How are state telehealth policies associated with services offered by substance use disorder treatment facilities? Evidence from 2019 – 2022

Abstract

Background:

The COVID-19 pandemic led several states to adopt policies permitting the delivery of substance use disorder treatment (SUDT) by telehealth. We assess the impact of state-level telehealth policies in 2020 that specifically permitted audio or audiovisual forms of telehealth offerings among SUDT facilities.

Procedure:

Cross-sectional analysis of secondary data from between 2019 and 2022. Pre-pandemic, federal law permitted states to allow audiovisual telehealth modes for SUDT to a limited extent. 2020 laws permitted states to allow audio-only modes for the first time and strengthened ability to offer audiovisual modes. We compared national SUDT facility self-reported telehealth offerings in 2020 and beyond to 2019, in states that in 2020 had policies permitting audiovisual and audio only, compared to other states.

Main Findings:

Among outpatient SUDT facilities (n = 5,227) present in all four years of our data, the proportion offering telehealth increased from 18% (n = 921) in 2019 to 26% in 2020, 60% in 2021, and 79% in 2022. We estimate an audiovisual and audio only policy in 2020 was associated with an increase in telehealth offering rates in 2022 of +16.5 percentage points (pp) (95% CI [+10.4,+22.6]) compared to the rates in states with no such listed policy. There was little evidence of an influence on telehealth offering in 2020 (−2.9 pp, CI [−9.0,+3.2]) and 2021 (+0.6 pp, CI [−5.5,+6.7]).

Conclusions:

The enactment of state-level telehealth policies that allow audio and audiovisual modalities may have increased SUDT facilities’ likelihood of offering telehealth services two years after enactment.

1. Introduction

Prior to the COVID-19 pandemic, the rapid increase in the number of drug overdose deaths was an urgent public health concern (Volkow 2020; Alexander et al. 2020). Throughout the COVID-19 pandemic, concerns arose that substance use disorder (SUD) and opioid use disorder (OUD) rates would further increase due to social isolation and lower treatment access (Volkow 2020). SUD and OUD treatment rates were expected to decline partly because individuals were encouraged to engage with their providers remotely. Telehealth appointments were suggested in order to slow the transmission of COVID-19 and prevent the overcrowding of hospitals (Centers for Disease Control and Prevention 2020). Federal law regulating telehealth for SUD changed after the SUPPORT Act of 2018, the CARES Act of 2020, and a new waiver issued by the Centers for Medicare & Medicaid Services (CMS) during the pandemic in March 2020. Federal law changes permitted telehealth SUD treatment (SUDT) in patients’ homes and in non-rural areas, and it expanded Medicare and Medicaid reimbursement for telehealth visits (e.g., covering audio-only telehealth, which had rarely been covered by CMS prior to the pandemic) (Uscher-Pines and Martineau 2021). States had the option of adopting flexibilities allowed under federal law 2020 to make audio-only telehealth delivery of SUDT possible as opposed to requiring audiovisual technology for telehealth or not allowing any telehealth. This paper studies how state policies permitting both audio-only and audiovisual telehealth for SUDT (as opposed to no telehealth or audiovisual only) influence facilities’ self-reporting of offering any form of telehealth SUDT services.

As the COVID-19 pandemic progressed, public health officials and policymakers also wanted to maintain access to medications for opioid use disorder (MOUD). MOUDs – including buprenorphine, methadone, and naltrexone are an effective treatment for OUD (National Institute on Drug Abuse 2016). Unfortunately, prior to 2020, in-person visit requirements commonly posed barriers to MOUD access (Harris and McElrath 2012; Sharma et al. 2017). For example, individuals with OUD were typically required to visit opioid treatment programs (OTPs) daily to receive methadone treatment. Similarly, although buprenorphine for OUD can be prescribed by waivered clinicians outside of OTPs (e.g., in primary care or non-OTP SUDT facilities), federal law had required an initial in-person visit. This visit could be challenging for individuals lacking reliable transportation or concerned about stigma associated with being seen receiving MOUD treatment (Huskamp et al. 2022).

Beginning in March 2020, the US Department of Health and Human Services, the US Department of Justice, and the US Drug Enforcement Administration permitted waivered clinicians to initiate buprenorphine treatment by audio or audiovisual telehealth without requiring an in-person evaluation (Drug Enforcement Administration & U.S. Department of Justice 2020). Under the new policy, patients began to initiate buprenorphine for OUD using telehealth (Uscher-Pines, Huskamp, and Mehrotra 2020), which could help address transportation barriers and stigma associated with in-person OUD treatment. Also, in March 2020, the federal government permitted OTPs to provide longer take-home durations for methadone treatment for OUD rather than requiring daily visits (Substance Abuse and Mental Health Services Administration 2021b), but unlike buprenorphine, the initial methadone visit was still required in person. These federal flexibilities were still in effect as of July 2022. Previous studies have shown that the share of SUDT facilities (Cantor et al. 2021) and OTPs (Cantor and Laurito 2021; Goldsamt et al. 2021; Krawczyk et al. 2022) offering telehealth increased after this federal policy changed.

Individual states have flexibility in adopting SUDT telehealth federal policy changes, thus national studies mask impacts of the telehealth laws that are likely isolated to states that adopted the laws (Alexander et al. 2020; Davis and Samuels 2021). Here, we study the association of state policies allowing audio-only as well as audiovisual modes of telehealth and the share of SUDT facilities that offer telehealth. Previous work has documented variation at the state-level in the permitted primary modality of telehealth delivery (e.g., audio-only) following the federal flexibility as of 2020 (Andraka-Christou et al. 2021). No previous studies have used this state-level variation in policies that permit audio-only as well as audiovisual telehealth SUD treatment to quantify their impact. We used a national longitudinal database of outpatient licensed SUDT facilities, including OTPs, between 2019 and 2022 to assess whether state 2020 policies on audio only and audiovisual telehealth predicted the likelihood of a facility offering telehealth, at a time of national easing of SUDT delivery. The results can inform policymakers and public health officials on approaches that influence the adoption of telehealth by SUDT facilities.

2. Material and methods

2.1. Data

The Mental health and Addiction Treatment Tracking Repository (MATTR) draws daily updates from the Substance Abuse and Mental Health Services Administration (SAMHSA) Behavioral Health Treatment Locator; we use annual data collected from April 23^rd of 2019 through 2022. The locator includes data from nearly all SUDT facilities that responded to a previous year’s survey, the National Survey of Substance Abuse Treatment Services (N-SSATS) between 2018 and 2020 and the National Substance Use and Mental Health Services Survey (N-SUMHSS) in 2021, which are answered by nearly all SUDT facilities in the U.S.. According to SAMHSA, the N-SUMHSS replaced the National N-SSATS in order to combine questions for substance use and mental health facilities to reduce the reporting burden for facilities, optimize government resources to collect data, and enhance the quality of data collected (Substance Abuse and Mental Health Services Administration 2022b). Eligible facilities meet one of three criteria. First, the facility is licensed, accredited or approved to provide SUDT. Second, the facility has staff with specialized credentials to provide SUDT services. Third, the facility is authorized to bill a third-party payer for SUDT services (Substance Abuse and Mental Health Services Administration 2022a).

This study focuses on outpatient treatment facilities that appear in all four years of the data. We identified such facilities by linking individual facility records across years based on their geocoded location, enabling us to address issues where names might have changed or been entered in different ways across the years. We identified outpatient facilities as those reporting offering outpatient SUDT services.

2.2. Outcome Variables

Our definition of offering telehealth is based on the question asked in the 2018 N-SSATS, “For each type of clinical/therapeutic approach listed below, please mark the box that best describes how often that approach is used at this facility.” One of the possible selections was “Computerized substance abuse treatment/telemedicine “. Facilities that selected, “sometimes” or “always or often” were classified as offering telehealth. The survey question changed beginning in the 2019 N-SSATS but was consistent through the 2022 N-SUMHSS. Specifically, facilities were asked “Which of the following clinical/therapeutic approaches listed below are used frequently at this facility?” The possible answer that we used to classify telehealth offering is: “Telemedicine/telehealth therapy (including Internet, Web, mobile, and desktop programs).” Telehealth services that could be offered include individual and group treatments, such as medication management, counseling, psychotherapy, and case management (Uscher-Pines, Cantor, et al. 2020).

2.3. Indicator Variables

Among the independent variables in our model are forms of MOUD offered by facilities. We classified a facility as offering methadone if it was federally certified as an OTP and reported offering methadone maintenance treatment. If a facility offered methadone detoxification alone, we did not classify it as a facility providing methadone treatment. We classified facilities that reported that they offered buprenorphine, buprenorphine with naloxone, buprenorphine without naloxone, or buprenorphine sub-dermal implants as offering buprenorphine. Finally, facilities that self-reported offering extended-release naltrexone were categorized as offering naltrexone.

We merged the annual facility data with information on state-level policy (Andraka-Christou et al. 2021), as well as with data on county-level measures of broadband access (United States Department of Commerce 2022). The policy data identified states that published a telehealth modality policy permitting audio-only telehealth as well permitting audiovisual telehealth for SUDT delivery on their Single State Agency (SSA) for Substance Abuse Services website in May or June 2020. States were considered to permit audio-only telehealth if they had any of the following policies: 1) audio-only was permitted, but only if audiovisual telehealth was not available (i.e., audiovisual was required if available); or 2) audio only telehealth was permitted regardless of whether audiovisual telehealth was available. All states classified as allowing audio-only telehealth also permitted audiovisual telehealth. A Single State Agency is a state government agency designated by a governor to lead planning and delivery of mental health and SUD services (Substance Abuse and Mental Health Services Administration 2017). Note that although states could not permit audio-only telehealth in 2019, they could have offered audiovisual telehealth in 2019, but at far less generous terms than they could in 2020. Thus, although in 2020 the ability of states to offer audio-only telehealth was novel, states also had a stronger ability in 2020 to allow audiovisual telehealth than they did in 2019. The full table of policies for each state can be found in Appendix Table 1.

We utilized the Federal Communication Commission definition of high-speed, or broadband, internet: having a minimum download speed of 25 megabits per second (Mbps) and minimum upload speed of 3 Mbps (Federal Communications Commission 2021). Counties were defined as having sufficient broadband access if median Mbps download and upload speed met these criteria. The data are from M-Lab test values during the period of January to June, 2020, as reported by the US Department of Commerce (United States Department of Commerce 2020).

2.4. Statistical Analyses

We compared facilities telehealth offerings by the state’s 2020 policy (whether they allowed audio-only as well as audiovisual) and estimated a linear probability model for an indicator of telehealth offering via ordinary least squares using the lm function in R version 4.1.2. Each model included a binary indicator for the policy in each year (2020, 2021, 2022) and an interaction between this indicator and the variable indicating 2020 audio-only policy. All models included indicators for type of insurance accepted (Medicare, Medicaid, private), an indicator for the facility being an OTP, indicators for MOUD offerings (methadone, buprenorphine, naltrexone, any MOUD, all forms of MOUD), and an indicator for location in a county with sufficient broadband speed.

We also fit the following models as sensitivity analyses: a model that included state fixed effects; a model only among facilities that accepted Medicare in 2019, as the rate of OUD among Medicare beneficiaries has grown over time and a recent study found the use MOUD by Medicare beneficiaries increased via telehealth during the pandemic (Shoff, Yang, and Shaw 2021; Jones et al. 2022); models among facilities in counties with and without adequate broadband access; models with facility fixed effects; and models that split the state policies into those that permitted audio-only only when audiovisual was not available, and those that permitted audio-only regardless of the availability of audiovisual. The model with facility fixed effects was estimated by subtracting the facility mean from the outcome and all time-varying covariates. This study was deemed exempt by the lead author’s Institutional Review Board. R version 4.1.2 (R Foundation for Statistical Computing) was used to complete the statistical analysis.

3. Results

First, we report on general trends in SUDT offering of telehealth and acceptance of various form of payment for treatment. We found that telehealth offering rates increased sharply among all SUDT facilities over the study period. In 2019, only 18% of facilities (n = 921) offered telehealth, but this number increased to 26% in 2020, 60% in 2021, and 79% in 2022 (Table 1). While there was a slight increase in acceptance of Medicaid or private insurance, acceptance of Medicare increased substantially over the study period, from 38% of facilities in 2019 to 50% in 2022, as did buprenorphine offering rates, from 35% in 2019 to 46% in 2022.

Table 1:

Characteristics of the study facilities, 2019–2022

Characteristic	2019, N = 5,2271	2020, N = 5,2271	2021, N = 5,2271	2022, N = 5,2271
Audio-only permitted in 2020	4,830 (92%)	4,830 (92%)	4,830 (92%)	4,830 (92%)
Telehealth offering	921 (18%)	1,375 (26%)	3,120 (60%)	4,118 (79%)
Medicare accepted	1,966 (38%)	2,028 (39%)	2,406 (46%)	2,604 (50%)
Medicaid accepted	3,825 (73%)	3,987 (76%)	4,097 (78%)	4,135 (79%)
Private insurance accepted	3,920 (75%)	4,017 (77%)	4,064 (78%)	4,079 (78%)
Opioid treatment program	857 (16%)	865 (17%)	875 (17%)	867 (17%)
Methadone offered	839 (16%)	846 (16%)	853 (16%)	851 (16%)
Buprenorphine offered	1,820 (35%)	2,105 (40%)	2,211 (42%)	2,424 (46%)
Naltrexone offered	1,506 (29%)	1,773 (34%)	1,871 (36%)	1,896 (36%)
Any MOUD offered	2,383 (46%)	2,600 (50%)	2,692 (52%)	2,850 (55%)
All forms of MOUD offered	233 (4.5%)	269 (5.1%)	260 (5.0%)	284 (5.4%)
Adequate broadband speeds, county	4,189 (80%)	4,189 (80%)	4,189 (80%)	4,189 (80%)

Second, we report the main regression results that evaluate the change in facility telehealth services association with the state policies allowing audio-only as well as audiovisual telehealth. We found that, after adjusting for other characteristics, facilities that accepted Medicaid were +7.2 percentage points more likely to offer telehealth (95% confidence interval (CI) [+5.7, +8.7]). Other types of insurance were also associated with smaller increases in the likelihood of offering telehealth, including Medicare (+2.7, CI [+1.4, +4.0]) and private insurance (+3.9, CI [+2.4, +5.4]). Facilities located in counties with adequate broadband speeds were 5.5 percentage points less likely to offer telehealth (CI [−7.0, −4.1]).

Telehealth offering rates were initially higher in states that did not eventually publish policies permitting audio-only SUDT (22% in 2019) than in states that did not eventually publish such policies (17% in 2019). After controlling for other facility characteristics, we found that in 2022, the state policy of permitting audio-only SUDT telehealth was associated with an increase in telehealth offering rates by 16.5 percentage points (CI [+10.4, +22.6]), compared with little evidence of an effect of the audio-only policy in 2020 (−2.9, CI [−9.0, +3.2]) or 2021 (+0.6, CI [−5.5, +6.7]). See Table 2 for all adjusted estimates. These estimates of the policy effect by year were virtually unchanged in the models that included state fixed effects (see Appendix Table 2), facility fixed effects (Appendix Table 3), and in counties with adequate broadband access (Appendix Table 4). Analyses that split the state policies into those that permitted audio-only only if audiovisual was available and those that permitted audio-only regardless were largely similar as well (Appendix Table 5).

Table 2:

Factors Associated with Substance Use Treatment Facility Offering Telehealth Services

Characteristic	Beta	95% CI1	p-value
Medicare accepted	0.027	0.014, 0.040	<0.001
Medicaid accepted	0.072	0.057, 0.087	<0.001
Private insurance accepted	0.039	0.024, 0.054	<0.001
Opioid treatment program	−0.137	−0.232, −0.041	0.005
Methadone offered	0.010	−0.089, 0.109	0.8
Buprenorphine offered	0.022	0.000, 0.044	0.046
Naltrexone offered	0.080	0.055, 0.104	<0.001
Any MOUD offered	0.052	0.020, 0.084	0.002
All forms of MOUD offered	0.126	0.085, 0.166	<0.001
Adequate broadband speeds, county	−0.055	−0.070, −0.041	<0.001
Year   2019	—	—
2020	0.102	0.044, 0.161	<0.001
2021	0.397	0.339, 0.456	<0.001
2022	0.436	0.378, 0.495	<0.001
Audio-only permitted in 2020	−0.063	−0.106, −0.020	0.004
Year * Audio-only permitted in 2020   2020 * Audio-only permitted in 2020	−0.029	−0.090, 0.032	0.3
2021 * Audio-only permitted in 2020	0.006	−0.055, 0.067	0.8
2022 * Audio-only permitted in 2020	0.165	0.104, 0.226	<0.001

¹CI = Confidence Interval

Among facilities that accepted Medicare in 2019 (Appendix Table 6), the results are largely the same, with little evidence of an effect in 2021 (+2.4, CI [−8.7, +13.6]) and a large effect in 2022 (+15.8, CI [+4.7, +27.0]). The estimated effect in 2020 is more negative (−8.7 percentage points), but not statistically significant with a wide CI [−19.9, +2.4], generally consistent with our main findings. Among facilities in counties with insufficient broadband access (Appendix Table 5), confidence intervals for coefficients on policies permitting audio-only telehealth are very wide and generally include moderate or large associations in both directions.

4. Discussion

The COVID-19 pandemic spurred the removal of several regulatory barriers to SUD and OUD treatment via telehealth. Our study is unique in that it evaluates the effect of state-level policies on the likelihood that a SUDT facility offered telehealth. Federal-level policies to ensure access to MOUD via telehealth, such as legislative action, regulatory change, and use of regulatory discretion (Davis and Samuels 2021), gave states latitude in adopting federal flexibilities. Our findings reinforce that state telehealth policies may be associated with a significant influence on the proportion of SUDT facilities that offer telehealth. Future research should examine whether these policies led to an increase in the use of buprenorphine prescribing via telemedicine.

Importantly, while we found evidence that state-level policies permitting audio-only telehealth as well as audiovisual telehealth did influence the likelihood of SUDT facilities offering telehealth, this influence was not felt until 2022, even though state policies permitting audio-only as well as audiovisual were present in 2020. It appears that adoption of telehealth by SUDT facilities did not occur immediately after the state audio-only policies went into effect.

Also, we found areas of the country with less broadband access were more likely to introduce telehealth as a result of the states permitting audio-only SUDT. One possible reason is that these state-level policies had a different effect in rural communities where broadband is lacking. Approximately 40 percent of the most rural counties do not have the necessary broadband infrastructure to support video based telehealth (Drake et al. 2020). And prior to the COVID-19 pandemic the adoption of telehealth at SUDT facilities was higher in rural than urban counties (Uscher-Pines, Cantor, et al. 2020). The disproportionate increase in rural counties may have continued during the COVID-19 pandemic, but more research is needed examining this issue and to what extent it explains the effect of state-level policies on communities with less broadband.

This study is not without limitations. First, state policy data are available only for 2020, as we did not have policies for 2019, 2021 or 2022. While major federal telehealth policy changes occurred in 2020, and therefore, we suspect that audio-only or audiovisual state policies in our dataset were enacted in 2020, we do not know when the state policies were enacted. It is possible that some states had some audiovisual telehealth policies in 2020 but that they were much less powerful than their 2020 version. Second, we are not able to define the mechanisms for the changes by the SUDT facilities in response to specific state-policies policy. Future work at the state-level could examine why a specific state’s policy was more effective or less effective. Third, we are unable to conduct a causal difference in differences estimation, having no information on what state policies were in 2019 as well as not having data for sufficient periods prior to 2020 to investigate the assumption of parallel trends for the offering of telehealth by SUDT facilities. Further, while federal policy changes in 2020 affected all facilities, it is difficult to disentangle the specific effects of state policy from the possibly heterogeneous effects of concomitant federal policy. Thus, we frame these results as suggestive rather than causally conclusive.

Fourth, we did not examine trends in the use of telehealth by patients of the SUD treatment facilities. Instead, we only measured whether the facilities offered telehealth, nor whether the facility offered audio-only telehealth, audiovisual telehealth, or some combination. To our knowledge there is no national survey of SUDT facilities that collect this detailed data. Despite this limitation the current study quantifies the accessibility of telehealth services at all SUDT facilities for all populations. This is in contrast to utilization studies which in many cases focuses on specific populations based on their insurance status (Jones et al. 2022; Mulvaney-Day et al. 2022). Fifth, we could only measure whether telehealth was offered for any SUDT services, not specifically whether telehealth is used for buprenorphine delivery vs other services. Sixth, our analysis was restricted to licensed SUDT facilities. Much of OUD treatment is provided by office-based physicians that are not included in our sample, but specialty SUDT facilities (our sample) are an integral part of the treatment continuum for both SUD and OUD. According to the Treatment Episodes Data Set, there were around 1.9 million treatment admissions to specialty providers in the United States in 2019 alone (Substance Abuse and Mental Health Services Administration 2021a). Seventh, we did not restrict our analyses to SUDT facilities that provide OUD treatment. Instead, we examined changes to all outpatient SUDT facilities in the data. Future research should consider focusing on facilities that provide OUD treatment, as facilities that offer OUD treatment may operate differently from those that do not (e.g., due to the need to administer methadone in person.) Eighth, we have no information about the extent to which patients would have received services absent telehealth, nor the type or quality of care that patients received at the treatment facility. Relatedly we have no measures of how telehealth was implemented by the SUDT facilities or effects of implementation. For example, it is possible that even when telehealth was implemented at a facility, telehealth did not protect patients from the risk of being vulnerable to COVID-19 (Meyerson et al. 2022; Poulsen et al. 2023). Ninth, there was a change in the question between the 2018 N-SSATS and the 2019 N-SSATS. This change may be responsible for some of the differences in the change in the rate of telehealth availability over time. Tenth, there may be other policy measures that our study does not account for. One example is differences in parity at the state-level for reimbursement of telehealth services. The differences in rates may explain some of the variation in the availability of telehealth services.

Telehealth is an innovation that could reduce geographic barriers and help patients navigate stigma in the receipt of care for SUD and OUD. Telehealth could increase treatment engagement in areas of the state without a local buprenorphine prescriber (Nunes et al. 2020; Samuels et al. 2020). While there are some indications of hesitancy about telehealth use in SUDT from both providers (Huskamp et al. 2022) and patients (Uscher-Pines, Sousa, et al. 2020; Hunter et al. 2021), there are also encouraging signs that, for example, tele-buprenorphine treatment was associated with high rates of continued care in the 30 days following an initial telehealth visit (Samuels et al. 2022). The rapid increase of telehealth offering rates that we found and the possibility of delayed effects on SUDT facilities suggests that future work is urgently needed to understand the downstream impacts of state-level telehealth policies on patient care. Research is also needed to inform policy decisions about the possible sunsetting of COVID-19 era federal telehealth policies that occurred during the national Public Health Emergency (Health Resources & Services Administration 2022; Czeisler 2022).

5. Conclusions

This is the first study to establish that state-level policies specifically allowing audio-only SUDT telehealth were associated with increases in the proportion of SUDT facilities that offer telehealth. State-level changes can lead to the adoption of novel treatment modalities, but a time lag in policy effects may exist. Effects of other state-level telehealth policy changes may require additional follow-up to determine whether they increased the utilization of and quality of care of SUDT.

Figure 1:

Telehealth offering in states where audio-only SUD treatment was permitted in 2020 and states with no such policy change, 2019–2022. Estimates and 95% confidence intervals from the difference-in-difference models are given in text.

Highlights.

Federal policies increased telehealth use for substance use disorder treatment

State policies permit audio or audiovisual substance use disorder treatment delivery

The effect of state policies is not well understood

State policies are associated with increased telehealth availability in 2022

Appendix Table 1:

State Telehealth Policy Citations

State	Policy permitting audio-only regardless of if audio/visual is available	Policy permitting audio-only only if audio/visual is unavailable
Alaska		Telemedicine Emergency Response Policy Guidance. Alaska Department of Health, Division of Behavioral Health. March 2020. https://content.govdelivery.com/attachments/AKDHSS/2020/03/23/file_attachments/1408967/DBH%20Expanded%20Telehealth%20Services%20Final%2003232020.pdf. Accessed June 16, 2020.
Arizona	Frequently Asked Questions (FAQs) Regarding Coronavirus Disease 2019 (COVID-19). Arizona Health Care Cost Containment System. March 2020. https://www.azahcccs.gov/AHCCCS/AboutUs/covid19FAQ.html. Accessed June 15, 2020.
Arkansas	Telemedicine Requirements for Certain Behavioral Health Providers during the COVID-19 Public Health Emergency. Arkansas Division of Medical Services. March 2020. https://humanservices.arkansas.gov/images/uploads/resources/Memorandum_DMS-02_Revised_04.20.20_AR_4_.22.2020.pdf. Accessed June 15, 2020.
California	Flexibility for Alcohol and Other Drug (AOD) facilities during the COVID-19 Public Emergency. State of California—Health and Human Services Agency Department of Health Care Services. April 2020. https://www.dhcs.ca.gov/Documents/COVID-19/BHIN-20–017-Alcohol-and-Other-Drug-Facilities.pdf. Accessed May 16, 2020.
Colorado	Colo. Exec. Order No. 20-E-05, https://www.sos.state.co.us/CCR/Upload/AGORequestEmergency/AdoptedRules02020–00207.doc
Connecticut	Conn. Exec. Order No. 7FF (Apr. 24, 2020), https://portal.ct.gov/-/media/Office-of-the-Governor/Executive-Orders/Lamont-Executive-Orders/Executive-Order-No-7ff.pdf
DC	DC Medicaid Coding for Telemedicine and Coronavirus (COVID-19). DC Department of Health Care Finance. 2020. https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/DC%20MEDICAID%20CODING%20FOR%20TELEMEDICINE%20AND%20CORONAVIRUS%20%28COVID-19%29%20GUIDE%20FINAL%20040820_0.pdf. Accessed June 15, 2020.
Georgia	Behavioral Health Service Provision: Telemedicine and Telehealth. Georgia Department of Behavioral Health & Developmental Disabilities. March 2020. https://dbhdd.georgia.gov/document/guidance/guidance-telemed-and-telephonic-coverage/download. Accessed May 16, 2020.
Hawaii	Interim COVID-19 Guidance to Providers and Stakeholders for Behavioral Health and Homelessness Services. The Behavioral Health & Homelessness Statewide Unified Response Group (BHHSURG). May 2020. https://health.hawaii.gov/bhhsurg/files/2020/04/COVID19-Guidance-200615.pdf. Accessed June 15, 2020.
Idaho		COVID-19 Information. Idaho Department of Health and Welfare (IDHW). March 2020. https://www.optumidaho.com/content/dam/ops-optidaho/idaho/docs/alerts/2020-alerts/Optum%20COVID-19%20Provider%20Alert%2020200316%20Final.pdf. Accessed June 15, 2020.
Illinois	Ill. Exec. Order No. 2020–09 (Mar. 19, 2020), https://coronavirus.illinois.gov/resources/executive-orders/display.executive-order-number-9.2020.html
Indiana	IHCP COVID-19 Response: IHCP responds to telemedicine FAQs as of April 1, 2020. Indiana Health Coverage Programs. April 2020. http://provider.indianamedicaid.com/ihcp/Bulletins/BT202034.pdf. Accessed May 17, 2020.
Iowa	Guidance for COVID-19. Iowa Department of Public Health. April 2020. https://idph.iowa.gov/Portals/1/userfiles/166/Licensure/LIcensed%20Program%20GUIDANCE%20FOR%20COVID-19%20%282020%2004%2014%29.pdf. Accessed June 16, 2020.
Kansas	Guidance for SUD Providers Concerning 2019 Novel Coronavirus Illness. Kansas Department for Aging and Disability Services. March 2020. https://www.kdads.ks.gov/docs/default-source/covid-19/bhs/guidance-sud-telephonic.pdf?sfvrsn=a67402ee_2. Accessed June 15, 2020.
Kentucky		Medicaid COVID-19 FAQs. Kentucky Department for Medicaid Services. 2020. https://chambermaster.blob.core.windws.net/userfiles/UserFiles/chambers/9322/CMS/ProviderFAQs.pdf. Accessed May 20, 2020.
Louisiana		Telemedicine/Telehealth Facilitation of Outpatient Substance Use Disorder (OP-SUD) Treatment during the COVID-19 Declared Emergency. Louisiana Department of Health. April 2020. https://www.amerihealthcaritasla.com/pdf/provider/newsletters/covid-19-hpa20–9-telemedicine.pdf. Accessed June 17, 2020.
Maine		MaineCare Guidance Relating to Telehealth and Telephone Services During COVID-19 Emergency Period. Maine Department of Health and Human Services. April 2020. https://mepca.org/wp-content/uploads/sites/93/2020/04/MaineCare-041620-Telehealth-Guidance.pdf. Accessed May 21, 2020.
Maryland		Frequently Asked Questions About Medicaid Telehealth. Maryland Department of Health. April 2020. https://health.maryland.gov/phpa/Documents/FAQPROVIDERtelehealth_covid19_medicaid_06.25.21.pdf. Accessed May 22, 2020.
Massachusetts	Waiver from Certain Regulatory Requirements. Massachusetts Department of Public Health’s (DPH) Bureau of Substance Addiction Services (BSAS). April 2020. https://www.mass.gov/doc/waiver-from-certain-regulatory-requirements/download. Accessed May 12, 2020.
Michigan		COVID-19 Response: Telemedicine Policy Expansion; Prepaid Inpatient Health Plans (PIHPs)/Community Mental Health Services Programs. Michigan Department Health & Human Services. March 2020. https://content.govdelivery.com/attachments/MIDHHS/2020/03/20/file_attachments/1406578/MSA%2020–13.pdf. Accessed May 16, 2020.
Minnesota	Expanding telemedicine in health care, mental health, and substance use disorder settings (CV30). Minnesota Department of Human Services. March 2020. https://mn.gov/dhs/waivers-and-modifications/#25. Accessed June 15, 2020.
Missouri		Temporary Program Changes and Billing Guidance Related to COVID-19: Third Revision. State of Missouri Department of Mental Health. March 2020. https://dmh.mo.gov/media/pdf/memo-2-revised-temporary-program-changes-and-billing-guidance-related-covid-19-third. Accessed June 15, 2020.
Montana	Mont. Exec. Order No. D20–25 (Apr. 21, 2020), https://covid19.mt.gov/Portals/223/Documents/4–21-20%20Telehealth%202.pdf?ver=2020-04-22-140845-733
Nebraska		General Statewide Telehealth - COVID-19 Frequently Asked Questions. Nebraska Department of Health and Human Services. April 2020. http://dhhs.ne.gov/Documents/COVID19%20General%20Statewide%20Telehealth%20FAQ.pdf. Accessed June 15, 2020.
New Hampshire	N.H. Exec. Order No. 2020–08 (Mar. 17, 2020), https://www.governor.nh.gov/sites/g/files/ehbemt336/files/documents/emergency-order-8.pdf
New Jersey	NJ Admin. Code § 11:20 App. Exh. B, https://artifacts.casetext.com/artifacts/20221120appxexhibitb
New Mexico	COVID-19 specialty behavioral health service guidance. The New Mexico Human Services Department. March 2020. https://2sg5k61xfi4340nxou43nvp0-wpengine.netdna-ssl.com/wp-content/uploads/sites/32/2020/03/COVID19-Specialty-Behavioral-Health-Guidance-32320.pdf. Accessed June 16, 2020.
New York	COVID-19 OTP Guidance and Frequently Asked Questions. New York State Office of Addiction Services and Supports. 2020. https://oasas.ny.gov/system/files/documents/2020/03/covid19-otp-faqs_2_0.pdf. Accessed May 12, 2020.
North Carolina	Department of Health and Human Services COVID-19 Service Guidance for State Funded Behavioral Health Services. The North Carolina Department of Health and Human Services (NC DHHS). March 2020. https://files.nc.gov/ncdhhs/documents/files/Joint-Communication-Bulletin-J358---Department-of-Health-and-Human-Services-COVID-19-Service-Guidance-for-State-Funded-Behavioral-Health-Services.pdf. Accessed June 5, 2020.
Ohio	Ohio Admin. Code 5160–1-21, https://cdn.cchpca.org/files/2020-03/OHIO%20Telehealth%20appendix_emergency%20rule%205160-1-21.pdf
Oklahoma		COVID-19 Frequently Asked Questions for Treatment Providers. Oklahoma Department of Mental Health and Substance Abuse Services. June 2020. https://www.ok.gov/odmhsas/COVID-19_Provider_FAQs.html. Accessed June 15, 2020.
Oregon		Telemedicine/Telehealth Billing Guidance for Oregon Health Plan Fee for Service Providers. The Oregon Health Authority. April 2020. https://www.oregon.gov/oha/HSD/OHP/Announcements/Telemedicine-telehealth%20billing%20guidance%20for%20Oregon%20Health%20Plan%20fee-for-service%20providers.pdf. Accessed June 15, 2020.
Pennsylvania	Telehealth Expansion. Pennsylvania Department of Drug and Alcohol Programs. March 2020. https://www.ddap.pa.gov/Get%20Help%20Now/Documents/COVID-Telehealth.pdf. Accessed May 16, 2020.
Rhode Island	COVID-19 TeleHealth Delivery Policy and Procedure Guidance for RI Medicaid. Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals. April 2020. https://bhddh.ri.gov/mh/pdf/COVID-19%20Memo%20for%20RI%20Medicaid%20Telehealth_03182020%20(002).pdf. Accessed May 20, 2020.
South Dakota		Coronavirus (COVID-19) Frequently Asked Questions. South Dakota Department of Social Services. June 2020. https://dss.sd.gov/docs/COVID19/COVID19_FAQ_Providers.pdf. Accessed June 15, 2020.
Tennessee	Behavioral Health Psychosocial Rehabilitation Telehealth Services for TennCare Enrollees. Tennessee Department of Mental Health & Substance Abuse Services. March 2020. https://www.tn.gov/content/dam/tn/tenncare/documents/TennCareCovidBHPSRTelehealth.pdf. Accessed June 5, 2020.
Texas	COVID-19 Behavioral Health Services Providers Frequently Asked Questions. Texas Health & Human Services. June 2020. https://hhs.texas.gov/sites/default/files/documents/services/health/behavioral-health-services-covid-faq.pdf. Accessed June 19, 2020.
Utah	Utah Medicaid Guidance: Telehealth Q&A for COVID-19 Emergency. Utah Department of Health. 2020. https://medicaid.utah.gov/Documents/pdfs/covid/COVID-19_TelehealthFAQ3.20.pdf. Accessed June 15, 2020.
Vermont	2020 Vermont Laws No. 91 (H. 742), https://legislature.vermont.gov/Documents/2020/Docs/ACTS/ACT091/ACT091%20As%20Enacted.pdf
Virginia		Behavioral Health Telehealth Services Decision Tree. Virginia Medicaid Program Department of Medical Assistance Services. April 2020. https://www.dmas.virginia.gov/media/2236/va-telehealth-algorithm_v3.pdf. Accessed May 17, 2020.
Washington	Apple Health (Medicaid) Telemedicine & Telehealth Brief. Washington State Health Care Authority. April 2020. https://www.hca.wa.gov/assets/billers-and-providers/apple-health-telemedicine-telehealth-brief-COVID19–20200428.pdf. Accessed May 18, 2020.
West Virginia	Community Psychiatric Support Treatment Providers (CSU). State of West Virginia Department of Health and Human Services. March 2020. https://dhhr.wv.gov/bms/Documents/CSU%20COVID%20Precautions.pdf. Accessed May 21, 2020.
Wisconsin	Additional Services To Be Provided Via Telehealth. Wisconsin Department of Health Services. March 2020. https://www.forwardhealth.wi.gov/kw/pdf/2020–15.pdf. Accessed June 15, 2020.

Appendix Table 2:

Model with state fixed effects

Characteristic	Beta	95% CI1	p-value
Medicare accepted	0.022	0.008, 0.035	0.002
Medicaid accepted	0.077	0.062, 0.093	<0.001
Private insurance accepted	0.044	0.028, 0.059	<0.001
Opioid treatment program	−0.126	−0.221, −0.030	0.010
Methadone offered	−0.002	−0.101, 0.097	>0.9
Buprenorphine offered	0.015	−0.007, 0.037	0.2
Naltrexone offered	0.075	0.050, 0.100	<0.001
Any MOUD offered	0.061	0.029, 0.094	<0.001
All forms of MOUD offered	0.131	0.090, 0.171	<0.001
Adequate broadband speeds, county	−0.034	−0.051, −0.018	<0.001
state   AK	—	—
AL	−0.081	−0.185, 0.023	0.13
AR	−0.115	−0.209, −0.021	0.017
AZ	−0.075	−0.154, 0.004	0.063
CA	−0.196	−0.270, −0.121	<0.001
CO	−0.093	−0.171, −0.015	0.020
CT	−0.245	−0.330, −0.160	<0.001
DC	−0.158	−0.292, −0.024	0.020
DE	0.032	−0.111, 0.175	0.7
FL	−0.108	−0.194, −0.023	0.013
GA	−0.107	−0.188, −0.027	0.009
HI	−0.312	−0.397, −0.226	<0.001
IA	−0.168	−0.252, −0.085	<0.001
ID	−0.073	−0.166, 0.021	0.13
IL	−0.170	−0.245, −0.096	<0.001
IN	−0.189	−0.268, −0.110	<0.001
KS	−0.164	−0.248, −0.080	<0.001
KY	−0.108	−0.188, −0.028	0.008
LA	−0.198	−0.291, −0.105	<0.001
MA	−0.200	−0.280, −0.119	<0.001
MD	−0.164	−0.242, −0.086	<0.001
ME	−0.131	−0.226, −0.037	0.006
MI	−0.171	−0.248, −0.093	<0.001
MN	−0.162	−0.241, −0.083	<0.001
MO	0.008	−0.072, 0.088	0.8
MS	−0.249	−0.363, −0.135	<0.001
MT	0.067	−0.041, 0.175	0.2
NC	−0.155	−0.233, −0.078	<0.001
ND	−0.091	−0.205, 0.022	0.12
NE	−0.095	−0.189, −0.001	0.047
NH	−0.231	−0.334, −0.127	<0.001
NJ	−0.186	−0.265, −0.108	<0.001
NM	−0.120	−0.213, −0.027	0.011
NV	−0.048	−0.154, 0.059	0.4
NY	−0.205	−0.281, −0.130	<0.001
OH	−0.174	−0.250, −0.097	<0.001
OK	−0.054	−0.144, 0.036	0.2
OR	−0.144	−0.230, −0.057	0.001
PA	−0.235	−0.311, −0.159	<0.001
RI	−0.180	−0.293, −0.067	0.002
SC	−0.151	−0.251, −0.052	0.003
SD	−0.249	−0.365, −0.133	<0.001
TN	−0.137	−0.218, −0.056	<0.001
TX	−0.153	−0.230, −0.075	<0.001
UT	−0.160	−0.241, −0.079	<0.001
VA	−0.164	−0.247, −0.081	<0.001
VT	−0.259	−0.378, −0.139	<0.001
WA	−0.184	−0.261, −0.107	<0.001
WI	−0.261	−0.343, −0.179	<0.001
WV	−0.093	−0.189, 0.002	0.055
WY	0.063	−0.062, 0.187	0.3
Year   2019	—	—
2020	0.102	0.044, 0.160	<0.001
2021	0.398	0.340, 0.456	<0.001
2022	0.437	0.379, 0.495	<0.001
Audio-only permitted in 2020  Year * Audio-only permitted in 2020   2020 * Audio-only permitted in 2020	−0.029	−0.089, 0.031	0.3
2021 * Audio-only permitted in 2020	0.006	-0.054, 0.066	0.8
2022 * Audio-only permitted in 2020	0.165	0.105, 0.225	<0.001

¹CI = Confidence Interval

Appendix Table 3:

Model with facility fixed effects

Characteristic	Beta	95% CI1	p-value
Medicare accepted	0.014	−0.006, 0.035	0.2
Medicaid accepted	−0.074	−0.105, −0.044	<0.001
Private insurance accepted	0.033	0.004, 0.062	0.028
Opioid treatment program	−0.015	−0.182, 0.152	0.9
Methadone offered	0.046	−0.134, 0.225	0.6
Buprenorphine offered	0.045	0.013, 0.078	0.006
Naltrexone offered	0.066	0.034, 0.097	<0.001
Any MOUD offered	−0.017	−0.060, 0.025	0.4
All forms of MOUD offered	0.041	−0.022, 0.104	0.2
Adequate broadband speeds, county	0.000	−0.011, 0.011	>0.9
Year   2019	—	—
2020	0.108	0.064, 0.151	<0.001
2021	0.410	0.367, 0.454	<0.001
2022	0.454	0.410, 0.497	<0.001
Audio-only permitted in 2020	−0.035	−0.067, −0.003	0.030
Year * Audio-only permitted in 2020   2020 * Audio-only permitted in 2020	−0.027	−0.072, 0.018	0.2
2021 * Audio-only permitted in 2020	0.005	−0.040, 0.051	0.8
2022 * Audio-only permitted in 2020	0.163	0.118, 0.208	<0.001

¹CI = Confidence Interval

Appendix Table 4:

Model among facilities in counties with adequate broadband access

Characteristic	Beta	95% CI1	p-value
Medicare accepted	0.020	0.006, 0.034	0.006
Medicaid accepted	0.071	0.055, 0.087	<0.001
Private insurance accepted	0.028	0.012, 0.044	<0.001
Opioid treatment program	−0.085	−0.189, 0.019	0.11
Methadone offered	−0.041	−0.150, 0.067	0.5
Buprenorphine offered	0.016	−0.008, 0.039	0.2
Naltrexone offered	0.079	0.051, 0.106	<0.001
Any MOUD offered	0.046	0.010, 0.082	0.012
All forms of MOUD offered	0.139	0.096, 0.182	<0.001
Adequate broadband speeds, county  Year   2019	—	—
2020	0.090	0.026, 0.153	0.006
2021	0.399	0.336, 0.463	<0.001
2022	0.436	0.373, 0.499	<0.001
Audio-only permitted in 2020	−0.068	−0.115, −0.021	0.005
Year * Audio-only permitted in 2020   2020 * Audio-only permitted in 2020	−0.025	−0.091, 0.041	0.5
2021 * Audio-only permitted in 2020	0.010	−0.056, 0.076	0.8
2022 * Audio-only permitted in 2020	0.175	0.109, 0.241	<0.001

¹CI = Confidence Interval

Appendix Table 5:

Model splitting state policy into those that permitted audio-only only if audiovisual not available and those that permitted regardless of audiovisual availability

Characteristic	Beta	95% CI1	p-value
Medicare accepted	0.025	0.012, 0.037	<0.001
Medicaid accepted	0.071	0.057, 0.086	<0.001
Private insurance accepted	0.039	0.025, 0.054	<0.001
Opioid treatment program	−0.131	−0.227, −0.036	0.007
Methadone offered	0.005	−0.094, 0.104	>0.9
Buprenorphine offered	0.020	−0.002, 0.042	0.073
Naltrexone offered	0.081	0.056, 0.105	<0.001
Any MOUD offered	0.054	0.022, 0.086	0.001
All forms of MOUD offered	0.126	0.086, 0.166	<0.001
Adequate broadband speeds, county	−0.050	−0.065, −0.036	<0.001
Year  2019	—	—
2020	0.102	0.044, 0.161	<0.001
2021	0.398	0.339, 0.456	<0.001
2022	0.437	0.378, 0.495	<0.001
Audio-only mention
No A/V mention	—	—
If no A/V	−0.007	−0.056, 0.042	0.8
Regardless of A/V	−0.077	−0.120, −0.033	<0.001
Year * Audio-only mention
2020 * If no A/V	−0.024	−0.093, 0.044	0.5
2021 * If no A/V	−0.019	−0.088, 0.049	0.6
2022 * If no A/V	0.126	0.058, 0.195	<0.001
2020 * Regardless of A/V	−0.030	−0.092, 0.031	0.3
2021 * Regardless of A/V	0.013	−0.048, 0.074	0.7
2022 * Regardless of A/V	0.175	0.114, 0.236	<0.001

¹CI = Confidence Interval

Appendix Table 6:

Model among facilities that accepted Medicare in 2019

Characteristic	Beta	95% CI1	p-value
Medicare accepted	0.034	−0.008, 0.076	0.11
Medicaid accepted	0.121	0.081, 0.161	<0.001
Private insurance accepted	−0.016	−0.052, 0.021	0.4
Opioid treatment program	−0.013	−0.157, 0.131	0.9
Methadone offered	−0.080	−0.233, 0.073	0.3
Buprenorphine offered	0.000	−0.034, 0.034	>0.9
Naltrexone offered	0.070	0.035, 0.105	<0.001
Any MOUD offered	0.074	0.026, 0.123	0.003
All forms of MOUD offered	0.111	0.040, 0.183	0.002
Adequate broadband speeds, county	−0.091	−0.113, −0.069	<0.001
Year   2019	—	—
2020	0.207	0.099, 0.315	<0.001
2021	0.432	0.324, 0.540	<0.001
2022	0.487	0.378, 0.595	<0.001
Audio-only permitted in 2020	−0.065	−0.144, 0.014	0.10
Year * Audio-only permitted in 2020   2020 * Audio-only permitted in 2020	−0.087	−0.199, 0.024	0.13
2021 * Audio-only permitted in 2020	0.024	−0.087, 0.136	0.7
2022 * Audio-only permitted in 2020	0.158	0.047, 0.270	0.005

¹CI = Confidence Interval

Appendix Table 7:

Model among facilities in counties without adequate broadband access

Characteristic	Beta	95% CI1	p-value
Medicare accepted	0.044	0.015, 0.073	0.003
Medicaid accepted	0.075	0.033, 0.118	<0.001
Private insurance accepted	0.092	0.053, 0.132	<0.001
Opioid treatment program	−0.382	−0.627, −0.137	0.002
Methadone offered	0.282	0.033, 0.532	0.026
Buprenorphine offered	0.078	0.026, 0.131	0.004
Naltrexone offered	0.096	0.040, 0.153	<0.001
Any MOUD offered	0.046	−0.028, 0.119	0.2
All forms of MOUD offered	0.020	−0.091, 0.131	0.7
Adequate broadband speeds, county  Year   2019	—	—
2020	0.176	0.027, 0.324	0.021
2021	0.393	0.245, 0.542	<0.001
2022	0.448	0.299, 0.597	<0.001
Audio-only permitted in 2020	−0.023	−0.132, 0.085	0.7
Year * Audio-only permitted in 2020   2020 * Audio-only permitted in 2020	−0.070	−0.224, 0.083	0.4
2021 * Audio-only permitted in 2020	−0.014	−0.168, 0.139	0.9
2022 * Audio-only permitted in 2020	0.112	−0.042, 0.265	0.2

¹CI = Confidence Interval