OUD Treatment Coverage, Prior Authorizations Common in Medicaid FFS

Medicaid fee-for-service (FFS) programs were more likely to cover medications for opioid use disorder (MOUD) but imposed more prior authorizations for the treatments compared to Medicaid managed care organizations, a study published in JAMA Health Forum found.

Medicaid covers around 40 percent of Americans with opioid use disorder (OUD), but OUD treatment access varies across Medicaid FFS programs. While the public payer is required to provide coverage for MOUD, plans can still enforce prior authorization requirements.

Prior authorization may help control healthcare spending and ensure appropriate care use, but it can also limit patient access to necessary treatment.

Researchers analyzed MOUD data from Medicaid managed care organization (MCO) plans—which cover 70 percent of all Medicaid beneficiaries—and Medicaid FFS programs in 38 states and the District of Columbia to compare coverage and prior authorization policies for MOUD.

The 266 MCO plans and 39 Medicaid FFS programs included in the study represented around 70 million Medicaid beneficiaries in 2018.

MCO plans were less likely than FFS programs to cover MOUD, the study found. All 39 Medicaid FFS programs covered buprenorphine, 32 covered methadone (82.1 percent), and 37 covered injectable naltrexone (94.9 percent).

Comparatively, 255 MCO plans covered buprenorphine (98.1 percent), 164 covered methadone (69.5 percent), and 188 covered injectable naltrexone (71.2 percent).

Almost all beneficiaries in both FFS programs and MCO plans had buprenorphine coverage. However, MCO beneficiaries were less likely to have coverage for methadone (75.6 percent versus 92.1 percent) and injectable naltrexone (76.8 percent versus 94.3 percent) than those in FFS programs.

When assessing prior authorization requirements, researchers found that a higher share of Medicaid FFS programs imposed prior authorizations for buprenorphine (64.1 percent versus 42.3 percent) and injectable naltrexone (46.2 percent versus 29.9 percent) compared to MCO plans.

For methadone, 35.6 percent of MCO plans had a prior authorization requirement compared to 30.8 percent of FFS programs. For all three MOUDs, FFS programs (47 percent) were more likely to impose prior authorizations than MCO plans (35.9 percent).

Similarly, FFS beneficiaries were more likely to face prior authorization for buprenorphine and injectable naltrexone. In contrast, a similar share of FFS (37.5 percent) and MCO-enrolled beneficiaries (38.5 percent) faced prior authorization for methadone.

Among all Medicaid beneficiaries who experienced prior authorization, 50 percent had buprenorphine coverage or injectable naltrexone coverage and nearly 40 percent had methadone coverage that required prior authorization. Overall, 53.2 percent of Medicaid beneficiaries with MOUD coverage faced prior authorization requirements.

Since 2018, eight states in the study and the District of Columbia have passed legislation limiting the use of prior authorization in their state Medicaid programs for some MOUDs, researchers noted. Three of these states have removed prior authorization policies for MOUD completely and just one state law restricts the use of prior authorization in Medicaid MCO plans.

Based on the study findings, researchers recommended that state Medicaid agencies consider reviewing their contractual agreements with MCO plans to ensure beneficiaries have adequate access to MOUD treatment.

“In addition, CMS should consider issuing guidance to support the removal of PA for MOUD in all Medicaid plans (MCO and FFS) as it has done for the Medicare program,” researchers wrote. “Finally, more states should consider passing legislation that limits the use of PA for MOUD in their Medicaid programs.”

Prior authorization requirements have been a talking point in the Medicare Advantage space. The House recently passed the Improving Senior’s Timely Access to Care Act (HR 3173), which aims to increase oversight on prior authorization utilization in Medicare Advantage plans.

According to the American Medical Association (AMA), prior authorizations can delay patient care and create administrative burden for physicians.

However, adjusting prior authorization requirements may not have the intended impact on MOUD access, according to past data. For example, research from June 2022 found that removing prior authorizations for buprenorphine led to a decrease in buprenorphine prescriptions in California and an increase in buprenorphine prescriptions in Illinois.