Length of Time That Medicaid Covers Medication for Opioid Use Disorder

Research Brief

State Medicaid provides coverage of medication for opioid use disorder (MOUD) for at least six months.

A panel of experts rated how they expect this type of policy to affect four outcomes: OUD treatment engagement, OUD treatment retention, OUD remission, and OUD overdose mortality. Another panel of experts rated the policy on four decisionmaking criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
No
No
Yes

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
OUD Treatment Engagement
No
Yes
No
OUD Treatment Retention
No
No
Yes
OUD Remission
No
Yes
No
Opioid Overdose Mortality
No
Yes
No
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
No
Yes
Affordability
No
No
Yes
Equitability
No
No
Yes

Summary of Expert Comments

  • Experts expect this policy to have minimal impacts on OUD treatment engagement (i.e., initiating treatment) but meaningful impacts on OUD treatment retention (for at least six months). They do not expect population-level impacts on OUD remission and opioid overdose mortality.
  • Experts rated this policy as highly implementable across all four criteria.
  • The experts believe that the public generally approves of expanded insurance coverage.
  • Experts view the policy as a common modification to administering Medicaid that is cost-effective due to significant societal benefits of scaling MOUDs.
  • Experts think the policy will improve outcomes among socially disadvantaged populations, especially if states extend MOUD coverage beyond six months.

Outcome Summaries

OUD Treatment Engagement

Percentage of people meeting the criteria for an OUD diagnosis who receive two or more OUD treatment services (including medication for OUD) within 34 days of initiating treatment.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial In states without current coverage requirements, guaranteed continuous (short-term) access to insurance will increase treatment engagement. “Knowing you will have access to medication will help with engagement. Few people will be excited about treatment if they know the medication they need will be terminated quickly”
Little-to-no

(selected)
Most people already have coverage for initial treatment engagement. “I’m not aware of current coverage policies but would be amazed if they were less than six months so I’m not clear this would represent a significant change”
Harmful N/A N/A

OUD Treatment Retention

Percentage of people meeting the criteria for an OUD diagnosis who remain continuously enrolled in OUD treatment services for at least six months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial

(selected)
Guaranteeing Medicaid coverage for six months should lead to retention in treatment for six months (although retention after six months may decrease if Medicaid coverage is not extended). “Medication for OUD improves retention in treatment. Since Medicaid is the largest provider of OUD treatment, if it covers treatment for 6 months or more, treatment retention would be greatly improved”
Little-to-no Depends on the status quo in a state, as well as the proportion of the population using opioids to which this policy would be applicable. “A sizable number of Americans have Medicaid, so coverage for at least 6 months should increase this retention metric. But there’s also a large population with private insurance, so that’s why this impact is not larger”
Harmful N/A N/A

OUD Remission

Percentage of people meeting the criteria for an OUD diagnosis who do not experience OUD symptoms (other than craving/desire/urge for opioid) for at least 12 months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Increases in retention will lead to increases in remission. “This policy is likely to have no impact on initiating treatment but would increase treatment engagement and retention and, therefore, a potentially modest increase in OUD remission”
Little-to-no

(selected)
Depends on the status quo in a state, and whether coverage will be extended past six months. “The coverage proposed is only guaranteed for 6 months, so I think the increase of people not experiencing OUD symptoms for 12 months would not change much”
Harmful Negative impacts on long-term remission if coverage ends at six months. “If it stops coverage [between] 6–12 months it will actually work to decrease people in treatment after 6 months”

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Greater treatment retention should lead to decreased overdose mortality, especially as the policy would facilitate greater access to MOUD for a higher-risk population. “People with lower incomes need access like everyone else. The greater the access to care, the greater the chances of avoiding overdose fatalities”
Little-to-no

(selected)
Limited impact given either (1) limited change from status quo or (2) limited time frame for extended coverage. “Slight reduction, could be larger if coverage extended beyond 6 [months]”
Harmful Potential short-term reductions in overdose mortality could be countered by increases after coverage ends at six months. “This will help save lives initially, but not making available after 6 months could be dangerous”

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Public generally approves of expanded insurance coverage, especially for medical care that can address the overdose epidemic. “Overall, I think that the general public expects treatment, including medication treatment, to be covered by insurance”
Moderate Might receive some pushback from those who do not understand MOUDs, who see Medicaid coverage for MOUD as unearned or inappropriate, or who approve of MOUD coverage but see six months as insufficient. “Depends on the public’s understanding of MOUD—would require public education on why these medications may be used for indefinite periods of time; might be pushback if people question why these medications are covered and not other medications for chronic diseases, such as diabetes, hypertension, that are more common among the general population and thus many are likely to have personal exposure”
Low Public would oppose setting a coverage limit to six months. “Most [of the] general public is not focused on length of time—they are more in the ‘yes’ or ‘no’ category. If they are already at ‘yes,’ why impose limits of any type?”

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
A common type of modification to Medicaid policy. “Operationalizing this would not be challenging, and modifications of service durations are something we do often”
Moderate Depends on how a state implements Medicaid policy. “Dependent in part on state budgets, although federal match is generous for expansion coverage”
Low N/A N/A

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Extending coverage to (affordable) MOUD will yield significant societal benefits (i.e., cost-effective policy). “In the grand scheme of things, MOUD is not that expensive, particularly if it reduces [emergency department] and hospital utilization”
Moderate Depends on the status quo in the state (e.g., current funding sources, length of coverage, medications covered). Costs could be offset by societal benefits. “There are inconsistent funding streams to support these models at high quality and volume matching need”
Low States using six months as the limit for coverage will lead people to return to opioid use, leading to downstream costs for these states. “Termination of coverage for OUD medication after a defined period of time will ultimately increase expenditures as a proportion of those patients who lose their coverage will be unable to afford medication on their own and may increase risk for return to use”

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High

(selected)
Focus on Medicaid specifically will lead to improved outcomes among socially disadvantaged populations (especially if states implement the policy for longer than the six-month minimum). “This may improve equity for those with Medicaid as compared to those with private pay as it relates to health outcomes (though again should be no lifetime limits)”
Moderate Depends on status quo among the Medicaid-eligible population within a state. “Hard to say. It’s good to cover MOUD for at least 6 months, and Medicaid covers the most vulnerable populations. So could increase equity. But also, 6 months isn’t very long”
Low States using six months as the limit for coverage will increase disparities in care and outcomes for OUD. “Limits on Medicaid coverage are by definition inequitable. … Limiting to 6 months is cruel; requiring at least 6 months is insufficient. Medicaid should not time-limit coverage for any life-threatening, treatable, chronic disease, like opioid use disorder. Otherwise, what is the point of insurance?”

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