U.S. Department of Health and Human Services 
Office of Inspector General 
 
 
Many Medicaid Enrollees with 
Opioid Use Disorder Were 
Treated with Medication; 
However, Disparities Present 
Concerns   
 
    
 
Ann Maxwell  
Deputy Inspector General 
   for Evaluation and Inspections 
September 2023, OEI-BL-22-00260  U.S. Department of Health and Human Services 
O  ffice of Inspector General 
 
Data in Brief 
 
S  eptember 2023, OEI-BL-22-00260 
 
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated 
with Medication; However, Disparities Present Concerns  
Why OIG Did This Review  
Key Results 
Nearly 81,000 people died from opioid overdoses in the United 
  One-third of the 1.5 million  States in 2021, an increase of 17 percent from the previous year.1  
Medicaid enrollees with opioid  Treating opioid use disorder with MOUD2 is essential to reducing 
use disorder did not receive  overdose deaths; however, many individuals in need experience 
medication treatment (referred  difficulties accessing this potentially life-saving treatment.  For 
to as MOUD) in 2021. 
example, the Office of Inspector General (OIG) found that fewer 
  Certain demographic groups than one in five Medicare enrollees with opioid use disorder 
including Black or African  received MOUD in 2021.3  Individuals seeking treatment often face 
American enrollees; enrollees  barriers such as difficulty finding providers who are authorized 
18 years of age and younger;  and/or willing to prescribe or dispense MOUD and stigma 
and enrollees with a disability  surrounding its use.4  For example, until recently, only providers 
and/or blindnesswere less 
with a Federal waiver could prescribe or administer buprenorphine 
likely to receive MOUD. 
for opioid use disorder in an office setting.  Research also suggests 
  In 10 States, less than half of  that particular demographic groups, such as adolescents or people 
enrollees with opioid use  of certain races, may be less likely to receive MOUD.5  Medicaid 
disorder received MOUD. 
covers an estimated 40 percent of nonelderly adults with opioid 
  use disorder, underscoring the programs key role in providing 
access to MOUD.6  In this data brief, we examine the extent to which Medicaid enrollees with opioid use 
disorder received MOUD in 2021.    
How OIG Did This Review 
We used Medicaid claims data to determine the extent to which Medicaid enrollees with opioid use 
disorder received MOUD through Medicaid in 2021.  Because Medicaid enrollees may be dually 
enrolled in Medicare, we also reviewed Medicare claims data to determine if enrollees who were 
enrolled in both programs received MOUD through Medicare.  Additionally, we used Medicaid 
enrollment and eligibility data to examine how MOUD treatment rates differed among demographic 
groups. 
What OIG Recommends  
Our findings underscore the need for continued efforts to increase the use of MOUD in Medicaid.  
Accordingly, we recommend that the Centers for Medicare & Medicaid Services (CMS) (1) encourage 
and support States efforts to reduce barriers to MOUD, especially among groups who may be 
underserved; and (2) encourage States and work with Federal partners to educate Medicaid and 
Children's Health Insurance Program (CHIP) enrollees about access to MOUD.  CMS neither concurred 
nor nonconcurred with our recommendations.  The agency instead stated that it already works with 
States to increase access to MOUD and ensure that enrollees are educated regarding access. 
   
   
  Opioid use disorder is a problematic pattern of opioid use that leads to clinically significant 
impairment or distress.7  It is a chronic disease that can change the reward circuitry of the brain.8 
 
  Certain medications decrease the risk of overdose mortality and improve quality of life for people 
with opioid use disorder. 
 
  Three drugs are currently approved by the U.S. Food and Drug Administration (FDA) for the 
treatment of opioid use disorder: methadone, buprenorphine, and naltrexone.9  These drugs are 
referred to as medications for opioid use disorder (MOUD). 
 
Methadone 
Methadone is a controlled substance that reduces opioid cravings and withdrawal symptoms by blunting or 
blocking the effects of opioids.  Only opioid treatment programs certified by the Substance Abuse and Mental 
Health Services Administration (SAMHSA) are allowed to administer or dispense methadone for treatment of 
opioid use disorder in outpatient settings.10  Typically, patients must visit opioid treatment programs to take 
their daily methadone dose under supervision.11 
 
Buprenorphine 
Buprenorphine is a controlled substance that reduces opioid cravings and withdrawal symptoms by blocking 
the effects of opioids.  Patients can generally access buprenorphine for opioid use disorder through opioid 
treatment programs or office-based providers.  However, during this studys period of review, office-based 
providers were required to obtain a waiver through SAMHSA to (1) prescribe buprenorphine for a patient to 
receive at a pharmacy, or (2) administer buprenorphine (e.g., injectable buprenorphine) for opioid use 
disorder.  Waivered providers were also limited in the number of patients they could treat.  Federal law 
eliminated the waiver requirement in December 2022.12  
 
Naltrexone 
Unlike buprenorphine and methadone, naltrexone is not a controlled substance.13  It works by blocking the 
opioid receptors in the brain, which is reported to reduce opioid cravings.  It can be prescribed or administered 
by any qualified health care provider but requires abstinence from opioids for several days before initiation.  
 
 
Medicaid and Childrens Health Insurance Program (CHIP) Coverage of MOUD 
State Medicaid programs are generally required to cover all FDA-approved medications for opioid use 
disorder from October 2020 to September 2025; however, three States were granted an exception due to 
provider shortages.14  Additionally, States have been required to provide MOUD since October 2019 under 
CHIP.15  States are permitted to apply utilization management controls (e.g., prior authorization 
requirements) to their MOUD coverage.    
Efforts to Increase MOUD Access in Medicaid 
With support from the Centers for Medicare & Medicaid Services (CMS), States have implemented policies 
and practices to make MOUD more accessible in Medicaid, which is estimated to cover almost 40 percent of 
nonelderly adults with opioid use disorder.16  For example, CMS has provided States with Federal policy 
guidance on implementing Medicaid MOUD coverage requirements.17  CMS has also provided States with 
technical assistance to improve the care and outcomes of enrollees with substance use disorders (including 
opioid use disorder) and considers the use of MOUD to treat opioid use disorder to be a core health care 
quality measure for adult Medicaid enrollees.18
  USE OF MOUD AMONG MEDICAID ENROLLEES 
Two-thirds of Medicaid enrollees with opioid use disorder received 
MOUD through Medicaid or Medicare in 2021   
In 2021, approximately 1.5 million people 
Characteristics of enrollees with opioid use disorder* 
enrolled in Medicaid had opioid use 
  Almost a quarter of Medicaid enrollees with opioid use 
disorder, representing nearly 2 percent of 
disorder lived in New York, Ohio, or Pennsylvania. 
the total Medicaid population that year.19  
Two-thirds (more than 1 million) of these    Nearly two-thirds were between the ages of 19 and 44. 
enrollees received MOUD that year    Ten percent had a disability and/or blindness. 
through Medicaid or, for some dually 
eligible enrollees, Medicare.20   Source: OIG analysis of 2021 Medicaid enrollment and claims data. 
*See Appendix A for additional characteristics of enrollees with opioid 
use disorder. 
 
Buprenorphine was the most commonly used MOUD among enrollees 
with opioid use disorder  
Most Medicaid enrollees with opioid use disorder who were treated with MOUD received 
buprenorphine, though methadone was also commonly used.  A small proportion of enrollees 
whose opioid use disorder was treated with MOUD received naltrexone.  Of the 1 million 
Medicaid enrollees with opioid use disorder who received MOUD in 2021, nearly 648,000 
(65 percent) were prescribed or administered buprenorphine.  The vast majority (97 percent) of 
the enrollees who received buprenorphine through Medicaid obtained their medication from a 
pharmacy to take at home.21  At the time of our review, Federal law required that office-based 
providers obtain a waiver from SAMHSA to prescribe buprenorphine for opioid use disorder.  
The waiver requirement was removed in December 2022.22 
Approximately 355,000 enrollees (35 percent) with opioid use disorder received methadone in 
2021.  Nearly all enrollees who were treated with methadone under Medicaid received the drug 
through opioid treatment programs.  In general, only SAMHSA-certified opioid treatment 
programs are allowed to administer or dispense methadone for opioid use disorder, with 
patients typically visiting each day to receive their daily methadone dose under supervision.23   
Sixty-five percent of Medicaid enrollees with opioid use disorder received 
buprenorphine.  
 
 
 
Source: OIG analysis of 2021 Medicaid and Medicare claims data. 
Note: Because some enrollees received more than one type of MOUD, the sum of the figures displayed is greater than 1,004,368 (i.e., 
the total number of enrollees who received MOUD). 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Findings | 3  More than half a million enrollees with opioid use disorder did not 
receive MOUD through Medicaid or Medicare in 2021 
In 2021, more than 510,000 (approximately one-third) of the 1.5 million Medicaid enrollees with 
opioid use disorder did not receive MOUD 
through Medicaid or Medicaredespite Federal 
and State governments relaxed restrictions 
surrounding MOUD access during the COVID-19 
pandemic.24  Some of these enrollees may have 
received MOUD through other sources such as 
self-pay or did not receive MOUD because it was 
not an appropriate treatment for their 
circumstances.  Still, this finding suggests more 
effort is needed to ensure that all enrollees in 
Source: OIG analysis of 2021 Medicaid and Medicare 
need can access treatment through Medicaid.   claims data. 
Further, if pandemic-related flexibilities end, the   
number of enrollees who are unable to access MOUD may be even higher in the future.   
In contrast, other recent policy changes may allow for expanded access to buprenorphinethe 
most commonly used MOUD among Medicaid enrollees.  As of December 2022, any provider 
with a standard Drug Enforcement Agency (DEA) registration can prescribe or directly administer 
buprenorphine for opioid use disorder.  Similarly, providers are no longer subject to patient 
limits, and therefore may expand the number of patients they treat with buprenorphine.25  
 
 
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Findings | 4  DISPARITIES IN MOUD USE AMONG MEDICAID ENROLLEES 
Black/African American enrollees with opioid use disorder were less 
likely to receive MOUD  
Research suggests that people of color may face significant barriers in accessing opioid use 
disorder treatment, which could result in racial and ethnic disparities in MOUD utilization.  
Barriers include shortages of MOUD providers in their communities, racial discrimination in 
health care settings, and increased stigma surrounding substance use disorders, including 
opioid use disorder.26  To explore potential disparities among Medicaid enrollees, we examined 
data from 15 States that provide relatively complete and valid enrollee race and ethnicity data 
according to CMS.27   
In the 15 States that we reviewed, almost three-quarters (71 percent) of enrollees with opioid 
use disorder who identified as White received MOUD in 2021 compared to approximately half 
(53 percent) of the enrollees with opioid use disorder who identified as Black or African 
American.  The lower rate of MOUD use among Black/African American enrollees is especially 
concerning because overdose deaths have increased at greater rates among Black people.28   
Enrollees with opioid use disorder who identified as Asian, Native Hawaiian/Other Pacific 
Islander, or American Indian/Alaska Native were also less likely to receive MOUD.  MOUD 
utilization rates were similar between Medicaid enrollees with opioid use disorder who identified 
as Hispanic or Latino and those who did not.29  
In the 15 States with reliable Medicaid race/ethnicity data, only 53 percent of 
Black/African American enrollees with opioid use disorder received MOUD compared 
to 71 percent of White enrollees.     
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Source: OIG analysis of 2021 Medicaid enrollment data and Medicaid/Medicare claims data. 
*The overall MOUD utilization rate among enrollees for whom race was populated in the 15 States with low-concern enrollee 
race/ethnicity data was 69 percent, which is slightly higher than the nationwide rate of 66 percent.  
Note: Figures displayed are based on enrollees voluntary self-identification of race and are limited to States with low concern 
enrollee race/ethnicity data per CMSs DQ Atlas.  In these States, race was populated in the Transformed Medicaid Statistical 
Information System (T-MSIS) for 531,098 enrollees with opioid use disorder.  Enrollees who selected multiple races were included in all 
corresponding race calculations.  For example, an enrollee who selected White and Asian was included in our analyses of both races.  
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Findings | 5  Only 11 percent of Medicaid enrollees 18 years of age and younger 
with opioid use disorder received MOUD through Medicaid or 
Medicare  
Although less than 1 percent of Medicaid enrollees with opioid use disorder were 18 years of 
age and younger, this age group faces unique challenges in accessing MOUD.30  Despite 
increasing overdose deaths among children and adolescents, some providers may be hesitant to 
treat this age group with MOUD due to its limited approval for patients under the age of 18.31, 32    
However, providers may deem unapproved use to be medically appropriate for some younger 
patients.33  Similarly, opioid treatment programs are permitted to treat patients under the age of 
18 with MOUD in certain circumstances (e.g., if the patient has demonstrated failed attempts at 
non-drug treatment).34  Still, some enrollees may be unable to find providers that offer or 
specialize in pediatric MOUD treatment.  For example, a recent study found that only 
one in four adolescent residential addiction treatment facilities offer buprenorphine.35   
In 2021, only 11 percent (1,439 of 12,938) of children and adolescent enrollees diagnosed with 
opioid use disorder received MOUD, compared to 70 percent of enrollees between the ages of 
19 and 44.  In other words, enrollees with opioid use disorder between the ages of 19 and 44 
were approximately six times more likely to receive MOUD than enrollees 18 years of age and 
younger.  Among children and adolescent enrollees with opioid use disorder, those under the 
age of 16 were especially less likely to receive treatment.  Less than 3 percent of enrollees with 
opioid use disorder (162 of 6,094) in this age group received MOUD.   
We also found that less than half of enrollees aged 65 and older with opioid use disorder 
received MOUD in 2021.  Misunderstandings about opioid use disorder among older adults; 
complications related to treating their comorbidities; and lack of nursing facilities that are willing 
and/or able to provide MOUD may contribute to lower MOUD utilization among this age 
group.36, 37 
Enrollees 18 years of age and younger with opioid use disorder were least likely to 
receive MOUD. 
 
 
 
 
 
 
 
Source: OIG analysis of 2021 Medicaid enrollment data and Medicaid/Medicare claims data.   
Note: Figures displayed represent 1,515,073 enrollees with opioid use disorder for whom age was known. 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Findings | 6  Enrollees who had a disability and/or blindness were less likely to 
receive MOUD for their opioid use disorder 
Only 56 percent of enrollees with opioid use disorder who had a disability and/or blindness 
received MOUD in 2021 as compared with 67 percent of those without a disability or blindness.  
People with disabilities may be less likely to receive MOUD because of insufficient accessibility at 
treatment centers or providers offices.  For example, providers may lack accessible parking and 
entrances at their facilities or may be unequipped to communicate with people whose vision or 
hearing is impaired.38   
Only 56 percent of enrollees with opioid use disorder who had a disability and/or 
blindness received MOUD.  
 
 
 
 
 
Source: OIG analysis of 2021 Medicaid enrollment data and Medicaid/Medicare claims data.    
Note: Figures displayed represent 1,515,126 enrollees with opioid use disorder.  We used eligibility data to identify enrollees who 
were eligible for Medicaid due to disability and/or blindness.  Eligibility records may not have accurately captured the actual 
disability/blindness status of all enrollees in 2021 (i.e., 2021 eligibility redeterminations may not have been conducted if a State was 
offering continuous coverage). 
 
We also examined differences in MOUD utilization by additional enrollee characteristics, such as 
sex, dual eligibility for Medicare, and pregnancy status.  See Appendix B for details. 
   
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Findings | 7  STATE VARIATION IN MOUD USE 
Among individual States, the rate of MOUD utilization varied widely  
Among individual States and Washington, D.C., the rate of opioid use disorder among Medicaid 
enrollees in 2021 ranged from less than 1 percent to 6 percent, with MOUD utilization varying 
widely.  For example, only 37 percent of Medicaid enrollees with opioid use disorder in Illinois 
received MOUD compared to 89 percent of Medicaid enrollees with opioid use disorder in 
Rhode Island.   
States have some flexibility in designing their coverage of MOUD, including whether to impose 
utilization management controls such as prior authorization and preferred drug lists.39  Such 
benefit designs, as well as differences in access to providers (e.g., State restrictions on opening 
new opioid treatment programs, lack of mobile treatment programs that deliver MOUD, etc.), 
may contribute to the variation of MOUD utilization rates among States.     
In 10 States, less than half of enrollees with opioid use disorder 
received MOUD  
In 10 States, less than half of enrollees with opioid use disorder received MOUD in 2021.  In 
these 10 States, approximately 119,000 of 215,000 enrollees with opioid use disorder did not 
receive MOUD, representing nearly a quarter of all such enrollees nationwide.   
We found that many of these States had significantly lower MOUD use compared to other 
States with similar rates of opioid use disorder.  For example, approximately 2 percent of 
Medicaid enrollees in both New York and Virginia had opioid use disorder in 2021.  However, 
only 47 percent of the enrollees in New York received MOUD compared to 79 percent of 
enrollees in Virginia.  Similarly, 1 percent of enrollees in both Illinois and South Carolina had 
opioid use disorder, but enrollees in South Carolina were twice as likely to receive MOUD as 
enrollees in Illinois.  See Appendix C for a full list of MOUD utilization rates by State.  
 
 
 
 
 
 
 
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Findings | 8  MOUD utilization rates among Medicaid enrollees varied widely by State in 2021, 
with less than 50 percent of enrollees receiving MOUD in 10 States.   
Source: OIG analysis of 2021 Medicaid enrollment data and Medicaid/Medicare claims data.  
*Before rounding, Wyomings rate of MOUD utilization was below 50 percent. 
 
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Findings | 9  CONCLUSION AND RECOMMENDATIONS  
Access to MOUD is crucial to reduce overdose mortality and improve the quality of life of 
people with opioid use disorder.  Medicaid is uniquely positioned to achieve these goals given 
that the program is estimated to cover almost 40 percent of nonelderly adults with opioid use 
disorder.40  Although CMS and States have taken several steps in recent years to increase MOUD 
access in Medicaid, our findings demonstrate that a significant number of enrollees with opioid 
use disorder may not be receiving this life-saving treatment.  OIG found that one-third of the 
1.5 million Medicaid enrollees with opioid use disorder did not receive MOUD through Medicaid 
or Medicare in 2021.  Enrollees in certain demographic groupsparticularly those who identify 
as Black or African American or those under the age of 19were less likely to receive MOUD 
than other enrollees.  In addition, we identified wide geographic variation in treatment rates.  
Notably, in 10 States, less than half of enrollees with opioid use disorder received MOUD.   
OIG recognizes that CMSs capacity to address the issues raised in this report is somewhat 
limited.  However, as laws and regulations surrounding drug-related treatment continue to 
evolve, CMS should take further steps to increase the use of MOUD among Medicaid enrollees 
in need, especially among groups who may be underserved.  Such efforts would align with 
CMSs Behavioral Health Strategy goals to strengthen equity and improve access to substance 
use disorder treatment, which includes MOUD.41   
Our recommendations reinforce CMSs overall policy agenda for Medicaid and CHIP, which 
includes providing actionable, timely technical assistance and guidance, and committing to 
pursu[ing] every avenue to engage with providers and other stakeholders, especially people 
and their families who are covered by Medicaid and CHIP.42      
We recommend that CMS:  
Encourage and support States efforts to reduce barriers to MOUD, 
especially among groups who may be underserved 
CMS should help Statesespecially those with low rates of MOUD useidentify and reduce 
barriers that hinder access to treatment.  CMS could offer States technical assistance, 
collaborative learning opportunities, webinars, toolkits, and other resources.  Through its 
Medicaid Innovation Accelerator Program, CMS offered States similar types of support from 
July 2014 through September 2020 for reducing substance use disorders.43  CMSs initiatives 
should include efforts to identify and reduce disparities in MOUD use among the groups we 
found to be underserved (e.g., enrollees of certain races). 
Complete and consistent enrollee race and ethnicity data are critical to (1) understand access 
challenges faced by certain racial and ethnic groups; (2) identify potential policies and programs 
that can reduce disparities; and (3) assess the effectiveness of the initiatives.  However, only 
15 States have relatively valid and complete race and ethnicity data, according to CMS.44  This  
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Conclusion and Recommendations | 10  prevented OIG from assessing racial and ethnic disparities in MOUD use nationwide for this 
study.  As part of its efforts to reduce disparities in MOUD use, and in alignment with CMSs 
2022-2032 Framework for Health Equity, the agency may therefore wish to continue helping 
States standardize and improve their Medicaid race and ethnicity data.45 
Encourage States and work with Federal partners to educate Medicaid 
and CHIP enrollees about access to MOUD  
Until October 2020, State Medicaid programs were not explicitly required to cover MOUD.46  
Similarly, CHIP coverage of MOUD was not required until October 2019.47  As a result, some 
enrollees may be unaware that they currently can obtain MOUD treatment under Medicaid and 
CHIP and should be informed about the mandatory coverage.  Additionally, CMS should 
encourage States and work with Federal partners to educate enrollees about the increased 
availability of buprenorphine in office-based settings due to the recent removal of the waiver 
requirement. 
For example, CMS could create a campaign to help disseminate this information to Medicaid 
and CHIP enrollees.  As part of the campaign, CMS could create resources such as fact sheets, 
social media materials, etc.  CMS could also work with its Federal partners, such as the Office of 
the Surgeon General, to educate Medicaid and CHIP enrollees about the benefits of MOUD.   
Targeted campaigns and other similar initiatives will become even more critical if the end of the 
mandatory MOUD coverage period in 2025 results in States placing restrictions on MOUD.  CMS 
should continue to stay apprised of State MOUD policies and encourage States to educate 
enrollees about any changes in MOUD coverage.     
 
 
 
 
 
 
   
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Conclusion and Recommendations | 11  AGENCY COMMENTS AND OIG RESPONSE 
 
CMS neither concurred nor nonconcurred with our recommendations.  The agency instead 
stated that it already works with States to increase access to MOUD and ensure that enrollees 
are educated regarding access.   
In response to our recommendation that CMS encourage and support States efforts to reduce 
barriers to MOUD, especially among groups who may be underserved, the agency stated that it 
works with States to increase access to MOUD via the mandatory state plan benefit and 
substance use disorder Section 1115 demonstration initiatives.  CMS also stated that it has 
imputed missing enrollee race and ethnicity data, which States can use to better understand 
where to target additional efforts.   
 
OIG acknowledges and thanks CMS for its efforts; however, opportunities exist for additional 
action given our concerning finding that certain demographic groups were much less likely to 
receive MOUD.  CMS shouldin alignment with the agencys Behavioral Health Strategy
further work with States to reduce disparities in MOUD use, ensuring that more enrollees receive 
life-saving treatment.  For example, CMS could offer States technical assistance, collaborative 
learning opportunities, webinars, toolkits, and other resources.  CMS could also help States 
gather more complete self-reported enrollee race and ethnicity data, as self-identification
rather than imputationis regarded as the preferred means for obtaining race and ethnicity 
information.48  
 
In response to our recommendation that CMS encourage States and work with Federal partners 
to educate Medicaid and CHIP enrollees about access to MOUD, the agency stated that it stays 
apprised of State policy changes through the State plan amendment process and already works 
with States to ensure that enrollees are educated regarding access.   
 
OIG recognizes CMSs efforts; however, we continue to recommend that CMS ensure that 
enrollees are educated about access to MOUD.  The 2020-2025 MOUD coverage requirement in 
the SUPPORT for Patients and Communities Act represents a significant expansion in 
comprehensive Medicaid coverage of MOUD.  Additionally, enrollees who were previously 
unable to access buprenorphine for opioid use disorder may be unaware that more providers 
can now prescribe buprenorphine due to the removal of the waiver requirement in late 2022.  
OIG believes that the rapidly evolving landscape of drug-related laws and regulations warrants 
concerted efforts to educate enrollees about expanded access beyond routine state plan 
amendment processes.   
 
CMS noted that it anticipates that States will continue to cover a wide variety of MOUD after the 
SUPPORT for Patients and Communities Act coverage requirement expires in September 2025.  
We ask that CMS encourage States that ultimately continue coverage of MOUD beyond 2025 to 
advertise their coverage to enrollees through campaigns, social media posts, or other easily 
accessible materials.  Additionally, OIG continues to encourage CMS to develop its own 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Agency Comments and OIG Response | 12  educational materials in collaboration with Federal partners such as the Surgeon General and 
SAMHSA.  State Medicaid programs could use such materials to educate enrollees about the 
availability and benefits of MOUD treatment or as models for developing their own materials.  
 
We ask that CMS clarify in its Final Management Decision its concurrence or nonconcurrence 
with each recommendation and the steps it is taking to implement each recommendation. 
For the full text of CMSs comments, see Appendix D. 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Agency Comments and OIG Response | 13  METHODOLOGY 
Data Analysis  
Identifying Enrollees with Opioid Use Disorder 
States submit Medicaid and CHIP (hereinafter collectively referred to as Medicaid) data to CMS 
through the Transformed Medicaid Statistical Information System (T-MSIS).  We used T-MSIS 
claims data to identify Medicaid enrollees with opioid use disorder in the 50 States and 
Washington, D.C.49  We considered an enrollee to have opioid use disorder if they had at least 
one 2021 Medicaid claim that included (1) an opioid abuse or opioid dependence diagnosis 
code or (2) a service from an opioid treatment program.50   
Identifying Enrollees Who Received Medications for Opioid Use Disorder 
To determine the extent to which Medicaid enrollees received MOUD, we counted the number 
of Medicaid enrollees with opioid use disorder who had a Medicaid pharmacy, outpatient, or 
inpatient claim for buprenorphine, methadone, or naltrexone in 2021 in the 50 States or 
Washington, D.C.51  Because Medicare is the primary payer for people dually enrolled in 
Medicare and Medicaid, we also determined the number of dual-eligible Medicaid enrollees 
who had a Medicare pharmacy, outpatient, or inpatient claim for buprenorphine, methadone, or 
naltrexone.  We used Medicaid claims data to identify the most common settings in which 
enrollees received MOUD through Medicaid.  We did not analyze the settings of Medicare-paid 
MOUD claims.  We used Medicaid enrollment (e.g., sex) and eligibility (e.g., basis for eligibility) 
data to identify demographic disparities among enrollees who received MOUD. 
Limitations  
This data brief relied on claims data to determine the extent to which Medicaid enrollees with 
opioid use disorder received MOUD.  Because we used claims data rather than medical records 
to identify enrollees with opioid use disorder, we likely underestimated the actual number of 
enrollees in Medicaid who are in need of treatment.52  In addition, because we did not examine 
medical records, we were unable to confirm the validity of the diagnosis code on the claim (e.g., 
whether the patient actually met diagnostic criteria for opioid use disorder, or whether a 
provider correctly used a diagnosis code, such as that of opioid dependence, etc.).   
Further, our analysis may have underestimated the actual number of enrollees who received 
MOUD if they received treatment through sources that were not included in this review (e.g., 
other insurance or self-pay).  Additionally, States may have misreported MOUD paid for by their 
Medicaid or CHIP programs.  Although T-MSIS is the most comprehensive national Medicaid 
and CHIP data set, its size, complexity, and frequency of updates influence the quality of its 
data.53  We did not independently verify the completeness or accuracy of the data.   
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Methodology | 14  We did not assess whether the enrollees included in our study were continuously covered by 
Medicaid in 2021.  In other words, some enrollees may not have received MOUD through 
Medicaid because they were enrolled in the program for only a short period of time.  However, 
we anticipate the number of people who disenrolled from Medicaid to be low in 2021 due to 
provisions that mandated continuous Medicaid enrollment during most of the Public Health 
Emergency in order to receive a temporary Federal medical assistance percentage increase.54   
Some enrollees with opioid use disorder may not have received MOUD if they or their provider 
determined that MOUD was not an appropriate treatment option.  For example, some providers 
may prefer to treat patients under the age of 18 with alternative therapies such as counseling.  
We did not examine whether enrollees received forms of treatment other than MOUD. 
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and Evaluation 
issued by the Council of the Inspectors General on Integrity and Efficiency. 
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Methodology | 15  APPENDIX A 
Characteristics of Medicaid enrollees with opioid use disorder in 2021  
  
 
 
 
 
 
 
 
 
 
                                                                                                                            
 
                                                                                                                                       
*Eligible under the Affordable Care Acts expanded coverage for adults 55 
Source: OIG analysis of 2021 Medicaid enrollment data and Medicaid/Medicare claims data.56  
Note: The summaries of race and ethnicity are based on enrollees voluntary self-identification.  Percentages sum to more than 100 percent 
because some enrollees selected multiple races, and some selected multiple ethnicities.  Race was unspecified for less than .1 percent of 
enrollees.   
   
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Appendix A | 16  APPENDIX B 
Differences in the rate of MOUD utilization among Medicaid 
 
enrollees with opioid use disorder, by enrollee characteristics 
Percentage within characteristic group who received MOUD 
  
 
 
 
 
  *Eligible under the Affordable Care Acts expanded coverage for adults 57 
 
Source: OIG analysis of 2021 Medicaid enrollment data and Medicaid/Medicare claims data.58  
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Appendix B | 17  APPENDIX C 
Rates of opioid use disorder and MOUD utilization among Medicaid 
enrollees in 2021, by State 
 
 
 
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Appendix C | 18  Source: OIG analysis of 2021 Medicaid enrollment data and Medicaid/Medicare claims data.  
Note: Some enrollees were associated with multiple States. 
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Appendix C | 19  APPENDIX D 
Agency Comments 
 
Following this page are the official comments from CMS. 
   
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Appendix D | 20   Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Appendix D | 21   Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Appendix D | 22   Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities    
Present Concerns, OEI-BL-22-00260  Appendix D | 23  ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Bahar Adili served as the team leader for this study, and Kasey Memphis served as the lead 
analyst.  Others in the Office of Evaluation and Inspections who provided support include 
Miriam Anderson, Robert Gibbons, Margaret Himmelright, Jason Kwong, Michael Novello, and 
Sarah Swisher.  
We would also like to acknowledge the contributions of other Office of Inspector General staff, 
including Lauren McNulty and Jessica Swanstrom.   
This report was prepared under the direction of Dave Tawes, Regional Inspector General for 
Evaluation and Inspections in the Baltimore Regional Office; Heather Barton, Deputy Regional 
Inspector General; and Louise Schoggen, Assistant Regional Inspector General. 
 
Contact 
To obtain additional information concerning this report, contact the Office of Public Affairs at 
Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found on the OIG website 
at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Acknowledgments and Contact | 24  ENDNOTES   
 
1 Centers for Disease Control (CDC), National Center for Health Statistics: Provisional Drug Overdose Death Counts.  Accessed 
at https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm on May 23, 2023. 
2 The Substance Abuse and Mental Health Services Administration (SAMHSA) currently recommends using the term 
medications for opioid use disorders (MOUD) instead of the historically used term medication-assisted treatment (MAT).  
The term MAT implies that medication plays a secondary role to other approaches while the term MOUD reinforces the 
idea that medication is its own treatment form.  87 FR 77330-77365 (December 16, 2022).  As of March 2023, the U.S. Food and 
Drug Administration (FDA) has approved three medications for opioid use disorder: methadone, buprenorphine, and 
naltrexone.   
3 The Office of Inspector General, Opioid Overdoses and the Limited Treatment of Opioid Use Disorder Continue To Be Concerns 
for Medicare Beneficiaries, OEI-02-22-00390, September 2022. 
4 U.S. Government Accountability Office, Opioid Addiction: Laws, Regulations, and Other Factors Can Affect Medication-Assisted 
Treatment Access, GAO-16-833, September 2016.  Comanici, K., et al., Understanding the Role of Community Pharmacies in 
Current Medication for Opioid Use Disorder Care Practices, Journal of the American Pharmacists Association, Volume 63, 
Issue 1, January 2023. 
5 Mauro, P., et al., Use of Medication for Opioid Use Disorder Among US Adolescents and Adults with Need for Opioid 
Treatment, 2019, Journal of the American Medical Association, Volume 5, Issue 3, March 2022.  Andraka-Christou, B., 
Addressing Racial and Ethnic Disparities in the Use of Medications For Opioid Use Disorder, Health Affairs, Volume 40, 
Issue 6, June 2021. 
6 Orgera, K., and Tolbert, J., The Opioid Epidemic and Medicaids Role in Facilitating Access to Treatment, Kaiser Family 
Foundation, May 24, 2019.  Accessed at https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-
facilitating-access-to-treatment/ on April 19, 2023. 
7 Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 2013. 
8 U.S. Department of Health and Human Services, Facing Addiction in America: The Surgeon Generals Spotlight on Opioids, 
September 2018. 
9 FDA, Information about Medication-Assisted Treatment (MAT), last updated May 23, 2023.  Accessed at 
https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat on June 23, 2023.  
We did not include naloxone in our review because it is not considered a medication to treat opioid use disorder.  Naloxone is 
a medicine that rapidly reverses an opioid overdose.  See National Institute on Drug Abuse, Naloxone DrugFacts, January 
2022.  Accessed at https://nida.nih.gov/publications/drugfacts/naloxone on April 20, 2023.  
10 Opioid treatment program refers to a program or practitioner that provides opioid agonist treatment medications (i.e., 
methadone and buprenorphine) to individuals with opioid use disorder.  Opioid treatment programs provide additional 
substance use services such as counseling and toxicology testing.  
11 Over time, patients can receive up to one months worth of methadone take-home doses.  See 42 CFR  8.12(i).  Also see 
SAMHSA, Federal Guidelines for Opioid Treatment Programs, January 2015.  SAMHSA has also increased the flexibility in 
dispensing take-home doses of methadone in response to the COVID-19 pandemic.  See SAMHSA, Opioid Treatment Program 
(OTP) Guidance, March 2020.  See also SAMHSA, Methadone Take-Home Flexibilities Extension Guidance, last updated May 1, 
2023.   
12 The Consolidated Appropriations Act, 2023, repealed the requirement that providers need a waiver to prescribe 
buprenorphine for opioid use disorder.  As of December 2022, all providers with a standard Drug Enforcement Agency 
registration may prescribe buprenorphine for opioid use disorder (in accordance with State law).  Separately, the Consolidated 
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Endnotes | 25   
Appropriations Act, 2023, introduced a requirement for providers to satisfy a one-time training requirement related to treating 
and managing patients with opioid or other substance use disorders.  See Sections 1262-1263 of the Consolidated 
Appropriations Act, 2023 (P.L. 117-328).  
13 Naltrexone also differs from methadone and buprenorphine in that it is an opioid antagonist whereas methadone is an 
opioid agonist and buprenorphine is an opioid partial agonist. 
14 See Section 1006(b) of the 2018 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for 
Patients and Communities Act (SUPPORT for Patients and Communities Act) (P.L. 115-271).  Although Hawaii, South Dakota, 
and Wyoming were granted an exception from the requirement to cover all FDA-approved MOUDs, each of the three States 
covered or reimbursed some form of buprenorphine or naltrexone in 2021. 
15 Section 5022 of the SUPPORT for Patients and Communities Act (P.L. 115-271) required child health and pregnancy-related 
assistance under the Childrens Health Insurance Program (CHIP) to include coverage of mental health services (including 
behavioral health treatment) necessary to prevent, diagnose, and treat a broad array of mental health symptoms and disorders, 
including substance use disorders.  As part of compliance with these requirements, States are generally required to provide 
coverage of MOUD.  CMS issued the following Federal policy guidance to notify States: CMS, Access to Mental Health and 
Substance Use Disorder Services for Children and Pregnant Women in the Childrens Health Insurance Program (SHO# 20-
002).  Accessed at https://www.medicaid.gov/federal-policy-guidance/downloads/sho20001.pdf on July 5, 2023. 
16 Orgera, K., and Tolbert, J., The Opioid Epidemic and Medicaids Role in Facilitating Access to Treatment, Kaiser Family 
Foundation, May 24, 2019.  Accessed at https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-
facilitating-access-to-treatment/ on April 19, 2023. 
17 Section 1006(b) of the SUPPORT for Patients and Communities Act (P.L. 115-271) generally requires States to cover MOUD 
until September 2025.  CMS issued the following Federal policy guidance to notify States: CMS, Mandatory Medicaid State 
Plan Coverage of Medication-Assisted Treatment (SHO# 20-005).  Accessed at https://www.medicaid.gov/federal-policy-
guidance/downloads/sho20005.pdf on March 16, 2022. 
18 For example, CMSs Medicaid Innovation Accelerator Program helped Medicaid agencies enhance their substance use 
disorder programs through technical assistance, webinars, and other tools.  Learn more at 
https://www.medicaid.gov/resources-for-states/innovation-accelerator-program/program-areas/reducing-substance-use-
  
disorders/index.html. The 2023 and 2024 Core Set of Adult Health Care Quality Measures for Medicaid can be accessed at 
https://www.medicaid.gov/medicaid/quality-of-care/downloads/2023-adult-core-set.pdf. 
19 We considered an enrollee to have opioid use disorder if they had at least one 2021 claim paid through Medicaid or CHIP 
that included (1) an opioid use disorder diagnosis code or (2) service from an opioid treatment program.  Because less than 
1 percent of the individuals in this review were below the age of 19 (i.e., potentially eligible for CHIP coverage), we collectively 
refer to our study population as Medicaid enrollees and refer to Medicaid or CHIP claims as Medicaid claims. 
20 Of the 1,004,368 Medicaid enrollees who received MOUD, 91 percent were treated through Medicaid only; 6 percent were 
treated through Medicare only; and 3 percent were treated through both Medicaid and Medicare.  Enrollees may have received 
MOUD through sources other than Medicaid or Medicare (e.g., self-pay). 
21 We did not analyze the settings of Medicare-paid MOUD claims. 
22 The Drug Addiction Treatment Act of 2000 (Title XXXV of the Childrens Health Act of 2000, P.L. No. 106-310) allowed 
providers to obtain a waiver to prescribe Schedule III, IV, and V drugsincluding buprenorphinefor substance use disorder 
treatment in office settings.  The Consolidated Appropriations Act, 2023, removed the waiver requirement. 
23 During this studys period of review, States were permitted to request an exception to allow certain patients to receive take-
home doses of MOUD, including methadone, from opioid treatment programs.  See SAMHSA, Opioid Treatment Program 
(OTP) Guidance, last updated March 19, 2020. 
24 Pandemic-related flexibilities included relaxed regulations surrounding take-home methadone and allowing providers to 
prescribe MOUD via telehealth.   
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Endnotes | 26   
25 See Section 1262 of the Consolidated Appropriations Act, 2023 (P.L. 117-328). 
26 Andraka-Christou, B., Addressing Racial and Ethnic Disparities in the Use of Medications For Opioid Use Disorder, Health 
Affairs, Volume 40, Issue 6, June 2021.  Mark, T., et al., Improving Research on Racial Disparities in Access to Medications to 
Treat Opioid Use Disorders, Journal of Addiction Medicine, Volume 17, Issue 3, May/June 2023.  SAMHSA, The Opioid Crisis and 
the Black/African American Population: An Urgent Issue, April 2020.  
27 All States collect self-reported applicant race and ethnicity data as part of the Medicaid application process; however, the 
race and ethnicity data that States submit to CMS are often incomplete or inconsistent.  Because information about applicants 
race and ethnicity is not necessary to determine eligibility, States must mark related questions as optional (see 42 CFR  
435.907(e)(1)).  Further, question details such as the number of race/ethnicity categories from which applicants can choose 
differ by State.  We therefore limited our race/ethnicity analysis to the following 15 States that CMSs DQ (Data Quality) Atlas 
rated as having enrollee race/ethnicity data that are of low concern for 2020 (i.e., the most recent assessment available at the 
time of our analysis): Alaska, California, Delaware, Michigan, Nebraska, Nevada, New Mexico, North Carolina, North Dakota, 
Ohio, Oklahoma, Pennsylvania, South Dakota, Virginia, and Washington.  The DQ Atlas assesses race/ethnicity data on the basis 
of (1) the completeness of a States race and ethnicity data and (2) the extent to which the distribution of a States non-missing 
race and ethnicity data aligns with an external benchmark, the American Community Survey.  See the DQ Atlas race and 
ethnicity page for more information: https://www.medicaid.gov/dq-
atlas/landing/topics/single/map?topic=g3m16&tafVersionId=25. 
28 CDC, Media Statement, Overdose death rates increased significantly for Black, American Indian/Alaska Native people in 
2020, July 19, 2022.  Accessed at https://www.cdc.gov/media/releases/2022/s0719-overdose-rates-vs.html on April 18, 2023. 
29 Ethnicity was populated for 544,022 enrollees with opioid use disorder in the 15 States rated as having low concern 
enrollee race/ethnicity data.  Sixty-seven percent of the enrollees who self-identified as Hispanic or Latino received MOUD 
compared to 68 percent of enrollees who identified as not Hispanic or Latino. 
30 CDC, Linking People with Opioid Use Disorder to Medication Treatment: A Technical Package of Policy, Programs, and 
Practices, 2022. 
31 Gaither, J., et al., US National Trends in Pediatric Deaths From Prescription and Illicit Opioids, 1999-2016, JAMA Network 
Open, Volume 1, Issue 8, December 2018.   
32 Methadone and naltrexone are not explicitly approved by FDA for patients under the age of 18, and buprenorphine is only 
approved for patients 16 years of age and older.   
33 According to FDA, once it has approved a drug, providers generally may prescribe the drug for unapproved use when they 
judge that it is medically appropriate for their patient.  See FDA, Understanding Unapproved Use of Approved Drugs Off 
Label, last updated February 5, 2018.  Accessed at https://www.fda.gov/patients/learn-about-expanded-access-and-other-
treatment-options/understanding-unapproved-use-approved-drugs-label on July 26, 2023.  
34 See 42 CFR  8.12(e)(2). 
35 King, C., Beetham, T., Smith, N., et al., Treatments Used Among Adolescent Residential Addiction Treatment Facilities in the 
US, 2022, JAMA, Volume 329, Number 22, June 2023.  
36 Han, B., and Moore, A., Prevention and Screening of Unhealthy Substance Use by Older Adults, Clinics in Geriatric Medicine, 
Volume 34, Issue 1, February 2018.  Joshi, P., et al., Medication-Assisted Treatment for Opioid Use Disorder in Older Adults: An 
Emerging Role for the Geriatric Psychiatrist, The American Journal of Geriatric Psychiatry, Volume 27, Issue 4, April 2019.  Bond, 
A., Nursing homes routinely refuse people on addiction treatment  which some experts say is illegal, STAT News, 
April 17, 2018.  Accessed at https://www.statnews.com/2018/04/17/nursing-homes-addiction-treatment/ on July 20, 2023. 
37 Medicare began reimbursing opioid treatment programs for opioid use disorder treatment services in January 2020.  See 
Section 2005 of the SUPPORT for Patients and Communities Act (P.L. 115-271). 
38 SAMHSA, Advisory: Mental and Substance Use Disorder Treatment for People with Physical and Cognitive Disabilities, 2019. 
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Endnotes | 27   
39 CMS, Mandatory Medicaid State Plan Coverage of Medication-Assisted Treatment (SHO# 20-005).  Accessed at 
https://www.medicaid.gov/federal-policy-guidance/downloads/sho20005.pdf on March 16, 2022. 
40 Orgera, K., and Tolbert, J., The Opioid Epidemic and Medicaids Role in Facilitating Access to Treatment, Kaiser Family 
Foundation, May 24, 2019.  Accessed at https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-
facilitating-access-to-treatment/ on April 19, 2023. 
41 CMSs Behavioral Health Strategy can be accessed at https://www.cms.gov/cms-behavioral-health-strategy.  Last updated 
May 5, 2022. 
42 Brooks-LaSure, C., and Tsai, D., A Strategic Vision for Medicaid And The Childrens Health Insurance Program (CHIP), Health 
Affairs Forefront, November 16, 2021.  Accessed at https://www.healthaffairs.org/do/10.1377/forefront.20211115.537685/ on 
May 22, 2023. 
43 From July 2014 through September 2020, CMS administered the Medicaid Innovation Accelerator Program.  The goal of the 
Innovation Accelerator Program was to improve the health and health care of Medicaid beneficiaries and to reduce costs by 
supporting States ongoing payment and delivery system reforms.  CMS, Medicaid Innovation Accelerator Program.  
Accessed at https://www.medicaid.gov/resources-for-states/medicaid-innovation-accelerator-program/index.html on 
March 16, 2023.  CMS, Reducing Substance Use Disorders.  Accessed at https://www.medicaid.gov/resources-for-
states/innovation-accelerator-program/program-areas/reducing-substance-use-disorders/index.html on March 16, 2023. 
44 States vary in how they obtain race/ethnicity data from Medicaid applicants, and questions about applicants race and 
ethnicity must be marked as optional (see 42  CFR 435.907(e)(1)).  Consequently, the race and ethnicity data that States 
submit to CMS are often incomplete or inconsistent.  CMSs DQ Atlas rated only 15 States as having enrollee race/ethnicity 
data that are of low concern for 2020 (i.e., the most recent assessment available at the time of our analysis).  The DQ Atlas 
assesses race/ethnicity data on the basis of (1) the completeness of a States race and ethnicity data and (2) the extent to which 
the distribution of a States non-missing race and ethnicity data aligns with an external benchmark, the American Community 
Survey.  See the DQ Atlas race and ethnicity page for more information: https://www.medicaid.gov/dq-
atlas/landing/topics/single/map?topic=g3m16&tafVersionId=25. 
45 CMS, CMS Framework for Health Equity 20222032, April 2022. 
46 Section 1006(b) of the SUPPORT for Patients and Communities Act (P.L. 115-271) generally requires States to cover MOUD 
until September 2025.  Three States are exempt from coverage: Hawaii, South Dakota, and Wyoming. 
47 Section 5022 of the SUPPORT for Patients and Communities Act (P.L. 115-271). 
48 Office of Management and Budget, Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity, 62 
FR 58782-58790 (October 30, 1997).  U.S. Department of Health and Human Services, Implementation Guidance on Data 
Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status, October 2011.  
49 Guam, American Samoa, and the Northern Mariana Islands did not report 2021 Medicaid data to T-MSIS.  Puerto Rico and 
the U.S. Virgin Islands reported 2021 data to T-MSIS but were not included in this review due to the unavailability of Medicaid 
enrollment data. 
50 We searched Medicaid claims for the following opioid abuse and opioid dependence diagnosis codes: F11.1, F11.2, 304.0, 
304.7, and 305.5. 
51 Methadone is used to treat pain in addition to opioid use disorder.  To avoid including methadone claims for the treatment 
of pain, we excluded methadone pharmacy claims from this review because methadone for the treatment of opioid use 
disorder can only be dispensed by opioid treatment programs.  Buprenorphine is also used to treat pain in addition to opioid 
use disorder.  We excluded buprenorphine products that are not explicitly indicated for the treatment of opioid use disorder 
from this review. 
 
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Endnotes | 28   
52 For example, an enrollee may not have disclosed symptoms to a provider due to the stigma surrounding opioid use disorder 
and therefore may not have had a Medicaid claim with an opioid use disorder diagnosis code.  As a result, the enrollee would 
not have been included in our review. 
53 CMSs DQ Atlas rated the completeness of several States 2021 T-MSIS claims, encounter records, and/or eligibility data as 
high concern.  See the DQ Atlas website for more information: https://www.medicaid.gov/dq-atlas/welcome. 
54 Section 6008 of the Families First Coronavirus Response Act, as amended by the Consolidated Appropriations Act, 2023, P.L. 
No. 117-328 (Dec. 29, 2022), provides a temporary increase to each qualifying States Federal Medical Assistance Percentage 
(FMAP), effective January 1, 2020, through December 31, 2023.  Among other conditions, to receive the increased FMAP, States 
must provide and continue benefits through March 31, 2023, to individuals who were enrolled in Medicaid as of March 18, 
2020, or became enrolled in Medicaid between March 18, 2020, and March 31, 2023, unless the individual requested a 
voluntary termination of eligibility, or the individual ceased to be a resident of the State.   
55 The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) extended Medicaid eligibility to all adults 
under the age 65 with incomes below 133 percent of the Federal poverty level.  The Supreme Court ruling in National 
Federation of Independent Business (NFIB) v. Sebelius effectively made the expansion optional for States. 
56 Figures summarizing enrollees with opioid use disorder do not include the small proportion for whom the relevant 
characteristics were missing.  Less than .1 percent of enrollees were associated with both urban and rural zip codes.  We used 
eligibility data to identify enrollees who were eligible for Medicaid due to (1) pregnancy; (2) disability and/or blindness; or (3) 
Medicaid expansion for adults.  Some enrollees were eligible for multiple reasons (including reasons other than the three we 
analyzed).  Eligibility records may not have accurately captured the actual status of all enrollees in 2021 (i.e., 2021 eligibility 
redeterminations may not have been conducted if a State was offering continuous coverage). 
57 The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) extended Medicaid eligibility to all adults 
under the age 65 with incomes below 133 percent of the Federal poverty level.  The Supreme Court ruling in National 
Federation of Independent Business (NFIB) v. Sebelius effectively made the expansion optional for States. 
58 Summaries of MOUD utilization are limited to enrollees for whom the relevant characteristics were populated.  We used 
eligibility data to identify enrollees who were eligible for Medicaid due to (1) pregnancy; (2) disability and/or blindness; or (3) 
Medicaid expansion for adults.  Some enrollees were eligible for multiple reasons (including reasons other than the three we 
analyzed).  Eligibility records may not have accurately captured the actual status of all enrollees in 2021 (i.e., 2021 eligibility 
redeterminations may not have been conducted if a State was offering continuous coverage).  We used T-MSIS claims data to 
determine if the enrollees in our study were associated with (1) fee-for-service claims; (2) managed care claims; or (3) both fee-
for-service and managed care claims during the period of review.  Under fee-for-service, States pay providers directly for 
covered services received by enrollees.  Under managed care, States pay fees to managed care plans, and the plans pay 
providers for services received by enrollees in accordance with the plans contract with the State.   
Many Medicaid Enrollees with Opioid Use Disorder Were Treated with Medication; However, Disparities  
Present Concerns, OEI-BL-22-00260  Endnotes | 29