State Approaches to Addressing the Opioid Epidemic: Findings from a Survey of State Medicaid Programs

Opioid overdoses rose to 81,051 in 2022, a slight build up from 80,411 in 2021, however a considerable 63% soar from 2019 (49,860). The pointy upward thrust lately is principally because of fentanyl, because the illicit supply of this drug has risen considerably. Particularly, rises in overdose deaths were specifically sharp amongst people of color and young people. Including to those information, contemporary KFF polling presentations that 29% of adults say both they or a circle of relatives member have skilled an opioid dependancy. 3 medicines for opioid use dysfunction (MOUD) are FDA licensed: methadone, buprenorphine, and naltrexone. Beneath the SUPPORT Act (primary law handed in 2018 to handle the opioid epidemic) those medicines should be covered by Medicaid via 2025. Many provisions of the SUPPORT Act expired in September 2023 and Congress continues to discuss law to reauthorize some expiring provisions and undertake new insurance policies to handle the opioid epidemic. There are a number of efforts on the state point to handle the epidemic. State Medicaid methods play a specific position within the opioid epidemic, protecting just about 40% of people with opioid use dysfunction (OUD).

To raised know the way states are the usage of Medicaid to lend a hand deal with the opioid epidemic, the twenty third annual Medicaid budget survey, carried out by means of KFF and Well being Control Buddies (HMA) requested concerning the following particular methods followed or deliberate by means of state Medicaid officers for state fiscal years (SFYs) 2023 and 2024 to handle the opioid epidemic: putting off prior authorization for buprenorphine (a drugs remedy for OUD), reimbursing for the initiation of buprenorphine remedy by means of telehealth, protecting over the counter (OTC) Narcan, and imposing different tasks. Key takeaways come with:

• Maximum states have got rid of prior authorization necessities for positive buprenorphine therapies, however different obstacles stay and are sophisticated by means of the fentanyl epidemic. Prior authorization necessities for same old buprenorphine remedy have reduced considerably lately, however different hurdles, reminiscent of counseling mandates or prior authorization necessities for upper doses—probably essential for treating individuals who used fentanyl—nonetheless stay.
• Maximum Medicaid methods duvet buprenorphine induction by means of telehealth, however this coverage relies on evolving federal laws. Over three-quarters of states supply fee-for-service (FFS) repayment for buprenorphine induction over telehealth, however the way forward for this coverage is topic to evolving federal laws on prescribing managed components by means of telehealth.
• No less than one-third of states have or plan so as to add OTC Narcan to FFS Medicaid OTC formularies. One-third of states commented on plans or movements so as to add over-the-counter Narcan to their state’s FFS formularies. Higher accessibility can be impacted by means of efficient Medicaid communique about OTC repayment insurance policies and procedures.
• A lot of states are pursuing choices so as to add pre-release Medicaid protection for incarcerated populations. On the time of the survey, two states secured CMS approval to offer Medicaid protection to incarcerated folks earlier than launch, together with OUD remedy. As of January 2024, two states (California and Washington) have bought CMS approval, and 15 different states have waivers pending.

Opioid Use Dysfunction Remedy with out Prior Authorization

Medicaid methods must cover medicines to regard OUD, like buprenorphine and methadone, however the true get entry to to those medicines might range for numerous causes, together with utilization management methods reminiscent of prior authorization (PA) that fluctuate throughout Medicaid FFS methods and managed care organizations (MCO). In states with out PA, sufferers can have longer buprenorphine remedy episodes, and Medicare data means that putting off PA can scale back health facility and emergency division use. Despite the fact that quite a few states have enacted rules prohibiting PA for medicines to regard OUD, many have now not, leaving PA coverage choices as much as the state Medicaid methods and on occasion their shriveled well being plans.

As of SFY 2024, maximum states now not require prior authorization for a minimum of one same old formula of buprenorphine medicine remedy beneath fee-for-service (FFS), reflecting a coverage shift lately. As of SFY 2024, just about all states duvet a minimum of one same old formula and dosage of oral buprenorphine, reminiscent of buprenorphine-naloxone, with out PA (Determine 1). Only some years in the past, in 2018, MACPAC reported that 30 states required PA for buprenorphine-naloxone, however as of SFY 2024, just a small choice of Medicaid methods nonetheless have that requirement for a minimum of one same old formula or dosage. Many states impose PA necessities on non-standard forms of buprenorphine, reminiscent of upper doses or buprenorphine monotherapy, and PA necessities might range throughout Medicaid managed care organizations inside of a state. Categorizing prior authorization coverage is advanced because of impulsively evolving insurance policies and variations in prior authorization necessities that may range throughout dosing, formulations, and populations.

Even if maximum states got rid of prior authorization necessities for positive buprenorphine therapies, enrollees might nonetheless stumble upon ongoing and rising obstacles, together with insurance policies that experience now not but tailored to the unfold of the stronger fentanyl. Whilst many states got rid of prior authorization for particular buprenorphine formulations, they frequently take care of prior authorization for upper doses. But, some physicians report that upper dosing is also essential for sufferers with a historical past of fentanyl use, and research presentations that upper dosing has implications for remedy retention. Past prior authorization insurance policies, some states impose other criteria reminiscent of urine screening necessities, amount limits, and counseling mandates—further restrictions that can have an effect on get entry to to or retention in care. Supplier repayment charges may additionally play a job in attracting workforce to offer services and products.

Protection of Buprenorphine Remedy Initiation by means of Telehealth

All the way through the COVID-19 Public Well being Emergency (PHE), the Drug Enforcement Management (DEA) temporarily relaxed federal regulations to permit sufferers to start out buprenorphine remedy for OUD by means of telehealth, getting rid of the preliminary in-person discuss with requirement. This variation boosted access and retention in care with out expanding buprenorphine-related overdoses, and can have additionally helped to mitigate workforce shortages. Whilst most states expanded telehealth protection for behavioral well being services and products in each FFS and controlled care methods all the way through the PHE, the level of telehealth protection for buprenorphine remedy varies by means of state, as Medicaid methods in my view set their telehealth insurance policies, so long as they’re aligned with federal and state coverage. Just lately, the DEA, collectively with the Division of Well being and Human Products and services, approved a 2d temporary extension of COVID-19 telemedicine flexibilities, which continues the pandemic-era insurance policies that let managed substance prescribing with out an preliminary in-person discuss with in the course of the finish of 2024.

Over three-quarters of states reported protecting buprenorphine induction by means of telehealth beneath fee-for-service in SFY 2023. Then again, six states didn’t permit this protection, and one state reported plans to discontinue protection. The continuation of this coverage relies on federal regulations touching on telehealth and prescribing of managed components. All the way through the pandemic, federal laws have been comfortable to facilitate remedy get entry to, permitting buprenorphine to be prescribed by means of telehealth with out an in-person discuss with–a short lived measure set to expire on December 31^st 2024. Then again, state policies can nonetheless mandate in-person visits, probably complicating remedy get entry to in the ones states.

Protection of Over-the-Counter Narcan

Naloxone, often referred to as Narcan, a life-saving medicine that may opposite opioid overdoses, is now to be had over the counter as a nasal spray. Whilst the FDA has licensed two versions of OTC Narcan, just one is these days to be had in pharmacies. Its ticket, kind of $45 for a 2-dose, 4mg nasal spray, is also unaffordable for individuals who lack OTC insurance policy together with Medicaid enrollees in states that experience now not added OTC Narcan to their Medicaid OTC formularies and/or required their MCOs to take action. To acquire federal matching budget, federal Medicaid legislation additionally calls for Medicaid enrollees to procure a prescription for lined OTC merchandise – some other hurdle that can hinder get entry to. The newest KFF finances survey requested states about their methods to make stronger enrollee get entry to to OTC Narcan and plenty of states introduced feedback referring to their protection or deliberate protection of OTC Narcan.

About one-third of states reported that that they had added or deliberate so as to add OTC Narcan to their state’s OTC formularies. That is most probably an undercount of states these days protecting OTC Narcan as now not all states selected to in particular touch upon their Medicaid protection coverage. Along with including OTC Narcan to their formularies, Massachusetts commented that Narcan is exempt from Medicaid copay necessities and California discussed the state’s Naloxone Distribution Mission ships loose naloxone without delay to eligible entities reminiscent of legislation enforcement, colleges, group organizations, and town, county, and Tribal organizations. Different states discussed standing order insurance policies or different tasks that make it more straightforward for pharmacists to dispense Narcan. Despite the fact that those insurance policies may make it more straightforward for enrollees to get entry to OTC Narcan, factors reminiscent of transparent enrollee communique concerning the repayment for OTC Narcan, the place Narcan is positioned in shops, and Narcan get entry to for members of the family may additionally play a job in its total accessibility.

Different State Tasks

States have been requested about different Medicaid tasks to struggle the opioid epidemic.

Probably the most often discussed initiative was once the pursuit of Segment 1115 Demonstration Waiver authority to hide OUD services and products for inmates previous to launch. On the time of the survey, two states bought CMS approval (California and Washington) and 14 states had waiver requests beneath assessment for those demonstration projects beneath phase 1115, which allows Medicaid methods to offer services and products earlier than inmate launch (together with OUD remedy). As of January 2024, two states have approvals and an extra 15 states have re-entry waiver requests beneath CMS assessment. Following launch from jail, folks face a considerably upper possibility of overdose and demise, essentially from opioids, with a learn about in a single state appearing a 40 times higher possibility of opioid overdose within the first two weeks after launch in comparison to most people. In states that expanded Medicaid, most individuals just lately launched from jail meet source of revenue and eligibility necessities for Medicaid protection, however the Medicaid Inmate Exclusion Policy beneath federal Medicaid legislation prohibits federal bucks from paying for well being care services and products of inmates generally. CMS guidance calls for that states searching for pre-release waivers should duvet medication-assisted remedy, however different main points range.

States reported different tasks; some which are particular to Medicaid and others which are broader:

• Increasing get entry to to services and products by means of putting off copays, increasing supplier sorts, or adjusting repayment. For instance, Maryland added protection of peer restoration fortify services and products for SUD services and products equipped at particular places and Indiana started to reimburse Opioid Remedy Methods the usage of a weekly bundled charge, reasonably than a in step with diem charge. Extra widely, Medicaid methods are proceeding to develop protection for psychological well being and substance use dysfunction services and products. In FY 2023 and 2024, greater than a 3rd of states reported get advantages improvements or additions and about three-quarters of states reported will increase or plans to extend, the fee-for-service cost charges for a minimum of one form of behavioral well being supplier.
• Cutting edge methods or answers. Some states are checking out out new supply strategies or leading edge methods. For instance, Delaware submitted a waiver modification to permit protection for contingency management Texas is constant to offer services and products beneath the Maternal Opioid Misuse (MOM) style to offer remedy services and products to pregnant women with OUD. Steadily, state efforts contain collaborations that span throughout a number of state companies. For instance, Arizona is operating to increase get entry to to mobile opioid treatment programs to convey remedy to these in underserved spaces and is partnering with different state companies to coordinate an opioid reaction plan. Vermont has a longstanding method, Hub and Spoke style, to handle OUD that spans a couple of companies.
• Selection opioid remedy or secure opioid prescribing. Different states are running to scale back reliance on prescriptions opioids. For instance, Idaho and Alaska reported specializing in secure opioid prescribing insurance policies and Pennsylvania reported revising prior authorization pointers for opioid prescriptions. Missouri’s well being plans be offering a program supposed to lend a hand supply choices to opioids for the remedy of persistent ache.

Taking a look forward

In spite of contemporary increased access to OUD remedy, a notable remedy hole stays as one-third of recognized Medicaid enrollees don’t seem to be receiving remedy. This factor is particularly acute amongst Black folks, youth, and the ones with disabilities, the place considerable disparities in get entry to to MOUD persist. Behavioral well being workforce shortages, prevalent around the continuum of behavioral well being services and products and supplier sorts, also are found in Medicaid– along side a lack of provider diversity and few culturally competent care choices. Medicaid methods in lots of states are addressing those demanding situations by means of imposing methods to address workforce shortages and by means of the usage of managed care contracts to handle and scale back disparities, with some efforts in particular taken with decreasing disparities in substance use problems. Regulatory government just lately made permanent the pandemic-era coverage that permits opioid remedy sufferers to take house methadone doses, prior to now disbursed simplest onsite.

Each the Area and Senate are engaged in reauthorizing the just lately expired SUPPORT Act, regardless that the end result stays unsure. The Area handed a bill to reauthorize and lengthen the Act, specializing in reauthorizing methods and increasing fortify for prevention and remedy, team of workers tasks, and methods to handle trauma. The Area invoice additionally contains a number of Medicaid-specific measures, reminiscent of making everlasting the requirement that states duvet medicines for opioid use dysfunction, reminiscent of buprenorphine and methadone. Different Medicaid particular provisions come with making the state plan modification strategy to permit cost for remedy in establishments of psychological illness (IMD) everlasting, combating Medicaid disenrollment because of incarceration, and increasing the CMS substance use dysfunction information e book to incorporate psychological well being prerequisites. It additionally proposes classifying Xylazine as a managed substance and reevaluating the drug scheduling for medicines that mix buprenorphine and naloxone (in most cases thought to be decrease possibility). The Senate will quickly debate a separate version of the SUPPORT Act reauthorization, even if the overall main points don’t seem to be but to be had. The Senate HELP Committee additionally marked up some other invoice aimed toward broadening access to methadone by means of extending prescribing privileges to certified practitioners outdoor of federally registered opioid remedy methods and permitting meting out at pharmacies. Additional, the FEND off Fentanyl Act, a invoice that has just lately been attracting consideration, makes a speciality of decreasing the illicit provide of fentanyl.

Broader state-level alternatives and demanding situations are at play in efforts to handle the opioid epidemic. States are deciding tips on how to use opioid settlement funds, however questions about state spending choices and transparency were raised. Whilst some states and counties are using the funds to spend money on remedy for uninsured, increase remedy infrastructure, and build up get entry to to naloxone, some counties have made extra questionable choices–reminiscent of the usage of the agreement budget to plug holes in debt or acquire police patrol vehicles. In the meantime, leading edge state approaches to handle the opioid epidemic have additionally emerged. For instance, Pennsylvania constructed a “warm handoff” program, which gives direct referrals to SUD remedy for overdose survivors, bettering get entry to to care. In a similar way, to struggle overdoses, some states are making an investment budget in installing vending machines stocked with Narcan. In spite of those efforts, some state insurance policies might provide hindrances. For instance, state rules that deal with fentanyl check strips as drug paraphernalia and a lack of protections for those who prescribe or administer Narcan all the way through an overdose might impede growth in decreasing opioid overdoses.

Medicaid unwinding might result in loss or interruptions in protection for people who depend on Medicaid for OUD remedy, probably disrupting their get entry to to essential remedy and lengthening the chance of overdose and demise. The hot resumption of Medicaid renewals following a three-year pandemic halt – ‘Medicaid unwinding’ – has resulted in millions folks shedding Medicaid protection, essentially because of procedural causes. Many of us who lose Medicaid have choice insurance coverage choices. Then again, for individuals who depend on Medicaid to hide OUD remedy, the lack of Medicaid protection may disrupt their get entry to to ongoing OUD treatment. One of these loss might disrupt remedy and increase overdose dangers, particularly in the course of the continued fentanyl crisis this is just lately additional sophisticated by means of rising threats like Nitazenes and Xylazine.