing the gap. State Medicaid programs can take steps to ensure contracts with managed care plans explicitly require plans to align with state requirements and include processes for demonstrating alignment and clear accountability requirements.
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.
Plans should also confirm that their publicly available materials document the coverage of SUD treatment medications, so that people with SUD can make informed decisions about the plan they select to enroll with.
What This Means for People Seeking Free or Low-Cost Rehab
If you’re on Medicaid and have been denied coverage for addiction medications, you have options:
- Appeal the denial. Medicaid enrollees have the right to appeal coverage decisions. Ask your plan for the appeals process in writing.
- Ask your provider to request a peer-to-peer review. Your doctor can sometimes overturn a prior authorization denial by speaking directly with the plan’s medical reviewer.
- Contact your state Medicaid office. If your plan is out of compliance with state requirements, your state agency may be able to intervene.
- Seek a federally qualified health center (FQHC). FQHCs offer sliding-scale services regardless of insurance status and can often provide or refer you to medication-assisted treatment.
- Call SAMHSA’s National Helpline: 1-800-662-4357. Free, confidential, 24/7 referrals to local treatment programs, including free rehabs and low-cost rehabs near you.
Finding Affordable Treatment Near You
If Medicaid rehab coverage has failed you, free and low-cost rehab centers exist in most states, funded through state grants, federal block grants and nonprofit organizations. Many offer sliding-scale fees or accept patients at no cost based on income. You can search Rehabs.org’s directory of low-cost rehab centers or call
800-914-7089
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