Medicaid Managed Care Plan Alignment With State Substance Use Disorder Treatment Coverage Requirements

Policy Points States contract with Medicaid managed care plans to administer benefits for roughly 70 million Medicaid enrollees, yet little is known about how plan benefit policies for substance use disorder (SUD) treatment medications align with state requirements. In this study, we found that among the population of 167 Medicaid managed care plans responsible for SUD pharmacy benefits in 2021, many did not align with state requirements to cover SUD treatment medications. Many plans imposed prior authorization requirements on these medications, even when prohibited from doing so. Alignment between state requirements and reported plan policies was less common among plans operating in Republican-leaning states.

Medicaid is the largest payer of substance use disorder (SUD) treatment in the United States. Managed care plays an important role, administering benefits for more than 80% of Medicaid enrollees. While state governments have enacted coverage requirements for SUD treatment medications that managed care plans must follow, the extent to which managed care coverage policies align with these rules remains largely unknown.

We linked a national survey of state Medicaid officials regarding state requirements for SUD medication benefits in 2021 with data on SUD medication coverage and management from all 167 Medicaid managed care plans in 2021. We assessed the extent to which plans aligned with state requirements-overall, and by the dominant voter political lean in the state in which the plans were embedded.

In 2021, the proportion of Medicaid managed care plans aligned with state coverage requirements for alcohol use disorder treatment medications was slightly higher than that for opioid use disorder treatment medications. Alignment for coverage was more common than alignment with prior authorization prohibitions. Democratic-leaning states were more likely to require coverage of alcohol and opioid use disorder medications, except in the case of methadone. In Republican-leaning states, most managed care plans did not align with requirements to cover disulfiram and acamprosate and 45.4% did not align with methadone coverage requirements. Plans in Republican-leaning states were less likely to align with prior authorization bans on every SUD treatment medication.

Medicaid managed care plans located in Republican-leaning states were less likely to be subject to state requirements governing coverage and prior authorization of SUD treatment medications, with the exception of methadone, and were also less likely to align with requirements when imposed by states.