Among women ages 18-35 with a clinical visit in the past two years, more than four in 10 (46%) report experiencing a negative interaction with a health care provider, according to a new analysis of 2022 KFF Women’s Health Survey (WHS) data. These interactions included a provider either dismissing patients’ concerns, assuming something about them without asking, believing they were lying, blaming them for their health problems, or discriminating against them because of their age, gender, race, sexual orientation, religion, or some other personal characteristic.

Similar rates of women in low-income households (45%), uninsured women (46%), and women with a disability or ongoing health condition (45%) experienced at least one of these negative interactions. Negative interactions with health care providers can lead to poorer health outcomes, distrust of the health care system, and health inequities.

Analysts also found some statistically significant differences in the experiences of men and women. Somewhat more women than men report that their health care providers either dismissed their concerns (29% vs. 21%), didn’t believe they were telling the truth (15% vs. 12%) or discriminated against them during their visit (9% vs. 5%).

Additional findings from the analysis include the following:

Menopause received little attention in clinical visits. Only one-third (35%) of women ages 40-64 say their health care provider ever talked to them about what to expect in menopause, ranging from 42% of women who have gone through menopause, 39% of those currently going through menopause, and 19% of premenopausal women.

Screening for social determinants of health is infrequent in clinical settings, despite their impact on the health and wellbeing of patients. While nearly three in five (58%) women who have visited a health care provider in the past two years say they were asked about the kind of work they do, only one in five (20%) were asked about their ability to afford food or their access to reliable transportation.

The KFF WHS is a nationally representative survey of 5,145 self-identified women and 1,225 self-identified men ages 18 to 64, conducted May 10 – June 7, 2022.

Read “Women’s Experiences with Provider Communication and Interactions in Health Care Settings” for more information.

We’ve also released the data note “Many Use Preventive Services, but Not All Women Are Aware of Insurance Coverage Requirements,” which presents findings from the 2022 KFF WHS on women’s receipt of cancer screenings and other preventive services as well as knowledge of insurance coverage requirements for these services.

The Center for Medicare and Medicaid Services (CMS) has issued a proposed rule designed to address the administrative hassles of prior authorization by requiring certain payers to implement an automated process, meet shorter time frames for decision making, and improve transparency. The proposal applies to payer processes mainly in public programs, with more limited application to health insurance marketplaces and no requirements on employer-sponsored coverage. The proposal launches the government’s next step in addressing a longstanding goal to improve health care administration through “interoperable” systems based on the use of standardized protocols for payers and providers across federal health programs. As CMS seeks input on this proposal (as well as five separate requests for information and a separate proposal on prior authorization standards and coverage criteria for Medicare Advantage plans), we can expect that prior authorization and improved data sharing in health care will be front and center in upcoming policy discussions.

What is in the new prior authorization proposal and whom does it apply to?

Insurers use prior authorization to reduce payments for care that is not medically necessary or appropriate, which in turn helps to keep premiums down. However, prior authorization has come under increasing scrutiny for creating unnecessary burdens for providers, plans, and patients. Patients can find it challenging to know what services require prior authorization, the process and criteria plans use to make a prior authorization coverage decision, and whether providers are giving the needed information to a plan to determine coverage. Inefficient processes can delay decisions and consequently access to care, increasing health risks to patients. Improper denials may increase patient out-of-pocket costs or cause patients to abandon care. The process itself may have a chilling effect on individuals seeking out care and providers recommending it.

While some exceptions apply, CMS proposes to add new requirements for the prior authorization process and new timeframes for decision-making that apply to Medicare Advantage plans, Medicaid managed care plans, Medicaid fee-for-service (FFS) plans, Children’s Health Insurance Program (CHIP) managed care and fee-for-service arrangements, and Qualified Health Plans (QHP) on the federally facilitated health insurance marketplace (i.e., healthcare.gov). These payers (essentially insurers and, for Medicaid FFS, states) would have to meet new prior authorization rules that would apply to all items and services except prescription drugs. Most rules would not become effective until 2026. The major changes proposed include requiring these payers to:

Implement a standardized interface for prior authorization. CMS proposed to require affected payers to use a specific Application Programming Interface (API) to allow for more streamlined prior authorization processes. The specific API is called the “Fast Healthcare Interoperability Resources® (FHIR) Prior Authorization Requirements, Documentation, and Decision API” (or PARDD API). APIs generally are procedures that allow different software programs to communicate and share information. The PARDD API would be used to request and obtain information from plans and providers to automate the prior authorization process. Patients could also have access to this information about prior authorization requests and decisions.

Give information to providers about prior authorization status. Impacted payers would be required to send to the relevant provider information on whether a prior authorization request was approved, denied, or whether more information is needed. This information would have to include the specific reason for a denial. Currently some of the affected payers are only required to provide this information to the patient, but these rules would require all affected payers to notify the provider as well. For example, while current Medicaid managed care rules require provider notice, there are not equivalent rules for Medicare Advantage plans.

Provide shorter timeframes for making prior authorization decisions and notice of the decision to patients. Proposed rules would provide shorter timeframes for payers to make a prior authorization decision and provide notice to beneficiaries, aligning this timeframe across certain payers. For instance, timeframes for a standard prior authorization decision notice for Medicare Advantage plans and Medicaid managed care plans would shorten from 14 calendar days to 7 calendar days. No changes are proposed to equivalent timeframes for QHPs on the federal exchange (these would stay at 15 calendar days).

Publicly report specific prior authorization metrics annually. To provide more information about how prior authorization is used, impacted payers would be required to disclose annually on their website a list of all services requiring prior authorization and specific aggregated metrics. Metrics would include, among other items, the percentage of prior authorizations that were approved and denied, the percentage of prior authorization requests approved after appeal, and the average time for a prior authorization determination. The proposal does not require any specific format for the disclosure and none of the metrics call for specifics on the types of health care items and services approved and denied.

What other items are included in the proposal?

The proposal builds on earlier rulemaking, including a May 2020 final rule on interoperability and a now withdrawn interoperability regulation from December 2020. Generally, the proposal would require the information access rules described below to apply to Medicare Advantage plans, Medicaid managed care plans, Medicaid FFS plans, CHIP managed care and FFS arrangements, and Qualified Health Plans (QHP). In certain circumstances, state Medicaid and CHIP FFS programs and QHP issuers can apply for an exception from having to comply.

Patient information access. The May 2020 final rule required that certain payers allow patient electronic access to their own claims and encounter data (as well as some clinical data) through a standardized interface. This was designed to allow patients to share data with their providers and other payers via a health app. The new proposal adds requirements to include information about prior authorization and a requirement to annually report to CMS data about how patients use this Patient Access API.

Provider information access. To support care coordination, CMS proposes requiring affected payers to implement a standardized provider access interface. Providers could then obtain claims and encounter information about patients while they are enrolled in plans from the payer. The proposal also includes making available historic prior authorization decisions, which may reduce the likelihood of ordering duplicate or misaligned services and provide a more complete picture of a patient’s care. Payers must give patients the ability to opt out if they do not want their information exchanged via this interface.

Payer-to-payer data exchange. CMS proposes to change existing requirements that allow the exchange of certain patient information between different payers. In its new iteration, affected payers would be required to use a specific payer-to-payer data exchange standard. This would allow payers to exchange patient information including prior authorization decisions from a patient’s prior health insurer. This, for example, might reduce the burden when a patient must get a new prior authorization because they had to change health plans. The proposal does not include data sharing between payers of provider remittances and enrollee cost sharing, stating that this is “often considered proprietary” and would have limited impact on care. Also, instead of an opt out, the patient must affirmatively opt in to have their data exchanged between payers.

Five Requests for Information. Included in the proposal are five separate Requests for Information that request feedback on data information exchange:

• development of standards for exchange of data on social risk factors (social determinants of health such as housing and food security);
• use of APIs to facilitate electronic exchange of data for behavioral health services, a segment of health care that has lagged behind in electronic data exchange;
• electronic exchange of information in traditional Medicare with non-hospital providers (such as suppliers of durable medical equipment);
• improvement of prior authorization processes in maternal health across the care continuum, including the process for obtaining obstetric ultrasound and the use of a single authorization when a pregnant individual changes health plans; and
• methods to increase adoption of the Trusted Exchange Framework, a set of principles for guiding data exchange policies and practices.

What are some of the key policy issues?

CMS estimates that the proposed APIs and other changes will create administrative efficiencies that could save providers more than $15 billion over 10 years (2026 to 2035). The use of new technology to streamline processes could carry both benefits and burdens. Key issues to evaluate include:

• How will new electronic processes affect the patient experience in accessing care and information about cost and coverage? One policy issue implicated in these rules is whether reduced administrative burdens for providers means a better experience for patients. Are consumers able to take advantage of new technologies easily or will this create new action items that they will have to undertake on their own for the first time? Will patients without access to information through these proposed APIs be at a disadvantage under a new “modernized” prior authorization system? CMS does propose to require affected payers to provide educational materials to consumers about the new API functionality. Also, while the rules will require payers to allow consumers to use health apps to access their own information, there is no requirement to make these apps available. What incentive do payers and third-party developers have to offer these tools to consumers and encourage their use? Despite the potential for positive impact from automation through electronic processes, payers and providers have been slow to take up even the existing electronic data standard (ASC X12N 278) that might improve prior authorization processes.
• What are the risks to patients once more of their data is available electronically? As more patient data is accessible electronically via health apps, risks increase of security breaches, compromised confidentiality of health information, and inappropriate use of patient data for marketing. While payers are subject to HIPAA privacy protections, once information is in the hands of a third-party application developer, it may not have the same federal legal protections. Additionally, other federal rules prohibit providers and other entities from blocking consumer access to certain clinical information. There may be tension between the goal of broader access to information to improve care and patient knowledge of costs and coverage and the risk of inappropriate use for other purposes. These issues will likely be taken into consideration as HIPAA and other federal privacy protections are potentially revised and updated, and oversight of health apps by the Federal Trade Commission and the Food and Drug Administration moves forward.
• In addition to API technology, are there other ways to address administrative problems concerning prior authorization? Movement away from reliance on manual processes for prior authorization (phone, fax mail) will likely improve speed and coordination, but there may be additional ways to address prior authorization challenges. For example, the CMS proposal also seeks input on the use of “gold carding” designed to reduce the amount of prior authorization requests overall. Gold carding uses data about a provider’s record for compliance with prior authorization requests in the past and their patterns of utilization of specific services. Providers who meet threshold standards may be designated as gold card providers and exempt from some or all prior authorization requirements, resulting in the services they prescribe being subject to prior authorization less often.
• How useful is the structure of new transparency reporting to provide accessible and actionable information about prior authorization? One area to evaluate is whether standardized mechanisms and formats for reporting data are more useful for regulators and the public to assess how prior authorization is working across payers. Are there alternative disclosure mechanisms to this CMS proposal to require non-standardized information be placed on each insurer website? For example, it may be easier to compare the types of services subject to prior authorization by payer if payers provide the information in a standardized format and in a standard location on an insurer website or publicly posted by CMS, though this would be more prescriptive. Another issue is the level of aggregation of the data payers must report about prior authorization, and whether it is enough to make an objective assessment about whether the prior authorization process is a barrier to receipt of specific types of care. Similar questions apply for existing ACA transparency reporting, which indicates that for plans offered on HealthCare.gov, roughly 9% of these marketplace plan denials for in-network claims relate to prior-authorization or referrals but with no other detail explaining differences in denial rates for this reason among plans, or the nature of claims subject to such denials.
• What are the consequences of having API standards that do not apply to all payers? The promise of a more connected health system will likely require similar standards across plans, but the proposal does not reach the more than 150 million Americans in employer-sponsored coverage. While nothing prevents employers and issuers from adopting the same efficiencies and standards for employer coverage voluntarily, currently they can do this without a requirement to add consumer protections such as opt ins or opt outs for patients to control the disclosure of information or without requirements for patient education about how their data is used. Also, the proposal does not apply to traditional Medicare – which generally does not use prior authorization — but CMS has included in one of the new RFI’s questions about current and future use of APIs for this population to streamline the exchange of information for care coordination and other processes.
• To what extent are the coverage criteria used to make prior authorization decisions a barrier to receipt of medically necessary care, and what would be the cost implications of changing or regulating those criteria? This proposal does not address the criteria used by payers to make prior authorization determinations. These issues could prove to be just as important as efforts to improve the efficiency of the prior authorization process. CMS has proposed a Medicare Advantage regulation to address and change standards about the criteria used to make coverage decisions, including prior authorization. For example, CMS has proposed to clarify that Medicare Advantage plans must follow the same coverage guidelines that traditional Medicare uses to make medical necessity decisions. In addition, plans can only use internal or proprietary clinical criteria for medical necessity decisions if they are based on evidence-based guidelines made publicly available to CMS, enrollees, and providers. Any loosening of prior authorization criteria would increase access to care, but also potentially have cost and premium implications.

The Medicaid and CHIP Payment and Access Commission (MACPAC) recently started work on a new project examining denials and appeals in Medicaid managed care. In 2023, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is expected to release findings from audits conducted to determine whether Medicaid managed care organizations were in compliance with federal requirements when issuing denials of requested care that required prior authorization.

A recent KFF analysis of Medicare Advantage plans shows how widely prior authorization is used. In 2021 alone, Medicare Advantage plans made 35 million requests for prior authorization. As the federal government starts to assess how prior authorization is used across a broader set of health insurance plans, we might see changes and broader oversight concerning this longstanding and common insurance practice.

In this commentary for Barron’s, KFF’s Cynthia Cox and Jennifer Kates explore what will happen with access and costs to COVID-19 vaccines for people with and without insurance once the relevant public health emergency ends on May 11.  They also explore the potential increased cost to the health care system overall.

State Medicaid programs saw a doubling of prescriptions for medications used to treat Opioid Use Disorder (OUD) or rapidly reverse opioid overdoses from 2016 to 2019, finds a new KFF analysis.

KFF analysts studied the latest available Medicaid claims data — detailed and comprehensive administrative data that can help answer questions and inform policy — and found that the share of enrollees who received at least one medication used to treat OUD or reverse opioid overdose doubled from 0.6 percent to 1.2 percent over the period. In raw numbers, such prescriptions rose from 3.5 million in 2016 to 7.1 million in 2019.

Compared to Black and Hispanic enrollees, White enrollees were more likely to receive at least one treatment prescription and saw the largest percentage point increase over the period, suggesting the presence of racial disparities in access to prescription medication to treat OUD or reverse opioid overdoses.

The prescribing patterns in Medicaid mirror national trends, as policymakers in Washington and in state capitals around the country have implemented policies to increase access to treatment for OUD and reduce overprescribing of opioid prescriptions for pain. A provision in the federal omnibus legislation enacted in December will expand the number of providers who are able to prescribe buprenorphine for treating OUD.

Despite efforts to address the epidemic, deaths due to substance use disorder (SUD) have risen sharply during the pandemic.  Opioid overdose death rates increased by 38 percent from 2019 to 2020, with deaths involving illicitly manufactured synthetic opioids like fentanyl now driving the trend. The rise in deaths associated with drug overdose has disproportionately affected people of color.

Medicaid enrollees may be particularly impacted, as 21 percent have mild, moderate, or severe SUD, compared to 16 percent of commercially insured. In its role as a public program and the single largest payer of behavioral health services in the country, Medicaid is particularly well positioned to implement policy to improve the delivery, quality, and effectiveness of behavioral health services.

A second KFF analysis released today finds that 7.3 percent of Medicaid enrollees ages 12 to 64 had at least one clinically-identified SUD in 2019. Other data sources suggest that this may be an undercount because it is a measure of people who receive a diagnosis or prescription code that indicates the presence of a SUD. People with clinically-identified SUD were more likely to be male, White, over 25 years old, and qualify for Medicaid based on a disability or through Medicaid expansion.

Rates of clinically-identified SUD vary widely across states, not only because of prevalence, but also because of other factors, such as provider screening behavior and variation in Medicaid coverage of SUD services.

Understanding characteristics of Medicaid enrollees with SUD and receiving OUD prescription treatment can help shed light on longstanding gaps in access to care including under-identification and undertreatment of SUD and inform policies to address issues.

For more data and analyses on Medicaid and substance use disorder, visit kff.org

Key Takeaways

The opioid overdose epidemic, characterized by the rapid rise in opioid-involved overdoses and overdose-related deaths, began in the late 1990s, driven by increased prescribing of opioids to treat pain. In subsequent years, the epidemic evolved, and is now largely driven by synthetic opioid-involved deaths, including illicitly manufactured fentanyl. Medicaid enrollees have been particularly impacted by the opioid epidemic, with higher rates of substance use disorder (SUD) and prescribed opioids among Medicaid enrollees compared to people with other types of insurance. To combat the opioid overdose epidemic, policymakers have enacted legislation to reduce opioid prescriptions for pain and increase access to treatment for opioid use disorder (OUD), and the Consolidated Appropriations Act, passed in December 2022, vastly increased the number of providers authorized to prescribe controlled substance medication treatment to treat OUD.

This analysis builds on previous KFF work by using Medicaid claims data, administrative data on Medicaid enrollees’ health care utilization, for 2016-2019 to explore how prescriptions for opioids used to treat pain and those used to treat OUD or rapidly reverse overdose changed across states and enrollee demographic groups over time leading up to the COVID-19 pandemic. A full description of the data and methods can be found in the Methods section. Key findings include the following:

• Opioid prescriptions declined overall from 2016 to 2019, driven by a 44% decline in the number of prescriptions for opioids used to treat pain. At the same time, prescriptions for medications used to treat OUD or rapidly reverse opioid overdose doubled, driven by an increase in buprenorphine prescriptions.
• The share of enrollees receiving at least one opioid prescription for pain declined from 11.3% in 2016 to 7.2% in 2019, which drove the overall declines in utilization of opioids to treat pain. The magnitude of declines varied by state, eligibility group, and race/ethnicity.
• The share of enrollees receiving at least one medication used to treat OUD or reverse opioid overdose doubled from 2016 to 2019. Compared to Black and Hispanic enrollees, White enrollees were more likely to receive at least one treatment prescription and saw the largest increase their share over the period, suggesting racial disparities in access to prescription medication to treat OUD or reverse overdose.

Background

The opioid overdose epidemic began in the late 1990s with the increased prescribing of opioids to treat pain. Then, the epidemic shifted in 2010 with sharp increases in deaths due to heroin overdose, and, since 2013, synthetic opioid-involved deaths, including deaths involving illicitly manufactured fentanyl, have increased rapidly, far surpassing deaths involving commonly prescribed opioids and heroin. Opioid overdose death rates continue to rise, increasing by 38% from 2019 to 2020, and the recent rise in deaths associated with drug overdoses has disproportionately affected people of color. Prescription opioids were still involved in 24% of all opioid overdose deaths in 2020, though this share has declined sharply since 2007 when prescription opioids were involved in 78% of all opioid overdose deaths.

The opioid epidemic was declared a nationwide public health emergency on October 26, 2017, and there have been various strategies at the state and national level to address the opioid crisis, including actions to reduce opioid overprescribing and guidelines from the Centers for Disease Control and Prevention (CDC) in 2016. Since then, states have enacted limits on opioid prescriptions for acute pain, including limits on prescription length or daily dosage, requirements for naloxone prescription alongside opioid pain prescriptions, prescription drug monitoring programs (PDMPs), and state policies that enhance PDMPs. In 2018, a KFF survey of state Medicaid programs found all states and DC had implemented at least one opioid-focused pharmacy management policy, with 40 states expecting to implement additional opioid-focused strategies the following year. These interventions have reduced the number of opioid prescriptions in recent years; however some argue the 2016 CDC guidelines, which were voluntary, were too strictly applied or misapplied by providers, making it more difficult for some individuals to access needed pain relief.

Policy efforts have also aimed to improve access to medications for OUD treatment, as they have been shown to substantially reduce overdose and mortality rates. However, most people with OUD do not receive recommended treatment, with some estimates suggesting a gap of almost 90%. Of the three drugs currently approved to treat OUD (methadone, buprenorphine, and naltrexone), only two—buprenorphine and naltrexone—are available through prescription and can be taken at home. Methadone for OUD treatment must be dispensed onsite through licensed opioid treatment programs. Buprenorphine was first authorized to treat OUD outside of opioid treatment programs in the early 2000’s through the Drug Addiction Treatment Act of 2000, which permitted practitioners who obtained a separate controlled substances license (also referred to as an X-waiver) to prescribe buprenorphine. Over time, efforts have focused on increasing the supply of buprenorphine providers, and the Consolidated Appropriations Act completely eliminated the X-waiver, thus substantially increasing the number of providers who are authorized to prescribe buprenorphine to treat OUD.

The Medicaid population may be particularly impacted, as 21% have mild, moderate, or severe SUD, compared to 16% of commercially insured. Medicaid enrollees also receive prescriptions for pain medications at higher rates compared to individuals with other insurance types. In its role as a public program and the single largest payer of behavioral health services in the country, Medicaid is particularly well positioned to implement policy to improve the delivery, quality, and effectiveness of behavioral health services. In recent years, many states have used Medicaid Section 1115 waivers and other program authorities to expand treatment options for enrollees with OUD as well as enacted various laws to increase access to naloxone and promote the use of naloxone in Medicaid.

The detailed and comprehensive claims data available for Medicaid can help answer questions and inform policy. This analysis builds on previous KFF work by using Medicaid claims data for 2016-2019 to explore how prescriptions for opioids used to treat pain and those used to treat OUD or rapidly reverse overdose changed across states and Medicaid enrollee demographic groups over time. We exclude methadone for OUD treatment, which is only dispensed from licensed opioid treatment programs, and cannot be obtained using a prescription (for more information, see Table 1 and Methods).

What are recent trends in opioid prescribing?

The number of Medicaid prescriptions for opioids in this analysis declined by 27% from 2016 to 2019, driven by a decline in the number of opioid prescriptions used to treat pain. The utilization of opioids prescriptions to treat pain declined by 44% from 2016 to 2019 (Figure 1). While still widely prescribed, opioids are also making up an increasingly smaller share of all Medicaid outpatient prescription drug claims. In this analysis, opioids overall accounted for 3.0% of all Medicaid outpatient prescription drug claims by 2019, down from 4.1% in 2016.

Medicaid prescriptions used to treat OUD or rapidly reverse opioid overdose doubled from 2016 to 2019 and made up an increasing share of all opioid prescriptions over the period. While most opioid prescriptions over the period were for opioids used to treat pain, prescriptions for drugs used to treat OUD (buprenorphine and naltrexone) or rapidly reverse opioid overdose (naloxone), doubled over the period, and together they made up 33% of all opioid prescriptions by 2019, up from 12% in 2016. Table 1 describes what prescription drugs are included and how drugs are categorized as prescriptions used to treat pain or prescriptions used to treat OUD or reverse opioid overdose in this analysis (for more information, see Methods).

What is driving the decline in opioid prescriptions used to treat pain?

The share of Medicaid enrollees who received at least one opioid prescription used to treat pain within the year declined from 11.3% in 2016 to 7.2% in 2019, or 4.1 percentage points (Figure 2). The number of opioid prescriptions among those with at least one opioid prescription used to treat pain remained relatively stable over the period, around 3 prescriptions per person. This suggests the decline in utilization results from fewer enrollees receiving any prescriptions rather than from enrollees who already receive opioid prescriptions receiving fewer prescriptions. The share of Medicaid enrollees who received at least one opioid prescription used to treat pain declined across all eligibility groups over the period. In 2016, pregnant women accounted for the largest share of enrollees receiving at least one opioid prescription used to treat pain (23.9%). However, from 2017 onward, individuals eligible for Medicaid based on a disability had the largest share, with 18.8% receiving at least one opioid prescription used to treat pain by 2019 compared to 15.6% of pregnant women, 15.3% of traditionally eligible adults, 13.0% of expansion adults, 7.9% of seniors, and 1.7% of children. While there are likely many factors at play, state policies implemented over the period to prevent opioid-related harms as well as the release of the 2016 CDC guidelines to address opioid overprescribing likely contributed to these declines.

All states experienced declines in the share of Medicaid enrollees who received at least one opioid prescription to treat pain from 2016 to 2019, but the degree varied by state. The states that experienced the largest declines appear to be clustered around the Appalachian region, one of the areas hardest hit by the opioid epidemic. Of the top five states (TN, KY, OH, WV, MI) with the largest share of enrollees receiving at least one opioid prescription in 2016, the beginning of the study period, only one state (KY) remained in the top five states by 2019. On the other hand, states with the smallest declines over the period varied in location.

While all groups experienced a decline in the share of Medicaid enrollees receiving at least one opioid prescription used to treat pain from 2016 to 2019, White enrollees experienced the largest decline compared Black and Hispanic enrollees. White enrollees also had the highest share of enrollees with at least one opioid prescription used to treat pain in both 2016 and 2019 compared to all other racial/ethnic groups. In 2016, 14.9% of White Medicaid enrollees had at least one opioid prescription used to treat pain, compared with 12.6% of Black enrollees, the next highest group (Figure 4). By 2019, the share of White enrollees with at least one opioid prescription had fallen to 9.5% (a 5.4 percentage point decline) and the share for Black enrollees had fallen to 7.9% (a 4.7 percentage point decline). Multiple studies have shown racial disparities in opioid prescribing and pain management, and our findings suggest Black and Hispanic Medicaid enrollees are less likely to be prescribed opioids used to treat pain when compared with White enrollees.

What is driving the increase in prescriptions used to treat OUD or reverse opioid overdose?

Prescriptions for buprenorphine, an OUD treatment, grew 92% from 2016 to 2019 and made up the vast majority (87% in 2019) of all pharmacy prescriptions used to treat OUD or reverse opioid overdose (Figure 1). This reflects state efforts over the period to increase access to buprenorphine as well as changes to buprenorphine prescribing limits over the period. While they make up a smaller share of all prescriptions in this analysis, the number of opiate antagonist prescriptions almost tripled from 2016 to 2019.

The share of Medicaid enrollees who received at least one prescription used to treat OUD or reverse opioid overdose within the year doubled, growing from 0.6% in 2016 to 1.2% in 2019 (Figure 5). At the same time, the number of OUD treatment or opioid overdose prescriptions per enrollee (among those who received any prescription for OUD treatment or overdose reversal) stayed relatively stable around 9 prescriptions per enrollee, suggesting the increase in utilization results from additional enrollees starting to receive medication for OUD treatment or to reverse opioid overdose over the period. It is important to note that this analysis looks at the utilization among all Medicaid enrollees in the analysis, not among enrollees with an OUD diagnosis, which is why the shares for treatment are small.

While all groups experienced in increase in the share of Medicaid enrollees receiving at least one prescription used to treat OUD or reverse opioid overdose from 2016 to 2019, White enrollees experienced the largest increase compared to Black and Hispanic enrollees. White enrollees also had the highest share of enrollees with at least one prescription for OUD treatment or opioid overdose in both 2016 and 2019 compared to all other racial/ethnic groups. In 2016, 1.1% of White Medicaid enrollees had at least one prescription to treat OUD or reverse overdose, compared with 0.2% of Black enrollees, the next highest group (Figure 6). By 2019, the share of White enrollees with at least one prescription to treat or reverse overdose had grown to 2.2% (a 1.1 percentage point increase) and the share for Black enrollees had grown to 0.7% (a 0.5 percentage point increase). Various studies have shown racial disparities in access to medications for OUD, especially for buprenorphine, and some studies suggest these disparities may have worsened during the COVID-19 pandemic. Further, continuity of treatment, as measured by the number of treatment or overdose reversal prescriptions per enrollee among enrollees receiving at least one treatment or overdose reversal prescriptions, remained mostly stable for White enrollees (around 11 prescriptions per person), but declined for Black enrollees (from around 6 prescriptions per person to 5) and Hispanic enrollees (from 7 prescriptions per person to 5).

Looking Ahead

There have been recent actions to address opioid overprescribing and misuse, including a 2022 update to the 2016 CDC guidelines for prescribing opioids for pain. The guidelines are voluntary and are intended to help providers navigate providing appropriate care to patients in pain, and the update reportedly provides for more flexibility and individualized treatment, no longer including strict duration and dosage limits that the earlier guidelines included. It is unclear at this time whether states will update their policies to reflect the eased restrictions on prescription opioids seen in the recent guidelines. Some groups are also taking steps to address racial disparities in pain management including developing new assessment tools and raising awareness of systemic racism in medicine.

There have also been recent federal efforts to increase access to medications that treat OUD or reverse opioid overdose. Following the onset of the COVID-19 pandemic, the federal government allowed for new flexibilities in OUD treatment to ease access barriers, for example allowing for take-home methadone doses and covering telehealth treatment, and the Biden administration has proposed making these flexibilities permanent. The Biden administration also released a model law to make access to naloxone more consistent across states, new buprenorphine practice guidelines that eliminate a training requirement many viewed as a barrier to treatment, and a National Drug Control Strategy to combat addiction and the opioid epidemic.

Further, the 2023 Consolidated Appropriations Act eliminated the X-waiver requirement for prescribing buprenorphine, which substantially increases the number of providers who are authorized to prescribe buprenorphine to treat OUD. The Act will also require all providers with a controlled substances license to obtain training on treating and managing patients with OUD and SUD. States and localities have also started to receive funds as part of the National Opioid Settlement, and it is required that states use at least 70% of the funding toward opioid remediation efforts, though there are concerns about a lack of transparency about how funds will be spent in some states.

Deaths due to substance use disorder (SUD) have risen sharply during the pandemic, highlighting longstanding gaps—such as under-identification and undertreatment of SUD. Even before the pandemic, SUD contributed to a large and growing share of deaths. For example, alcohol was listed as a contributing factor in 20% of deaths in adults between the ages of 20 and 49 from 2015 to 2019 and drug overdose deaths increased by 35% over the same period. Yet in 2019, only 1 in 10 people (12 and older) with past year SUD received any treatment, including specialty treatment or self-help groups. The Medicaid population may be particularly impacted, as 21% have mild, moderate, or severe SUD, compared to 16% of commercially insured. In its role as a public program and the single largest payer of behavioral health services in the country, Medicaid is particularly positioned to implement policy to improve the delivery, quality, and effectiveness of behavioral health services. The detailed and comprehensive claims data available for Medicaid can help answer questions and inform policy.

Efforts are being made at the state and federal levels to increase SUD awareness, coordination, and treatment access—including some provisions that were recently passed as a part of the Consolidated Appropriations Act enacted in December 2022, such as expanding providers who are able to prescribe buprenorphine for treating OUD. In light of recent efforts to expand access to SUD treatment services, we examine the share of enrollees with SUD using both Medicaid claims and data from the National Survey on Drug Use and Health (NSDUH).

What are the rates and characteristics of Medicaid enrollees with identified SUD?

In 2019, 7.3% of Medicaid enrollees ages 12 to 64 had at least one clinically-identified SUD in Medicaid claims data. Opioid use disorder was identified in 3.3% of Medicaid enrollees; alcohol use disorder in 2.5%; cannabis use disorder in 1.9%; stimulant use disorder (including cocaine or other stimulants) in 1.7%; and 1.7% of Medicaid enrollees had some other type of substance use disorder. These groups were not mutually exclusive, and while we did not look at the share of people with multiple substance use disorders, it is not uncommon for substance use disorders to co-occur. For this analysis, any diagnosis or prescription code that suggests the presence of a SUD is flagged as a “clinically-identified SUD.” This is not a measure of overall prevalence of SUD because not everyone is screened and diagnoses are not always recorded, but it does provide some insight into how often SUD is recognized and possibly treated in clinical settings (Figure 1).

People with clinically-identified SUD are more likely to be male, White, over 25 years old, and qualify for Medicaid based on a disability or through Medicaid expansion. At least one clinically-identified substance use disorder is found in Medicaid claims data for 8.9% of males, 10.0% of White people, and 11.6% of individuals aged 35 to 49. Medicaid beneficiaries who qualify as a result of a disability or through Medicaid expansion have higher rates of clinically-identified SUD than other groups. This pattern holds across most types of SUD, with only a few exceptions. For example, alcohol use disorder is most commonly identified among people aged 50 to 64, while cannabis use disorder is the most commonly identified among people aged 26 to 34. Clinically-identified SUD rates are highest among White people for all substance types except cannabis, where Black people have similar or slightly higher rates (2.4% versus 2.1%, respectively) (Figure 2).

Rates of clinically-identified SUD vary widely by state. Vermont has the highest share of any clinically-identified SUD, with 13.3% of Medicaid enrollees having a clinically-identified SUD, while Arkansas has the lowest rate, with only 3% of Medicaid enrollees having at least one clinically-identified SUD (Figure 3). Rates of clinically-identified SUD vary across states not only because of prevalence, but also because of other factors, such as provider screening behavior and variation in Medicaid coverage of SUD services.

What are implications of findings from claims data?

Other data sources generally suggest that SUD rates from Medicaid claims are undercounts—but even national survey data may undercount SUD for a variety of reasons. National prevalence of SUD is estimated through surveys such as the National Survey of Substance Use and Health (NSDUH), which uses questions based on diagnostic criteria to identify individuals with SUD, including those who haven't already been diagnosed. We analyzed NSDUH data and found that the prevalence estimates of SUD among Medicaid enrollees is generally higher in national survey data than in Medicaid claims data, and that difference is greatest among adolescents, young adults, and Hispanic people. Even national survey data may undercount SUD due to underreporting of substance use and exclusion of unhoused, incarcerated, and institutionalized people—which are populations where SUD may be more prevalent. Research that adjusts for these undercounts estimates that alcohol and opioid use disorders are at least four times more prevalent than the NSDUH estimates.

National recommendations instruct providers to screen for substance use and conduct brief interventions for adults 18+, yet there may be gaps between SUD screening and referral. Research found that while most patients with an alcohol use disorder were screened for alcohol use, only 14.6% received brief interventions from their providers, and even fewer--about 6%--were referred to treatment.  Despite the serious health consequences and comorbidity of physical health and SUD conditions, most doctors do not receive much training in substance use disorders. Even within psychiatric residency programs, only 2% of training time is dedicated to substance use disorders. According to fourth-year medical students in Massachusetts, fewer than one-fifth report feeling very prepared to screen for opioid use disorders and/or refer patients with related symptoms to treatment.

Other factors--such as patient privacy concerns or few healthcare visits--may also play a role in low identification of SUD. Even when providers ask about substance use, patients may feel uncomfortable disclosing their use or may be worried about stigma or legal consequences if they do. Even if a SUD is identified, providers may be hesitant to record it due to concerns about whether recording the SUD violates the privacy rules that add additional protections for people receiving SUD treatment. Other reasons may be population specific. For example, people who are younger and generally healthier may have fewer health care appointments and therefore fewer opportunities for providers to identify SUD. In at least one state, school-based screenings are required for younger populations. Growing drug overdose deaths among adolescents and people of color may suggest disparities in the identification and treatment of SUD.

There is broad variation in Medicaid policy and coverage of SUD services across states. Medicaid coverage of SUD services, as well as utilization management policies, such as prior authorization, can vary widely across states (and even across managed care organizations within states). Although more comprehensive coverage of SUD services has been linked to higher Medicaid acceptance by SUD treatment facilities, as of 2018, only 12 states covered the full continuum of SUD services. People experiencing symptoms of a substance use disorder may find it difficult to navigate this complex landscape, and difficulty accessing treatment is likely exacerbated in areas with workforce shortages.

Looking Ahead

In response to the growing number of overdose deaths and longstanding challenges accessing SUD treatment, state and federal governments have taken action to address ongoing gaps in SUD care—from identification of SUD to treatment. For example, many Medicaid programs have expanded coverage of SUD services and extended benefits to new eligibility groups; increased provider reimbursement rates for SUD services; and/or permanently adopted or continued pandemic-era telehealth expansions for behavioral health services.

At a federal level, HHS has issued notices of proposed rulemaking that may result in improved coordination of SUD services (42 CFR part 2) and expanded access to methadone for opioid use disorder treatment. Congress passed the Consolidated Appropriations Act (CAA) in December 2022, with funding to improve SUD awareness, prevention, treatment, coverage, and increase workforce. For example, the CAA added at least 100 new residency positions dedicated to psychiatry and required that all prescribers of controlled substances undergo training in managing and treating patients with SUD. CAA also lifted some administrative barriers to expand access to medications to treat opioid use disorder including the removal of additional registration requirements for prescribing buprenorphine (X-waiver) and reduced barriers to opioid treatment programs. Recent legislative efforts may lessen some longstanding barriers to SUD care, which could lead to better identification, referral, and treatment of SUD.

Methods

Medicaid Claims (T-MSIS) and State Exclusion Criteria

This analysis uses the following 2019 T-MSIS Research Identifiable claims files: demographic eligibility base (DE) and header and line files from inpatient (IP), long-term care (LT), other services (OT), and prescription (RX) claim files.

We use 48 states and D.C. in the main analysis and 29 states in our analyses that include race and ethnicity. We evaluated states’ claims data using the DQ Atlas criteria and by comparing SUD estimates from T-MSIS to NSDUH. Specific DQ Atlas measures used to determine state data quality include the restricted benefits code, Medicare benefits code, OT claims/encounter volume. We excluded Alabama because the Medicare coverage code was missing for more than 10% of enrollees and the T-MSIS SUD rates were 93 percent lower than NSDUH estimates. We excluded Colorado because the OT file encounter data volume was below 50% of the national median and the T-MSIS SUD rates were 156 percent lower than NSDUH estimates. For analyses involving race/ethnicity, the following states rated as "high concern" or "unusable" data by the DQ Atlas were also excluded:  AL, AZ, AR, CO, CT, DC, HI, IA, KS, LA, MD, MA, MO, MT, NY, OR, RI, SC, TN, UT, WV, WY.

T-MSIS Enrollee Sample Selection

Our sample includes nonelderly Medicaid and CHIP enrollees between the ages of 12 and 64 that have at least one day of enrollment in 2019. Enrollees were excluded if they did not have full or comprehensive Medicaid, had Medicare coverage, or were enrolled for less than one month in 2019. These exclusions are similar to those reported in the CMS SUD data book technical specifications, but the CMS data book included people with Medicare coverage. After enrollee and data quality exclusions, our main sample includes 46,967,389 enrollees from 48 states and the District of Columbia.

Identification of SUD in T-MSIS

We linked header and line files using MSIS_ID and CLM_ID and linked claims files to the DE file using MSIS_ID (see the T-MSIS User Guide for information on linking variables) for fee-for-service and encounter claims. We identified ICD-9 and ICD-10 diagnosis codes and National Drug Codes (NDCs) from an adapted version of reference codes used in the 2019 CMS SUD data book. Modifications to CMS SUD reference codes include (1) exclusion of tobacco in our definition of “any SUD”; (2) removal of NDC codes primarily used to treat pain rather than opioid use disorder; and (3) removal of methadone NDC codes as these codes are thought to represent pain treatment, rather than opioid use disorder. One or more occurrence of a SUD diagnosis code or NDC code in OT, IP, LT, or RX files is coded as an SUD. Following CMS data book technical specifications, naltrexone—used to treat alcohol use disorder and opioid use disorder—is coded as alcohol use disorder when an alcohol use disorder diagnosis code is present, but coded as opioid use disorder in all other instances. "Any Substance Use Disorder" includes enrollees with at least one opioid, alcohol, cannabis, stimulant, or other SUD. "Other Substance Use Disorder" includes diagnosis codes for sedative, hallucinogen, caffeine, inhalant, unknown, or other SUD.

National Survey on Drug Use and Health. The National Survey of Drug Use and Health (NSDUH) asks respondents 12 and older about substance use and symptoms of substance use disorders, and those who exceed certain thresholds are classified as having a SUD. This analysis uses 2018/19 NSDUH data and includes Medicaid enrollees between the ages of 12 and 64. Although the NSDUH collects nationally representative data and asks each respondent about their substance use and symptoms, it may still underestimate SUD prevalence. NSDUH only collects data from people with an address--excluding those who are unhoused, institutionalized, or incarcerated – which is relevant because these populations may have higher rates of substance use disorders.

Once again, Medicare is getting political attention.

Medicare is the main source of health insurance coverage for 65 million people, and a major source of revenue for hospitals, other health care providers, and health insurers that offer Medicare Advantage plans. Over the years, policymakers have debated major changes to Medicare driven by concerns about solvency, sustainability, and affordability, propelled by an aging population and systemwide increases in health care spending, as well as the program’s contributions to federal budget deficits and debt. While the possibility of reducing Medicare spending emerged recently in the context of the debt limit debate – and some members of Congress continue to talk about changes to the program — President Biden and now House Speaker McCarthy have both declared that Medicare will not be part of those negotiations.

Nevertheless, discussion about Medicare cuts is heating up, partly based on two announcements by the Centers for Medicare and Medicaid Services (CMS) related to Medicare Advantage. Medicare Advantage is the private plan alternative to traditional Medicare that now provides Medicare coverage to approximately half of Medicare beneficiaries. The federal government pays private insurers a capitated payment to provide Medicare-covered services to enrollees based on a formula set by statute and implemented by CMS. Last week, CMS finalized a rule making changes to how Medicare Advantage risk adjustment data validation (RADV) audits are conducted and released the annual notice of proposed changes to Medicare Advantage plan payments for the forthcoming year.

What’s the issue? To improve program integrity, the RADV rule modifies how CMS calculates the amount a plan is required to pay back to the federal government when diagnoses codes submitted for risk adjustment are not supported by information in the medical records. Risk adjustment is a process where payments to plans are adjusted based on the health status of their enrollees. Under the finalized rule, CMS will extrapolate error rates in the audit sample to the full contract – a practice common to other audits, but not previously included in the RADV program. CMS estimates that it will collect $4.5 billion over the next decade by applying this and other changes to audits starting with plan year 2018 (though no new collections will come in until 2025). These are recouped payments that should not have been made in the first place, based on an extrapolation of audited records.

In addition, the Administration is proposing to modify Medicare Advantage payments for the upcoming plan year, as it does every year when it publishes the annual notice of proposed changes to Medicare Advantage payments. The proposed changes are largely technical adjustments that update the payment formula to account for changes in the economy, as well as Medicare spending trends. In addition, the Administration proposes to make revisions in how risk scores are calculated.

CMS estimates that Medicare Advantage plan payments per enrollee will be 1% higher in 2024 than they are this year. Changes in star ratings (which lead to higher payments for plans with higher ratings) and revisions to the risk model (that would by themselves reduce per enrollee payments) are more than offset by an increase in Medicare Advantage benchmarks (driven by growth in traditional Medicare spending, including inflation) and expected growth in Medicare Advantage risk scores (that are expected to increase per enrollee payments). The proposed payment changes for 2024, taken together, are unlikely to have a meaningful impact on the trajectory of Medicare Advantage spending, which CBO estimates will exceed $7 trillion (cumulative) through the decade that ends in 2032.

Despite the expected net increase in Medicare Advantage payments in 2024, overall and per enrollee, some industry stakeholders are focusing specifically on changes to the risk adjustment model, rather than the total change in payments for 2024. The proposed changes to the risk adjustment model address higher “coding intensity” (incentives for Medicare Advantage plans to code more intensely than traditional Medicare) that will result in $23 billion in excess payments in 2023, according to MedPAC. Specifically, CMS proposes updating the conditions used to predict expenditures, similar to revisions made in previous years, as well as transition to ICD-10 diagnoses codes, consistent with the system currently used in clinical settings. CMS estimates that the changes made to the risk adjustment model will result in payments to Medicare Advantage plans that are $11 billion lower in 2024 compared to the status quo, before taking into account other proposed changes and underlying trends that are expected to result in a net increase in per enrollee and total payments.

Some in the industry say the payment changes will lead to premium increases or cuts in benefits for Medicare beneficiaries, though there is no clear evidence to suggest that. Plans use payments from the federal government in excess of the cost of providing Medicare benefits to provide extra benefits or lower premiums to beneficiaries. In theory, lower payments from the federal government could reduce the surplus available for extra benefits. However, plans also compete aggressively for enrollees with zero premiums and those extra benefits.

During the debate over the Affordable Care Act, when Congress made significant reductions in Medicare Advantage payments, there were similar warnings that plans would respond by pulling out of the market and dropping extra benefits, when in fact, the opposite happened. The Medicare Advantage market has proven to be robust and relatively profitable. Plans may very well continue to offer extra benefits, and zero-premium offerings, to attract and retain enrollees, and grow market share. Medicare Advantage plans have responded to payment changes in the past by reducing their profits or lowering administrative costs. And plans have more money than ever to pay for extra benefits. Since 2018, the portion of Medicare Advantage payments that is used to fund extra benefits, called rebates, has doubled from $1,140 per enrollee in 2018 to $2,352 per enrollee in 2023.

At some point, lawmakers will likely engage in a debate about how best to sustain Medicare for the future, including how to shore up the Medicare Hospital Insurance Trust Fund that is projected to be depleted in 2028. That debate could involve difficult decisions about various ways to reduce spending and/or increase revenues, and could impact health care providers, plans and beneficiaries. However, current efforts to improve the accuracy of payments made by the federal government, and improve program integrity, are unlikely to have a major impact on the program, the insurance industry or beneficiaries, given relatively generous payments to plans and the robustness of the Medicare Advantage market.

Concerns about youth mental health and well-being continue to increase, particularly in light of gun violence and the COVID-19 pandemic. Despite these mental health concerns, many children and adolescents face barriers in accessing behavioral health services (including mental health and/or substance use services). To address these challenges, recent legislation includes provisions to improve access to behavioral health services for youth. A number of these provisions involve expansions through Medicaid, including leveraging Medicaid to further build on school-based behavioral health services. Medicaid covers nearly four in ten children and adolescents nationwide, and provides significant financing for the delivery of behavioral health services through school-based programs.

To better understand the use of Medicaid in delivering and promoting of school-based behavioral health services, KFF surveyed state Medicaid officials about initiatives to promote access to Medicaid behavioral health services in school-based settings. These questions were part of KFF’s Behavioral Health Survey of state Medicaid programs, fielded as a supplement to the 22^nd annual budget survey of Medicaid officials conducted by KFF and Health Management Associates (HMA). A total of 44 states (including the District of Columbia) responded to the survey; of these, 41 states responded to the question about school-based care. In this analysis, we explore the strategies state Medicaid programs reported taking to promote and improve access to school-based behavioral health services, and how recent policies call on Medicaid to expand access to care for youth, particularly in schools.

Most schools offer behavioral health services to students and over time Medicaid has played a larger role in the delivery of these services. In the 2021-2022 school year, almost all (96%) public schools reported offering mental health services (although student utilization of offered services was unclear). These services are often supported through multiple sources of funding at the national, state, and local level. Over time, Medicaid has played a larger role in supporting these services and by 2014, nearly nine in ten school-based health centers (SBHCs) reported billing Medicaid. School-based behavioral health programs may rely on Medicaid in several ways, including reimbursement for medically necessary services that are part of a student’s Individualized Education Plan (IEP), for eligible health services for students with Medicaid coverage, and for some administrative activities. Additionally, since the 2014 reversal of the free care policy, the Centers for Medicare and Medicaid Services (CMS) has permitted payment of Medicaid services delivered to covered children, regardless of whether the school provides these services to all students without charge.

State Medicaid programs vary in how they promote access to Medicaid behavioral health services provided in schools. Although most schools provide mental health services, many report challenges in meeting the needs of all students, such as insufficient provider coverage and funding shortages. These challenges underscore the importance of addressing access issues in the school setting. KFF’s 2022 Behavioral Health survey asked Medicaid officials to report state initiatives to promote access to Medicaid behavioral health services provided in school-based settings. We found that states vary in their approaches – for example, some state Medicaid programs reported working more closely with local education agencies to help promote school-based behavioral health services (including Alabama, Massachusetts, Tennessee, and Vermont). Several states (including Arizona, Kentucky, Michigan, and Virginia) reported that they had or planned to take advantage of the reversal of the free care policy by expanding Medicaid reimbursement for school-based services provided to children without IEPs. A few states (including Oklahoma and the District of Columbia) are taking steps to incorporate crisis services for students. To incentivize providers, several states have also increased reimbursements for school-based providers (including Arizona, California, and South Carolina) – a strategy that many state Medicaid programs have adapted more broadly in order to attract Medicaid behavioral health professionals.

Below we highlight findings from several states that offer innovative and multipronged approaches to promoting access to Medicaid-based services.

• Arizona: Arizona has expanded its work with the local Department of Education to facilitate mental health and suicide prevention trainings in schools; and has taken steps to expand the number of school-based behavioral health providers. For example, the state Medicaid program has encouraged collaboration between schools and behavioral health outpatient providers interested in providing services at schools; and they incentivize behavioral health providers through enhanced payments. Additionally, Arizona’s Medicaid agency oversees administration of funds from the Children’s Behavioral Health Services Fund, which provides a pathway for students who are underinsured or uninsured to receive behavioral health services from providers contracted with Arizona’s Medicaid program.
• California: California’s recent state-wide Children and Youth Behavioral Health Initiative is a multistep approach to expanding access to youth behavioral health care. One focus of this initiative allows for managed care plans to earn incentive payments for implementing interventions that increase access to school-based behavioral health services (further outlined in the Student Behavioral Health Incentive Program). Higher incentive payments may be offered for interventions that increase reimbursement rates, serve vulnerable youth populations, and/or reduce inequities. Further, California will develop statewide all-payer fee schedules for school-based behavioral health services with the intention of streamlining the reimbursement process; and will develop a statewide network of school-based behavioral health counselors..
• South Carolina: Beginning in 2022, South Carolina modified its school-based behavioral health policy to give districts more options for delivery of behavioral health services in their schools. Previously, school districts were only able to provide behavioral health services through the Department of Mental Health (DMH). However, districts will now be able to either contract with DMH, hire their own counselors, and/or contract with private providers. With each option, school districts can bill the state’s Medicaid program. Additionally, through this initiative, an alternative fee schedule was developed in order to ensure that schools have sufficient provider capacity.

Some school-based programs have long provided behavioral health services through telehealth, even before the pandemic. In our survey, a few states reported plans to expand these remote services in unique ways, including creating a hub location away from school grounds that is staffed with behavioral health providers. Students could then access these providers remotely from their schools or travel to the hub location for in-person services. While this model may expand access to students overall by increasing telehealth services, if telehealth replaces existing in-person behavioral health services, some students may experience disruptions in care. In general, during the COVID-19 pandemic states have taken advantage of broad authority to expand Medicaid telehealth policies, resulting in high telehealth utilization across populations.

Looking Ahead

Recognizing Medicaid’s importance in covering and financing behavioral health care for children, recent legislation utilizes Medicaid as one pathway to expand school-based behavioral health services. The Bipartisan Safer Communities Act signed into law in June 2022 included a requirement for CMS to provide updated guidance on how to support and expand school-based behavioral health services, and also allocated $50 million in planning grants for states. In August 2022, CMS released its first guidance outlining state flexibilities and strategies for expanding Medicaid-covered behavioral health services in schools. Additionally, CMS indicated it intends to release further guidance, including an updated claiming guide and technical assistance guide. This guidance is expected to provide best practices for paying for school-based services, provide strategies for reducing administrative burdens, and supply examples of providers who can provide school-based Medicaid services.

More recently, the Consolidated Appropriations Act (CAA) passed in December 2022 includes Medicaid provisions that may promote access to behavioral health and other care for children, such as a requirement for states to implement 12 months of continuous eligibility for children in Medicaid and CHIP and a requirement for CMS to issue guidance and provide technical support to expand crisis services.  The CAA also requires state Medicaid and CHIP programs to maintain updated provider network directories that include behavioral health providers participating in Medicaid and information on whether they are accepting new patients and on language and cultural competencies, among others. Current directories are often outdated and may contribute to barriers to care. In addition to expanding access through Medicaid, the CAA includes other provisions focused on youth behavioral health support. For example, additional funding was allocated for Project AWARE, which provides trauma-based support for youth.

These recent changes at the federal level combined with state-level Medicaid efforts to streamline and promote access to services further highlight the increased attention on youth mental health and substance use concerns. Moreover, in his State of the Union address, President Biden spotlighted continued efforts to improve school-based mental health services, including how Medicaid can be used. Moving forward, steps to address workforce shortages and increases in behavioral health care via telehealth may also help mitigate access to care issues for youth mental health.

Executive Summary

At the start of the pandemic, Congress enacted the Families First Coronavirus Response Act (FFCRA), which included a requirement that Medicaid programs keep people continuously enrolled through the end of the COVID-19 public health emergency (PHE) in exchange for enhanced federal funding. Primarily due to the continuous enrollment provision, Medicaid enrollment has grown substantially compared to before the pandemic. When the continuous enrollment provision ends, millions of people could lose coverage if they are no longer eligible or face administrative barriers during redeterminations despite remaining eligible. The Consolidated Appropriations Act, 2023 de-links the Medicaid continuous enrollment provision from the PHE allowing states to resume disenrollments starting April 1, 2023. States can work with Medicaid managed care organizations (MCOs), which deliver care to more than two-thirds of all Medicaid beneficiaries nationally, to conduct outreach to enrollees to prepare them for the end of the continuous enrollment period. CMS has issued specific guidance allowing states to permit MCOs to update enrollee contact information and conduct outreach about the eligibility renewal process to facilitate continued enrollment as well as Marketplace transitions, where appropriate.

To better understand the role Medicaid MCOs may play in unwinding the continuous enrollment provision, KFF, in collaboration with the Association for Community Affiliated Plans (ACAP), fielded a short survey of Medicaid MCOs (also referred to as managed care plans throughout) in October-November 2022. ACAP member plans are not-for-profit safety net health plans that serve more than 20 million Medicaid enrollees, or about one in five Medicaid enrollees. The survey was fielded among all ACAP health plans that participate in the Medicaid market. A total of 29 plans (of 65), accounting for over 13.2 million Medicaid beneficiaries enrolled in Medicaid MCOs as of September 2022, across 15 states¹  (of 26) responded to the survey. To gain additional insights, a roundtable discussion was held in mid-November 2022 with representatives from 10 plans. While ACAP member plans may differ in important ways from for-profit plans (which enroll more than 50% of all Medicaid beneficiaries nationally), all plans are going to want to maintain enrollment and revenue to the extent possible, and results provide important insights into implications and challenges of unwinding. For additional details, see the Methods section at the end of this brief. Key findings include the following:

Updating beneficiary contact information. Only about one-third of responding plans reported having verified/current contact information for between 76% to 100% of their Medicaid members. Most responding plans reported they are taking action to reach out to members directly to assist with updating contact information and many are working with third parties (e.g., providers, community-based organizations (CBOs), subcontractors/vendors etc.). Nearly all responding plans said that reaching Medicaid beneficiaries is a challenge. Plans also described challenges involved with transferring updated contact information data to the state.

Renewal Outreach. Nearly all responding plans reported the state where they operate is planning to provide monthly files containing information on members for whom the state is initiating the renewal process, and more than half reported that they expect to receive monthly files with information on members that have not submitted renewal information and are at risk of losing coverage. Only one in five responding plans reported hiring (or planning to hire) additional staff to help with renewal efforts. About half of responding plans indicated their renewal outreach strategy includes targeted outreach for specific populations (e.g., pregnant, or postpartum individuals, individuals with chronic conditions, individuals with mental illness or substance use disorder (SUD)).

Coverage Transitions. More than half of responding plans reported that their state Medicaid agency is planning to provide periodic termination files so plans can conduct outreach to individuals terminated for procedural reasons. However, several plans indicated termination files received from the state do not include the reason a beneficiary may be losing coverage. Plans stressed that without this information their ability to conduct targeted outreach is constrained. Nearly all responding plans that also offer a Qualified Health Plan (QHP) in the Affordable Care Act (ACA) marketplace reported that the state will permit the plan to share information about their QHP with enrollees found ineligible for Medicaid. The expectation is that many people no longer eligible for Medicaid because their incomes have risen will be eligible for premium assistance under the ACA.

Unwinding implications. Three-quarters of responding plans reported expecting between 10% to 25% of their enrollees to lose Medicaid coverage over the unwinding period. Responding plans most frequently reported decline in Medicaid enrollment, loss in revenue, churn, and disruptions in member care as significant challenges they expect related to unwinding. Most responding plans expect the risk profile (or acuity) of members to increase, as plans anticipate “stayers” will be sicker than “leavers” and expect medical loss ratios (MLRs) – the share of premiums going to pay for care – to increase.

With a date certain for the end of the continuous enrollment provision, states are finalizing unwinding operational plans and prioritization approaches as well as readying systems. Plans highlighted strategies that could help address unwinding challenges including strengthening communication across state and county agencies, providers, community-based organizations (CBOs), and health insurance Marketplaces; providing detailed, timely data transfers to enable plans to conduct targeted outreach; increasing automatic (“ex parte”) renewals; maximizing lead time for plans to conduct outreach to members before terminating coverage; state consideration of adopting continuous eligibility policies, and improving alignment of eligibility requirements and processes across programs/eligibility pathways.

Findings

Updating Beneficiary Contact Information

To help ensure eligible enrollees retain coverage, states may direct MCOs to seek updated contact information from enrollees. If plans contract with a third party to collect this information, they must confirm the accuracy of updates with enrollees directly. MCOs may share this information with the state or assist individuals in providing their updated contact information to the state. States may accept updated enrollee contact information from MCOs including mailing addresses, telephone numbers, and email addresses provided the state complies with certain beneficiary notice requirements (to confirm the accuracy of updated contact information) or the state receives a waiver of such requirements from CMS.

Only about one-third of responding plans reported having verified/current contact information for between 76% to 100% of their Medicaid members (Figure 1). As background, plans were asked to identify the share of Medicaid members for which they currently have verified contact information. This information is essential to ensuring members receive renewal notices and other communication from the state and the plan. Plans were also asked how often member mailing address, phone number, and email information received from the state is accurate. Less than half of responding plans (38%) reported member information received from the state Medicaid agency is accurate “most of the time” (Figure 1). During the roundtable, several plans discussed the need to maintain “shadow files” to retain up-to-date member contact information, as periodic data feeds from the state may override their member data. Plan staff also reported variable success in transferring updated data to the state (discussed in more detail below).

Most plans reported they are taking action to reach out to members directly to assist with updating contact information. Plans reported conducting direct member outreach via text, email, phone, robocall, interactive voice response (IVR), and letter/postcard. Several plans noted they verify contact information on every inbound and outbound call. In addition to conducting direct member outreach, plans also reported mass messaging via social media, website, member newsletter, tv/radio segments, and other marketing/advertisements. Plans may assist Medicaid members with updating their contact information with the state (or county) Medicaid agency or may obtain updated contact information to share with the state directly. Generally, plans reported live calls and text messaging have been the most effective methods to obtain and update contact information.

Nearly all responding plans reported reaching Medicaid beneficiaries poses a challenge to updating member contact information (Figure 2). In particular, restrictions on text messaging imposed by the Telephone Consumer Protection Act (TCPA) or state rules were cited as a challenge by about half of responding plans. TCPA prohibits sending automated text messages without obtaining the recipient's prior consent. While prior Federal Communications Commission (FCC) rulings confirmed federal and state governments are not subject to TCPA restrictions, CMS had been working to clarify with the FCC whether contractors of state agencies (including MCOs) are subject to the TCPA. On January 23, 2023, the FCC provided guidance to federal and state agencies, as well as their partners (including managed care entities), enabling them to make autodialed (and prerecorded) text and voice calls to raise awareness about Medicaid eligibility and enrollment requirements without violating the TCPA. Other challenges identified by plans include difficulty obtaining documentation from beneficiaries to assist with updating information; lack of communication between state Medicaid agency and Medicaid beneficiaries during the PHE leading to more outdated member information; and difficulty obtaining member approval/confirmation for updates received from third parties.

The majority of plans reported working with third parties to help obtain updated member contact information and to support outreach and communication efforts. Plans said they are partnering with different entities including providers, community-based organizations (CBOs), other state and local agencies (e.g., social services, public health, schools), and subcontractors and vendors (e.g., transportation vendors, pharmacy benefit managers (PBMs), contractors engaged specifically to do outreach/help members during the unwinding process) to ensure member contact information is up-to-date. A few plans described efforts to implement “feeds” for updated addresses or to flag instances of mismatched data with pharmacy or transportation vendors. One plan reported all competitor health plans in the market came together and developed a rack card which includes contact information/branding for each health plan, brief messaging around ensuring Medicaid member addresses are up-to-date, and a QR code enabling members to easily update their address. Their goal is to deliver these cards to hospitals, providers, behavioral health agencies, social service community agencies, schools, and pharmacies across the state. Plans also reported a variety of efforts to educate and engage providers and CBOs about the upcoming end of the continuous enrollment period (e.g., developing provider toolkits and training) and to support provider and CBO outreach and communication efforts (e.g., hosting renewal/recertification events with providers and CBOs and other co-branded strategies).

Nearly three in four responding plans reported providing updated member contact information data to the state or county Medicaid agency on a weekly, bi-weekly, or monthly basis, although plans also identified challenges that undermine efforts to share this information. In a number of states, counties administer the Medicaid program; notably, plans operating in California reported data is exchanged with county agencies instead of directly with the state Medicaid agency. Plans described a variety of challenges involved with transferring updated data including building systems/processes to allow for data exchange; lack of confirmation from the state agency that updated contact information was received and action was taken; lag in time for state systems to update member records; and subsequent state data runs that do not reflect updated data supplied by plan. Plans from a few states reported the state is currently unable to receive updated contact information from the plan.

Renewal Outreach

Nearly three-quarters of responding plans reported conducting outreach about Medicaid renewals prior to the COVID-19 pandemic. As background, plans were asked whether they communicated with enrollees about renewals prior to the pandemic. Pre-pandemic outreach reported by plans ranged from sending member reminders (mailings, phone calls etc.) to more active renewal application assistance as well as engagement with community partners.

Nearly all responding plans said their state is planning to provide monthly files containing information on members for whom the state is initiating the renewal process. Additionally, more than half of responding plans reported they expect the state Medicaid agency to provide monthly files with information on members that have yet to submit renewal forms or additional documentation and are at risk of losing coverage. CMS guidance emphasizes federal Medicaid managed care marketing rules (42 CFR 438.104) do not prohibit plans from providing information and conducting general outreach about the eligibility renewal process on behalf of states. To enable plans to conduct targeted outreach and provide assistance with the renewal process, CMS has encouraged states to share information with plans including beneficiaries due for renewal and those at risk of losing coverage who have yet to submit renewal forms or other documentation.

Only one in five responding plans reported hiring (or planning to hire) additional staff to help with renewal efforts.  Even without new staff, plans reported planning multiple outreach efforts. Nearly three-quarters of responding plans said they will disseminate outreach materials developed by the state Medicaid agency about the need to renew coverage and will also develop other outreach materials to communicate with Medicaid members. All responding plans reported outreach materials will be available in multiple languages, most commonly Spanish. About three-quarters of responding plans reported using social media to conduct outreach. Some plans indicated they will be developing text messaging campaigns around renewals and others noted they will call members whose renewals are due. Plans also said they were developing provider toolkits specifically focused on renewals that, in some cases, include videos providers can show in their waiting rooms.

About half of responding plans reported their renewal outreach strategy includes targeted outreach for specific populations (Figure 3), most frequently for individuals with chronic conditions, pregnant individuals, postpartum individuals, and individuals with mental illness or substance use disorder. Plans indicated these targeted outreach strategies would include additional communication; customized messaging; call center and provider portal alerts for select members; leveraging care managers, transition teams, and life coaches; and partnering with CBOs to provide in-home application assistance for members with disabilities and homebound members.

Coverage Transitions

More than half of responding plans reported that the state Medicaid agency is planning to provide periodic termination files; however, outreach may be difficult if files do not include the reason for termination. Most plans reported expecting to receive termination files monthly. Medicaid managed care marketing rules at 42 CFR 438.104 do not prohibit general outreach from Medicaid managed care plans for eligibility purposes; a plan’s ability to conduct this activity depends on the plan’s contract with the state agency. CMS also clarified in recent guidance that federal marketing rules do not differentiate between coverage termination reasons and states may use plans to conduct general eligibility outreach (on behalf of the state) for any potential coverage termination reason. However, several plans indicated termination files often do not include the reason a beneficiary may be losing coverage. Plans stressed that without this information, their ability to conduct targeted outreach is constrained.

Nearly all responding plans that also offer a QHP reported that the state will permit the plan to share information about their QHP with enrollees found ineligible for Medicaid. CMS guidance outlines states may encourage MCOs that also offer a QHP in the ACA Marketplace to share information with their own enrollees who have been determined ineligible for Medicaid to assist in the transfer of individuals to Marketplace coverage (which has higher income eligibility thresholds than Medicaid). To avoid gaps in coverage, managed care plans may reach out to individuals before they lose coverage to allow them to apply for Marketplace coverage in advance. Even though CMS indicates this activity is allowable under federal rules, plans must comply with state-specific laws and/or contract requirements that may prohibit this activity. During the roundtable, a few plans highlighted the significance of being able to direct ineligible members to affiliated Marketplace plans which was not standard protocol previously. Plans will outreach in a variety of ways (e.g., disseminating written materials) and affiliated QHP plans are also planning to do direct outreach as well.

Implications and Challenges

Three-quarters of responding plans reported they expect between 10% to 25% of their enrollees to lose Medicaid coverage over the unwinding period (Figure 4). While the number of Medicaid enrollees who may be disenrolled during the unwinding period is highly uncertain, it is estimated that millions will lose coverage. The share of individuals disenrolled across states will vary due to differences in how states prioritize and process renewals. One-quarter of responding plans reported they expect that among enrollees who lose coverage, 26% or more will lose coverage for procedural reasons (i.e., related to missing or incomplete information) versus being determined ineligible (Figure 4).  Only a small share of responding plans participate as a QHP in the health insurance Marketplace (9 plans), but these plans reported they expect to only enroll a small share of individuals into their QHP offering following Medicaid disenrollment during unwinding (data not shown).

Responding plans most frequently reported decline in Medicaid enrollment and related revenue loss, enrollee churn, and disruptions in member care as significant challenges they are expecting related to unwinding (Figure 5). Prior to the pandemic, managed care plans long cited lack of continuous eligibility, or churn, as a key challenge in ensuring access to care and care continuity for members. During the roundtable, plans expressed concern about members with chronic conditions and the significant impact of interrupted coverage on access to needed services (e.g., loss of access to HIV, behavioral health, hypertension, or diabetes care). On the survey, plans were also asked to discuss the anticipated effects of the end of the continuous enrollment provision on service utilization, enrollee composition, and plan medical loss ratio (MLR). Most responding plans expect the risk profile (or acuity) of members to increase, as plans anticipate “stayers” will be sicker than “leavers.” Plans also expect MLRs to increase (the MLR reflects the proportion of total capitation payments received by an MCO spent on clinical services and quality improvement, with the remainder going to administrative costs and profits).

Looking Ahead

During the unwinding, millions of people could lose coverage if they are no longer eligible or face administrative barriers to renewing coverage despite remaining eligible. The significant volume of work that states face will place a heavy burden on eligibility and enrollment staff and could contribute to disenrollments due to procedural reasons. Medicaid managed care plans may be well positioned to assist states in conducting outreach and providing support to enrollees who will need to navigate the renewal process. With a date certain for the end of the continuous enrollment provision, states are finalizing unwinding operational plans and prioritization approaches as well as readying systems. Plans highlighted strategies that could help address unwinding challenges including strengthening communication across state and county agencies, providers, CBOs, and health insurance Marketplaces; providing detailed, timely data transfers to enable plans to conduct targeted outreach; increasing automatic (“ex parte”) renewals; maximizing lead time for plans to conduct outreach to members before terminating coverage; and state consideration of adopting continuous eligibility policies, and improving alignment of eligibility requirements and processes across programs programs/eligibility pathways.

Methods

To better understand the role of Medicaid MCOs in unwinding, KFF fielded a short Medicaid managed care plan survey in October 2022 in collaboration with the Association for Community Affiliated Plans (ACAP). ACAP member plans are not-for-profit safety net health plans which serve more than 20 million Medicaid enrollees, or about one in five Medicaid enrollees. While ACAP member plans may differ in important ways from for-profit plans (which enroll more than 50% of all Medicaid beneficiaries nationally), results provide important insights into implications and challenges of unwinding. The survey was fielded among all ACAP health plans that participate in the Medicaid market as of October 2022 (65 plans across 26 states). A total of 29 plans accounting for over 13.2 million Medicaid beneficiaries enrolled in comprehensive MCOs as of September 2022 across 15 states (AZ, CA, IL, IN, MA, MD, MN, NY, OH, OR, PA, RI, TX, WA, and WI) responded to the survey. Responding plan enrollment ranged from approximately 3,600 to 2.5 million with median enrollment of approximately 310,000. Nine plans that participated in the survey reported their health plan also participates as a qualified health plan (QHP) in the health insurance Marketplace. Staff from 10 plans across 9 states (AZ, CA, IL, MN, NY, OH, PA, TX, and WA) participated in a roundtable discussion held on November 16, 2022.

1. AZ, CA, IL, IN, MA, MD, MN, NY, OH, OR, PA, RI, TX, WA, WI ↩︎