By Jeffrey H. Brochin, J.D.
Although the federal government has identified expanding access to MAT as important for reducing opioid use disorders and overdoses, some states’ prior authorization requirements necessitate pre-approval for coverage.
The Government Accountability Office (GAO) has issued a report to Congress on the barriers that exist to Medicaid beneficiaries’ access to treatment medications that have proven effective in reducing opioid use disorders (OUDs). A 2018 study disclosed that about 40 percent of states may not provide Medicaid coverage for some formats of medication-assisted treatment (MAT) medications, such as injectable and implantable formats, as required by federal law (GAO Report, GAO-20-233, January 24, 2020).
Medication-assisted treatment. MAT is a method of treating OUD that combines behavioral therapy and the use of certain medications, such as buprenorphine, and has been shown to be effective at reducing the misuse of or addiction to opioids and in increasing treatment retention. The federal government has identified expanding access to MAT as important for reducing opioid use disorders and overdoses, and has taken action to increase access. The Medicaid program provides health coverage to an estimated 75 million low-income and medically needy individuals is one of the largest sources of federal funding of health care services for individuals with OUD, including the provision of MAT.
States’ Medicaid programs have flexibility in how they design their programs and can therefore vary in how MAT medications are covered and distributed, such as through retail pharmacies. However, little information exists on how different distribution methods may affect beneficiaries’ access to the medications.
Why GAO conducted the study. Almost 70,000 people died from drug overdoses in 2018, and an estimated 69 percent of those involved opioids. CMS has not determined the extent to which states are in compliance with the federal requirements to cover MAT medications, and therefore Congress included a provision in the Medicaid statute for the GAO to review access barriers to MAT medications, including the distribution methods. The report describes policies that can restrict Medicaid beneficiaries’ access to MAT medications, including any related to the distribution methods.
How the study was conducted. The GAO reviewed relevant laws, policies, and documents, as well as studies describing access barriers and the benefits and challenges of the distribution methods. The GAO also interviewed federal officials; stakeholders representing state Medicaid directors, health care providers, patients, and pharmacies; and state officials and health care providers from Minnesota, North Carolina, and Ohio, as well as the District of Columbia. The GAO selected those three states and the District of Columbia, based on their Medicaid programs’ coverage of the MAT medications, their programs’ spending for the treatment of opioid use disorder, and other criteria. The study was conducted from February 2019 to January 2020.
What the study found. The report found that some MAT medications and formats are subject to prior authorization, which requires the medications to be pre-approved before being covered by Medicaid. While those requirements are generally used to reduce expenditures, unnecessary utilization, and improper payments, stakeholders told the GAO that such requirements may cause life-threatening delays in the case of MAT medications. Some states, including the three states and the District of Columbia that the GAO reviewed, have taken steps to remove prior authorization requirements for MAT medications.
States may individually mandate the ways MAT medications can be distributed. For example, Minnesota’s fee-for-service plan requires the use of the buy-and-bill distribution method for all injectable and implantable medications. That method requires providers, such as physicians, to purchase and store these medications until administered to the patient, allowing immediate access to the MAT medication for Medicaid beneficiaries. However, for expensive injectable medications, which can cost $1,200 per treatment, that method places providers at financial risk if the medication is not used or the reimbursement is less than the providers’ costs, requiring resources some providers may lack. As a result, some states have removed such restrictions to maximize beneficiary access.
According to stakeholders the GAO interviewed, some providers are unwilling to obtain the federal waiver necessary to prescribe or administer buprenorphine for opioid use disorder—due to reasons such as the hours of training associated with the waiver—which can restrict beneficiary access to that MAT medication. In addition, while nurse practitioners and physician assistants are eligible for those waivers, some state laws require them to be supervised by a physician.
Recommendations and response. The GAO report recommended that CMS determine the extent to which states are in compliance with federal requirements to cover MAT medications, and take action as appropriate. HHS concurred with the GAO’s recommendation.
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