How Does Medicaid Managed Care Address the Needs of Beneficiaries with Opioid Use Disorders? A Deep Dive into Contract Design

Rebecca Morris; Sara Rosenbaum; Colleen Grogan; Meredith Rhodes; Christina Andrews

doi:10.1017/amj.2023.35

. Author manuscript; available in PMC: 2024 Jun 18.

Published in final edited form as: Am J Law Med. 2024 Feb 12;49(2-3):339–348. doi: 10.1017/amj.2023.35

How Does Medicaid Managed Care Address the Needs of Beneficiaries with Opioid Use Disorders? A Deep Dive into Contract Design

Rebecca Morris ¹, Sara Rosenbaum ², Colleen Grogan ³, Meredith Rhodes ⁴, Christina Andrews ⁴

PMCID: PMC11185417 NIHMSID: NIHMS1995170 PMID: 38344786

Abstract

Many people who experience opioid use disorder rely on Medicaid. The high penetration of managed care systems into Medicaid raises the importance of understanding states’ expectations regarding coverage, access to care, and health system performance and effectively elevates agreements between states and plans into blueprints for coverage and care. Federal law broadly regulates these structured agreements while leaving a high degree of discretion to states and plans. In this study, researchers reviewed the provisions of 15 state Medicaid managed care contract related to substance use disorder (SUD) treatment to identify whether certain elements of SUD treatment were a stated expectation and the extent to which the details of those expectations varied across states in ways that ultimately could affect evaluation of performance and health outcomes. We found that while all states include SUD treatment as a stated contract expectation, discussions around coverage of specific services and nationally recognized guidelines varied. These variations reflect key state choices regarding how much deference to afford their plans in coverage design and plan administration and reveal important differences in purchasing expectations that could carry implications for efforts to examine similarities and differences in access, quality, and health outcomes within managed care across the states.

Keywords: Medicaid, substance use, coverage, insurance

Introduction

The magnitude of the OUD public health crisis

The United States remains in the midst of an epidemic of opioid-related overdose and mortality driven by use of heroin and synthetic opioids. In 2020, an estimated 2.7 million Americans had an opioid use disorder (OUD).¹ Opioid-related mortality has increased by more than four-hundred percent since 1999, surpassing that of traffic fatalities.² The COVID-19 pandemic has exacerbated these challenges, giving rise to a dramatic increase in overdose deaths. In 2020 alone, the nation witnessed over 93,000 estimated drug-related overdose deaths--the highest number of overdose deaths ever recorded in a twelve-month period.³ In addition to the devastating personal consequences for individuals and families, the epidemic has also exacted an astounding economic toll: sequalae resulting from SUD, including unemployment, incarceration, and poverty have resulted in an economic burden of over $1 billion annually.⁴

Decades of research show that evidence-based treatment for opioid misuse, including medication and psychosocial intervention, reduces the risk of relapse, overdose, and death.⁵ Effective OUD treatment encompasses a broad range of services designed to address OUD, including four levels of care (outpatient, intensive outpatient, residential, and inpatient), as well as several medications approved by the Food and Drug Administration (FDA) for treatment of OU: methadone, buprenorphine, and extended-release injectable naltrexone.⁶ Numerous studies have also revealed a high prevalence of mental health conditions coinciding with opioid use,⁷ and the National Institute for Health has created the HEAL Initiative specifically to address these co-occurring illnesses,⁸ underscoring the importance of structuring Medicaid policy to address the high rates of OUD co-occurring with mental health conditions.

Remarkably, most Americans with OUD do not receive any treatment for their condition. In 2021, only one-quarter of Americans with an OUD secured treatment.⁹ Because the condition disproportionately affects poor working-age adults,¹⁰ treatment affordability is an enormous issue. While there are other accessibility barriers, such as the lack of available sources of care, the inability to pay for care remains a serious obstacle to access, even among insured Americans.¹¹

Medicaid and OUD Treatment

The prevalence of OUD is higher among Medicaid enrollees than among other insured populations. For this reason Medicaid assumes an outsized role where access to effective treatment is concerned.¹² In 2020, Medicaid covered roughly forty percent of all Americans with OUD, and over half of people with OUD who are below two-hundred percent of the federal poverty level.¹³ Medicaid also financed OUD medication-assisted treatment for over half of all Americans who received it nationwide.¹⁴ Medicaid funds an estimated $12 billion in treatment services annually—more than six times the combined annual funding provided by the federal Substance Abuse Prevention and Treatment Block Grant¹⁵ and the grants appropriated under the 2018 SUPPORT Act, which contains significant reforms aimed at expanding access to care.¹⁶

Given states’ central role in Medicaid administration, how states design OUD treatment programs is highly consequential. Research has documented extensive gaps in coverage and heavy use of utilization management protocols that together can impede access.¹⁷ While curbing unnecessary use of care is important, overuse can restrict access to the point at which essential care is being denied and people with OUD cannot initiate and remain in treatment. ¹⁸ Indeed, removing utilization controls on FDA-approved medications for opioid use disorder (MOUD) has been shown to improve health outcomes by increasing relevant prescribing rates and decreasing hospitalization rates.¹⁹

In recent years, Congress has taken steps to strengthen state Medicaid response to OUD. The Affordable Care Act’s (ACA’s) Medicaid eligibility expansion opened coverage to millions of poor working-age adults, including those with an elevated risk for OUD, providing a foundation for OUD-specific reforms within Medicaid. In addition to the ACA’s Medicaid eligibility expansion, reforms contained in the 2018 SUPPORT Act, which among its many provisions, enables states to use Medicaid funds for treatment of individuals with SUDs at institutions for mental disease (IMDs) as well as to use waivers to increase the SUD treatment workforce. It also requires Medicaid programs to cover medication assisted treatment, fulfill new drug utilization review conditions, and report on behavioral health quality measures.²⁰

Moreover, because the majority of state contract with managed care organizations (MCOs), the road to OUD treatment runs through Medicaid managed care, which in 2020 represented seventy-two percent of all enrollment and fifty-two percent of total Medicaid spending. ²¹ State MCO contracts lie at the heart of the managed care model and create a performance blueprint for plan operations, so we undertook what appears to be the first-ever effort to systematically examine state Medicaid MCO contracts to determine how their terms align with what are considered the standard in the field for the treatment of OUD. We begin with an overview of Medicaid managed care and state MCO contracts. Following a summary of our research approach, we present principal findings and discuss their implications.

Medicaid managed care and contracts on which managed care rests

How states organize and structure their Medicaid programs becomes central to any discussion of Medicaid’s effectiveness in building access to OUD treatment. In today’s world, Medicaid-financed investment in health care, including OUD treatment, largely rests on the large managed care systems that have emerged as the program’s dominant strategy for organizing, covering, delivering, and paying for care.

Managed care (originally known as prepaid health care) has been a state option for five decades, but few states in the 1970s and 1980s pursued this model owing to its novelty, the dearth of sellers, early evidence of corruption, and provider resistance to any model—in any insurance market—that would give payers direct control over care. As the ground shifted in the commercial insurance market, federal Medicaid policy also shifted toward a formal embrace of managed care as a program organizing principle.²² Earlier reforms culminated with enactment of 1997 legislation that dramatically expanded states’ ability to contract with comprehensive managed care plans built exclusively for Medicaid beneficiaries (Medicaid-only plans); Congress authorized use of such plans to cover both outpatient and inpatient care and to operate like other insurers, on a financial risk basis. The 1997 amendments thus marked Medicaid’s full emergence as a distinct insurance market.

At the heart of the model, as with all insurance, lies the contract between the sponsor (in this case, the Medicaid agency) and health plans known as managed care organizations (MCOs). Federal law gives states broad leeway in structuring their contracts, which must address enrollment, coverage, access, networks, program integrity, and quality performance. But the scope and breadth of the agreement lies with each state, and as a result, state managed care markets vary dramatically. Most importantly perhaps, federal law permits states to select which services covered under the state plan will be included in their contracts and which to maintain as a directly paid state benefit (e.g., long term nursing home care; highly specialized treatments for certain populations). Although states remain obligated to directly cover state plan services not included in the contract, as extracontractual benefits,²³ no study has ever tested whether services not explicitly addressed in the contract remain available to beneficiaries.

There are several other plan requirements that states can include in MCO contracts, but the most common include utilization management requirements, inclusion of provider types, and carve-outs for certain benefits. Most importantly, states can contract for a care model in which the contractor is obligated to conduct policies that vary from the state’s own practices. For example, states can require plans to employ utilization management strategies that vary from the state’s own practices. Conversely, states can allow MCOs discretion over utilization management that allows variation from the state’s own practices. Under federal law, the only bottom line is that utilization management be reasonable and efficient—a standard that is virtually never enforced by federal officials, if they satisfy the federal “reasonableness standard” governing Medicaid utilization management generally.²⁴

As mentioned, states can assign other state plan administration duties to their contractors, such as making the supplemental payments to which certain providers (e.g., federally qualified health centers or disproportionate share hospitals) are entitled, assuming that plans do not incorporate special payment rules into their own schedules. ²⁵

Finally, states can operate their managed care systems through multiple related contracts, such as coupling a contract covering physical health services and basic mental health care with special “carve-out” arrangements with specialty plans. Bifurcation can be complex, since multiple contractors may find that they must coordinate coverage and treatment. For this reason, carve-outs are specified less often in state contracts, though prime contractors may have their own internal subcontracts with major subsidiaries that carry their own cross-plan navigation complexities.

Drafting managed care contracts is difficult. A crucial decision on any aspect of the contract is how specifically to address its coverage and care terms—that is, how closely to manage the work of the contractor. Explicit provisions such as detailed utilization management guidelines give states control over plan decision-making; it also means that states do not get the benefit of plans’ own experiences and innovations. By contrast, silence on the meaning of terms and fewer detailed requirements offer plans considerable leeway to substitute their own approach to care and their own utilization management techniques. In the absence of overarching law limiting plan discretion, silence and deference effectively signals that states desire its contractors to use their judgement about how to manage care. A purchaser presumably might tie a deferential approach to specific and measurable performance outcomes—that is a recognized standard of care to which plans are expected to adhere. This approach is what controls Medicaid and Medicaid plans in the case of childhood immunizations, which under federal Medicaid law must be furnished in accordance with recommendations of the Advisory Committee on Immunization Practice (ACIP). Such universally recognized gold standards of care that have the force and effect of law tend to be extremely few in number, and embedding such standards into contract as a binding performance expectation is quite uncommon.

Other factors further complicate the drafting process. First, a state may have its own policy or political preferences that bind plans. These detailed priorities may encourage the state to lessen demands for other populations and services, giving them lower priority. A second consideration is that ultimately, managed care systems can be only as strong as the underlying health care system on which they rest. If a plan’s service area is also an addiction treatment desert, the state might afford the contractor more discretion to impose strict treatment limits and other controls in order to not unduly stress whatever treatment is available. While certain innovations such as telehealth can mitigate shortages, for very acute health problems that demand intensive in-person care in specialized settings, health care shortages are an ever-present problem for Medicaid agencies, beneficiaries, and plans.

A third consideration relates to the very nature of managed care and why states use it. States buy managed care because they want more budgeting certainty through an all-inclusive per-member-per-month premium and because they want the twin benefits of access (the desire for which overlooks the second consideration) and cost containment. This desire to make use of what managed care presumably has to sell means giving plans a fair amount of leeway to control utilization—more, perhaps, than what the state historically has done.

Fourth, Medicaid managed care enrollees are disproportionately health and socially burdened and without the resources to supplement current coverage through additional out-of-pocket payments. This dependence creates especially high needs among a population without the means to meet those needs and exerts serious upward pressure on plans. Rather than trying to deal with health needs for which there are insufficient resources, plans may respond through aggressive efforts to shield heightened need by imposing tougher utilization controls as a means of classifying the demand as simply social needs that do not satisfy medical necessity criteria.

Finally, as with any product, managed care plans function according to their own internal operating rules. States can write their contracts with specificity and yet find that plans are more restrictive than they intended. This tendency on the part of plans to operate according to their own rules has been shown in both government studies²⁶ and litigation²⁷ that reveal instances in which plans are denying care that should have been furnished under law or under the terms of state laws, policies, and plan documents. The evidence shows that, effectively, managed care is a product like any other and that efforts to customize the product amount to an uphill climb.

Methods

This project focuses on Medicaid managed care purchasing agreements that specify SUD treatment as a covered benefit. This analysis of state Medicaid contracts is part of a larger multi-state study of the effects of Medicaid MCO coverage and utilization management design on OUD treatment receipt and outcomes. Contracts were collected from fifteen states for in-depth analysis: the fifteen states selected for this study are intended to be illustrative of the level of discretion given plans as well other factors including (1) the prevalence of OUD in the state; (2) the quality of MMC claims data submitted to the federal government (CMS) for each state; and (3) the availability of plan-specific design data in each state. The states selected also show a mix of contracting approaches including both all-inclusive plans offering both comprehensive physical and behavioral health care and multi-plan arrangements where OUD treatment is managed by specialty managed care arrangements.

While the contracts are point-in-time, they do not change materially from year to year. Managed care purchasing is done through multi-year bids that set the basic framework in effect over the multi-year time period. Thus, while the contracts evaluated here come from 2021, they reflect the basic performance blueprint in effect over a longer time period. States may supplement initial documents with clarifying policies, but they do not deviate from the requirements in effect, at least not without a formal re-bid.

Collection of contracts was conducted online (documents are publicly available) supplemented by outreach to individual states where documents were missing. A list of topics to be researched was developed that reflects a review of the literature regarding the range of treatments crucial to effective care. These treatments are by and large captured by what are widely considered the definitive standards in the field of OUD treatment developed by the American Society of Addiction Medicine (ASAM). Numerous validation studies have established that matching the severity of a patient’s substance use disorder to the levels of care specified in the ASAM criteria optimizes treatment processes and outcomes.²⁸ This research has supported the ASAM guidelines, which are now the most widely used and evaluated set of guidelines for treating patients with substance use disorders²⁹ and are formally recognized by the Centers for Medicare and Medicaid Services (CMS), which requires states to adopt ASAM guidelines as a condition of approving Medicaid 1115 demonstrations aimed at improving SUD treatment.³⁰ The ASAM criteria specify four levels of treatment encompassing intensive inpatient care, residential treatment, and varying levels of outpatient care as patients progress.³¹ Additionally, the Food and Drug Administration (FDA) has approved four medications that can be used in combination with psycho-social treatment for effective treatment of OUD.³² These medications are methadone, buprenorphine, and both oral and extended-release injectable naltrexone. The ASAM guideline also recommends that all OUD medications be offered in conjunction with the appropriate level of psycho-social treatment, typically furnished through the appropriate level of outpatient care. In sum, we examine state MCO contracts against the ASAM standards to determine how contractual terms align with what are considered the standard of care in the field for the treatment of OUD.

Results

As shown in Table I, approximately half (eight) of the states examined include any mention of ASAM. Most commonly, ASAM was identified as the standard applicable to medical necessity determinations.

Table I.

Medicaid Managed Care Contracts ASAM Language, 2021¹

STATE	Any Mention of ASAM	Contract is explicit on coverage that spans the ASAM continuum of care^*		Contract is explicit on provider requirements for all treatment services in accordance with ASAM recommendations^Ɣ		Contractors are required to use ASAM criteria to determine medical necessity
		Incl. in Contract	Relevant Provisions	Incl. in Contract	Relevant Provisions	Incl. in Contract	Relevant Provisions
		Y/N	Relevant Provisions	Y/N	Relevant Provisions	Y/N	Relevant Provisions
AZ	Y	N		N		Y	Xi
IL	N	N		N		N
IN	N	N		N		N
KY	Y	N		N		Y	Xii
MA	Y	N		N		Y	Xiii
MD²	N	N		N		N
MI⁶	N3	N		N		N
NH	Y	Y	Xiv	N		N
NM	N	N		N		N
NY	Y	N		Y	Xv	N
OH	N	N		N		N
PA⁶	Y	N		N		Y	Xvi
SC	N	N		N		N
VA	Y	Y	Xvii	N		N
WV	Y	Y	Xviii	Y	Xix	Y	Xx
TOTAL	8/15	3		2		5

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Used most recently available contract as of 2021, which varies due to differences in timing of states updating contracts.

Behavioral health is carved out; used the main primary care contract and supplemental publicly available resources as source to account to keep analyses consistent across states.

Discusses within the text of its 1115 waiver, though not directly in its purchasing agreements.

The ASAM continuum of care includes the five following levels of services: (0.5) Early intervention, (1) outpatient services, (2) intensive outpatient or partial hospitalization services, (3) residential or inpatient services, and (4) medically managed intensive inpatient services.

^Ɣ

Staff must be appropriate for the specified level of care, to include proper credentialing and/or licensing of physicians, nurses, social workers, counselors, etc. For full provider requirements specified in ASAM see the Overview of Substance Use Disorder (SUD) Care Clinical Guidelines.

(5). Fewer states specified the actual ASAM continuum of care (from intensive inpatient care to residential treatment and then through stepdown intensive and ongoing outpatient care) in regard to coverage or actually ensuring that care is furnished in a manner consistent with ASAM recommendations. West Virginia is the only state of the fifteen studied that discusses ASAM in relation to specific services covered, staffing, and medical necessity, a finding consistent with the fact that their OUD system operates under 1115 demonstration authority.³³ Plans may well be covering and furnishing ASAM-level care to members, but the requirement is not an express condition of performance. Similarly, states may aspire to plan coverage at the ASAM level through additional transmittals,³⁴ but our study classifies ASAM as a formal expectation only if references are found in the formal plan document, as an express performance condition.

In Table II, we examine seven coverage dimensions, three of which directly address ASAM continuum of care services: outpatient services, intensive outpatient/partial hospitalization services, residential services, and inpatient services.³⁵ The least common service to be explicitly included in the contracts is residential and inpatient services, followed closely by intensive outpatient and partial hospitalization services, withdrawal management services, and methadone maintenance. The most common services discussed were outpatient services, followed by recovery and peer support services. Six states—Michigan, New Hampshire, New Mexico, New York, Virginia, and West Virginia—discuss coverage of at least six ASAM treatment dimensions.

The states that employ separate “carve-out” arrangements to cover and deliver OUD care show a range of approaches in describing plan obligations. This is the case for Michigan, Pennsylvania and Maryland. In Maryland’s case, the basic MCO contract thus explicitly clarifies that plans are “not responsible for reimbursing … regardless of diagnosis (1) Services delivered by a [certified] community-based provider [furnishing specified] Alcohol and/or drug services; ambulatory detoxification.”³⁶

The contracts show variable degrees of deference in how covered treatments are described. For example, New Hampshire specifies that partial hospitalization must be offered within a set number of days from the date of ASAM level of care assessment, while Pennsylvania makes partial hospitalization an optional MCO service furnished “in lieu of” other covered services as permitted under federal managed care rules.³⁷ (The New Hampshire and Pennsylvania contract language is shown in Appendix A)

Even when the contract specifies inclusion of a particular service, the actual descriptions vary significantly. This is especially the case for peer support services, considered an important element of care under ASAM standards. West Virginia details the duties of peer support specialists and required trainings that MCOs must follow, while New Mexico provides only a short statement of coverage and reference to its 1115 waiver, leaving more ambiguity within the bounds of the purchasing agreement. New Hampshire’s language suggests peer support services is a state priority. Whereas West Virginia focused on training and New Mexico is in an earlier demonstration phase, New Hampshire is the only state studied that requires MCOs to “actively promote” its peer support program.³⁸

The types of covered withdrawal management services described can also vary substantially by state. Kentucky’s language is limited to “management of symptoms during the acute withdrawal phrase,”³⁹ while New York includes outpatient withdrawal services with details about what those services must entail.⁴⁰ Michigan pays particular attention to coverage of withdrawal services for individuals with co-occurring mental health disorders.⁴¹

Discussion

The differences in language and emphasis identified in this study may point to a state’s priorities in addressing OUD. These study findings show that among the states selected here—states that make extensive use of managed care and have a high incidence of OUD—only some expressly reference the ASAM guidelines. Among these states, references are scattered, and no state unequivocally specifies that in all coverage and treatment decisions involving people diagnosed with OUD, the plan is bound by the ASAM guidelines as the standard of both coverage and care. The language differences also suggest the absence of consensus regarding exactly how to translate ASAM guidelines into contract language other than specifying the guidelines as the standard of coverage and care that binds plans, whether full-service or behavioral carve-out.

As expected, all states studied here cover OUD treatment, and there is no question regarding states’ commitment to providing at least some forms of treatment for OUD. Indeed, in some states—regardless of what plan language specifies—care may be happening at the ASAM level. Certain services furnished in connection with OUD are mandatory for the population such as physician and hospital care, and states cannot discriminate in the provision of coverage based on diagnosis. All states cover prescription drugs in their plans, making FDA-approved OUD drugs a basic element of their formularies, since federal Medicaid law requires that state plans include all FDA-approved prescribed drugs. States effectuate their coverage either through their general service agreements or via a multi-plan approach that utilizes the services of specialty care and coverage arrangements that supplement what the basic plan offers. But because ASAM is not specified as the unconditional coverage and treatment standard, plans’ approaches may diverge in terms of both what treatments they cover and the standard of care they follow when making coverage decisions.

CMS has tried to move states in this direction by tying approval of 1115 Medicaid demonstrations focused on OUD treatment to use of ASAM guidelines. But even here, state 1115 demonstrations are generally not unequivocal on this point by binding contractors to the standard as a matter of compliance.

Many factors may drive states’ decisions not to expressly and unequivocally make ASAM the standard of care when managing coverage and treatment. ASAM-level care is undoubtedly costly, even if cost effective. Cost-effectiveness studies that assume multi-year savings have limited utility for states that are under pressure in any single year to keep costs down. As a result, even a gold standard such as ASAM might be cost-prohibitive.

An additional consideration is that states and plans simply lack the on-the-ground resources to offer gold-standard care. The shortage of residential treatment and outpatient care—both generally and at the prices Medicaid can afford to pay—can defeat any effort by states and plans to increase the quality of care. The states whose contracts were examined in this study constituted twenty-one percent of pain reliever use disorders (328 thousand individuals) and twenty-six percent of heroin use (201 thousand individuals) in the United States in 2019.⁴² The high prevalence of these conditions within this sample of states results in a state average of 757 individuals with pain reliever disorders and 431 heroin users per specialty facility with opioid treatment programs, though, on average, these facilities saw a median of only 325 outpatient clients in total in 2020.⁴³ In 2021, almost 5.6 million individuals had an opioid use disorder, but only 1.2 million received treatment for one.⁴⁴ Critical shortages of appropriate treatment could result in coverage decisions meant to maintain care at accessible levels in order to avoid (or at least mitigate) the problem of long waiting lists for services.

Ensuring that Medicaid managed care plans perform at the ASAM standard of care means saying so unequivocally in plan documents. It also means a massive investment in on-the-ground care and sufficient financing to enable states to buy, and plans to provide, treatment at the definitive standard of care. In particular, lack of attention to coverage of residential treatment appears to be an ongoing issue.⁴⁵ This level of investment is not likely to materialize. Multiple states continue to reject basic Medicaid eligibility for the low income working-age adult population, and those that have expanded coverage must confront the high cost of care, even at the enhanced federal funding rates available for the Medicaid expansion population.⁴⁶ What might help address this problem beyond the obvious of lessening the incidence of OUD is the possibility of guidelines that offer an effective but less costly alternative strategy for managing OUD.

Of course, it is not only in the case of OUD that there exists a gulf between known, effective clinical standards of care and what binding plan documents specify. This is true across the care spectrum, from preventive pediatric care to maternity care, to guidelines governing treatment for cancer, heart conditions or diabetes. And Medicaid is hardly alone in this gap; insurers generally are not held to express standards of care. The gap between what is known and what is permitted means that plans are free to impose their own judgment and preferences, which may or may not reflect such standards. Changing Medicaid in this regard means changing the way insurance works more broadly: an advance in American health care that likely is a long way off.

Supplementary Material

Appendix

NIHMS1995170-supplement-Appendix.pdf^{(354.5KB, pdf)}

Acknowledgments

The authors wish to thank Josemiguel Rodriguez, GW Law, J.D. (expected) 2024, for his indispensable research support and Morgan Handley, Eyman Associates, J.D., for her contract review work.

Biographies

Rebecca Morris, MPP, is a PhD candidate in health policy and a research scientist at the Milken Institute School of Public Health at George Washington University. She previously worked at Mathematica and Stanford Law School. Her research areas of interest include Medicaid policy, access to behavioral health services, and the role of community health centers in the safety net.

Colleen M. Grogan, PhD is the Deborah R. and Edgar D. Jannotta Professor in the Crown Family School at the University of Chicago. She is involved in two NIH-funded grants to study the impact of Medicaid Managed Care coverage policies on access to care and health outcomes for persons with substance use disorder. Grogan’s forthcoming book (July 2023) is titled Grow and Hide: The History of America’s Health Care State. Her new project (with Miriam Laugesen) focuses on the role of financialization in the U.S. health care system and its implications for health policies and health equity.

Appendix

Appendix Table II.

Selected Substance Use Disorder Treatment Coverage Dimensions, 2021¹

STATE	Contractors are required to cover outpatient services^¥		Contractors are required to cover intensive outpatient/partial hospitalization services ^Ŧ		Contractors are required to cover residential services^∞		Contractors are required to cover inpatient services^∞		Contractors are required to cover withdrawal management services		Contractors are required to cover recovery/peer support services		Contractors are required to cover opioid treatment services -methadone maintenance^{^}
	Incl. in Contract	Relevant Provisions	Incl. in Contract	Relevant Provisions	Incl. in Contract	Relevant Provisions	Incl. in Contract	Relevant Provisions	Incl. in Contract	Relevant Provisions	Incl. in Contract	Relevant Provisions	Incl. in Contract	Relevant Provisions
	Y/N	Relevant Provisions	Y/N	Relevant Provisions	Y/N	Relevant Provisions	Y/N	Relevant Provisions	Y/N	Relevant Provisions	Y/N	Relevant Provisions	Y/N	Relevant Provisions
AZ	Y	X^xi	N		Y	X^xii	N		N	N	Y	X^xiii	N
IL	N		N		N		N		N	N	N		N
IN	N		N		N		N		N	N	N		Y	X^xiv
KY	Y	X^xv	Y	X^xvi	Y	X^xvii	N		Y	X^xviii	N		N
MA	N		N		N		N		N	N	Y	X^xix	Y	X^xx
MD²	N³	X^xxi	N¹⁰	X^xxii	N¹⁰		N¹⁰	X^xxiii	N¹⁰	X^xxiv	N¹⁰		N¹⁰	X^xxv
MI⁹	Y⁴	X^xxvi	Y¹¹	X^xxvii	Y¹¹	X^xxviii	Y¹¹	X^xxix	Y¹¹	X^xxx	Y¹¹	X^xxxi	Y¹¹	X^xxxii
NH	Y	X^xxxiii	Y	X^xxxiv	Y	X^xxxv	N		Y	X^xxxvi	Y	X^xxxvii	Y	X^xxxviii
NM	Y	X^xxxix	Y	X^xl	N		Y	X^xli	Y	X^xlii	Y	X^xliii	Y	X^xliv
NY	Y	X^xlv	Y	X^xlvi	Y	X^xlvii	Y	X^xlviii	Y	X^xlix	Y	X^l	Y	X^li
OH	N		N		N		N		N		N		N
PA¹	Y	X^lii	N	X^liii	N	X^liv	N		Y	X^lv	Y	X^lvi	Y	X^lvii
SC	N		N		N		N		N	N	N		N
VA	Y	X^lviii	Y	X^lix	Y	X^lx	Y	X^lxi	Y	X^lxii	Y	X^lxiii	Y	X^lxiv
WV	Y	X^lxv	Y	X^lxvi	N		Y	X^lxvii	Y	X^lxviii	Y	X^lxix	Y	X^lxx
TOTAL	11		7		6		6		8		9		8

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Used most recently available contract as of 2021, which varies due to differences in timing of states updating contracts.

Behavioral health is carved out; used the main primary care contract, and supplemental publicly available resources as source to account to keep analyses consistent across states.

Maryland covers behavioral health services under fee for service Medicaid. Specialty substance use disorder services are administered under an Administrative Services Organization.

⁴

Michigan covers substance use disorder treatment under PIHPs. Currently, this service is covered under the Michigan 1115 Behavioral Health Demonstration.

^¥

Level 1 outpatient services may offer several therapies and service components, including individual and group counseling, motivational enhancement, family therapy, educational groups, occupational and recreational therapy, psychotherapy, MOUD/MAUD, or other skilled treatment services.

^Ŧ

Level 2.1 intensive outpatient programs provide 9–19 hours of weekly structured programming for adults or 6–19 hours of weekly structured programming for adolescents. Level 2.5 Partial hospitalization programs are able to provide 20 hours or more of clinically intensive programming each week to support patients who need daily monitoring and management in a structured outpatient setting.

^∞

Level 3 programs include four sublevels that represent a range of intensities of service. The uniting feature is that all services are provided in a structured, residential setting that is staffed 24 hours daily and are clinically managed.

^®

This level of care is appropriate for patients with biomedical, emotional, behavioral and/or cognitive conditions severe enough to warrant primary medical care and nursing care. Patients receive daily direct care from a licensed physician who is responsible for making shared treatment decisions with the patient (i.e. medically managed care). These services are provided in a hospital-based setting and include medically directed evaluation and treatment.

^{^}

OTPs, commonly known as methadone maintenance treatment clinics or opioid maintenance therapy clinics, directly administer MOUD (primarily methadone) to patients on a daily basis.

ⁱ

“The Contractor shall employ a phased-in implementation approach, as directed by AHCCCS to utilize the American Society of Addiction Medicine (ASAM) Criteria (Third Edition, 2013) in substance use disorder assessments, service planning, and level of care placement; and implement standardized substance use disorder assessments as specified in the AMPM. This includes substance use disorder assessments for members who have co-occurring mental health and substance use disorders. Beginning October 1, 2022, the Contractor shall utilize ASAM Continuum for substance use disorder assessments for members age 18 and older.” Arizona Managed Care Model Contract, AHCCS, 77 (2021–22), https://www.azahcccs.gov/Resources/OversightOfHealthPlans/SolicitationsAndContracts/contracts.html [https://perma.cc/LU3Y-BQMW].

ⁱⁱ

“The Contractor shall adopt Interqual for Medical Necessity except that the Contractor shall utilize the American Society of Addiction Medicine (ASAM) for substance use.” Id.

ⁱⁱⁱ

“4. The Contractor shall, unless otherwise directed by EOHHS, work collaboratively with EOHHS and with MassHealth-contracted plans to implement a unified Network Management strategy for managing the Residential Rehabilitation Services for Substance Use Disorders (RRS) network. The Contractor shall: … c. Ensure that RRS is provided in accordance with EOHHS-approved RRS performance specifications and RRS Medical Necessity Criteria which shall align with the American Society for Addiction Medicine (ASAM) criteria; Submit for EOHHS’s approval authorization and concurrent review procedures for RRS and any changes to such authorization and concurrent review procedures prior to their implementation. The Contractor shall: 1) Utilize the American Society for Addiction Medicine (ASAM) criteria as the basis for establishing authorization and concurrent review procedures; …” MANAGED CARE ORGANIZATION THIRD AMENDED AND RESTATED CONTRACT BY AND BETWEEN THE EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES AND BOSTON MEDICAL CENTER HEALTH PLAN, INC., MASS. DEPT. HEALTH & HUM. SERVS., 169 (2021), https://www.mass.gov/doc/3rd-amended-and-restated-mco-contract-bmchp/download.

^iv

“4.7.5.17.3 American Society of Addiction Medicine (ASAM) Level of Care 4.7.5.17.3.1. “The MCO shall ensure Members timely access to care through a network of Participating Providers In each ASAM Level of Care. During the Readiness Review process and in accordance with Exhibit O.” Medicaid Care Management Services Contract, EXHIBIT A – AMENDMENT #5, SCOPE OF SERVICES, STATE OF N.H., DEPT. OF HEALTH & HUM. SERVS., 160 (2021), https://sos.nh.gov/media/p4yppqma/009-gc-agenda-012221.pdf.

“16.2 Standards of Care a) The Contractor must adopt practice guidelines consistent with current standards of care, and, where available, evidence-based practices, complying with recommendations of professional specialty groups or the guidelines of programs such as the American Academy of Pediatrics, the American Academy of Family Physicians, the American Psychiatric Association, the US Task Force on Preventive Care, the New York State Child/Teen Health Program (C/THP) standards for provision of care to individuals under age twenty-one (21), the American Medical Association’s Guidelines for Adolescent and Preventive Services, the US Department of Health and Human Services Center for Substance Abuse Treatment, New York State OASAS clinical standards, American Society of Addiction Medicine (ASAM), US Substance Abuse and Mental Health Services Administration (SAMHSA), the American College of Obstetricians and Gynecologists, the American Diabetes Association, the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care developed by the Office of Minority Health of the US Department of Health and Human Services, and the AIDS Institute clinical standards for adult, adolescent, and pediatric care. Medicaid Advantage Model Contract, N.Y. DEPT. OF HEALTH, 16–3 (2019), https://www.health.ny.gov/health_care/medicaid/redesign/docs/mrt90_medicaid_advantage_model_contract.pdf.

^vi

“Drug and alcohol reviews for children and adolescents must be conducted in accordance with criteria compatible with those of the American Society of Addiction Medicine (ASAM) which can be purchased through ASAM and found at http://www.asam.org/publications.” HEALTHCHOICES BEHAVIORAL HEALTH PROGRAM: PROGRAM STANDARDS AND REQUIREMENTS PRIMARY CONTRACTOR, COMMONWEALTH OF P.A. DEPT. OF HUM. SERVS., 62 (2018).

^vii

“The Contractor’s ARTS criteria shall be consistent with the American Society for Addiction Medicine (ASAM).” Medallion 4.09 Managed Care Services Agreement, COMMONWEALTH OF VA. DEPT. OF MEDICAL ASSISTANCE SERVS., 143 (2020–21).

^viii

“SUD 1115 Demonstration Waiver - Building on legislative and health systems activities, the goal is to create a seamless continuum of care to support enrollees in their recovery. The MCO is expected to support the following goals: … • Increase enrollee access to and utilization of appropriate SUD treatment services based on American Society of Addiction Medicine (ASAM^®) Criteria; … BMS has established standards of care for SUD demonstration waiver services that incorporate industry standard benchmarks from the ASAM^® Criteria for patient assessment and placement, service, and staffing specifications….Medicaid State Plan SUD services include: • Targeted Case Management; • Naloxone Administration Services (non-covered MCO service); • Screening, Brief Intervention and Referral to Treatment (0.5 ASAM^® Level of Care); • Outpatient Services (1.0 ASAM^® Level of Care); • Intensive Outpatient Services (2.1 ASAM^® Level of Care); • Partial Hospitalization Services (2.5 ASAM^® Level of Care); • Medically Monitored Intensive Inpatient Services (3.7 ASAM^® Level of Care); • Medically Managed Intensive Inpatient Services (4.0 ASAM^® Level of Care); • Ambulatory Withdrawal Management Services (1-WM & 2-WM ASAM^® Level of Care); • Medically Monitored Inpatient Withdrawal Management Services (3.7-WM ASAM^® Level of Care); and • Non-Methadone Medication Assisted Treatment (MAT). (p. 162). SUD 1115 demonstration waiver services include: • Peer Recovery Support Services (1.0 ASAM^® Level of Care); • Clinically Managed Low Intensity Residential Services (3.1 ASAM^® Level of Care); • Clinically Managed Population-Specific High Intensity Residential Services (3.3 ASAM^® Level of Care); • Clinically Managed High Intensity Residential Services (3.5 ASAM^® Level of Care); and • Clinically Managed Residential Withdrawal Management Services (3.2-WM ASAM^® Level of Care). (p. 162–63, 2021 West Virginia Medicaid Managed Care Contract).

^ix

BMS has established standards of care for SUD demonstration waiver services that incorporate industry standard benchmarks from the ASAM^® Criteria for patient assessment and placement, service, and staffing specifications….10.11.6 SUD Provider Training and Education Requirements SUD providers are responsible for providing training and education to their staff on the ASAM^® Level of Care criteria and the application of the ASAM^® Criteria in the assessment process. As part of BMS’ quality monitoring strategy, personnel and clinical records of a sample of the provider network will be reviewed to evaluate if there is appropriate application of and fidelity to the ASAM^® Levels of Care and the Medicaid Provider Manual. The MCO will perform these retro reviews of providers to ensure SUD program providers are consistently applying ASAM^® Criteria throughout an individual’s stay and that documentation and personnel records meet established Medicaid standards. STATE FISCAL YEAR 2021 MODEL PURCHASE OF SERVICE PROVIDER AGREEMENT BETWEEN STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES BUREAU FOR MEDICAL SERVICES AND (MANAGED CARE ORGANIZATION), STATE OF W.V. DEPT. OF HEALTH & HUM. SERVS., 162 (2021), https://dhhr.wv.gov/bms/Members/Managed%20Care/Documents/Contracts/WV_SFY21_MCO_Model_Contract_final%20v7%207–10-20%20CleanSLH.pdf.

“10.11.3.4 SUD Residential Treatment Services Treatment services delivered to residents of an institutional care setting, including facilities that meet the definition of an IMD, are provided to West Virginia Medicaid enrollees with an SUD diagnosis when determined to be medically necessary by the MCO’s utilization staff and in accordance with an individualized service plan (ISP). The MCO’s utilization staff, physicians, or Medical Directors will perform independent reviews of assessments to determine the level of care and length of stay recommendations based upon the ASAM^® multidimensional assessment criteria.” Id. at 163.

^xi

“Behavioral Health Services: The Contractor shall provide medically necessary behavioral health services to all members in accordance with AHCCCS policies and A.A.C. R9–22, Article 12. Refer also to the AMPM Policy 310-B, AMPM Exhibit 300–2A, and the Behavioral Health Services Matrix. Behavioral Health services include but are not limited to the following: … Behavioral Health Day Program Services: Includes services such as therapeutic nursery, in-home stabilization, after school programs, and specialized outpatient substance use/abuse programs.” Arizona Managed Care Model Contract, AHCCS, 55–56 (2021–22), https://www.azahcccs.gov/Resources/OversightOfHealthPlans/SolicitationsAndContracts/contracts.html.

^xii

“Behavioral Health Services: The Contractor shall provide medically necessary behavioral health services to all members in accordance with AHCCCS policies and A.A.C. R9–22, Article 12. Refer also to the AMPM Policy 310-B, AMPM Exhibit 300–2A, and the Behavioral Health Services Matrix. Behavioral Health services include but are not limited to the following: … Behavioral Health Residential Facility Services: Services provided by a licensed behavioral health service agency that provides treatment to an individual experiencing a behavioral health symptom that: 1. Limits the individual’s ability to be independent, or 2. Causes the individual to require treatment to maintain or enhance independence (A.A.C. R9–10-101).” Id.

^xiii

“Peer-Run Organizations and Family-Run Organizations: Members shall be offered the option to receive medically necessary behavioral health and/or other services from a PRO and/or FRO. The Contractor shall provide access to peer and family support services for members to assist with understanding and coping with the stressors of a member’s disability and how to effectively, and efficiently, utilize the service delivery system for covered benefits. The Contractor shall provide access to peer support services for members with Substance Use Disorders (SUDs) including but not limited to: Alcohol Misuse, Benzodiazepine Misuse and Dependence, and Opioid Use Disorders (OUDs). Where appropriate, Peer Support Specialists may navigate members to Medication Assisted Treatment (MAT) providers, for the purpose of increasing the member’s participation and retention in MAT treatment and recovery support services.” Id. at 49.

^xiv

“6.17 Opioid Treatment Program (OTP) The Contractor shall provide coverage for the daily Opioid Treatment Program (OTP). A daily opioid treatment program includes administration and coverage of methadone, routine drug testing, group therapy, individual therapy, pharmacological management, HIV testing, Hepatitis A, B, and C testing, pregnancy tests, Tuberculosis testing, Syphilis testing, follow-up examinations, case management and one evaluation and management office visit every 90 days for the management of patient activities identified in the individualized treatment plan that assist in patient goal attainment, including referrals to other service providers and linking patients to recovery support groups. OTP coverage will include those members as defined by OMPP and approved by CMS. The MCE will be responsible for OTP services provided by the provider type Addictions Provider and the provider specialty OTP as defined in the IHCP Provider Enrollment Type and Specialty Matrix.” PROFESSIONAL SERVICES CONTRACT, INDIANA FAMILY & SOC. SERVS. ADMIN., 89 (2022).

^xv

“I. In addition to any Community Mental Health Center or Local Health Department which the Contractor has in its network, the Contractor shall include in its network Mental Health and Substance Abuse providers for both adults and children in no fewer number than fifty (50%) percent of the Mental Health and Substance Abuse providers enrolled in the Medicaid program to provide out-patient, intensive out-patient, substance abuse residential, case management, mobile crisis, residential crisis stabilization, assertive community treatment and peer support services.” CONTRACT FOR MEDICAID MANAGED CARE SERVICES BETWEEN THE COMMONWEALTH OF KENTUCKY CABINET FOR HEALTH & HUMAN SERVICES DIVISION OF MEDICAID SERVICES AND COVENTRY HEALTH & LIFE INSURANCE COMPANY, COMM. OF KY. CABINET FOR HEALTH & FAM. SERVS., 91 (2019).

^xvi

^xvii

xviii: APPENDIX H. COVERED SERVICES I. Contractor Covered Services … R. Medical Detoxification, meaning management of symptoms during the acute withdrawal phrase from a substance to which the individual has been addicted. Id. at 223.

^xix

“4. The Contractor shall ensure that Enrollees receive Medically Necessary and appropriate care and follow-up based on their identified needs through any assessment or screening, including but not limited to those performed pursuant to this Section. The Contractor shall: … g. Ensure that all Enrollees with significant BH needs, as further defined by EOHHS, receive appropriate services to address their care needs, as follows: … 2) Such services shall include but not be limited to services such as: … c) Peer Supports, recovery coaches, and self-help groups …” MANAGED CARE ORGANIZATION THIRD AMENDED AND RESTATED CONTRACT BY AND BETWEEN THE EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES AND BOSTON MEDICAL CENTER HEALTH PLAN, INC., MASS. DEPT. HEALTH & HUM. SERVS., 74 (2021), https://www.mass.gov/doc/3rd-amended-and-restated-mco-contract-bmchp/download.

^xx

“The Contractor shall: a. Cover and pay for the administering and dispensing of methadone, buprenorphine, and naltrexone through its OTP Network Providers. If the Contractor utilizes a Material Subcontractor for Behavioral Health Services, cover and pay for such services solely through such Material Subcontractor and require such Material Subcontractor to comply with the requirements in this Section 2.8.C.8; b. Use the codes specified by EOHHS for the coverage of methadone, buprenorphine, and naltrexone and related services when delivered by OTP Network Providers; …” Id. at 171.

^xxi

“D. An MCO is not responsible for reimbursing for the following substance use disorder services if the MCO is billed with a primary diagnosis listed in §K of this regulation: ….(2) Services delivered by an outpatient hospital with the following revenue codes:…” HEALTHCHOICE MANAGED CARE ORGANIZATION AGREEMENT, MD. DEPT. OF HEALTH, 237 (2022), https://health.maryland.gov/mmcp/healthchoice/Documents/CY%202022%20HealthChoice%20MCO%20Agreement%20%28Master%20-%20Combined%29.pdf.

^xxii

“.02 Behavioral Health Non-Capitated Covered Services. A. An MCO is not responsible for reimbursing for the following substance use disorder services, regardless of diagnosis: (1) Services delivered by a community-based provider as described in COMAR 10.09.80 with the following procedure codes:… 0015 Alcohol and/or drug services; intensive outpatient….H2036 Alcohol and/or drug services; partial hospitalization.” Id. at 235–236.

xxiii: “D. An MCO is not responsible for reimbursing for the following substance use disorder services if the MCO is billed with a primary diagnosis listed in §K of this regulation: (1) Services delivered by an inpatient hospital with the following revenue codes…” Id. at 237.

^xxiv

“.02 Behavioral Health Non-Capitated Covered Services. A. An MCO is not responsible for reimbursing for the following substance use disorder services, regardless of diagnosis: (1) Services delivered by a community-based provider as described in COMAR 10.09.80 with the following procedure codes … H0014 Alcohol and/or drug services; ambulatory detoxification.” Id. at 235–236.

^xxv

“.02 Behavioral Health Non-Capitated Covered Services. A. An MCO is not responsible for reimbursing for the following substance use disorder services, regardless of diagnosis: (1) Services delivered by a community-based provider as described in COMAR 10.09.80 with the following procedure codes… H0020 Alcohol and/or drug services; methadone administration and/or service.” Id.

^xxvi

“VII. Coordination for Services Covered Outside this Contract. The Contractor must provide information to the Enrollee regarding the availability of these services and coordinate care as appropriate….7. Substance use disorder services through accredited Providers including: a. Assessment b. Detoxification (see Appendix 8) c. Intensive outpatient counseling and other outpatient services d. Methadone treatment and other substance use disorder treatment (pp. 64–65). APPENDIX 7 MEDICAID MENTAL HEALTH AND SUBSTANCE USE DISORDER AUTHORIZATION AND PAYMENT RESPONSIBILITY GRID….Outpatient Substance Abuse Office, Residential Substance Abuse Center or Sub-Acute Detox Center… The PIHP is responsible for payment. SUD services should be coordinated with the MHP—this is especially true if the individual has cooccurring disorders (mental health and SUD). Refer to the document “Medicaid Mental Health Substance Use Disorder Inpatient Medical Acute Detoxification” for information regarding acute care hospital inpatient medical detoxification.” STATE OF MICHIGAN Contract No. [ ] Comprehensive Health Care Program for the Michigan Department of Health and Human Services, MICHIGAN DEPT. OF HEALTH & HUM. SERVS., 203–204 (2021), https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Folder1/Folder101/contract_7696_7.pdf?rev=6b613a9a8ae04ede8b764176b3b9ab7e. “F. Covered Services…The Contractor will be responsible for the operation of the 1115 Behavioral Health Demonstration Waiver.” Id. at 30. SUD TREATMENT…Level 1 - Outpatient Services. Michigan 1115 Behavioral Health Demonstration, MICH. DEPT. OF HEALTH & HUM. SERVS., 96–97 (2019), https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder3/Folder89/Folder2/Folder189/Folder1/Folder289/1115-Behavioral-Health-Demo-Amendment.pdf?rev=f3ba92cea57c4593b657250aaa51e6d0.

xxvii: “VII. Coordination for Services Covered Outside this Contract The Contractor must provide information to the Enrollee regarding the availability of these services and coordinate care as appropriate….7. Substance use disorder services through accredited Providers including: a. Assessment b. Detoxification (see Appendix 8) c. Intensive outpatient counseling and other outpatient services d. Methadone treatment and other substance use disorder treatment.” STATE OF MICHIGAN Contract No. [ ] Comprehensive Health Care Program for the Michigan Department of Health and Human Services, MICHIGAN DEPT. OF HEALTH & HUM. SERVS., 64–65 (2021), https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Folder1/Folder101/contract_7696_7.pdf?rev=6b613a9a8ae04ede8b764176b3b9ab7e. “F. Covered Services…The Contractor will be responsible for the operation of the 1115 Behavioral Health Demonstration Waiver.” Prepaid Inpatient Health Plan (PIHP), STATE OF MICH. PROCUREMENT, 30 (2021), https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder4/Folder1/Folder3/Folder101/Folder2/Folder201/Folder1/Folder301/FY21_MA-PIHP_Contract.pdf?rev=780f33cd005f45ef9517b5aa61e7de6c. “SUD TREATMENT… Level 2.1 – Intensive Outpatient Services … Level 2.5 – Partial Hospitalization Services.” Michigan 1115 Behavioral Health Demonstration, MICH. DEPT. OF HEALTH & HUM. SERVS., 96–102 (2019), https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder3/Folder89/Folder2/Folder189/Folder1/Folder289/1115-Behavioral-Health-Demo-Amendment.pdf?rev=f3ba92cea57c4593b657250aaa51e6d0.

xxviii: “F. Covered Services…The Contractor will be responsible for the operation of the 1115 Behavioral Health Demonstration Waiver.” Id. at 30. “SUD TREATMENT… Level 3.1 – Clinically Managed Low-intensity Residential Services… Level 3.3 – Clinically Managed Population-specific High-Intensity Residential Services… Level 3.5 – Clinically Managed High-Intensity Residential Services.” Id. at 96–105.

^xxix

“APPENDIX 7 MEDICAID MENTAL HEALTH AND SUBSTANCE USE DISORDER AUTHORIZATION AND PAYMENT RESPONSIBILITY GRID….Outpatient Substance Abuse Office, Residential Substance Abuse Center or Sub-Acute Detox Center… The PIHP is responsible for payment. SUD services should be coordinated with the MHP—this is especially true if the individual has cooccurring disorders (mental health and SUD). Refer to the document “Medicaid Mental Health Substance Use Disorder Inpatient Medical Acute Detoxification” for information regarding acute care hospital inpatient medical detoxification.” STATE OF MICHIGAN Contract No. [ ] Comprehensive Health Care Program for the Michigan Department of Health and Human Services, MICHIGAN DEPT. OF HEALTH & HUM. SERVS., 203–04 (2021), https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Folder1/Folder101/contract_7696_7.pdf?rev=6b613a9a8ae04ede8b764176b3b9ab7e. “F. Covered Services…The Contractor will be responsible for the operation of the 1115 Behavioral Health Demonstration Waiver.” Id. at 30.

^xxx

VII. Coordination for Services Covered Outside this Contract The Contractor must provide information to the Enrollee regarding the availability of these services and coordinate care as appropriate….7. Substance use disorder services through accredited Providers including: a. Assessment b. Detoxification (see Appendix 8) c. Intensive outpatient counseling and other outpatient services d. Methadone treatment and other substance use disorder treatment. Id. at 64–65. APPENDIX 7 MEDICAID MENTAL HEALTH AND SUBSTANCE USE DISORDER AUTHORIZATION AND PAYMENT RESPONSIBILITY GRID….Outpatient Substance Abuse Office, Residential Substance Abuse Center or Sub-Acute Detox Center… The PIHP is responsible for payment. SUD services should be coordinated with the MHP—this is especially true if the individual has cooccurring disorders (mental health and SUD). Refer to the document “Medicaid Mental Health Substance Use Disorder Inpatient Medical Acute Detoxification” for information regarding acute care hospital inpatient medical detoxification. Id. at 203–04. “F. Covered Services…The Contractor will be responsible for the operation of the 1115 Behavioral Health Demonstration Waiver.” Id. at 30. “SUD TREATMENT… Level 1-WM – Ambulatory Withdrawal Management without Extended On-site Monitoring (Outpatient Withdrawal Management)… Level 2-WM – Ambulatory Withdrawal Management with Extended On-site Monitoring (Outpatient Withdrawal Management)… Level 3.2- WM – Clinically Managed Residential Withdrawal Management (Residential Withdrawal Management)… Level 3.7 WM – Medically Monitored Inpatient Withdrawal Management Level 4 WM – Medically Managed Intensive Inpatient.” Michigan 1115 Behavioral Health Demonstration, MICH. DEPT. OF HEALTH & HUM. SERVS., 96–111 (2019), https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder3/Folder89/Folder2/Folder189/Folder1/Folder289/1115-Behavioral-Health-Demo-Amendment.pdf?rev=f3ba92cea57c4593b657250aaa51e6d0.

^xxxi

“B. Provide or Arrange for Services 1. Primary Care Provider a. Contractor agrees to provide primary care training on evidence-based behavioral health service models for Primary Care Providers, such as Screening, Brief Intervention and Referral to Treatment (SBIRT). b. Contractor agrees to reimburse its primary care practices for behavioral health screening services provided to Enrollees. 2. Community Health Workers (CHWs) a. Contractor must provide or arrange for the provision of Community Health Workers (CHW) in accordance with CHW requirements of this Contract or Peer-Support Specialist Services to Enrollees who have significant behavioral health issues and complex physical co-morbidities who will engage with and benefit from CHW or Peer-Support Specialist Services. b. Contractor agrees to establish a reimbursement methodology for outreach, engagement, education and coordination services provided by CHWs or Peer Support Specialists to promote behavioral health integration.” STATE OF MICHIGAN Contract No. [ ] Comprehensive Health Care Program for the Michigan Department of Health and Human Services, MICHIGAN DEPT. OF HEALTH & HUM. SERVS., 203–04 (2021), https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Folder1/Folder101/contract_7696_7.pdf?rev=6b613a9a8ae04ede8b764176b3b9ab7e. “F. Covered Services…The Contractor will be responsible for the operation of the 1115 Behavioral Health Demonstration Waiver.” Id. at 30. “SUD TREATMENT… Peer Supports.” Michigan 1115 Behavioral Health Demonstration, MICH. DEPT. OF HEALTH & HUM. SERVS., 96–112 (2019), https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder3/Folder89/Folder2/Folder189/Folder1/Folder289/1115-Behavioral-Health-Demo-Amendment.pdf?rev=f3ba92cea57c4593b657250aaa51e6d0.

xxxii: “VII. Coordination for Services Covered Outside this Contract The Contractor must provide information to the Enrollee regarding the availability of these services and coordinate care as appropriate….7. Substance use disorder services through accredited Providers including: a. Assessment b. Detoxification (see Appendix 8) c. Intensive outpatient counseling and other outpatient services d. Methadone treatment and other substance use disorder treatment.” STATE OF MICHIGAN Contract No. [ ] Comprehensive Health Care Program for the Michigan Department of Health and Human Services, MICHIGAN DEPT. OF HEALTH & HUM. SERVS., 64–65 (2021), https://www.michigan.gov/mdhhs/-/media/Project/Websites/mdhhs/Folder1/Folder101/contract_7696_7.pdf?rev=6b613a9a8ae04ede8b764176b3b9ab7e. “F. Covered Services…The Contractor will be responsible for the operation of the 1115 Behavioral Health Demonstration Waiver.” Id. at 30. “SUD TREATMENT… Level 1 - Opioid Treatment Program (OTP)… Approved pharmacological support services… Oral medication administration, direct observation, physician evaluations, individual and person-centered assessments, nursing assessments, counseling and laboratory testing and access to primary care (approved for use of Methadone and/or Buprenorphine).” Michigan 1115 Behavioral Health Demonstration, MICH. DEPT. OF HEALTH & HUM. SERVS., 96–97 (2019), https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder3/Folder89/Folder2/Folder189/Folder1/Folder289/1115-Behavioral-Health-Demo-Amendment.pdf?rev=f3ba92cea57c4593b657250aaa51e6d0.

xxxiii: “4.7.5.20 The MCO shall ensure that Members identified for withdrawal management, outpatient or intensive outpatient services shall start receiving services within seven (7) business days from the date ASAM Level of Care Assessment was completed until such a time that the Member is accepted and starts receiving services by the receiving agency. Members identified for partial hospitalization or rehabilitative residential services shall start receiving interim services (services at a lower level of care than that identified by the ASAM Level of Care Assessment) or the identified service type within seven (7) business days from the date the ASAM Level of Care Assessment was completed and start receiving the identified level of care no later than fourteen (14) business days from the date the ASAM Level of Care Assessment was completed.” Medicaid Care Management Services Contract, EXHIBIT A – AMENDMENT #5, SCOPE OF SERVICES, STATE OF N.H., DEPT. OF HEALTH & HUM. SERVS., 160 (2021), https://sos.nh.gov/media/p4yppqma/009-gc-agenda-012221.pdf.

xxxiv: “4.7.5.20 The MCO shall ensure that Members identified for withdrawal management, outpatient or intensive outpatient services shall start receiving services within seven (7) business days from the date ASAM Level of Care Assessment was completed until such a time that the Member is accepted and starts receiving services by the receiving agency. Members identified for partial hospitalization or rehabilitative residential services shall start receiving interim services (services at a lower level of care than that identified by the ASAM Level of Care Assessment) or the identified service type within seven (7) business days from the date the ASAM Level of Care Assessment was completed and start receiving the identified level of care no later than fourteen (14) business days from the date the ASAM Level of Care Assessment was completed.” Id.

^xxxv

“4.7.5.20 The MCO shall ensure that Members identified for withdrawal management, outpatient or intensive outpatient services shall start receiving services within seven (7) business days from the date ASAM Level of Care Assessment was completed until such a time that the Member is accepted and starts receiving services by the receiving agency. Members identified for partial hospitalization or rehabilitative residential services shall start receiving interim services (services at a lower level of care than that identified by the ASAM Level of Care Assessment) or the identified service type within seven (7) business days from the date the ASAM Level of Care Assessment was completed and start receiving the identified level of care no later than fourteen (14) business days from the date the ASAM Level of Care Assessment was completed.” Id.

xxxvi: “4.7.5.20 The MCO shall ensure that Members identified for withdrawal management, outpatient or intensive outpatient services shall start receiving services within seven (7) business days from the date ASAM Level of Care Assessment was completed until such a time that the Member is accepted and starts receiving services by the receiving agency. Members identified for partial hospitalization or rehabilitative residential services shall start receiving interim services (services at a lower level of care than that identified by the ASAM Level of Care Assessment) or the identified service type within seven (7) business days from the date the ASAM Level of Care Assessment was completed and start receiving the identified level of care no later than fourteen (14) business days from the date the ASAM Level of Care Assessment was completed.” Id.

xxxvii: “4.11.5.11 Peer Recovery Support Services 4.11.5.11.1 In coordination with CMH Programs and CMH Providers, the MCO shall actively promote the delivery of PRSS provided by Peer Recovery Programs in a variety of settings such as CMH Programs, New Hampshire Hospital, primary care clinics, and EDs. 4.11.5.11.2 The MCO shall provide updates as requested by DHHS during regular behavioral health meetings between the MCO and DHHS.” Id. at 222. “4.11.6.4.6 The MCO shall reimburse Peer Recovery Programs in accordance with rates that are no less than the equivalent DHHS FFS rates.” Id. at 230.

xxxviii: “4.11.6.4.7 When contracting with methadone clinics, the MCO shall contract with and have in its network all Willing Providers in the state.” Id. at 230.

xxxix: “Non-Community Benefit Services Included Under Centennial Care…Behavioral Health Professional Services: outpatient Behavioral Health and substance abuse services.” Medicaid Managed Care Services Agreement Among New Mexico Human Services Department, New Mexico Children, Youth, and Families Department, New Mexico Early Childhood Education and Care Department, New Mexico Behavioral Health Purchasing Collaborative and [Contractor], STATE OF N.M. HUM. SERVS. DEPT., 384 (2021), https://www.hsd.state.nm.us/wp-content/uploads/Turquoise-Care-MCO-Model-Contract-CLEAN_Final.pdf.

^xl

“Non-Community Benefit Services Included Under Centennial Care…Outpatient Hospital based Psychiatric Services and Partial Hospitalization Outpatient and Partial Hospitalization in Freestanding Psychiatric Hospital.” Id. at 385. “Alternative Benefit Plan Services Included Under Centennial Care…Drug/alcohol dependency treatment services, including outpatient detoxification, therapy, partial hospitalization and intensive outpatient program (IOP) services … Specialized Behavioral Health services for adults: Intensive Outpatient Programs (IOP), Assertive Community Treatment (ACT) and Psychosocial Rehabilitation (PSR).” Id. at 397–399.

^xli

“Non-Community Benefit Services Included Under Centennial Care…Inpatient Hospitalization in Freestanding Psychiatric Hospitals Institutions for Mental Disease (IMD) for SUD only.” Id. at 384.

^xlii

“Non-Community Benefit Services Included Under Centennial Care…Recovery Services (Behavioral Health).” Id. at 385. “Alternative Benefit Plan Services Included Under Centennial Care…Drug/alcohol dependency treatment services, including outpatient detoxification, therapy, partial hospitalization and intensive outpatient program (IOP) services." Id. at 397.

xliii: “Non-Community Benefit Services Included Under Centennial Care…Peer Support Services.” Id. at 385.

^xliv

“Non-Community Benefit Services Included Under Centennial Care…Medication Assisted Treatment for Opioid Dependence.” Id. at 385.

^xlv

“K.1 PREPAID BENEFIT PACKAGE…33. SUD Outpatient (Includes outpatient clinic; outpatient rehabilitation; and opioid treatment).” Medicaid Advantage Model Contract, N.Y. DEPT. OF HEALTH, K-1 – K-7 (2019), https://www.health.ny.gov/health_care/medicaid/redesign/docs/mrt90_medicaid_advantage_model_contract.pdf.

^xlvi

“h) Partial Hospitalization The Contractor shall commence covering this benefit on the effective date of Behavioral Health Benefit Inclusion. Provides active treatment designed to stabilize and ameliorate acute systems, serves as an alternative to inpatient hospitalization, or reduces the length of a hospital stay within a medically supervised program by providing the following: assessment and treatment planning; health screening and referral; symptom management; medication therapy; medication education; verbal therapy; case management; psychiatric rehabilitative readiness determination and referral and crisis intervention. These services are certified by OMH under 14 NYCRR Part 587.” Id. at K-39. 33. “SUD Outpatient Services a) Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic Programs Medically Supervised Ambulatory Chemical Dependence Outpatient Clinic Programs are licensed under Title 14 NYCRR Part 822 to deliver service to individuals who suffer from chemical abuse or dependence and/or their family members or significant others. Such services may be provided at the certified site or in the community include and provide chemical dependence outpatient treatment (including intensive outpatient services) and continuing care treatment. b) Medically Supervised Chemical Dependence Outpatient Rehabilitation Programs Medically Supervised Chemical Dependence Outpatient Rehabilitation Programs provide outpatient rehabilitation services for individuals with more chronic SUD conditions and emphasize development of basic skills in prevocational and vocational competencies, personal care, nutrition, and community competency. The individual must have an adequate support system and either substantial deficits in interpersonal and functional skills or health care needs requiring attention or monitoring by health care staff. These services are provided in combination with all other clinical services provided by CD-OPs. Programs are certified by OASAS as Chemical Dependence Outpatient Rehabilitation Programs under Title 14 NYCRR § 822. c) Outpatient Chemical Dependence for Youth Programs Outpatient Chemical Dependence for Youth Programs (OCDY) licensed under Title 14 NYCRR Part 823, establishes programs and service regulations for OCDY programs. OCDY programs offer discrete, ambulatory clinic services to chemically dependent youth in a treatment setting that supports abstinence from chemical dependence (including alcohol and substance abuse) services…..” Id. at K-32.

xlvii: “K.1 PREPAID BENEFIT PACKAGE…31. SUD Inpatient Rehabilitation and Treatment Services… 32. SUD Residential Addiction Treatment Services.” Id. at K-1 – K-7.

xlviii: “K.1 PREPAID BENEFIT PACKAGE…31. SUD Inpatient Rehabilitation and Treatment Services… 32. SUD Residential Addiction Treatment Services.” Id.

^xlix

“K.1 PREPAID BENEFIT PACKAGE… 30. SUD Inpatient Detoxification Services… 34. SUD Medically Supervised Outpatient withdrawal.” Id. “34. SUD Medically Supervised Outpatient Withdrawal[:] The Contractor shall commence covering this benefit on the effective date of Behavioral Health Benefit Inclusion. These programs offer treatment for moderate withdrawal on an outpatient basis. Required services include, but are not limited to: medical supervision of intoxication and withdrawal conditions; bio-psychosocial assessments; individual and group counseling; level of care determinations; discharge planning; and referrals to appropriate services. Maintenance on methadone while a patient is being treated for withdrawal from other substances may be provided where the provider is appropriately authorized. Medically Supervised Outpatient Withdrawal services are provided by facilities licensed under 14 NYCRR §816.7.” Id. at K-42.

“56. Peer Supports– [Applicable to HARP and HIV SNP Programs Only] Peer Support services are peer-delivered rehabilitation and recovery services designed to promote skills for coping with and managing behavioral health symptoms while facilitating the utilization of natural resources and the enhancement of recovery-oriented principles (e.g. hope and self-efficacy, and community living skills). Peer supports may be provided in a variety of settings, including inpatient, outpatient, community, and respite programs. Peer support providers must be certified as either an OMH-established Certified Peer Specialist or a OASAS-established Peer Advocate. Peer support uses trauma-informed, non-clinical assistance to achieve long-term recovery from behavioral health issues. The structured, scheduled activities provided by this service emphasize the opportunity for peers to support each other in the restoration and expansion of the skills and strategies necessary to move forward in recovery. Persons providing these services will do so through the paradigm of the shared personal experience of recovery.” Id. at K-52.

^li

“d) Opioid Treatment Program (OTP) The Contractor shall commence covering this benefit on the effective date of Behavioral Health Benefit Inclusion. Opioid Treatment Program (OTP) means one or more OASAS certified sites where methadone or other approved medications are administered to treat opioid dependency, following one or more medical treatment protocols as defined by 14 NYCRR Part 822. OTPs may provide patients with any or all of the following: Opioid detoxification; Opioid medical maintenance; and Opioid taper. The term “OTP” encompasses medical and support services at the certified site or in the community including counseling, educational and vocational rehabilitation. OTP also includes the Narcotic Treatment Program (NTP) as defined by the federal Drug Enforcement Agency (DEA) in 21 CFR Section 1301. Facilities that provide opioid treatment do so as their principal mission and are certified by OASAS under 14 NYCRR Part 822.” Id. at K-43.

^lii

“The following services are covered: • Behavioral health rehabilitation services (BHRS) (children and adolescent) • Clozapine (Clozaril) support services • Drug and alcohol inpatient hospital-based detoxification services (adolescent and adult) • Drug and alcohol inpatient hospital-based rehabilitation services (adolescent and adult) • Drug and alcohol outpatient services • Drug and alcohol methadone maintenance services • Family based mental health services • Laboratory (when related to a behavioral health diagnosis and prescribed by a behavioral health practitioner) • Mental health crisis intervention services • Mental health inpatient hospitalization • Mental health outpatient services • Mental health partial hospitalization services • Peer support services • Residential treatment facilities (children and adolescent) • Targeted case management services.” (Healthchoices Agreement, PA DEPT. OF HUM. SERVS., 61 (2021), https://www.dhs.pa.gov/HealthChoices/HC-Services/Documents/HC%20Agreement%202021.pdf. 3”2. SUD Residential Addiction Services The Contractor shall commence covering this benefit on the effective date of Behavioral Health Benefit Inclusion. Residential addiction services include individual centered residential services consistent with the individual’s assessed treatment needs, with a rehabilitation and recovery focus designed to promote skills for coping with and managing substance use disorder symptoms and behaviors. These services are designed to help individuals achieve changes in their substance use disorder behaviors. Services also address an individual’s major lifestyle, attitudinal, and behavioral problems that have the potential to undermine the goals of treatment. These programs are certified under 14 NYCRR Part 820.” Id. at K-42.

^liii

“The BH-MCO may, however, choose to purchase such services in lieu of or in addition to an in-plan service…. Partial hospitalization for drug and alcohol dependence/addiction; …Targeted drug and alcohol case management and Intensive Outpatient Services;… Adult residential treatment (including long term structured residences and residential treatment facilities for adults); …Drug and alcohol prevention/intervention services, including student assistance programs;” Id. at U-2.

^liv

^lv

^lvi

^lvii

lviii: “The Contractor shall provide coverage for services at the most appropriate levels of care based on the Department’s criteria defined in 12VAC30–130-5000 et al and the ARTS Provider Manual, which includes … SUD outpatient services by licensed or credentialed staff through the Department of Health Professions (DHP). (p. 143, 2020–21 Medallion 4.0 Virginia Managed Care Contract). SUMMARY OF COVERED SERVICES - PART 2 C - ADDICTION AND RECOVERY TREATMENT SERVICES (ARTS)… Outpatient ARTS Individual, Family, and Group Counseling Services.” Medallion 4.09 Managed Care Services Agreement, COMMONWEALTH OF VA. DEPT. OF MEDICAL ASSISTANCE SERVS., 353 (2020–21).

^lix

“SUMMARY OF COVERED SERVICES - PART 2C - ADDICTION AND RECOVERY TREATMENT SERVICES (ARTS) …. ARTS Partial Hospitalization …. ARTS Intensive Outpatient.” Id. at 351.

^lx

“The Contractor shall provide coverage for services at the most appropriate levels of care based on the Department’s criteria defined in 12VAC30–130-5000 et al and the ARTS Provider Manual, which includes inpatient detoxification services provided in an acute care hospital settings licensed by the Virginia Department of Health (VDH); residential treatment services provided in a facility licensed by DBHDS…” Id. at 143. “SUMMARY OF COVERED SERVICES - PART 2C - ADDICTION AND RECOVERY TREATMENT SERVICES (ARTS)… INPATIENT AND RESIDENTIAL SUD TREATMENT SERVICES.” Id. at 351.

^lxi

“The Contractor shall provide coverage for services at the most appropriate levels of care based on the Department’s criteria defined in 12VAC30–130-5000 et al and the ARTS Provider Manual, which includes inpatient detoxification services provided in an acute care hospital settings licensed by the Virginia Department of Health (VDH); residential treatment services provided in a facility licensed by DBHDS…” Id. at 143. SUMMARY OF COVERED SERVICES - PART 2C - ADDICTION AND RECOVERY TREATMENT SERVICES (ARTS)… INPATIENT AND RESIDENTIAL SUD TREATMENT SERVICES.” Id. at 351.

^lxii

“SUMMARY OF COVERED SERVICES - PART 2C - ADDICTION AND RECOVERY TREATMENT SERVICES (ARTS) …. Medically Monitored Intensive Inpatient Services.” Id.

lxiii: SUMMARY OF COVERED SERVICES - PART 2C - ADDICTION AND RECOVERY TREATMENT SERVICES (ARTS) …. Peer Recovery Supports. Id. at 253.

^lxiv

“The Contractor shall require all ARTS Intensive Outpatient Program, Partial Hospitalization Programs, and Residential Treatment Providers ensure that Medicaid members with an Opioid Use Disorder admitted to any of these programs have access to evidence-based and FDA-approved medication-assisted treatment, including buprenorphine, methadone, or naltrexone.” Id. at 146.

^lxv

“Medicaid State Plan SUD services include: … Outpatient Services (1.0 ASAM^® Level of Care); … (p. 162). MCO Covered Behavioral Services for West Virginia Health Bridge…Behavioral Health Outpatient Services…Hospital Services, Inpatient – Behavioral Health and SUD Stays…Substance Use Disorder (SUD) Services.” STATE FISCAL YEAR 2021 MODEL PURCHASE OF SERVICE PROVIDER AGREEMENT BETWEEN STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES BUREAU FOR MEDICAL SERVICES AND (MANAGED CARE ORGANIZATION), STATE OF W.V. DEPT. OF HEALTH & HUM. SERVS., A-15 – A-16 (2021), https://dhhr.wv.gov/bms/Members/Managed%20Care/Documents/Contracts/WV_SFY21_MCO_Model_Contract_final%20v7%207–10-20%20CleanSLH.pdf.

^lxvi

“10.11.3.1 Medicaid State Plan SUD Services Medicaid State Plan SUD services include:… • Intensive Outpatient Services (2.1 ASAM^® Level of Care); • Partial Hospitalization Services (2.5 ASAM^® Level of Care).” Id. at 162.

lxvii: “MCO Covered Behavioral Services for West Virginia Health Bridge…Behavioral Health Outpatient Services…Hospital Services, Inpatient – Behavioral Health and SUD Stays…Substance Use Disorder (SUD) Services.” Id. at A-15 – A-16. “Medicaid Benefits Covered Under Fee-For-Service (FFS) Medicaid…Opioid Treatment Program services under the Substance Use Disorder (SUD) Services 1115 waiver.” Id. at A-19). “Medicaid State Plan SUD services include: … • Medically Monitored Intensive Inpatient Services (3.7 ASAM^® Level of Care); • Medically Managed Intensive Inpatient Services (4.0 ASAM^® Level of Care); …” Id. at 162.

lxviii: "10.11.3.1 Medicaid State Plan SUD Services Medicaid State Plan SUD services include:… • Medically Monitored Intensive Inpatient Services (3.7 ASAM^® Level of Care); • Medically Managed Intensive Inpatient Services (4.0 ASAM^® Level of Care); • Ambulatory Withdrawal Management Services (1-WM & 2-WM ASAM^® Level of Care); • Medically Monitored Inpatient Withdrawal Management Services (3.7-WM ASAM^® Level of Care); and • Non-Methadone Medication Assisted Treatment (MAT).” Id. at 162.

^lxix

“10.11.3.2 SUD Demonstration Waiver Services SUD 1115 demonstration waiver services include: • Peer Recovery Support Services (1.0 ASAM^® Level of Care) (p. 162). 10.11.3.3 Peer Recovery Support Services. Peer recovery support services are designed and delivered by individuals called Peer Recovery Support Specialists who are in recovery from SUD. These Peer Recovery Support Specialists provide counseling support to help prevent relapse and promote recovery. Services must be provided by appropriately trained staff when working under the supervision of a competent behavioral health professional, as defined by the State. A Peer Recovery Support Specialist must be certified as outlined in the West Virginia Medicaid Provider Manual, Chapter 504. BMSapproved training program provides Peer Recovery Support Specialists with a basic set of competencies necessary to perform the peer support function. The Peer Recovery Support Specialist must demonstrate the ability to support the recovery of others from SUD. Similar to other provider types, ongoing continuing educational requirements for Peer Recovery Support Specialists must be in place” Id. at 163.

^lxx

“10.3 Behavioral Health Covered Services. The MCO covered behavioral services must be rendered by providers within the scope of their license and in accordance with all State and Federal requirements. Behavioral services include: mental health outpatient services, mental health inpatient services, SUD outpatient services (including but not limited to pharmacologic management and including methadone treatment), targeted case management, behavioral health rehabilitation and clinic services, and psychiatric residential treatment services. The MCO must follow BMS FFS policies specific to the drug testing limit requirements contained in Chapter 529 of the WV Medicaid Provider Manual for drug screening services. The MCO may implement its own prior authorization requirements for these services.” Id. at 159.

Footnotes

Supplementary material. The supplementary material for this article can be found at http://doi.org/10.1017/amj.2023.35.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix

NIHMS1995170-supplement-Appendix.pdf^{(354.5KB, pdf)}

[R1] 1.U.S. Dep’t Health & Hum. Servs., Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health 30 (2021), https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf. [Google Scholar]

[R2] 2.Compare Overdose Death Rates, Nat’l Insts. Health (Jan. 20, 2022), https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates (92,000 drug-overdose deaths) [https://perma.cc/R8VF-6BX5] with All Injuries, Ctrs. for Disease Control & Prevention (Sept. 6, 2022), https://www.cdc.gov/nchs/fastats/injury.htm (40,698 traffic fatalities) [https://perma.cc/UR92-MGUE]. [Google Scholar]

[R3] 3.U.S. Overdose Deaths in 2021 Increased Half as Much as in 2020 – But Are Still Up 15%, Ctrs. for Disease Control & Prevention (May 11, 2022), https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/202205.htm [https://perma.cc/X7DX-WPNB]. [Google Scholar]

[R4] 4.Luo Feijun et al. , State-Level Economic Costs of Opioid Use Disorder and Fatal Opioid Overdose — United States, 2017, 70 Morbidity & Mortality Wkly. Rep. 541, 543 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]

[R5] 5.See, e.g., Carlos Blanco & Nora D. Volkow, Management of Opioid Use Disorder in the USA: Present Status and Future Directions, 393 Lancet 1760, 1762, 66 (2019). [DOI] [PubMed] [Google Scholar]

[R6] 6.See, e.g., Pia M. Mauro et al., Use of Medication for Opioid Use Disorder among US Adolescents and Adults with Need for Opioid Treatment, 2019, 5 JAMA Network Open 1, 1–14 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]

[R7] 7.See, e.g., Matthew A. Davis et al., Prescription Opioid Use among Adults with Mental Health Disorders in the United States, 30 J. Am. Bd. Fam. Med 407, 412 (2017), https://www.jabfm.org/content/30/4/407 [https://perma.cc/X7AR-LJ5E]; [DOI] [PubMed] [Google Scholar]

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PERMALINK

How Does Medicaid Managed Care Address the Needs of Beneficiaries with Opioid Use Disorders? A Deep Dive into Contract Design

Rebecca Morris

Sara Rosenbaum

Colleen Grogan

Meredith Rhodes

Christina Andrews

Abstract

Introduction

The magnitude of the OUD public health crisis

Medicaid and OUD Treatment

Medicaid managed care and contracts on which managed care rests

Methods

Results

Table I.

Discussion

Supplementary Material

Acknowledgments

Biographies

Appendix

Appendix Table II.

Footnotes

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Cite

Add to Collections

PERMALINK

How Does Medicaid Managed Care Address the Needs of Beneficiaries with Opioid Use Disorders? A Deep Dive into Contract Design

Rebecca Morris

Sara Rosenbaum

Colleen Grogan

Meredith Rhodes

Christina Andrews

Abstract

Introduction

The magnitude of the OUD public health crisis

Medicaid and OUD Treatment

Medicaid managed care and contracts on which managed care rests

Methods

Results

Table I.

Discussion

Supplementary Material

Acknowledgments

Biographies

Appendix

Appendix Table II.

Footnotes

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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