MEDICAID 

EXPANSION

Behavioral Health 

Treatment Use in 

Selected States in 

2014

Report to Congressional Requesters

June 2017

GAO-17-529

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-529, a report to 

congressional requesters

June 2017

MEDICAID EXPANSION

Behavioral Health Treatment Use in Selected States in 

2014

What GAO Found

In four selected states, from 17 to 25 percent of enrollees who were covered by

state expansions of Medicaid—authorized by the Patient Protection and 

Affordable Care Act (PPACA)—had diagnosed behavioral health conditions 

(mental health and substance use conditions) in 2014. Mental health conditions 

were more common than substance use conditions; from 11 to 20 percent of 

expansion enrollees were diagnosed with a mental health condition, compared 

with 6 to 8 percent diagnosed with a substance use condition. The most common 

mental health condition category was mood disorders, such as depression. For 

substance use, substance-related conditions (e.g., addiction to drugs like 

opioids) were more prevalent than alcohol-related conditions.

From 20 to 34 percent of expansion enrollees in the four selected states received 

behavioral health treatment in 2014, which includes outpatient services such as 

psychotherapy or prescription drugs. Treatment rates exceeded rates of 

diagnosed conditions, in part, because prescription drugs are not recorded with 

diagnosis codes. Thus, enrollees who only used behavioral health prescription 

drugs—and no outpatient services—were not counted in the diagnosis totals.

• The two most commonly used behavioral health service categories were 

psychotherapy services (visits with a provider aimed at reducing and 

managing symptoms) and diagnostic services, such as diagnostic 

evaluations.

• Antidepressants were the most commonly used behavioral health 

prescription drug category; over two-thirds of expansion enrollees who used 

a behavioral health drug took an antidepressant. 

Use of Behavioral Health Treatment among Medicaid Expansion Enrollees in 

Selected States, 2014

Type of behavioral health 

treatment

Percentage of expansion enrollees

Iowa New York Washington West Virginia

Any behavioral health 

treatment (services or drugs)

34 20 26 33

Behavioral health services 16 13 9 11

Behavioral health drugs 30 16 23 31

Both services and drugs 12 8 7 9

Source: GAO analysis of Medicaid data. | GAO-17-529

Officials in three of the four selected states said that expansion enrollees likely 

had greater access to behavioral health treatment after enrolling in Medicaid.

Officials from Iowa, Washington, and West Virginia reported that, compared to 

being uninsured, expansion enrollees could more easily access treatment, such 

as community-based mental health services and behavioral health prescription 

drugs. Officials in New York said expansion enrollees experienced less of a 

change, because most of its enrollees were previously eligible for Medicaid.

View GAO-17-529. For more information, 

contact Carolyn L. Yocom at (202) 512-7114 

or yocomc@gao.gov.

Why GAO Did This Study

Behavioral health conditions 

disproportionately affect low-income 

populations. Treatment can improve 

individuals’ symptoms and help avoid 

negative outcomes. The expansion of 

Medicaid to cover low-income adults in 

some states—authorized by PPACA—

may have increased the demand for 

such treatment. However, little is 

known about the extent to which 

Medicaid expansion enrollees 

experienced behavioral health 

conditions or utilized treatment during 

the first year of expansion in 2014. 

GAO was asked to provide information 

about the utilization of behavioral 

health treatment among Medicaid 

expansion enrollees during the first 

year of expansion in 2014. For 

selected states in 2014, this report 

describes (1) the population of 

Medicaid expansion enrollees with 

behavioral health diagnoses, and (2) 

the use of behavioral health treatment 

among Medicaid expansion enrollees.

GAO selected four expansion states—

Iowa, New York, Washington, and 

West Virginia—based on, among other 

criteria, availability and reliability of 

Medicaid enrollment and utilization 

data. GAO analyzed Medicaid data on 

behavioral health diagnoses and 

treatment use for expansion enrollees 

for 2014, the most recent year 

available. GAO also reviewed 

documents and interviewed Medicaid 

officials from all selected states to 

understand how data were recorded, 

and how treatment for expansion 

enrollees compared with what was 

available prior to expansion. The 

Department of Health and Human 

Services provided technical comments 

on a draft of this report, which GAO 

incorporated as appropriate.
Page i GAO-17-529 Medicaid Expansion

Letter 1

Background 7

From 17 to 25 Percent of Expansion Enrollees in Selected States 

Had a Behavioral Health Diagnosis; Enrollees’ Gender and Age 

Were Similar across the States 14

From 20 to 34 Percent of Expansion Enrollees in Selected States 

Received Behavioral Health Treatment; Psychotherapy and 

Antidepressant Medications Were Most Common 17

Agency Comments 27

Appendix I Behavioral Health Prescription Drugs Included in Utilization 

Analyses, by Category 28

Appendix II Scope and Methodology 32

Appendix III Use of Treatment and Opioid Pain Medications among Enrollees 

with Diagnosed Opioid Abuse or Dependence 43

Appendix IV GAO Contact and Staff Acknowledgments 49

Tables

Table 1: Coverage of Behavioral Health Benefits for Medicaid 

Expansion Enrollees in Selected States, 2014 12

Table 2: Diagnosed Behavioral Health Conditions among 

Expansion Enrollees in Selected States, 2014 15

Table 3: Use of Behavioral Health Treatment among Expansion 

Enrollees in Selected States, 2014 19

Table 4: Use of Emergency Room Visits among Expansion 

Enrollees in Selected States, 2014 23

Table 5: Use of Behavioral Health Prescription Drugs among 

Expansion Enrollees in Selected States by 

Demographics, 2014 25

Table 6: Use of Treatment among Medicaid Expansion Enrollees 

Diagnosed with Opioid Abuse or Dependence, 2014 45

Contents
Page ii GAO-17-529 Medicaid Expansion

Table 7: Use of Opioid Pain Medications among Expansion 

Enrollees Diagnosed with Opioid Abuse or Dependence 

Compared with All Other Expansion Enrollees, 2014 47

Figures

Figure 1: Characteristics of Selected Medicaid Expansion States 11

Figure 2: Demographic Characteristics of Expansion Enrollees 

with Diagnosed Behavioral Health Conditions in Selected 

States, 2014 16

Figure 3: Use of Behavioral Health Services by Category among 

Enrollees Who Used One or More Services, 2014 21

Figure 4: Use of Behavioral Health Drugs by Category among 

Enrollees Who Used One or More Drugs, 2014 24

Figure 5: Demographic Characteristics of Expansion Enrollees 

with Diagnosed Opioid Abuse or Dependence in Selected 

States, 2014 44
Page iii GAO-17-529 Medicaid Expansion

Abbreviations

ADHD attention-deficit/hyperactivity disorder

CMS Centers for Medicare & Medicaid Services

HHS Department of Health and Human Services

FDA Food and Drug Administration 

FPL federal poverty level

MSIS Medicaid Statistical Information System 

MAT medication-assisted treatment

PPACA Patient Protection and Affordable Care Act

SAMHSA Substance Abuse and Mental Health Services 

Administration

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page 1 GAO-17-529 Medicaid Expansion

441 G St. N.W.

Washington, DC 20548

June 22, 2017

The Honorable Frank Pallone, Jr.

Ranking Member

Committee on Energy and Commerce

House of Representatives

The Honorable Diana DeGette

Ranking Member

Subcommittee on Oversight and Investigations

Committee on Energy and Commerce

House of Representatives

The Honorable Joseph P. Kennedy, III

House of Representatives

Research has shown that low-income individuals disproportionately 

experience behavioral health conditions. Such conditions include those 

related to mental health, such as depression, and to substance use, such 

as alcohol use disorder. In particular, research has shown that individuals 

enrolled in Medicaid—a joint federal-state program that finances health 

care coverage for certain low-income and medically needy individuals—

experience a higher rate of behavioral health conditions than those with 

private insurance.1 Access to behavioral health treatment—including both 

behavioral health services and prescription drugs—is important because 

of the consequences of untreated conditions, which may include 

worsening health, increased medical costs, and negative effects on 

employment and workplace performance.

As of January 1, 2014, states have the option to expand eligibility for the 

Medicaid program—as allowed by the Patient Protection and Affordable 

Care Act (PPACA)—to certain adults with incomes up to 138 percent of 

 1

See Substance Abuse and Mental Health Services Administration, Center for Behavioral 

Health Statistics and Quality, 2015 National Survey on Drug Use and Health: Detailed 

Tables (Rockville, Md.: September 2016).

Letter
Page 2 GAO-17-529 Medicaid Expansion

the federal poverty level (FPL).2 PPACA requires states that choose to 

expand Medicaid to provide enrollees with benefit plans that include 

behavioral health treatment, and therefore Medicaid programs in these 

states may have experienced increased demand for behavioral health 

treatment.3 However, little is known about the extent to which expansion 

enrollees had diagnosed behavioral health conditions, or what types of 

behavioral health services and related prescription drugs enrollees 

received during the first year of Medicaid expansion in 2014.4

Given the importance of access to treatment for individuals with 

behavioral health conditions, and the likely increased demand on 

Medicaid programs in expansion states, you asked us to provide 

information about the utilization of behavioral health treatment among 

Medicaid expansion enrollees during the first year of expansion in 2014. 

This report describes

1. the population of Medicaid expansion enrollees with behavioral health 

diagnoses in selected states in 2014, and

 2

Under PPACA, enacted on March 23, 2010, states may opt to expand their Medicaid 

programs to cover nonelderly, nonpregnant adults who are not eligible for Medicare, and 

whose income does not exceed 133 percent of the FPL beginning January 1, 2014. Pub. 

L. No. 111-148, 124 Stat. 119 (2010), as amended by the Health Care and Education 

Reconciliation Act of 2010 (HCERA), Pub. L. No. 111-152, 124 Stat. 1029 (2010). For 

purposes of this report, references to PPACA include the amendments made by HCERA. 

PPACA also provides for a 5 percent disregard when calculating income for determining 

Medicaid eligibility, which effectively increases this income level to 138 percent of the FPL. 

PPACA also permitted an early expansion option, whereby states could expand eligibility 

for this population (or a subset of this population) starting on April 1, 2010.

3

Our prior work found that states that chose not to expand Medicaid targeted state-funded 

behavioral health treatment to uninsured adults with the most serious behavioral health 

needs or established waiting lists for treatment. See GAO, Behavioral Health: Options for 

Low-Income Adults to Receive Treatment in Selected States, GAO-15-449 (Washington, 

D.C.: June 19, 2015). 

4

We define Medicaid expansion enrollees as nonpregnant adults aged 19 through 64 

years who were not eligible for Medicare and whose income did not exceed 138 percent of 

the FPL. We included both newly eligible and not newly eligible enrollees. Newly eligible 

expansion enrollees are those individuals who would not have been eligible for full 

Medicaid benefits under the state’s eligibility rules that were in effect on December 1, 

2009, and whose coverage began after their state opted to expand Medicaid as 

authorized by PPACA. Newly eligible expansion enrollees also include individuals, who as 

of December 1, 2009, received limited Medicaid benefits under a state demonstration or 

waiver; or were enrolled in a state-only funded health care program. Not newly eligible 

expansion enrollees would have been eligible for Medicaid based on the state’s eligibility 

rules that were in effect on December 1, 2009, such as under a pre-existing state 

demonstration or waiver, in states that subsequently opted to expand Medicaid as 

authorized under PPACA.
Page 3 GAO-17-529 Medicaid Expansion

2. the use of behavioral health treatment among Medicaid expansion 

enrollees in selected states in 2014.

To describe the population of Medicaid expansion enrollees with 

behavioral health diagnoses in selected states in 2014, we selected four 

states (Iowa, New York, Washington, and West Virginia) that met the 

following criteria: (1) were among the 25 states that chose to expand 

Medicaid as allowed under PPACA as of January 1, 2014; (2) had 

enrollment and utilization data for expansion enrollees in the Medicaid 

Statistical Information System (MSIS) for all of calendar year 2014 that 

were sufficiently reliable for the purpose of our reporting objectives; and 

(3) had available information and documentation on Medicaid behavioral 

health benefits, and how enrollment, service utilization, and prescription 

drug data were recorded for expansion enrollees in MSIS.5 Our selected 

states were the only four states that met these criteria as of January 

2016, and they are not representative of all states and their Medicaid 

programs.6 In addition, a number of state-specific factors—such as 

differences in population health status and provider supply—could 

contribute to variation across our selected states, but attributing this 

variation to such factors was beyond the scope of this study. For each 

state, we analyzed enrollment and service utilization data to (1) identify all 

expansion enrollees (both newly and not newly eligible), (2) determine the 

extent to which they had diagnosed behavioral health conditions, and (3) 

describe characteristics of enrollees with these conditions. We considered 

an enrollee to have a diagnosed behavioral health condition if that 

enrollee received any outpatient services with a recorded diagnosis code 

for a behavioral health condition in 2014.7 Among the substance-related 

conditions, we also identified opioid abuse and dependence as a unique 

 5

Service utilization data comprise claims and encounters for medical services reimbursed 

by the Medicaid program. Claims are records of medical services paid for on a fee-forservice basis, whereas encounters represent services provided under managed care 

arrangements. Under a fee-for-service model, states pay providers for each covered 

service for which the providers bill the state. Under a managed care model, states contract 

with managed care organizations to provide or arrange for medical services, and 

prospectively pay the plans a fixed monthly fee per enrollee.

6

As of January 2016, the most recent year for which one or more states had complete 

data in MSIS was 2014. 

7

We used behavioral health condition codes from the International Classification of 

Diseases, Ninth Revision, range of 291.0 – 314.9. We selected these codes based on a 

review of published research reports and studies that examined behavioral health 

utilization. Unless otherwise noted, we considered both primary and secondary diagnoses 

when determining whether enrollees had a diagnosed behavioral health condition.
Page 4 GAO-17-529 Medicaid Expansion

category, and we selected these codes based on prior research on opioid 

use in Medicaid.8 Because we measured behavioral health conditions 

based on outpatient service utilization data, our estimates do not include 

individuals with conditions who did not use outpatient services during 

2014—such as individuals who used no services or who only used 

inpatient services—or those who used only behavioral health prescription 

drugs.9 For the group of enrollees with a behavioral health condition, we 

used enrollment data to describe their characteristics; specifically, we 

examined age, gender, and geographic (i.e., urban vs. rural) location.10

To describe the use of behavioral health treatment among Medicaid 

expansion enrollees in selected states in 2014, we used enrollment, 

service utilization, and prescription drug data for the same four selected 

states. We defined behavioral health treatment as the receipt of 

behavioral health services, behavioral health prescription drugs, or both. 

We defined behavioral health services as outpatient screening, 

assessment, diagnostic, treatment, rehabilitation, and habilitation services 

used primarily or exclusively to evaluate and address the needs of

individuals with behavioral health conditions. To identify behavioral health 

services, we reviewed the following for each state: (1) Medicaid provider 

manuals and other coverage documentation that contained the procedure 

codes and descriptions for covered services, and (2) a list of all services 

that were provided to expansion enrollees in calendar year 2014 that 

were recorded with a primary diagnosis of a behavioral health condition. 

We selected codes from these two sources that we determined to be 

behavioral-health specific based on their descriptions.11 Consequently, 

lists of services are different for each state based on their coverage and 

 8

See A. J. Gordon et al., “Patterns and Quality of Buprenorphine Opioid Agonist 

Treatment in a Large Medicaid Program,” Journal of Addiction Medicine, vol. 9, no. 6 

(2015). Opioid abuse and dependence diagnoses were of interest due to the rising 

number of opioid-related overdose deaths and other public health impacts of opioid use.

9

From 3 to 7 percent of expansion enrollees in selected states used a behavioral health 

drug in 2014, but did not have a behavioral health diagnosis recorded on an outpatient 

service. MSIS prescription drug data do not include diagnosis codes. 

10We defined geographic location based on enrollees’ zip code of residence using the 

most recent available rural-urban commuting area codes from the Department of Health 

and Human Services and the Department of Agriculture. 

11We identified services as behavioral-health-specific if their descriptions indicated that 

they were primarily or exclusively used to evaluate and address behavioral health 

conditions.
Page 5 GAO-17-529 Medicaid Expansion

utilization of services in 2014.12 We also analyzed behavioral health 

service use by category; for this analysis, we divided the top 25 mostused behavioral health services by state into categories, such as 

diagnostic services and psychotherapy services, based on their 

descriptions. We excluded all inpatient and laboratory services from our 

analysis.13 In addition, because our analysis was limited to Medicaid 

service utilization data, our results do not reflect the use of behavioral 

health services not paid for by Medicaid, such as state- or grant-funded 

services.14

To more fully examine service utilization patterns among expansion 

enrollees, we also examined evaluation and management services—

more general medical visits with a physician or other medical provider—

because some individuals may have received behavioral health treatment 

during these visits, including services provided by a psychiatrist. We 

limited our analysis of evaluation and management services to those 

visits recorded with a primary diagnosis of a behavioral health condition. 

However, because of the uncertainty of the extent to which behavioral 

health treatment was provided as part of evaluation and management 

services, we do not count them as behavioral health services, or include 

them in our overall definition of behavioral health treatment.

We also examined outpatient emergency room visits—for any condition, 

not just a behavioral health condition—among expansion enrollees with 

and without a behavioral health diagnosis. Emergency room visits were of 

interest, because prior research has suggested that individuals who have 

a behavioral health condition may access emergency care more 

frequently than those without such conditions.15

 12Each state was provided with the opportunity to review and comment on the list of 

services selected for analysis, and we made revisions as appropriate. 

13We excluded inpatient services because Medicaid generally does not allow for the 

payment of claims for inpatient or residential behavioral health treatment for adults ages 

21 to 64 years provided in certain settings. Consequently, data for services provided in 

these settings would not have been available for analysis. We excluded laboratory 

services primarily because we determined that it would be difficult to count these services 

accurately in a way that was consistent across states. 

14States may fund services for Medicaid enrollees that Medicaid does not cover, or 

services for uninsured adults who are not Medicaid-eligible, by using general revenues or 

federal grants. See GAO-15-449.

15See, e.g., J. Castner et al., “Frequent Emergency Department Utilization and Behavioral 

Health Diagnoses,” Nursing Research, vol. 64, no. 1 (2015). 
Page 6 GAO-17-529 Medicaid Expansion

To examine behavioral health prescription drug use, we examined 

Medicaid data for prescription drugs provided to expansion enrollees in 

2014. We defined behavioral health prescription drugs as Food and Drug 

Administration (FDA)-approved drugs used, on- or off-label, to treat adults 

with behavioral health conditions in the United States as of 2014.16 To 

identify these drugs, we worked with a contractor, QuintilesIMS, who 

developed a list of behavioral health drugs based on information on how 

drugs are classified by therapeutic use, survey data on prescribing 

patterns, and expert clinical opinion. We categorized the list of drugs into 

12 categories, such as antidepressants, based on our prior work and 

consultation with QuintilesIMS. See appendix I for the list of behavioral 

health prescription drugs we included in our analysis.

We conducted interviews with officials from our selected states to discuss 

behavioral health benefits for Medicaid expansion enrollees; how 

enrollment, service utilization, and prescription drug data were recorded 

in MSIS; officials’ perspectives on the results of our analysis; and whether 

Medicaid expansion affected the availability of behavioral health 

treatment for expansion enrollees, relative to what was available for lowincome, uninsured adults prior to the first year of expansion in 2014. We 

also interviewed a physician group specializing in addiction medicine and 

consulted with clinical experts from QuintilesIMS for additional 

perspectives on our results.

We assessed the reliability of MSIS data by interviewing knowledgeable 

federal and state officials; reviewing related documentation, such as 

studies that assessed the completeness and quality of Medicaid data; 

comparing the results of our analysis to published figures from the 

Centers for Medicare & Medicaid Services (CMS), which oversees 

Medicaid at the federal level; and testing the data for logical errors. Based 

on this work, we determined that the data were sufficiently reliable for the 

purposes of our reporting objectives. For further details on our scope and 

methodology, including our data reliability assessment, see appendix II.

We conducted our performance audit from November 2015 through June 

2017 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

 16The term off-label means prescribed for conditions and in populations that are not 

included in FDA-approved drug labeling.
Page 7 GAO-17-529 Medicaid Expansion

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

Behavioral health conditions—including those related to mental health 

and substance use—affect a substantial number of adults in the United 

States. The Substance Abuse and Mental Health Services Administration 

(SAMHSA) estimated that in 2015 about 43 million adults (18 percent) 

had a mental health condition—including about 10 million adults (4 

percent) with a serious mental illness—and about 20 million (8 percent) 

had a substance use condition. Examples of common mental health 

conditions include anxiety disorders, such as phobias and post-traumatic 

stress disorder, and mood disorders, such as depression and bipolar 

disorder. Examples of common substance use conditions include alcohol 

use disorder and opioid use disorder. There is substantial overlap 

between individuals with mental health and substance use conditions; 

about 8 million adults had both types of conditions, also referred to as cooccurring conditions. Individuals with behavioral health conditions also 

experience higher rates of physical health conditions.17 Low-income 

individuals, such as those enrolled in Medicaid, are at greater risk for 

developing behavioral health conditions. In 2015, a greater percentage of 

individuals covered by Medicaid experienced mental health conditions 

and co-occurring conditions than individuals with private insurance.18

Treatment for behavioral health conditions can help individuals reduce 

their symptoms, improve their ability to function, and avoid the potential 

consequences of untreated conditions, such as worsening health, 

reduced educational attainment, loss of employment, and involvement 

with the justice system. Treatment for behavioral health conditions can 

include behavioral health services, prescription drugs, or a combination of 

both. Behavioral health services include diagnostic services, which 

 17For example, the Medicaid and CHIP Payment and Access Commission found that adult 

Medicaid enrollees with a behavioral health diagnosis were more likely to have a chronic 

medical condition, such as heart disease or diabetes, than those without a behavioral 

health diagnosis. See Medicaid and CHIP Payment and Access Commission, Report to 

the Congress on Medicaid and CHIP (Washington, D.C.: June 2015). 

18See SAMHSA, Center for Behavioral Health Statistics and Quality, 2015 National 

Survey on Drug Use and Health: Detailed Tables (Rockville, Md.: September 2016).

Background

Behavioral Health 

Conditions

Behavioral Health 

Treatment
Page 8 GAO-17-529 Medicaid Expansion

involve the collection and evaluation of information to determine the 

nature and extent of behavioral health problems, and psychosocial 

therapies, such as psychotherapy. Psychotherapy—also referred to as 

counseling or “talk therapy”—typically involves regular visits with a 

provider focused on helping individuals understand, reduce, and manage 

their symptoms. Prescription drugs may also be used to treat both mental 

health and substance use conditions. SAMHSA estimated that in 2015, 

more adults used a mental health medication (12 percent) than received 

outpatient mental health treatment (7 percent).19 A common type of drug 

used to treat mental health conditions is antidepressants, which treat 

depression as well as other conditions, such as anxiety. For certain 

substance use conditions, individuals may receive medication-assisted 

treatment (MAT), which involves the use of medications in conjunction 

with behavioral health services, such as psychotherapy. According to 

SAMHSA, the use of medications like methadone, buprenorphine, and 

naltrexone for individuals with opioid use disorders can help them

more fully engage in their recovery.

One potential barrier to accessing treatment is a shortage of qualified 

behavioral health professionals, particularly in rural areas. According to 

the Health Resources and Services Administration, there were more than 

4,500 mental health professional shortage areas in the United States as 

of April 2017, containing about a third of the American population (about 

109 million people). Over half of these shortage areas were in rural or 

partially rural locations. We previously reported that states were taking a 

number of steps to address behavioral health workforce shortages, such 

as providing Medicaid reimbursement for telehealth services.20 Telehealth 

services allow a patient in a rural location to interact with a medical 

provider through interactive video conferencing. Research has suggested 

that telehealth services are particularly effective for specialties such as 

mental health that involve mostly verbal interaction rather than physical 

examination.21

 19See SAMHSA, Center for Behavioral Health Statistics and Quality, Key Substance Use 

and Mental Health Indicators in the United States: Results from the 2015 National Survey 

on Drug Use and Health, HHS Publication No. SMA 16-4984, NSDUH Series H-51 

(Rockville, Md.: 2016).

20See GAO-15-449. 

21M. Gilman & J. Stensland, “Telehealth and Medicare: Payment Policy, Current Use, and 

Prospects for Growth,” Medicare & Medicaid Research Review: vol. 3, no. 4 (Baltimore, 

Md.: 2013).
Page 9 GAO-17-529 Medicaid Expansion

CMS and states jointly fund and administer the Medicaid program, and 

states have flexibility within broad federal parameters for designing and 

implementing their Medicaid programs. For example, state Medicaid 

programs must cover certain mandatory populations and benefits, but 

states may choose to also cover other optional populations and benefits. 

Traditionally, Medicaid did not require states to include behavioral health 

services in their Medicaid programs; however, all state Medicaid 

programs provided some behavioral health services. Likewise, states 

were not required to include coverage for prescription drugs in their 

Medicaid programs, but all states did. Under PPACA, most expansion 

enrollees must be covered under an alternative benefit plan, which must 

cover 10 essential health benefits categories. Mental health and 

substance use services, including behavioral health treatment, and 

prescription drugs are 2 of the 10 essential health benefits categories. 

Medicaid is the largest source of funding for behavioral health treatment 

in the nation, with spending estimated at about $53 billion for 2014.22

Prior to 2014—when states had the option to expand Medicaid to all 

adults up to 138 percent of the FPL—states had varying levels of 

coverage available for low-income, uninsured adults. For example, the 

four states we selected had the following coverage available.

• Iowa had coverage available for low-income adults up to 200 percent 

of the FPL under a Medicaid waiver, but coverage did not include 

behavioral health treatment.23

• New York provided Medicaid benefits to low-income, childless adults 

up to 100 percent of the FPL.24 Enrollees with incomes up to about 78 

percent of the FPL were served through traditional Medicaid. 

Enrollees above this income level and up to 100 percent of the FPL 

were covered under New York’s Family Health Plus program, which 

was implemented in 2001 through a Medicaid waiver.

 22See SAMHSA, Behavioral Health Spending and Use Accounts, 1986–2014, HHS 

Publication No. SMA-16-4975 (Rockville, Md.: August 2016).

23With CMS’s approval, states may use Medicaid waivers—which allow states to set aside 

certain, otherwise applicable federal Medicaid requirements—to provide health care to 

individuals who would not otherwise be eligible for those benefits under the state’s 

Medicaid program. 

24New York provided Medicaid benefits to adults with children up to 150 percent of the 

FPL.

Medicaid
Page 10 GAO-17-529 Medicaid Expansion

• Washington expanded Medicaid as of January 3, 2011, as part of 

PPACA’s early expansion option.25 Although the state covered 

enrollees up to 138 percent of the FPL, enrollment was limited to 

around 41,000 individuals who were previously enrolled in Basic 

Health, a state-funded health coverage program for adults up to 200 

percent of the FPL with capped enrollment.

• West Virginia did not have Medicaid coverage for low-income, 

childless adults prior to its Medicaid expansion in 2014.26

As a result, the extent to which expansion enrollees were newly eligible 

for Medicaid coverage in 2014 varied among our selected states. For 

example, while most Medicaid expansion enrollees in New York were 

previously eligible for coverage under the state’s pre-PPACA Medicaid 

program, all expansion enrollees in West Virginia were newly eligible. See 

figure 1 for information on the size of each state’s Medicaid expansion 

population, the percent who were newly eligible, as well as other state 

characteristics.

 25PPACA’s early expansion option allowed states to expand eligibility for low-income 

adults (or a subset of these adults) starting on April 1, 2010. 

26West Virginia did have coverage for parents with dependent children up to 31 percent of 

the FPL prior to 2014.
Page 11 GAO-17-529 Medicaid Expansion

Figure 1: Characteristics of Selected Medicaid Expansion States

Notes: We analyzed state-reported enrollment data for December 2014 from CMS. We calculated the 

percentage of expansion enrollees who were newly eligible by dividing the number of newly eligible 

enrollees by the total number of expansion enrollees. Newly eligible expansion enrollees are those 

individuals who would not have been eligible for full Medicaid benefits under the state’s eligibility rules 

that were in effect on December 1, 2009, and whose coverage began after their state opted to 

expand Medicaid as authorized by the Patient Protection and Affordable Care Act. Newly eligible 
Page 12 GAO-17-529 Medicaid Expansion

expansion enrollees also include individuals, who as of December 1, 2009, received limited Medicaid 

benefits under a state demonstration or waiver; or were enrolled in a state-only funded health care 

program. Percentages of urban and rural residents by state are based on 2010 Census data.

States that expanded Medicaid could choose different delivery systems to 

provide benefits to expansion enrollees, such as fee-for-service or 

managed care. Under a fee-for-service model, states pay providers for 

each covered service for which the providers bill the state. Under a 

managed care model, states contract with managed care organizations to 

provide or arrange for medical services, and prospectively pay the plans a 

fixed monthly fee per enrollee. States that provide Medicaid benefits 

through managed care may contract with separate companies to manage 

medical and behavioral health benefits, often referred to as “carving out” 

behavioral health benefits. See table 1 for information on Medicaid 

coverage of physical and behavioral health benefits for expansion 

enrollees in our selected states for 2014.

Table 1: Coverage of Behavioral Health Benefits for Medicaid Expansion Enrollees in Selected States, 2014

 Delivery systems

State Physical health services Mental health services Substance use services 

Behavioral health 

prescription drugs

Iowa Fee-for-service or managed 

care

Carved out; managed care Carved out; managed care Fee-for-service

New York Managed care Partially carved out; fee-forservicePartially carved out; fee-forserviceManaged care

Washington Managed care Partially carved out; 

managed care

Managed care Managed care

West Virginia Fee-for-service Fee-for-service Fee-for-service Fee-for-service

Source: GAO interviews with state officials and analysis of state Medicaid programs. | GAO-17-529

Note: The term “carve out” refers to states with Medicaid managed care contracts that choose to have 

a separate company manage or administer behavioral health benefits apart from medical or other 

benefits. “Partially carved out” refers to states that chose to include some behavioral health services 

in their managed care contracts, while carving out others.
Page 13 GAO-17-529 Medicaid Expansion

Although Medicaid is the largest source of funding for behavioral health 

treatment in the nation, states have historically also had a large role in 

funding behavioral health services through programs other than Medicaid, 

especially for low-income, uninsured adults.27 In addition, states may use 

SAMHSA-administered mental health and substance use block grants to 

design and support a variety of treatments for individuals with behavioral 

health conditions.28 As we previously reported, some states that did not 

expand Medicaid provided behavioral health treatment to priority 

populations to focus care on adults with the most serious conditions and 

used waitlists for those with more modest behavioral health needs. We 

also reported that the Medicaid expansion states we examined generally 

reported an increase in the availability of behavioral health treatment for 

previously uninsured low-income adults who enrolled in Medicaid, 

particularly in states that had no prior coverage available for this 

population.29

 27In contrast to Medicaid, for which payment of benefits to eligible persons is required by 

law, state general funding for the treatment of uninsured and underinsured residents is 

discretionary. The extent to which state-funded treatment is provided may depend on the 

availability of funding. 

28According to SAMHSA, in state fiscal year 2012, state general funds accounted for 45 

percent of state mental health and 40 percent of state substance use agency budgets. 

SAMHSA block grants accounted for 1 percent of state mental health and 34 percent of 

state substance use agency budgets. See SAMHSA, Funding and Characteristics of 

Single State Agencies for Substance Abuse Services and State Mental Health Agencies, 

2013, HHS Pub. No. (SMA) 15-4926 (Rockville, Md.: 2015).

29See GAO-15-449.

Funding for Behavioral 

Health Treatment
Page 14 GAO-17-529 Medicaid Expansion

Across our four selected states in 2014, from 17 to 25 percent of 

expansion enrollees were diagnosed with a behavioral health condition. 

Diagnoses of mental health conditions were more common than 

diagnoses of substance use conditions. The distribution of expansion 

enrollees with a behavioral health diagnosis by gender and age was 

generally similar across states.

Behavioral health diagnoses among expansion enrollees ranged from 17 

to 25 percent across our selected states in 2014, with mental health 

conditions being more common than substance use conditions. From 11 

to 20 percent of expansion enrollees were diagnosed with a mental health 

condition, compared with 6 to 8 percent diagnosed with a substance use 

condition. (See table 2.) However, patterns of specific mental health and 

substance use diagnoses were similar across selected states. The most 

common mental health condition categories were mood disorders, such 

as depression, and anxiety disorders, such as panic disorder. Among 

expansion enrollees diagnosed with a substance use condition, a greater 

percentage were diagnosed with a substance-related condition, such as 

cocaine dependence, compared with alcohol-related conditions. From 1 

to 3 percent of all expansion enrollees were diagnosed with opioid abuse 

or dependence, a subset of substance-related conditions. (See app. III for 

more information on this group of enrollees.)

From 17 to 25 

Percent of Expansion 

Enrollees in Selected 

States Had a 

Behavioral Health 

Diagnosis; Enrollees’ 

Gender and Age 

Were Similar across 

the States

From 17 to 25 Percent of 

Expansion Enrollees had a 

Behavioral Health 

Diagnosis in Selected 

States, Most Commonly a 

Mental Health Condition
Page 15 GAO-17-529 Medicaid Expansion

Table 2: Diagnosed Behavioral Health Conditions among Expansion Enrollees in Selected States, 2014

Type of behavioral health diagnosis

Percentage of expansion enrollees

(number of enrolleesa)

Iowa

(131,967)

New York

(1,759,414)

Washington

(566,193)

West Virginia

(197,071)

Any behavioral health diagnosisb 25 17 24 24

Mental health diagnosis 20 11 17 20

Substance use condition diagnosisc 8 7 8 6

Opioid abuse/dependence diagnosis 1 3 1 3

Both mental health and substance use conditionsc 5 3 4 3

Source: GAO analysis of Medicaid program data. | GAO-17-529

Note: We considered an enrollee to have a diagnosed behavioral health condition if that enrollee 

received any outpatient services with a recorded diagnosis code for a behavioral health condition in 

2014. Our estimates do not include individuals with conditions who did not use outpatient services 

during 2014, or those who used only behavioral health prescription drugs.

a

Number of enrollees is the total number of expansion enrollees who were enrolled for at least one 

month during 2014.

b

Any behavioral health diagnosis refers to all mental health and substance use diagnosis codes that 

were within the scope of our study. This includes opioid abuse and dependence, and tobacco use 

disorder.

c

Does not include tobacco use disorder.

The distribution of expansion enrollees with diagnosed behavioral health 

conditions by age and gender was generally similar across the selected 

states. Expansion enrollees with diagnosed behavioral health conditions 

were fairly evenly divided among age groups across all selected states. 

(See fig. 2.) Women accounted for a larger percentage of enrollees with 

diagnosed behavioral health conditions in three of the four selected 

states—Iowa, Washington, and West Virginia. In New York, men 

accounted for 58 percent of expansion enrollees with diagnosed 

behavioral health conditions.

Age and Gender of 

Expansion Enrollees with 

a Behavioral Health 

Diagnosis Were Generally 

Similar across Selected 

States, while Enrollees’ 

Geographic Location 

Varied
Page 16 GAO-17-529 Medicaid Expansion

Figure 2: Demographic Characteristics of Expansion Enrollees with Diagnosed Behavioral Health Conditions in Selected 

States, 2014

Note: We considered an enrollee to have a diagnosed behavioral health condition if that enrollee 

received any outpatient services with a recorded diagnosis code for a behavioral health condition in 

2014. Our estimates do not include individuals with conditions who did not use outpatient services 

during 2014, or those who used only behavioral health prescription drugs.
Page 17 GAO-17-529 Medicaid Expansion

Geographic location of enrollees in selected states varied, with some 

states having a greater proportion of rural enrollees. The geographic 

location of expansion enrollees diagnosed with behavioral health 

conditions was consistent with the more general urban/rural distribution of 

residents in these states. State officials discussed efforts to meet the 

behavioral health needs of rural residents, who may have difficulty 

accessing care, because of the need to travel long distances to access 

relatively fewer providers. For example, officials in Iowa, Washington, and 

West Virginia discussed the important role of telehealth services in 

allowing rural residents to access care for behavioral health conditions. 

Officials in Iowa also noted that the state has provided funding to help 

rural communities establish the infrastructure needed to host psychiatric 

telehealth appointments. In West Virginia, as of July 1, 2014, 85 percent 

of procedure codes in the Medicaid program were eligible for 

reimbursement when provided via telehealth. West Virginia officials also 

emphasized the role of Federally Qualified Health Centers, which can 

provide a “one-stop shop” for both medical and behavioral health 

treatment for residents in rural areas who have to travel long distances to 

access care.30

Use of behavioral health treatment—services and drugs to address 

mental health and substance use conditions—ranged from 20 to 34 

percent in selected states in 2014. Among expansion enrollees who used 

a behavioral health service, the two most commonly used service 

categories were psychotherapy services and diagnostic services. 

Antidepressants were the most commonly used category among 

expansion enrollees who used a behavioral health drug.

 30Federally Qualified Health Centers are urban or rural centers that provide 

comprehensive community-based primary care services to individuals regardless of their 

ability to pay.

From 20 to 34 

Percent of Expansion 

Enrollees in Selected 

States Received 

Behavioral Health 

Treatment; 

Psychotherapy and 

Antidepressant 

Medications Were 

Most Common
Page 18 GAO-17-529 Medicaid Expansion

Use of behavioral health treatment ranged from 20 percent of expansion 

enrollees in New York to 34 percent in Iowa. (See table 3.) These rates 

exceeded the rates of diagnosed conditions presented above, in part, 

because prescription drugs are not recorded with diagnosis codes. Thus, 

enrollees who only used behavioral health prescription drugs—and no 

outpatient services—were not counted in the diagnosis totals.31

Rates of behavioral health prescription drug use were higher than the use 

of services across the four selected states. The higher rates of 

prescription drug use suggest that some enrollees received drugs without 

also receiving behavioral health services. Officials from one state 

commented that this may be appropriate for some conditions, such as 

mild depression, where a prescription drug may be adequate without 

accompanying counseling. In addition, some enrollees may have received 

evaluation and management services, which may have included 

treatment for behavioral health conditions, but which are not included in 

our measure of behavioral health treatment.32

 31Other potential reasons for this difference include (1) providers not recording a 

behavioral health diagnosis for an enrollee treated for multiple conditions at the same visit 

(e.g., due to a lack of space on a claim or encounter form); and (2) enrollees receiving 

behavioral health screening or evaluation services, which are counted as behavioral 

health services, but which may result in a provider determining that an enrollee does not 

have a diagnosable behavioral health condition. 

32Evaluation and management services are general medical visits with a physician or 

other medical provider that may address a wide range of physical or mental health 

conditions. We analyzed evaluation and management services that were recorded with a 

primary diagnosis of a behavioral health condition in an effort to capture behavioral health 

treatment that expansion enrollees may have received during these visits. However, 

because of the uncertainty of the extent to which behavioral health treatment was 

provided as part of evaluation and management services, we do not count them as 

behavioral health services, or include them in our overall definition of behavioral health 

treatment.

Expansion Enrollee Use of 

Behavioral Health 

Treatment Ranged from 

20 to 34 Percent in 

Selected States, and 

Medicaid Expansion 

Generally Increased 

Treatment Availability
Page 19 GAO-17-529 Medicaid Expansion

Table 3: Use of Behavioral Health Treatment among Expansion Enrollees in Selected States, 2014

Type of behavioral health treatment

Percentage of expansion enrollees

(number of expansion enrolleesa)

Iowa

(85,669)

New York

(1,222,309)

Washington

(399,785)

West Virginia

(132,137)

Any behavioral health treatmentb 34 20 26 33

Behavioral health services 16 13 9 11

Behavioral health drugs 30 16 23 31

Both services and drugs 12 8 7 9

Source: GAO analysis of Medicaid program data. | GAO-17-529

Note: Percentages are weighted by expansion enrollees’ length of enrollment in 2014.

a

The number of expansion enrollees is expressed as person years, which is the total number of 

enrollment months for expansion enrollees divided by 12.

b

Any behavioral health treatment refers to the receipt of behavioral health services, behavioral health 

prescription drugs, or both.

Officials we spoke with from three of the selected states told us that 

expansion enrollees likely had greater access to behavioral health 

treatment after enrolling in Medicaid.

• Iowa officials noted that some county-based mental health agencies, 

which were responsible for serving uninsured residents as of 2014, 

had waiting lists for mental health services prior to the state 

expanding Medicaid.33

• Washington officials said that Medicaid expansion had resulted in a 

significant increase in access to services for enrollees, particularly for 

less acute, community-based services for people who needed 

ongoing therapy. Officials explained that uninsured residents not 

eligible for Medicaid would generally rely on the state’s Regional 

Support Networks—managed care entities responsible for providing 

mental health services for uninsured residents—generally provided 

crisis services, or services for individuals with serious and persistent 

mental illnesses. Officials also noted that the expansion had resulted 

in more consistent access to behavioral health prescription drugs, 

because Medicaid covers such prescriptions with no copayment.34

 33By contrast, Medicaid enrollees would have been able to seek care through Iowa 

Medicaid’s behavioral health managed care carve-out plan, which contracted with a range 

of behavioral health providers. 

34A copayment is a fixed amount an enrollee must pay for a covered service or 

prescription drug.
Page 20 GAO-17-529 Medicaid Expansion

Uninsured residents, according to the officials, would have been 

limited to charity programs from drug manufacturers or block-grantfunded prescriptions, neither of which consistently funds medications 

for everyone who needs them. Officials noted that consistent access 

to medications can make a big difference for individuals whose 

conditions are stable on medications, but unstable off medications.

• West Virginia officials said that access to behavioral health 

prescription drugs, particularly MAT for substance use conditions, 

increased for Medicaid expansion enrollees. West Virginia’s charity 

care program for uninsured residents does not pay for behavioral 

health prescription drugs. Officials said that some uninsured residents 

may have relied on family members or may have sold personal 

belongings to afford their medications prior to Medicaid expansion.

By contrast, there was less of a change for expansion enrollees in New 

York. Due to New York’s Medicaid waiver program, which covered lowincome childless adults up to 100 percent of the FPL, most Medicaid 

expansion enrollees in New York were already eligible for Medicaid prior 

to 2014. One state official said that these enrollees would not have 

experienced a change in access to treatment, because New York’s 

expansion coverage was modeled on its existing Medicaid coverage.35

The official said that newly eligible enrollees who were previously 

uninsured would have had access to state-licensed and funded 

behavioral health programs prior to enrollment. However, the official said 

that New York did not generally pay for behavioral health prescription 

drugs for uninsured individuals.

Among the 9 to 16 percent of expansion enrollees who used a behavioral 

health service in the four selected states, the two most commonly used 

service categories were psychotherapy—regular visits with a provider to 

help a patient understand, reduce, and manage symptoms—and 

diagnostic services. Diagnostic services involve sessions with a provider 

designed to collect information to determine whether a patient has a 

behavioral health condition and to make a diagnosis, if appropriate. (See 

fig. 3.) In New York, substance-use-specific services were almost as 

common as diagnostic services. New York officials noted that the state 

has a more extensive array of specialty substance use services available 

 35Enrollees in New York’s Family Health Plus program were subject to limits on the 

number of behavioral-health-related visits. For these individuals, enrolling in Medicaid 

would have resulted in the removal of those coverage limitations.

The Most Commonly Used 

Behavioral Health Service 

Categories were 

Psychotherapy and 

Diagnostic Services
Page 21 GAO-17-529 Medicaid Expansion

than other states. For example, New York covers methadone 

administration through Medicaid, whereas West Virginia does not. 

Diagnostic services may have been less used in New York than in other 

states, because most of the expansion enrollees were not newly eligible; 

consequently, enrollees with behavioral health needs may have already 

been seen by a Medicaid provider and received a diagnosis prior to 2014.

Figure 3: Use of Behavioral Health Services by Category among Enrollees Who Used One or More Services, 2014

Notes: These results are based on the top 25 behavioral health services in each state as measured 

by the percentage of enrollees who used them. The top 25 behavioral health services account for 

over 95 percent of all behavioral health services used in selected states. The percentages of 

enrollees who used services from each category do not add to 100 percent, because enrollees could 

have used services from more than one category. Percentages are weighted by expansion enrollees’ 

length of enrollment.
Page 22 GAO-17-529 Medicaid Expansion

We also examined use of evaluation and management services—more 

general medical visits with a physician or other medical provider—and 

found that 8 to 17 percent of expansion enrollees used this type of 

service. Although, by definition, evaluation and management services 

may address a wide range of physical or behavioral health conditions, we 

examined these services because some individuals may have received 

behavioral health treatment during these visits, including services 

provided by a psychiatrist.36 An evaluation and management visit with a 

psychiatrist, for example, may include prescribing or monitoring the 

effects of behavioral health prescription drugs. Evaluation and 

management services also encompass services provided by primary care 

physicians, who are often the first point of contact for individuals with 

conditions like depression.37

Our examination of emergency room use, which involved comparing rates 

of use among expansion enrollees with and without behavioral health 

diagnoses, found that up to 3 times as many enrollees with a behavioral 

health diagnosis had an emergency room visit compared to enrollees 

without such a diagnosis.38 From 42 to 57 percent of individuals with a 

behavioral health condition had an emergency room visit, compared with 

13 to 32 percent of individuals without a behavioral health condition. (See 

table 4.) Most emergency room visits among enrollees with behavioral 

health conditions were not primarily for a behavioral health condition (81 

to 92 percent across selected states). Our finding that emergency room 

use is more common among enrollees with behavioral health conditions is 

consistent with previous research, including research showing that 

Medicaid enrollees with a behavioral health condition typically have more 

complex health needs, including comorbid physical health conditions.39

 36In 2013, CMS made changes that affected how psychiatry services could be billed, 

eliminating psychotherapy with medical services and pharmacologic management codes, 

among others. According to the American Psychiatric Association, this led to an increase 

in psychiatrists billing for evaluation and management services. 

37See T.F. Bishop et al., “Care management processes used less often for depression 

than for other chronic conditions in U.S. primary care practices,” Health Affairs, vol. 35, 

no.3 (2016).

38For the purposes of our analysis, we defined emergency room visits as evaluation and 

management services provided in an emergency room setting.

39See Medicaid and CHIP Payment and Access Commission, Report to the Congress on 

Medicaid and CHIP (Washington, D.C.: June 2015). 
Page 23 GAO-17-529 Medicaid Expansion

Table 4: Use of Emergency Room Visits among Expansion Enrollees in Selected States, 2014

Emergency room visits by enrollee type Iowa New York Washington West Virginia

Percent of expansion enrollees who had an emergency 

room visit (number of enrolleesa)

For enrollees with a diagnosed behavioral health 

condition

54

(14,265)

42

(103,333)

51

(56,683)

57

(21,064)

For enrollees without a diagnosed behavioral health 

condition 

22

(13,313)

13

(125,607)

18

(52,737)

32

(30,348)

Number of emergency room visits per user per year 

For enrollees with a diagnosed behavioral health 

condition

6 3 6 6

For enrollees without a diagnosed behavioral health 

condition

4 2 4 4

Source: GAO analysis of Medicaid program data. | GAO-17-529

Notes: Percentages are weighted by expansion enrollees’ length of enrollment in 2014. We 

considered an enrollee to have a diagnosed behavioral health condition if that enrollee received any 

outpatient services with a recorded diagnosis code for a behavioral health condition in 2014. Our 

estimates do not include individuals with conditions who did not use outpatient services during 2014, 

or those who used only behavioral health prescription drugs. Emergency room visits comprise 

evaluation and management services provided in an emergency room setting.

a

The number of enrollees is expressed as person years, which is the total number of enrollment 

months divided by 12.

Among expansion enrollees who used a behavioral health drug, 

antidepressants were the most commonly used category, and patterns of 

use by drug category were similar across our four selected states. From 

67 to 78 percent of expansion enrollees who used a behavioral health 

drug took an antidepressant. Anti-anxiety medications, anticonvulsants, 

and antipsychotics were the next most commonly used categories, 

respectively, in three of the four selected states.40 (See fig. 4.) Together, 

these four drug categories accounted for upwards of 80 percent of total 

prescriptions in each state. The fifth most common drug category varied 

by state and included sedative/hypnotic medications in Iowa, smoking 

cessation medications in New York, and attention-deficit/hyperactivity 

disorder (ADHD) medications in West Virginia.

 40In Washington, slightly more enrollees used a drug from the sedative/hypnotic 

medications category (15 percent) than the antipsychotics category (14 percent). For 

Washington, the top five categories, in order, are antidepressants, anti-anxiety 

medications, anticonvulsants, sedative/hypnotic medications, and antipsychotics. 

Anticonvulsants—medications originally developed to treat seizures—can be used as 

mood stabilizers for conditions such as bipolar disorder. 

Antidepressants Were the 

Most Frequently Used 

Category among Users of 

Behavioral Health Drugs
Page 24 GAO-17-529 Medicaid Expansion

Figure 4: Use of Behavioral Health Drugs by Category among Enrollees Who Used One or More Drugs, 2014

Notes: The percentages of enrollees who used drugs from each category do not add to 100 percent, 

because enrollees could have used drugs from more than one category. Use of the eight other drug 

categories is not shown. Percentages are weighted by expansion enrollees’ length of enrollment.

a

Anticonvulsants are medications originally developed to treat seizures that can also be used as 

mood stabilizers for conditions such as bipolar disorder.

Use of behavioral health prescription drugs was greater among women 

and enrollees aged 30 and over. (See table 5.) In all four selected states, 

a greater percentage of women received behavioral health prescription 

drugs than did men, ranging from 2 percentage points greater in New 

York to 13 percentage points greater in West Virginia. Use of behavioral 

health drugs was 8 to 12 percentage points greater among enrollees 

aged 30 and above compared with enrollees aged 19 to 29 across the 

four states. Clinical experts from QuintilesIMS noted that women in 

general have greater rates of prescription drug use, including nonbehavioral-health drugs, and are also generally more likely to seek 

medical care than men. They also noted that although many behavioral 

health conditions first occur in late adolescence and early adulthood, 
Page 25 GAO-17-529 Medicaid Expansion

there is a time lag between development of symptoms and treatment that 

may partially explain why more individuals aged 30 and over received 

drug treatment.41

Table 5: Use of Behavioral Health Prescription Drugs among Expansion Enrollees in Selected States by Demographics, 2014

Demographic group

Percentage of expansion enrollees

(number of enrolleesa)

Iowa New York Washington West Virginia

Gender

Female 35

(15,224)

17

(95,796)

27

(54,676)

37

(25,963)

Male 25

(10,604)

15

(96,121)

20

(38,679)

24

(14,454)

Age

19-29 22

(5,492)

10

(43,266)

17

(21,316)

22

(8,426)

30 and over 34

(20,335)

18

(148,650)

26

(72,039)

34

(31,991)

Source: GAO analysis of Medicaid program data. | GAO-17-529

Note: Percentages are weighted by expansion enrollees’ length of enrollment.

a

The number of enrollees is expressed as person years, which is the total number of enrollment 

months divided by 12.

Patterns of behavioral health prescription drug use by category also 

varied by gender and age in selected states.

• Gender: Among the drug categories with the biggest gender 

differences were antidepressants, used by more women than men, 

and antipsychotics, used by more men than women.42 Clinical experts 

from QuintilesIMS noted that the prevalence of depression is 

 41Research studies have estimated that 75 percent of behavioral health conditions are 

developed by age 24, but that there is a median gap of 11 years between onset of 

symptoms and initial treatment contact. See R.C. Kessler et al., “Lifetime Prevalence and 

Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey 

Replication,” Archives of General Psychiatry, vol. 62 (2005); and P. Wang et al., “Delays in 

Initial Treatment Contact after First Onset of a Mental Disorder,” Health Services 

Research, vol. 39 (2004). 

42While antipsychotics showed the biggest gender difference (used by more men than 

women) in Iowa and Washington, substance use disorder medications showed the biggest 

gender difference in New York and West Virginia. 
Page 26 GAO-17-529 Medicaid Expansion

significantly higher in women than in men; in men there are more 

concerns about agitation and behavior management, which can be 

treated with antipsychotics.

• Age: Among the drug categories with the biggest age differences 

were ADHD medications, which had greater use among 19 to 29 year 

olds compared with enrollees aged 30 and older, and 

sedative/hypnotic medications, used by more enrollees aged 30 and 

over compared with enrollees aged 19 to 29.43 QuintilesIMS clinical 

experts said that the prevalence of ADHD declines rapidly in the late 

teen years, which may explain the lower use of these drugs in the 

older age group. The sedative/hypnotic drug category includes drugs 

that address insomnia, which is a condition that increases with age; 

this may partially explain the higher use of these drugs in the 30 and 

over age group.44

Over a quarter of expansion enrollees in the selected states who took a 

behavioral health prescription drug in 2014 took drugs from three or more 

different drug categories. From 25 to 31 percent of enrollees in selected 

states who took a behavioral health drug took drugs from three or more 

drug categories, and 4 to 6 percent took drugs from five or more 

categories. These enrollees may have used drugs from multiple 

categories at the same time to treat their conditions (concomitant use), or 

they may have filled prescriptions for these drugs at different points in 

time during 2014. QuintilesIMS clinical experts noted that a common 

example of concomitant use is taking both an antidepressant and a sleep 

medication, which are often prescribed together during initial treatment for 

depression. Regarding the use of different categories of drugs over time, 

experts said that sometimes when a patient does not improve after taking 

a drug, a physician may switch the patient to a drug from a different 

category. For example, a patient with bipolar disorder who is initially 

treated with an anticonvulsant may be switched to an antipsychotic if 

symptoms do not adequately resolve. We also found that more enrollees 

aged 30 and over used drugs from three or more categories than 

enrollees aged 19 to 29, which our clinical experts said could be partly 

 43While sedative/hypnotic medications showed the biggest age difference (used by more 

enrollees aged 30 and over) in Iowa and New York, antidepressants and anti-anxiety 

medications showed the biggest age differences in Washington and West Virginia, 

respectively.

44See T. Roth, “Insomnia: Definition, Prevalence, Etiology, and Consequences,” Journal of 

Clinical Sleep Medicine, vol. 3 (2007).
Page 27 GAO-17-529 Medicaid Expansion

because some behavioral health conditions become more difficult to treat 

with age, which may result in more drugs being prescribed.

We provided a draft of this report to the Department of Health and Human 

Services (HHS) for review. HHS provided technical comments, which we 

incorporated as appropriate.

As discussed with your offices, unless you publicly announce the contents 

of this report earlier, we plan no further distribution until 30 days after its 

issuance date. At that time, we will send copies of this report to the 

Secretary of Health and Human Services and other interested parties. In 

addition, the report will be available at no charge on the GAO website at 

http://www.gao.gov.

If you or your staff members have any questions, please contact me at 

(202) 512-7114 or yocomc@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. Major contributors to this report are listed in appendix IV.

Carolyn L. Yocom

Director, Health Care

Agency Comments
Appendix I: Behavioral Health Prescription 

Drugs Included in Utilization Analyses, by 

Category

Page 28 GAO-17-529 Medicaid Expansion

Drug category Drug ingredient Limits on inclusion in utilization analyses

Anti-anxiety medication Alprazolam -

Anti-anxiety medication Buspirone -

Anti-anxiety medication Chlordiazepoxide Limited to enrollees with related diagnoses

Anti-anxiety medication Clobazam Limited to enrollees with related diagnoses

Anti-anxiety medication Clonazepam Limited to oral medications; limited to enrollees with 

related diagnoses

Anti-anxiety medication Clorazepate Limited to enrollees with related diagnoses

Anti-anxiety medication Diazepam Limited to enrollees with related diagnoses

Anti-anxiety medication Hydroxyzine Limited to enrollees with related diagnoses

Anti-anxiety medication Lorazepam Limited to enrollees with related diagnoses

Anti-anxiety medication Meprobamate Limited to enrollees with related diagnoses

Anti-anxiety medication Oxazepam -

Anticonvulsant Carbamazepine Limited to enrollees with related diagnoses

Anticonvulsant Divalproex Limited to enrollees with related diagnoses

Anticonvulsant Gabapentin Limited to enrollees with related diagnoses

Anticonvulsant Lamotrigine Limited to enrollees with related diagnoses

Anticonvulsant Levetiracetam Limited to oral medications; limited to enrollees with 

related diagnoses

Anticonvulsant Oxcarbazepine Limited to enrollees with related diagnoses

Anticonvulsant Phenytoin Limited to enrollees with related diagnoses

Anticonvulsant Pregabalin Limited to enrollees with related diagnoses

Anticonvulsant Tiagabine Limited to enrollees with related diagnoses

Anticonvulsant Topiramate Limited to enrollees with related diagnoses

Anticonvulsant Valproic Acid Limited to oral medications; limited to enrollees with 

related diagnoses

Anticonvulsant Zonisamide Limited to enrollees with related diagnoses

Antidepressant Amitriptyline Limited to enrollees with related diagnoses

Antidepressant Amoxapine Limited to enrollees with related diagnoses

Antidepressant Bupropiona -

Antidepressant Citalopram -

Antidepressant Clomipramine Limited to enrollees with related diagnoses

Antidepressant Desipramine Limited to enrollees with related diagnoses

Antidepressant Desvenlafaxine Limited to enrollees with related diagnoses

Antidepressant Doxepin Limited to enrollees with related diagnoses

Antidepressant Duloxetine Limited to enrollees with related diagnoses

Antidepressant Escitalopram -

Antidepressant Fluoxetine -

Appendix I: Behavioral Health Prescription 

Drugs Included in Utilization Analyses, by 

Category
Appendix I: Behavioral Health Prescription 

Drugs Included in Utilization Analyses, by 

Category

Page 29 GAO-17-529 Medicaid Expansion

Drug category Drug ingredient Limits on inclusion in utilization analyses

Antidepressant Fluvoxamine -

Antidepressant Imipramine Limited to enrollees with related diagnoses

Antidepressant Isocarboxazid -

Antidepressant Levomilnacipran Limited to enrollees with related diagnoses

Antidepressant Maprotiline Limited to enrollees with related diagnoses

Antidepressant Milnacipran Limited to enrollees with related diagnoses

Antidepressant Mirtazapine Limited to enrollees with related diagnoses

Antidepressant Nefazodone -

Antidepressant Nortriptyline Limited to enrollees with related diagnoses

Antidepressant Paroxetine -

Antidepressant Phenelzine -

Antidepressant Protriptyline Limited to enrollees with related diagnoses

Antidepressant Selegiline Limited to transdermal patch

Antidepressant Sertraline -

Antidepressant Tranylcypromine -

Antidepressant Trazodone -

Antidepressant Trimipramine Limited to enrollees with related diagnoses

Antidepressant Venlafaxine Limited to enrollees with related diagnoses

Antidepressant Vilazodone -

Antidepressant Vortioxetine -

Antidepressant combination Amitriptyline; chlordiazepoxide -

Antidepressant combination Amitriptyline; perphenazine -

Antidepressant combination Bupropion; naltrexone Limited to enrollees with related diagnoses

Antidepressant combination Fluoxetine; olanzapine -

Anti-mania medications Lithium -

Antipsychotic Aripiprazole -

Antipsychotic Asenapine -

Antipsychotic Chlorpromazine -

Antipsychotic Clozapine -

Antipsychotic Fluphenazine -

Antipsychotic Haloperidol -

Antipsychotic Iloperidone -

Antipsychotic Loxapine -

Antipsychotic Lurasidone -

Antipsychotic Molindone -

Antipsychotic Olanzapine -

Antipsychotic Paliperidone -
Appendix I: Behavioral Health Prescription 

Drugs Included in Utilization Analyses, by 

Category

Page 30 GAO-17-529 Medicaid Expansion

Drug category Drug ingredient Limits on inclusion in utilization analyses

Antipsychotic Perphenazine -

Antipsychotic Pimozide -

Antipsychotic Prochlorperazine Limited to enrollees with related diagnoses

Antipsychotic Quetiapine -

Antipsychotic Risperidone -

Antipsychotic Thioridazine -

Antipsychotic Thiothixene -

Antipsychotic Trifluoperazine -

Antipsychotic Ziprasidone -

Attention-deficit/hyperactivity disorder 

(ADHD) medication

Amphetamine; 

dextroamphetamine

Limited to enrollees with related diagnoses

ADHD medication Atomoxetine -

ADHD medication Clonidine Limited to enrollees with related diagnoses

ADHD medication Dexmethylphenidate Limited to enrollees with related diagnoses

ADHD medication Dextroamphetamine Limited to enrollees with related diagnoses

ADHD medication Guanfacine Doses less than 4mg limited to enrollees with related 

diagnoses

ADHD medication Lisdexamfetamine -

ADHD medication Methamphetamine Limited to enrollees with related diagnoses

ADHD medication Methylphenidate Limited to enrollees with related diagnoses

Sedative/hypnotic medication Amobarbital Limited to enrollees with related diagnoses

Sedative/hypnotic medication Butabarbital Limited to enrollees with related diagnoses

Sedative/hypnotic medication Estazolam -

Sedative/hypnotic medication Eszopiclone -

Sedative/hypnotic medication Flurazepam -

Sedative/hypnotic medication Methylphenobarbital Limited to enrollees with related diagnoses

Sedative/hypnotic medication Midazolam Limited to enrollees with related diagnoses

Sedative/hypnotic medication Phenobarbital Limited to enrollees with related diagnoses

Sedative/hypnotic medication Quazepam -

Sedative/hypnotic medication Ramelteon -

Sedative/hypnotic medication Secobarbital Limited to enrollees with related diagnoses

Sedative/hypnotic medication Suvorexant -

Sedative/hypnotic medication Temazepam -

Sedative/hypnotic medication Triazolam Limited to enrollees with related diagnoses

Sedative/hypnotic medication Zaleplon -

Sedative/hypnotic medication Zolpidem Limited to enrollees with related diagnoses

Sexual function disorder medication Alprostadil Limited to enrollees with related diagnoses

Sexual function disorder medication Avanafil Limited to enrollees with related diagnoses
Appendix I: Behavioral Health Prescription 

Drugs Included in Utilization Analyses, by 

Category

Page 31 GAO-17-529 Medicaid Expansion

Drug category Drug ingredient Limits on inclusion in utilization analyses

Sexual function disorder medication Sildenafilb Limited to enrollees with related diagnoses

Sexual function disorder medication Tadalafilc Limited to enrollees with related diagnoses

Sexual function disorder medication Testosterone Limited to enrollees with related diagnoses

Sexual function disorder medication Vardenafil Limited to enrollees with related diagnoses

Smoking cessation medication Nicotine -

Smoking cessation medication Varenicline -

Substance use disorder medicationd Acamprosate -

Substance use disorder medication Buprenorphine Limited to oral medications

Substance use disorder medication Buprenorphine; naloxone -

Substance use disorder medication Disulfiram -

Substance use disorder medication Naloxone Limited to enrollees with related diagnoses

Substance use disorder medication Naltrexone Limited to enrollees with related diagnoses

Other Dextromethorphan; quinidine Limited to enrollees with related diagnoses

Other Mecamylamine Limited to enrollees with related diagnoses

Other Phentermine Limited to enrollees with related diagnoses

Other Pindolol Limited to enrollees with related diagnoses

Other Pramipexole Limited to enrollees with related diagnoses

Other Prazosin Limited to enrollees with related diagnoses

Other Promethazine Limited to enrollees with related diagnoses

Source: GAO and QuintilesIMS | GAO-17-529

Note: The “─” indicates that these drugs were counted as behavioral health medications any time 

they were filled by an expansion enrollee.

a

Bupropion was counted as an antidepressant except when packaged as the brand name drug 

Zyban, in which case it was counted as a smoking cessation medication.

b

Sildenafil was excluded from analysis when packaged as the brand name drug Revatio, which is a 

pulmonary arterial hypertension medication.

c

Tadalafil was excluded from analysis when packaged as the brand name drug Adcirca, which is a 

pulmonary arterial hypertension medication.

d

Substance use disorder medications do not include methadone, because, under federal law, 

prescriptions cannot be issued for methadone when used for opioid addiction treatment. These 

medications can generally only be administered or dispensed within an opioid treatment program. 

Consequently, we did not analyze prescriptions for methadone, but we did include methadone 

administration as a behavioral health service for selected states that covered or used that service in 

2014.
Appendix II: Scope and Methodology

Page 32 GAO-17-529 Medicaid Expansion

To describe the population of Medicaid expansion enrollees with 

behavioral health diagnoses and their use of behavioral health treatment 

in 2014 in selected states, we analyzed enrollment, service utilization, 

and prescription drug data from the Medicaid Statistical Information 

System (MSIS) for calendar year 2014 for selected states.1 Our analysis 

consisted of the following three steps: (1) state selection, including 

assessing the reliability and usability of MSIS data; (2) enrollee, service, 

and drug identification; and (3) utilization analysis.

We selected four states: Iowa, New York, Washington, and West Virginia. 

These were the only states that met the following criteria as of January 

2016. The four selected states

1. were among the 25 states that expanded Medicaid as allowed under 

the Patient Protection and Affordable Care Act (PPACA) as of 

January 1, 2014;

2. had enrollment and utilization data for expansion enrollees in MSIS for 

all of calendar year 2014 that were sufficiently reliable for the 

purposes of our reporting objectives; and

3. had available information and documentation on Medicaid behavioral 

health benefits, and on how enrollment, service utilization, and 

prescription drug data were recorded for expansion enrollees.

There were eight expansion states with data for all of calendar year 2014 

in MSIS as of January 2016. In addition to our selected states, we 

reviewed information from Arkansas, Connecticut, New Jersey, and 

Vermont, but ultimately did not select these states for review for the 

following reasons.

 1

MSIS is a national Medicaid eligibility and claims data set, and is the federal source of 

Medicaid expenditure data that can be linked to a specific enrollee. State Medicaid 

agencies are required to provide the Centers for Medicare & Medicaid Services, through 

MSIS, quarterly electronic files that contain information on Medicaid enrollment and use of 

services and prescription drugs for each Medicaid enrollee during a given calendar year. 

Enrollment data comprise one record for each person who was eligible for Medicaid for at 

least one day. Service utilization data comprise claims and encounters for medical 

services reimbursed by the Medicaid program. Claims are records of medical services 

paid for on a fee-for-service basis, whereas encounters represent services provided under 

managed care arrangements. Under a fee-for-service model, states pay providers for 

each covered service for which the providers bill the state. Under a managed care model, 

states contract with managed care organizations to provide or arrange for medical 

services, and prospectively pay the plans a fixed monthly fee per enrollee. Prescription 

drug data contain claims and encounters for filled prescriptions.

Appendix II: Scope and Methodology

Step 1: State Selection
Appendix II: Scope and Methodology

Page 33 GAO-17-529 Medicaid Expansion

• Arkansas was not selected because it implemented its expansion 

through premium assistance, also known as the private option, 

whereby the state pays premiums to purchase private insurance for 

enrollees through a state or federal exchange. According to the 

Centers for Medicare & Medicaid Services (CMS), states are not 

required to submit data on the utilization of services or drugs for 

enrollees who receive premium assistance; consequently, no data 

were available for our utilization analyses.

• Connecticut was not selected because the enrollment data in MSIS 

for 2014 were not reliable enough for the purpose of identifying its 

population of expansion enrollees. CMS officials told us that 

Connecticut had entered enrollment data incorrectly for the expansion 

population in 2014.

• New Jersey was not selected due to the lack of available information 

on behavioral health benefits and how its data were recorded in MSIS.

• Vermont was not selected because its Medicaid program had 

coverage for adults with incomes up to 150 percent of the federal 

poverty level (FPL) that pre-dated the enactment of PPACA.

Iowa and New York were also missing key information in MSIS that we 

needed to identify all expansion enrollees, but we conducted our analyses 

after receiving the necessary data from the states directly. We limited our 

analysis of Iowa’s data to individuals with incomes at or below 100 

percent of the FPL, because individuals with higher incomes were served 

through premium assistance as of 2014; consequently, there were no 

utilization data available for them. Our selected states are not 

representative of all expansion states and their Medicaid programs. In 

addition, a number of state-specific factors—such as differences in 

population health status and provider supply—could contribute to 

variation across our selected states, but attributing this variation to such 

factors was beyond the scope of this study.

We assessed the reliability and usability of MSIS data for our purposes by 

interviewing knowledgeable federal and state officials; reviewing related 

documentation, such as studies that assessed the reliability of Medicaid 

data; comparing the results of our analysis of expansion enrollment to 

published enrollment figures from CMS; and testing the data for logical 
Appendix II: Scope and Methodology

Page 34 GAO-17-529 Medicaid Expansion

errors and missing information.2 Based on our assessment, we excluded 

data from Iowa for months in which expansion enrollees were served 

under comprehensive managed care, because the results of our reliability 

testing suggested missing data. This resulted in the exclusion of data 

from about 17 percent of expansion enrollees. We excluded data from 

Washington for months in which expansion enrollees were served under 

fee-for-service arrangements, because of missing diagnosis codes, which 

were needed for our analysis. This resulted in the exclusion of data from 

about 2 percent of expansion enrollees. Following these exclusions, we 

determined the data were sufficiently reliable for the purposes of our 

reporting objectives.

Based on enrollment information in MSIS, supplemented by stateprovided information from Iowa and New York, we restricted our analysis 

to nonpregnant adults aged 19-64 who were not eligible for Medicare and 

whose income did not exceed 138 percent of the FPL, i.e., the “new adult 

group” under Section 1902(a)(10)(A)(i)(Vlll) of the Social Security Act. We 

included both newly eligible and not newly eligible expansion enrollees 

who were enrolled for at least one month in calendar year 2014 (i.e., 

ever-enrolled).3 We excluded the following individuals, who represented 3 

percent or less of expansion enrollees across the four states:

1. Individuals who did not appear to be eligible for Medicaid expansion, 

because they were recorded as dually eligible for Medicare and 

 2

For studies that assessed the reliability of Medicaid data, see Mathematica Policy 

Research, Medicaid Policy Brief: Assessing the Usability of MAX 2008 Encounter Data for 

Enrollees in Comprehensive Managed Care 2008, Brief 7 (Washington, D.C.: July 2012); 

Medicaid Policy Brief: Assessing the Usability of Encounter Data for Enrollees in 

Comprehensive Managed Care Across MAX 2007–2009, Brief 15 (Washington, D.C.: 

December 2012);and Medicaid Policy Brief: The Availability and Usability of Behavioral 

Health Organization Encounter Data in MAX 2009, Brief 14 (Washington, D.C.: July 2013). 

3

Newly eligible expansion enrollees are those individuals who would not have been 

eligible for full Medicaid benefits under the state’s eligibility rules that were in effect on 

December 1, 2009, and whose coverage began after their state opted to expand Medicaid 

as authorized by PPACA. Newly eligible expansion enrollees also include individuals, who 

as of December 1, 2009, received limited Medicaid benefits under a state demonstration 

or waiver; or were enrolled in a state-only funded health care program. Not newly eligible 

expansion enrollees would have been eligible for Medicaid based on the state’s eligibility 

rules that were in effect on December 1, 2009, such as under a pre-existing state 

demonstration or waiver, in states that subsequently opted to expand Medicaid as 

authorized under PPACA.

Step 2: Enrollee, Service, 

and Drug Identification
Appendix II: Scope and Methodology

Page 35 GAO-17-529 Medicaid Expansion

Medicaid; were younger than 19 years of age as of December 31, 

2014; or were older than 64 years of age as of January 1, 2014; and

2. Individuals with multiple dates of birth, multiple values for gender; or 

multiple values for MSIS identification number.4

To describe the population of Medicaid expansion enrollees with 

behavioral health diagnoses in selected states in 2014, we analyzed 

enrollment and service utilization data in MSIS for each state. We 

considered an enrollee to have a diagnosed behavioral health condition if 

that enrollee received any outpatient services with a recorded diagnosis 

code for a behavioral health condition in 2014.5 The presence of such 

diagnosis codes on claims does not necessarily indicate that a clinical 

interview was conducted. In addition, because we measured behavioral 

health conditions based on outpatient service utilization data, our 

estimates do not include individuals with conditions who did not use 

outpatient services during 2014—such as individuals who used no 

services or who only used inpatient services—or those who used only 

 4

We excluded the following number of enrollees for each selected state based on these 

exclusions: 3,844 in Iowa, 32,673 in New York, 7,925 in Washington, and 4,745 in West 

Virginia.

5

We used behavioral health condition codes from the International Classification of 

Diseases, Ninth Revision, Clinical Modification range of 291.0 – 314.9. We used the Ninth 

Revision codes rather than the newer Tenth Revision codes, because we analyzed 

calendar year 2014 data, and the Tenth Revision was not implemented in Medicaid until 

2015. We selected these codes based on a review of five published research reports and 

studies that examined behavioral health utilization: (1) Department of Health and Human 

Services, Assistant Secretary for Planning and Evaluation, Using MSIS Data to Analyze 

Mental Health Service Use and Expenditures for Medicaid Beneficiaries with Mental 

Illness in New Jersey in1999, (Washington, D.C.: 2004); (2) S. Zuvekas, “Prescription 

Drugs and the Changing Patterns of Treatment for Mental Disorders, 1996-2001,” Health 

Affairs, vol. 24, no. 1 (2005); (3) H.T. Ireys et al., “Medicaid Beneficiaries Using Mental 

Health or Substance Abuse Services in Fee-for-Service Plans in 13 States, 2003,” 

Psychiatric Services, vol. 61, no. 9 (2010); (4) GAO, Children’s Mental Health: Concerns 

Remain about Appropriate Services for Children in Medicaid and Foster Care, GAO-13-15 

(Washington, D.C.: Dec. 10, 2012); and (5) Medicaid and CHIP Payment and Access 

Commission, Report to the Congress on Medicaid and CHIP (Washington, D.C.: June 

2015). We defined “behavioral health conditions” as mental health and substance use 

codes that were used by three or more of the five studies. We defined “substance use 

conditions” as codes that were used by all three of the studies that included substance 

use in the scope of their studies and that provided the specific diagnosis codes they used 

for substance use. Unless otherwise noted, we considered both primary and secondary 

diagnoses when determining whether enrollees had a diagnosed behavioral health 

condition.
Appendix II: Scope and Methodology

Page 36 GAO-17-529 Medicaid Expansion

behavioral health prescription drugs.6 Using the Agency for Healthcare

Research and Quality’s Clinical Classifications Software groupings, we 

further categorized mental health conditions into 11 categories:

1. adjustment disorders;

2. anxiety disorders;

3. attention-deficit, conduct, and disruptive behavior disorders;

4. delirium, dementia, and amnestic and other cognitive disorders;

5. developmental disorders;

6. disorders usually diagnosed in infancy, childhood, or adolescence;

7. impulse control disorders not elsewhere classified;

8. mood disorders;

9. personality disorders;

10. schizophrenia and other psychotic disorders; and

11. miscellaneous mental health disorders.

We further categorized substance use disorders into substance-related 

(i.e., addiction to drugs like cocaine or heroin) and alcohol-related 

disorders. Among the substance-related conditions, we also identified 

opioid abuse and dependence as a unique category, and we selected 

these codes based on prior research on opioid treatment use in 

Medicaid.7 We considered enrollees to have a behavioral health condition 

if they had any diagnosis code within our selected range. Substance use 

conditions were all diagnosis codes within the Agency for Healthcare

Research and Quality’s substance-related and alcohol-related disorders 

categories, including opioid abuse and dependence, but excluding 

tobacco use disorder. While we considered tobacco use disorder to be a 

behavioral health condition, we did not consider it to be a substance use 

condition, which is consistent with how the Substance Abuse and Mental 

Health Services Administration collects and reports data on substance 

use. For the group of enrollees with a behavioral health condition, we 

 6

From 3 to 7 percent of expansion enrollees in selected states used a behavioral health 

drug in 2014, but did not have a behavioral health diagnosis recorded on an outpatient 

service. MSIS prescription drug data do not include diagnosis codes. 

7

See A.J. Gordon et al., “Patterns and Quality of Buprenorphine Opioid Agonist Treatment 

in a Large Medicaid Program,” Journal of Addiction Medicine, vol. 9, no. 6 (2015).
Appendix II: Scope and Methodology

Page 37 GAO-17-529 Medicaid Expansion

used enrollment data to describe their characteristics; specifically, we 

examined age, gender, and geographic location. We measured enrollees’ 

age based on date of birth and latest month of enrollment in 2014. 

Gender was determined as recorded in the relevant MSIS data field. We 

defined geographic location based on enrollees’ zip code of residence 

using the most recent available rural-urban commuting area codes from 

the Department of Health and Human Services and the Department of 

Agriculture. The set of rural-urban commuting area codes has 10 tiers 

along the spectrum of rurality, each of which is further broken down into 

secondary codes. We used the four-tiered data consolidation 

recommended for analysis by the Washington State Department of 

Health.8

To describe the use of behavioral health services among Medicaid 

expansion enrollees in selected states in 2014, we selected a set of 

behavioral health services for each state based on each state’s coverage 

and utilization of services in 2014. We defined behavioral health services 

as outpatient screening, assessment, diagnostic, treatment, rehabilitation, 

and habilitation services used primarily or exclusively to evaluate and 

address the needs of individuals with behavioral health conditions. To 

identify behavioral health services, we reviewed the following for each 

state: (1) Medicaid provider manuals and other coverage documentation 

that contained the procedure codes and descriptions for covered 

services, and (2) a list of all services that were provided to expansion 

enrollees in calendar year 2014 that were recorded with a primary 

diagnosis of a behavioral health condition. We selected codes from these 

two sources that we determined to be behavioral-health-specific based on 

their descriptions.9 We gave each state the opportunity to review and 

comment on the list of services selected for analysis, and made revisions 

as appropriate based on their input. To further examine behavioral health 

service use by category, we reviewed the top 25 most-used services (by 

 8

See Washington State Department of Health, Guidelines for Using Rural-Urban 

Classification Systems for Public Health Assessment, revised February 2009.

9

We identified services as behavioral-health-specific if their descriptions indicated that 

they were primarily or exclusively used to evaluate and address behavioral health 

conditions. In some cases, a single service code could be considered to be behavioralhealth-specific in one state and not in another. For example, one state may require a 

diagnosis of a behavioral health condition to authorize reimbursement for a service, 

whereas another state may authorize reimbursement for the treatment of individuals with 

other types of conditions, such as intellectual or learning disabilities. In this case, we 

would consider the former to be behavioral-health specific, and we would exclude the 

latter.
Appendix II: Scope and Methodology

Page 38 GAO-17-529 Medicaid Expansion

number of enrollees who used the service at least once) for each state.10

Based on service descriptions, we divided them into the following service 

categories: diagnostic services, psychotherapy services, rehabilitation 

and habilitation services, substance-use-specific services, and other 

services.

To more fully examine service utilization patterns among expansion 

enrollees, we also examined evaluation and management services—

more general medical visits with a physician or other medical provider—

because some individuals may have received behavioral health treatment 

during these visits, including services provided by a psychiatrist. We 

limited our analysis of evaluation and management services to those 

visits recorded with a primary diagnosis of a behavioral health condition. 

However, because of the uncertainty of the extent to which behavioral

health treatment was provided as part of evaluation and management 

services, we do not count them as behavioral health services, or include 

them in our overall definition of behavioral health treatment.

We also examined outpatient emergency room visits—for any condition, 

not just a behavioral health condition—among expansion enrollees with 

and without a behavioral health diagnosis. Emergency room visits were of 

interest, because prior research has suggested that individuals who have 

a behavioral health condition may access emergency care more 

frequently than those without such conditions.11

For both behavioral health and evaluation and management services, we 

accounted for the possibility of duplicate claims or encounters by 

restricting our analysis to a single claim or encounter for the same service 

for the same patient on the same day, and by counting services with addon codes as a single service.12 We excluded all inpatient and laboratory 

 10The top 25 most-used behavioral health services accounted for upwards of 95 percent 

of all behavioral health services that were used in each state. 

11See, e.g., J. Castner et al., “Frequent Emergency Department Utilization and Behavioral 

Health Diagnoses,” Nursing Research, vol. 64, no. 1 (2015).

12According to CMS, an add-on code is a procedure code that describes a service that is 

always performed in conjunction with another primary service. For example, psychiatrists 

may bill for an evaluation and management service and use an add-on code for 

psychotherapy.
Appendix II: Scope and Methodology

Page 39 GAO-17-529 Medicaid Expansion

services from our analysis.13 In addition, because our analysis was limited 

to Medicaid claims and encounters, our results do not reflect the use of 

services not paid for by Medicaid, such as state- or grant-funded 

services.14

To examine behavioral health prescription drug use, we examined both 

filled prescriptions and services that included physician administration of 

drugs. We defined behavioral health prescription drugs as Food and Drug 

Administration (FDA)-approved drugs used, on- or off-label, to treat adults 

with behavioral health conditions in the United States as of 2014.15 We 

excluded drugs used to treat the side effects of other behavioral health 

prescription drugs, such as drugs for diabetes that may be used to 

address the metabolic effects of antipsychotic drugs. To identify 

behavioral health prescription drugs, we worked with a contractor—

QuintilesIMS—that developed a list of behavioral health drugs based on 

drug reference information (i.e., how drugs are classified), survey data on 

prescribing patterns, and expert clinical opinion.16 From among drugs that 

were classified as psychotherapeutic or were identified as being 

prescribed to treat a behavioral health condition based on survey data, 

QuintilesIMS identified those drugs and drug categories that are primarily 

or exclusively used to treat behavioral health conditions. We counted 

 13We excluded inpatient services because Medicaid generally does not allow for the 

payment of claims for inpatient or residential behavioral health treatment for adults ages 

21 to 64 years provided in certain settings. Consequently, data for services provided in 

these settings would not have been available for analysis. We excluded laboratory 

services primarily because we determined that it would be difficult to count these services 

accurately in a way that was consistent across states.

14States may fund services for Medicaid enrollees that Medicaid does not cover by using 

general revenues or federal grants. See GAO, Behavioral Health: Options for Low-Income 

Adults to Receive Treatment in Selected States, GAO-15-449 (Washington, D.C.: June 

19, 2015).

15The term off-label means prescribed for conditions and in populations that are not 

included in FDA-approved drug labeling.

16Drug reference information refers to QuintilesIMS’s Uniform System of Classification, a 

five-digit, hierarchical system that groups drugs according to their therapeutic uses. 

QuintilesIMS selected categories of drugs from the Uniform System of Classification with 

uses related to behavioral health. QuintilesIMS also used data from its National Disease 

and Therapeutic Index survey, which collects information from office-based physicians 

about the specific conditions for which drugs were prescribed. From this survey, 

QuintilesIMS selected all drugs for which a prescriber indicated that the condition being 

treated was a behavioral health condition. QuintilesIMS also used clinical experts to 

determine which drugs had other, non-behavioral-health uses, and how to identify and 

exclude these instances. 
Appendix II: Scope and Methodology

Page 40 GAO-17-529 Medicaid Expansion

these drugs as behavioral health prescription drugs whenever an 

expansion enrollee filled a prescription for them. QuintilesIMS also 

identified drugs that may be used for behavioral health purposes, but are 

also used to treat non-behavioral-health conditions. For this group of 

drugs, we used information about the characteristics of the drug, such as 

dose, form, or route of administration, if applicable, to identify whether 

they were likely to have been used for a behavioral health purpose.17 For 

drugs without characteristics that distinguished their use, we counted 

them as a behavioral health drug only when an individual had an 

outpatient service some time in 2014 that was recorded with a related 

behavioral health diagnosis (i.e., a behavioral condition that survey data 

identified as one a prescriber intended to treat by prescribing that drug.) 

As a result, our analysis does not account for the use of these drugs by 

individuals who did not have an outpatient service in 2014 that included a 

relevant diagnosis code. See appendix I for the list of behavioral health 

drugs we included in our analyses.

Based on our prior work and consultation with the contractor, we 

categorized the 126 behavioral health drugs on our list into 12 

categories:18

1. Anti-anxiety medications

2. Anticonvulsants

3. Antidepressants

4. Antidepressant combination medications

5. Anti-mania medications

6. Antipsychotics

7. Attention-deficit/hyperactivity disorder medications

8. Sedative/hypnotic medications

9. Sexual function disorder medications

 17For example, QuintilesIMS clinical experts identified buprenorphine as a drug with 

potential non-behavioral-health uses. Experts advised that the transdermal patch and 

injectable forms were more likely used for pain, whereas the oral forms were more likely to 

be used for substance use treatment. Based on this information, we limited our 

consideration of buprenorphine to only oral medications. 

18See GAO, Children’s Mental Health: Concerns Remain about Appropriate Services for 

Children in Medicaid and Foster Care, GAO-13-15 (Washington, D.C.: Dec. 10, 2012). 
Appendix II: Scope and Methodology

Page 41 GAO-17-529 Medicaid Expansion

10. Smoking cessation medications

11. Substance use disorder medications

12. Other

As part of our analysis of individuals with opioid abuse and dependence, 

we looked at the use of drugs used for medication-assisted treatment 

(MAT). We defined MAT drugs as drugs that are FDA-approved to treat 

opioid use disorder: methadone, buprenorphine, buprenorphine/naloxone, 

and naltrexone.19 For the purposes of our analysis, we counted 

methadone administration as a service rather than a prescription drug.20

For characteristics of the Medicaid expansion population with behavioral 

health diagnoses, we calculated numbers and percentages of enrollees 

who were enrolled for one or more months (i.e., ever enrolled). For 

behavioral health services, evaluation and management services, and 

behavioral health prescription drugs provided to enrollees, we calculated 

the user rate and the number of services per enrollee per year.21 The user 

rate is defined as the percent of enrollees who used at least one service 

or prescription in a year. This rate is weighted by enrollees’ length of 

enrollment in the program and is calculated as follows:

 19MAT for opioid addiction is defined as the combination of behavioral therapy and the 

use of medications. For the purposes of this report, we looked at the use of MAT drugs

and did not determine whether MAT users also received counseling.

20Under federal law, prescriptions cannot be issued for methadone when used for opioid 

addiction treatment. These medications can generally only be administered or dispensed 

within an opioid treatment program. Consequently, we did not analyze prescriptions for 

methadone; instead, we analyzed methadone administration as a behavioral health 

service for selected states that covered or used that service in 2014. 

21We did not calculate the number of prescriptions per user per year, because enrollees 

may appear to have more or fewer prescriptions based on the amount of the drug 

prescribed. 

Step 3: Utilization 

Analyses
Appendix II: Scope and Methodology

Page 42 GAO-17-529 Medicaid Expansion

�

TTTTTTTTTT eeeeee eeeeee hss ff eeeeee eeee wwww h ss ss ss 2014

TTTTTTTTTT hss eeeeee ee ee eeeeee eeee eeeeee eeeeee 2014 �

The number of services per user per year is annualized and is calculated 

as follows:

� TTTTTTTTTT nn nn ss ss ss ss 2014

TTTTTTTTTT hss ff ee wwh uu ss ss ss ss 2014�

× 12

We conducted interviews with officials from our four selected states to 

discuss behavioral health benefits for Medicaid expansion enrollees; how 

enrollment, service utilization, and prescription drug data were recorded 

in MSIS; officials’ perspectives on the results of our analysis; and whether 

Medicaid expansion affected the availability of behavioral health 

treatment for expansion enrollees, relative to what was available for lowincome, uninsured adults prior to the first year of expansion in 2014. We 

also interviewed a physician group specializing in addiction medicine and 

consulted with clinical experts from QuintilesIMS for additional 

perspectives on our results.

We conducted our performance audit from November 2015 through June 

2017 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.
Appendix III: Use of Treatment and Opioid Pain 

Medications among Enrollees with Diagnosed 

Opioid Abuse or Dependence

Page 43 GAO-17-529 Medicaid Expansion

In light of increased interest among policy makers in addressing the 

negative effects of opioid addiction, we focused a portion of our analyses 

on the subset of expansion enrollees diagnosed with opioid abuse or 

dependence.1 We analyzed Medicaid enrollment, service utilization, and 

prescription drug data for 2014 to determine the characteristics of 

expansion enrollees with diagnosed opioid abuse or dependence, 

including gender, age, and geographic location, as well as the extent to 

which these enrollees accessed medication-assisted treatment (MAT) or 

received outpatient services. We also considered the extent to which 

expansion enrollees diagnosed with opioid abuse or dependence 

received prescriptions for opioid pain medications following their 

diagnosis.2 While opioid pain medication can constitute proper medical 

care for enrollees suffering from painful conditions, their use among 

enrollees with previously diagnosed opioid abuse or dependence also 

raises concerns about potential inappropriate prescribing.

Characteristics of expansion enrollees diagnosed with opioid abuse or 

dependence were generally similar across our four selected states. 

Across all the selected states, men represented a greater proportion of 

enrollees diagnosed with opioid abuse or dependence than women. (See 

fig. 5.) This is especially the case in New York, where 71 percent of 

expansion enrollees diagnosed with opioid abuse or dependence were 

men. Across all four selected states, those aged 19-29 and 30-39 

accounted for a greater proportion of enrollees diagnosed with opioid 

abuse or dependence compared with older enrollees. The geographic 

location of enrollees diagnosed with opioid abuse or dependence varied 

based on state demographics more generally.

 1

We selected expansion enrollees with service utilization data that included a diagnosis of 

opioid abuse or dependence. These diagnoses do not reflect whether or not the enrollee 

met the criteria for an opioid use disorder per the criteria of the Diagnostic and Statistical 

Manual of Mental Disorders. 

2

We defined opioid pain medication use as a filled prescription for an oral drug (e.g., pills 

or tablets) used to treat pain that contains one or more opiate/opioid controlled 

substances, excluding drugs that the Food and Drug Administration has approved to treat 

opioid addiction (i.e., methadone and buprenorphine). 

Appendix III: Use of Treatment and Opioid 

Pain Medications among Enrollees with 

Diagnosed Opioid Abuse or Dependence

Characteristics of 

Expansion Enrollees 

Diagnosed with Opioid 

Abuse or Dependence
Appendix III: Use of Treatment and Opioid Pain 

Medications among Enrollees with Diagnosed 

Opioid Abuse or Dependence

Page 44 GAO-17-529 Medicaid Expansion

Figure 5: Demographic Characteristics of Expansion Enrollees with Diagnosed Opioid Abuse or Dependence in Selected 

States, 2014
Appendix III: Use of Treatment and Opioid Pain 

Medications among Enrollees with Diagnosed 

Opioid Abuse or Dependence

Page 45 GAO-17-529 Medicaid Expansion

Large proportions of expansion enrollees diagnosed with opioid abuse or 

dependence utilized outpatient services, while use of MAT was lower and 

varied greatly across our selected states. Outpatient services in our 

analysis include behavioral health services such as diagnostic services 

and psychotherapy, as well as evaluation and management services 

recorded with a primary behavioral health diagnosis. From 62 to 81 

percent of expansion enrollees in the selected states diagnosed with 

opioid abuse or dependence received an outpatient service for a 

behavioral health condition in 2014.3 (See table 6.) Expansion enrollees 

with diagnosed opioid abuse or dependence received MAT at divergent 

rates among the selected states, from 11 to 41 percent. A physician 

group we interviewed noted that while not every enrollee diagnosed with 

opioid addiction is a candidate for MAT, they would like to see all patients 

diagnosed with opioid addiction offered MAT as an option. We previously 

reported that factors that affect patients’ access to MAT for opioid 

addiction include laws and regulations, the availability of qualified 

practitioners and their capacity to meet patient demand for MAT, and 

perceptions of MAT and its value among patients, practitioners, and 

institutions.

4

Table 6: Use of Treatment among Medicaid Expansion Enrollees Diagnosed with Opioid Abuse or Dependence, 2014

Treatment type Percentage of expansion enrollees diagnosed with opioid abuse or dependence 

(number of enrolleesa)

Iowab

(845)

New York

(42,269)

Washington

(6,832)

West Virginia

(4,721)

Any outpatient servicec 81 79 62 80

Medication-assisted treatment (MAT) 11 30 19 41

Source: GAO analysis of Medicaid program data. | GAO 17-529

Note: Percentages are weighted by expansion enrollees’ length of enrollment in 2014.

a

Number of enrollees is expressed as person years, which is the total number of enrollment months 

divided by 12.

b

Our analysis may underestimate the use of MAT in Iowa, because we were not able to confirm with 

Iowa officials how the state recorded methadone administration in MSIS in 2014.

 3

Outpatient services include any behavioral health services, or evaluation and 

management services received in 2014, excluding the service during which the enrollee 

received the initial diagnosis of opioid abuse or dependence.

4

See GAO, Opioid Addiction: Laws, Regulations, and Other Factors Can Affect 

Medication-Assisted Treatment Access, GAO-16-833 (Washington, D.C.: Sept. 27, 2016).

Use of Treatment among 

Expansion Enrollees 

Diagnosed with Opioid 

Abuse or Dependence
Appendix III: Use of Treatment and Opioid Pain 

Medications among Enrollees with Diagnosed 

Opioid Abuse or Dependence

Page 46 GAO-17-529 Medicaid Expansion

c

Any outpatient service includes behavioral health services, as well as evaluation and management 

services recorded with a primary behavioral health diagnosis, excluding the service during which the 

enrollee received the initial diagnosis of opioid abuse or dependence.

Recent federal guidance and state actions seek to connect Medicaid 

enrollees diagnosed with opioid abuse or dependence to treatment. In 

January 2016, the Centers for Medicare & Medicaid Services released an 

informational bulletin outlining best practices for addressing prescription 

opioid overdose, misuse, and addiction, which recommends expanding 

the use of MAT.5 In interviews, state officials discussed ongoing efforts to 

ensure that enrollees diagnosed with opioid abuse or dependence receive 

appropriate treatment. Many of these efforts seek to increase the number 

of providers that can prescribe drugs for MAT. For example, Iowa is using 

a Certified Community Behavioral Health Clinics planning grant from the 

Substance Abuse and Mental Health Services Administration to train 

providers and increase the number of providers that can prescribe 

buprenorphine, a drug used for MAT. In Washington, officials discussed 

efforts to recruit primary care physicians to prescribe buprenorphine, 

which would make MAT more accessible to enrollees living in rural areas 

who might have to travel great distances to receive MAT from a clinic.

The use of opioid pain medications was generally higher among the 1 to 3 

percent of expansion enrollees diagnosed with opioid abuse or 

dependence compared with all other expansion enrollees. From 24 to 48 

percent of expansion enrollees diagnosed with opioid abuse or 

dependence in selected states were prescribed opioid pain medication 

following their diagnosis, compared with 14 to 35 percent of all other 

expansion enrollees.6 (See table 7.) Authors of previous research on the 

use of opioid pain medication among individuals with opioid abuse or 

dependence have suggested that such use could reflect a lack of 

coordination between specialists providing addiction treatment and those 

 5

See Department of Health and Human Services, Centers for Medicare & Medicaid 

Services, Best Practices for Addressing Prescription Opioid Overdose, Misuse, and 

Addiction, Center for Medicaid & CHIP Services Informational Bulletin (Baltimore, Md.: 

Jan. 28, 2016).

6

Oxycodone, hydrocodone, and tramadol were the most commonly prescribed opioid pain 

medications, for both enrollees with and without a diagnosis of opioid abuse or 

dependence. 

Use of Opioid Pain 

Medications among 

Expansion Enrollees 

Diagnosed with Opioid 

Abuse or Dependence
Appendix III: Use of Treatment and Opioid Pain 

Medications among Enrollees with Diagnosed 

Opioid Abuse or Dependence

Page 47 GAO-17-529 Medicaid Expansion

treating patients for pain.7 However, representatives from a physician 

group we interviewed noted that patients diagnosed with opioid addiction 

suffer from the same issues that would result in an opioid prescription for 

patients without an addiction, such as recovery after surgery. In addition, 

those with opioid addiction also face additional medical issues resulting 

from their addiction that may warrant treatment with pain medication. 

However, these representatives also emphasized that the prescription of 

opioids for someone diagnosed with opioid abuse or dependence is 

nonetheless a “medical crisis” that requires a high level of attention. In 

addition, representatives from this physician group advised providers to 

ensure that there is no better treatment option available, and follow up 

with patients regularly.

Table 7: Use of Opioid Pain Medications among Expansion Enrollees Diagnosed with Opioid Abuse or Dependence Compared 

with All Other Expansion Enrollees, 2014

Expansion population Percentage of enrollees with an opioid prescription

(number of enrolleesa)

Iowa New York Washington West Virginia

Expansion enrollees diagnosed with opioid 

abuse or dependence

44

(370)

24

(10,102)

48

(3,287)

28

(1,338)

All other expansion enrolleesb 27

(23,165)

13

(155,191)

26

(103,240)

35

(44,740)

Source: GAO analysis of Medicaid program data. | GAO 17-529

Note: Percentages are weighted by enrollees’ length of enrollment in 2014.

a

The number of enrollees is expressed as person years, which is the total number of enrollment 

months divided by 12.

b

All other expansion enrollees comprises all expansion enrollees without an outpatient service with a 

recorded diagnosis of opioid abuse or dependence.

Recent state actions seek to address and prevent opioid abuse and 

ensure appropriate prescribing of opioid pain medication. All four selected 

states have implemented some form of prescription drug monitoring 

program, although the extent to which providers are required to 

 7

See M. Daubresse et al., “Non-buprenorphine Opioid Utilization among Patients Using 

Buprenorphine,” Addiction, (2017), accessed on April 18, 2017, 

http://onlinelibrary.wiley.com/doi/10.1111/add.13762/full; and A.J. Gordon et al., “Patterns 

and Quality of Buprenorphine Opioid Agonist Treatment in a Large Medicaid Program,” 

Journal of Addiction Medicine, vol. 9, no. 6 (2015).
Appendix III: Use of Treatment and Opioid Pain 

Medications among Enrollees with Diagnosed 

Opioid Abuse or Dependence

Page 48 GAO-17-529 Medicaid Expansion

participate varies by state.8 According to state officials in New York and 

West Virginia, use of the prescription drug monitoring database is 

mandated for providers in those states. Iowa officials said that providers 

must review the state’s prescription drug monitoring database before 

obtaining prior authorization from Medicaid to prescribe certain opioid 

pain medications, and Washington encourages, but does not require, 

providers to enroll in and use the state’s database.

9 The selected states 

have also initiated provider education campaigns. For example, officials in 

Iowa said the state has worked to educate providers and pharmacists by 

providing them with individual patient profiles and narcotics reports for 

patients with three or more prescribers, while West Virginia has provided 

feedback to providers about their prescribing patterns.

 8

The Centers for Disease Control and Prevention defines prescription drug monitoring 

programs as state-run electronic databases used to track the prescribing and dispensing 

of controlled prescription drugs to patients.

9

Iowa’s requirement was limited to long-acting opioids—medications that have a more 

sustained effect than short-acting opioids—that were not on the state’s preferred drug list.
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 49 GAO-17-529 Medicaid Expansion

Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov

In addition to the contact named above, William Black (Assistant 

Director), Hannah Locke (Analyst-in-Charge), Britt Carlson, Giselle Hicks, 

Drew Long, Diona Martyn, Sean Miskell, Vikki Porter, and Emily Wilson 

made key contributions to this report.

Appendix IV: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(100483)
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 50 GAO-17-529 Medicaid Expansion

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