Medicaid: Opioid Use Disorder Services for Pregnant and Postpartum Women, and Children
Released: 2019-10-24T00:00:00

Letter

Background

Opioid Use Disorder

Opioids—such as hydrocodone, oxycodone, morphine, and methadone— can be prescribed to treat both acute and chronic pain. Many opioids have a high potential for abuse and may lead to severe psychological or physical dependence. OUD, which is a type of substance use disorder, is generally characterized by a loss of control of opioid use, risky opioid use, impaired social functioning, tolerance, and withdrawal.

According to SAMHSA and the National Institute on Drug Abuse, OUD is a chronic, treatable illness. SAMHSA states that treatment for OUD should be individualized and can include a range of treatment options that include medication and behavioral health services. Specifically, services related to the treatment of OUD include the following:

Screening can identify individuals who have OUD, are at risk for developing OUD, or have medical problems related to opioid use. Screening, brief intervention, and referral to treatment (SBIRT) is a specific type of screening that involves a health care provider educating individuals with a positive screen for opioid use and referring them to specialized treatment, as needed.

Outpatient counseling and therapy includes counseling and treatment services individually or in a group.

Inpatient hospital services include those that occur in a hospital, such as services for detoxification.

Inpatient residential services include care in a 24-hour residential setting. Inpatient residential providers offer medical care in combination with housing, typically lasting from a week to several weeks or more.

Medication-assisted treatment (MAT) combines the use of certain prescription medications (such as methadone, buprenorphine, and naltrexone) and behavioral therapy. Methadone and buprenorphine suppress withdrawal symptoms and control the craving for opioids, while naltrexone suppresses the euphoric effects of opioids. Research has shown that MAT for OUD reduces opioid use and increases the chance that patients will continue OUD treatment compared to abstinence-based treatment (where patients are treated without medication).

Case management services include providing coordination and management of care across multiple health care providers.

Crisis intervention includes immediate care intended to prevent harm.

Peer recovery coaching includes recovery support through a certified peer specialist with experience of recovery from addiction.

Medicaid Program Overview

States administer their Medicaid programs within broad federal requirements and according to a state plan approved by CMS. The Medicaid program allows states to design and implement their programs within certain federal parameters, resulting in more than 50 distinct programs. A state’s approved Medicaid plan outlines the services provided and the groups of individuals covered. States also have the option of using waivers to expand services under the Medicaid program. As such, the types of services covered by Medicaid can vary across states.

Historically, Medicaid eligibility has been limited to certain categories of low-income individuals, such as children, parents, pregnant women, persons with disabilities, and individuals aged 65 and older. The Patient Protection and Affordable Care Act (PPACA), enacted in 2010, allowed states to expand Medicaid coverage to nearly all individuals with incomes up to 138 percent of the FPL, regardless of eligibility category. As of October 2019, 33 states and the District of Columbia expanded Medicaid eligibility, and 17 states had not.

Medicaid Services for Pregnant and Postpartum Women

Under federal law, state Medicaid programs must provide coverage for health care services for certain pregnant women, including low-income pregnant women with incomes at or below 138 percent FPL. Most states opt to extend coverage to pregnant women with incomes above this threshold. By statute, states are permitted to limit the services covered for certain pregnant women, including low-income pregnant women, to services related to the pregnancy. Such coverage is referred to as “pregnancy-related coverage.” CMS defines pregnancy-related services as those services necessary for the health of the pregnant woman and fetus, or that have become necessary as a result of the woman having been pregnant, which includes prenatal, delivery, postpartum, and family planning services, as well as services for other conditions that may complicate the pregnancy. In contrast, states are required by statute to provide pregnant women who qualify for Medicaid on another basis, such as a disability, full Medicaid benefits. At a minimum, states must provide Medicaid coverage for pregnant enrollees through 60 days postpartum, though states may extend coverage further. Some women may qualify for continued Medicaid coverage after the 60-day postpartum period if they meet the requirements for another eligibility pathway, such as for parents, while others may transition to other programs or become uninsured.

Medicaid Services for Children

Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is the primary mechanism to help ensure the provision of appropriate health care services to children under Medicaid. Under the EPSDT benefit, states are required to cover comprehensive health screenings and preventive health services, such as those related to vision and oral health, and all other Medicaid coverable services that are necessary to correct or ameliorate any conditions discovered through screenings. States are required to follow a schedule of screenings, known as a periodicity schedule, that are recommended for children at specific ages and frequencies. States can develop their own schedule within federal parameters or follow an established schedule, such as from the American Academy of Pediatrics (AAP).

States are required to report annually on the provision of certain EPSDT services to CMS. States must report information on the number of children provided health screening services, the total number of health screenings services provided, the number of children referred for corrective treatment, the number of children receiving dental services, and the state’s results in attaining EPSDT participation goals. States may also voluntarily report annually on the quality of health care services provided under EPSDT using a set of quality measures known as the Child Core Set. CMS plans to increasingly use the Child Core Set in the future and state reporting will be mandatory beginning with the state reports for fiscal year 2024.

States also have flexibility in determining where EPSDT services can be delivered. As a means of improving access—particularly in underserved communities, such as rural areas—Medicaid programs may cover certain services delivered by health care providers in schools. There were approximately 130,000 schools across the United States as of 2016, according to data from the Department of Education. Some of these schools have health clinics. Additionally, there were approximately 2,600 school-based health centers as of 2017, some of which served children in underserved communities, according to the School-Based Health Alliance.

Telehealth as a Modality to Provide Services

Some state Medicaid programs allow for services to be delivered via telehealth, including in schools. Telehealth can be used to provide clinical care remotely, such as for screening, counseling, and therapy. Health care providers offer care to patients through remote technology, such as a live, two-way video call. Such services could be provided, for example, via a video conference on a desktop computer or laptop that connects a student in school with a provider in another location. States have flexibility to choose whether to cover services delivered via telehealth. Because the federal Medicaid statute does not recognize telehealth as a distinct service, CMS views telehealth as a service delivery mechanism. According to CMS, services delivered via telehealth are subject to the same Medicaid requirements as those services provided in person.

Selected States Provide Medicaid and Other Coverage for a Range of Opioid Use Disorder Services for Eligible Pregnant and Postpartum Women

Selected States Provide Medicaid Coverage of Most Opioid Use Disorder Services for Eligible Pregnant Women and Women through 60 Days Postpartum

The Medicaid programs in our six selected states provided coverage of most OUD services during pregnancy and the first 60 days postpartum, as of January 1, 2019. Specifically, the selected states’ Medicaid manuals indicate these states provide coverage for at least seven of the eight OUD services we identified in our review, such as screenings, inpatient and outpatient services, and MAT. (See fig. 1.)

In the six states we reviewed, we did not identify differences between the types of covered OUD services for pregnant women in expansion and non-expansion states. For example, the three expansion states— Arkansas, Colorado, and Massachusetts—and the three non-expansion states—Alabama, South Dakota, and Texas—each covered at least seven of the eight OUD services for pregnant women.

Similarly, we did not identify differences in Medicaid coverage for OUD services between the selected states that limited coverage to pregnancy- related services and those that provided full benefits. Arkansas and South Dakota—the two states providing only pregnancy-related coverage— covered seven of the eight OUD services for pregnant women. According to Medicaid officials in these two states, the programs cover these OUD services because they are considered medically necessary. In contrast, neither state generally provides Medicaid coverage for peer recovery coaching for beneficiaries, including pregnant women.

Three of the selected states—Alabama, Colorado, and Texas—covered certain OUD services for pregnant women that they do not cover for other beneficiaries under Medicaid. For example, in Alabama, screening services and inpatient residential services were covered only for pregnant women, but not other eligible, low-income women. In Colorado, pregnant women were the only group in the state for whom residential OUD services were covered under Medicaid. In Texas, pregnant women were the only group in the state for whom case management is a covered service under Medicaid.

Selected States Provide Medicaid Coverage for Most Opioid Use Disorder Services If Women Are Able to Maintain Medicaid Eligibility beyond 60 Days Postpartum

In all six selected states, once Medicaid coverage furnished on the basis of pregnancy ends after 60 days postpartum, women can continue to receive most OUD services under Medicaid if they qualify for Medicaid on another basis. For example, these women could qualify if their income is equal to or lower than the maximum allowable income for parents. However, in the six selected states, the maximum allowable income for eligible parents was generally lower than that for pregnant women, as of January 2019. (See fig. 2.)

Women in the six selected states who are eligible to maintain Medicaid coverage after 60 days postpartum can continue most of the same OUD services that were covered during pregnancy. However, officials in two states said that the OUD services covered specifically for pregnant women under Medicaid would generally not be covered after the postpartum period ends. Four of the selected states provided estimates of the number of women who maintain Medicaid eligibility after the postpartum period ends. For example, officials in Massachusetts, an expansion state, estimated that in 2017 and 2018, approximately 99 percent of women with Medicaid coverage while pregnant maintained Medicaid coverage after the postpartum period ended. State officials in Colorado, also an expansion state, estimated that in 2015, 75 percent of women maintained coverage after the postpartum period ended. Additionally, in Arkansas, another expansion state, officials estimated that about 60 percent of women in 2017 and 2018 maintained Medicaid coverage after the postpartum period ended. Officials in Alabama, a non-expansion state, estimated that in 2017, about 43 percent of women maintained Medicaid coverage after the postpartum period ended.

States may also obtain approval from CMS, such as under a waiver, to extend Medicaid coverage for women with OUD beyond 60 days postpartum, according to CMS officials. However, CMS officials were not aware of the number of states that have done so. In our review, we found that one of the six selected states, Colorado, used a section 1915(b) waiver to extend Medicaid eligibility for substance use services, including OUD services, for women beyond 60 days postpartum. Under the state’s “Special Connections” program, which was approved under the waiver, women who are eligible for Medicaid during their pregnancy can continue Medicaid coverage for OUD services for up to 12 months postpartum, including inpatient residential services, which would not otherwise be covered under Medicaid. A state official told us that the program began in 1991 to provide substance use disorder services to pregnant women and up to 60 days postpartum. In 2006, the state extended coverage under the program to provide substance use disorder services up to 12 months postpartum. The program aids in early identification and intervention for pregnant women with substance use disorders who are at risk of delivering low birth weight babies with health complications. Officials said the goal of the program is to improve the likelihood that the mother remains free from substance abuse. According to Colorado officials, 227 women participated in the program in 2018.

Selected States Use Other Funding Sources to Provide Coverage of Opioid Use Disorder Services for Postpartum Women Not Eligible for Medicaid

We also found that the six selected states use other funding sources to provide coverage of OUD services for women with incomes that exceed the state’s Medicaid eligibility thresholds. Officials from the six selected states reported that they received SAMHSA grants so each state could provide OUD services for pregnant and postpartum women that extend beyond 60 days. According to the SAMHSA officials we interviewed, grants have been used to increase access to MAT, expand recovery support for pregnant women, and provide enhanced services for women to access OUD treatment. Furthermore, SAMHSA officials said that pregnant and postpartum women are specifically identified as target populations for grants, such as the agency’s State Targeted Response to the Opioid Crisis grant and its State Opioid Response grant. For example, officials in Arkansas told us that by using SAMHSA grants, they are able to allow uninsured or underinsured women who are seeking treatment for OUD to continue MAT treatment after 60 days postpartum. In addition, officials in the six selected states told us that women beyond 60 days postpartum generally would not experience gaps in treatment for OUD when transitioning from Medicaid to SAMHSA grant-funded programs, as women can generally continue receiving the same services and seeing the same providers. For example, state officials in Alabama, South Dakota, and Texas told us the state Medicaid agency contracts with providers that agree to participate in both the state’s Medicaid program and SAMHSA’s grant programs to allow for continuity of eligible services.

Officials in Texas also told us they used state funds to implement a program to provide OUD services for up to 18 months postpartum. State officials told us that in this program—called the Neonatal Abstinence Syndrome-Opioid Treatment Services program—when a woman’s Medicaid coverage ends, she transitions to state-funded treatment to continue the same OUD services with the same provider. According to state officials, this program, funded since 2015, expands treatment services to postpartum women who would typically lose Medicaid coverage and become unable to pay for MAT services, which officials say help reduce relapse, overdose, and maternal mortality risk. State officials added that there is flexibility to extend services for postpartum women participating in the program for up to 2 years, if needed. State officials told us that since 2016, 296 women have participated in the program.

In addition to the efforts in the selected states, the federal government has planned efforts to help states combat the opioid crisis, specifically for pregnant and postpartum women with OUD. For example, CMS plans to offer up to 12 cooperative agreements to states under the Maternal Opioid Misuse model as a way to improve access to services under Medicaid to pregnant and postpartum women with OUD. The model will have a 5-year performance period, 2020 through 2024, to allow states to implement strategies to improve the quality of care for pregnant and postpartum women with OUD. According to CMS officials, the model does not require that states extend coverage beyond 60 days postpartum, but states could choose to do so. CMS published the funding opportunity for the model in February 2019, and plans to select states to participate by the fall of 2019. In July 2019, CMS issued guidance to states regarding Medicaid coverage of services such as counseling for postpartum women while their infant is receiving treatment for Neonatal Abstinence Syndrome. The Centers for Disease Control and Prevention also issued a publication in September 2019 summarizing an initiative on state strategies to address OUD among pregnant and postpartum women and infants prenatally exposed to substances. The initiative identified five focus areas, including access to and coordination of quality services, provider awareness and training, and financing and coverage. In addition, the SUPPORT Act includes a provision for HHS to issue guidance to improve care for postpartum women with substance use disorder by the fall of 2019.

Selected States Provide Medicaid Coverage for Annual Screenings and Any Medically Necessary Services for Substance Use, Including Opioids, for Eligible Children

The six selected states provide Medicaid coverage for annual screenings of eligible children for substance use, including opioids, as well as any medically necessary treatment for conditions identified through these screenings, as of 2019. This coverage is provided through the Medicaid EPSDT benefit. Based on our review of Medicaid state plans and EPSDT policies and periodicity schedules, we found that the six selected states established the following screening schedules at the time of our review:

Arkansas’ Medicaid state plan and Colorado’s and South Dakota’s EPSDT policies specify that these states follow AAP’s screening schedule. AAP recommends annual substance use screening for all children beginning at age 11 until they reach the age of 21.

Alabama’s EPSDT policy requires annual screening for all children ages 6 to 13.

Massachusetts’ EPSDT policy requires providers to conduct an annual assessment of every child’s risk for substance use as part of a health history assessment during a child’s annual visit. This assessment can be conducted at any age.

Texas’ EPSDT periodicity schedule recommends annual screening for all children ages 12 to 18.

Additionally, Massachusetts and Texas Medicaid programs require behavioral health screening for all eligible children. The Medicaid programs in these states provide separate payment for behavioral health screening if the screening is conducted using an approved screening tool, some of which also screen for substance use, such as opioids. Texas officials reported that substance use screenings are considered part of the required overall mental health screening component of annual checkups. Similarly, Arkansas officials said that as part of a new EPSDT policy they are drafting, the state Medicaid program will require behavioral health screening for all children, which can include substance use screening if determined medically necessary by the provider.

The six selected state Medicaid programs report data on the total number of screenings provided under EPSDT for children’s health care needs. However, officials from five of the selected states said that it is difficult or impossible to separate and thus track the number of the substance use screenings as distinct from other types of EPSDT screenings or visits that are recorded in Medicaid data. States are required to track and report the total number of EPSDT screenings provided, but not the number of substance use disorder screenings.

Officials from all six selected states said that they conduct outreach and education to providers and parents to ensure awareness of the EPSDT benefits, as required. We found that the extent of information the states provide on these services varied among the six states. For example, outreach materials from three of the six selected states included information about the availability of substance use screening, and one of these three states, Alabama, also included information about services for opioid use.

For all six selected states, officials emphasized that Medicaid’s EPSDT benefit requires states to cover any medically necessary treatment or service to address health conditions for a child, including opioid use. Officials from the six selected states also described a variety of initiatives to increase access to substance use disorder, including OUD, services for children. For example:

Officials from Alabama said they recently began a program that offers more substance use disorder services in schools in a face-to-face capacity to help increase convenience and reduce stigma around these services for both the children and the parents. They explained that the Alabama Department of Mental Health added modifiers to ensure that their systems can capture data appropriately and analyze trends in providing school-based services, which are currently offered in over 40 individual schools. Officials added that Medicaid pays for covered services that are provided to Medicaid-eligible children in schools under this program.

Officials from two states—Arkansas and Massachusetts—said they recently expanded the types of substance use disorder services covered for all Medicaid beneficiaries. Officials from Arkansas added that they are working to expand the number of providers who can offer substance use disorder treatment under Medicaid.

Officials from two states—Massachusetts and Texas—said they had recently developed programs specifically aimed at serving children with substance use disorder, including OUD, using federal authority. Massachusetts received approval from CMS to conduct a Medicaid demonstration to establish OUD programs for children. Texas is using SAMHSA grant funding to support eight youth recovery centers that are intended to improve services and recovery supports for youth with substance use disorder, including OUD.

Over 30 States Reported Medicaid Coverage of Opioid Use Disorder Services Delivered through Telehealth in Schools, but No Evidence Services are Being Used

We conducted outreach to Medicaid officials from all 50 states and the District of Columbia between February and July 2019 to inquire about whether the state provided Medicaid coverage of OUD services delivered via telehealth in schools as a means of increasing access to these services for children. Officials from 31 states and the District of Columbia reported that they provide Medicaid coverage of OUD services delivered in schools via telehealth. Medicaid officials from some states reported that their Medicaid policies explicitly allow for coverage of OUD services provided in schools via telehealth, while others reported that they allow for Medicaid coverage of these services, but their policies do not explicitly address the issue. (See app. I for the state responses regarding Medicaid coverage of OUD services provided in schools via telehealth.)

Officials from the remaining 18 states reported that their Medicaid policies do not allow for payment for OUD services delivered in schools via telehealth. Some of these state officials reported that they did not allow schools to serve as a location for patient services during a telehealth visit for Medicaid payment purposes. Other state officials reported that they allowed Medicaid payment for certain services provided in schools via telehealth, but OUD services were not among them. For example, officials from Texas said the state established a school-based telehealth program for behavioral health services. However, this program does not include services for the treatment of substance use disorder, including OUD. Officials added that the state has a requirement that substance use disorder services can only be delivered in certain approved facilities.

While Medicaid officials from 31 states and the District of Columbia reported that they provide Medicaid coverage of OUD services in schools via telehealth, they also said they were not aware of any instances of these services being utilized. Medicaid officials from the 31 states and the District of Columbia reported that either these services were not being provided based on data or other information they had, or they were unaware if the services were being provided. Officials from seven states responded that they either reviewed Medicaid utilization data or asked school-based staff and determined that there was no utilization of these services. For example, officials from one state—Ohio—conducted a data query and found that in 2018 there had been two instances of substance use disorder services billed to Medicaid that were delivered via telehealth in a school. However, officials noted that these instances involved treatment for substances other than opioids. While not for OUD, these two instances were the only instances of Medicaid payment for substance use disorder services delivered via telehealth in schools that we identified in our review.

As part of our outreach to states and background research, we did find that some states or localities have taken steps to facilitate the use of telehealth for delivery of substance use disorder services, including OUD, in schools. For example:

Officials from one county in Maryland said they recently began using a telehealth smart device application to screen students in schools for substance use disorder, including OUD, and refer them to treatment. However, county officials said that the program was locally funded, and they had not considered seeking Medicaid payment.

A South Dakota tribal reservation recently implemented a new school- based telehealth program for behavioral health. According to officials, this program could include OUD services delivered via telehealth in schools, and these services could be billed to Medicaid if the provider was already licensed to bill Medicaid; however, officials said that none of these services had been provided to date.

Massachusetts recently expanded its Medicaid telehealth policy to allow for the payment of mental health and substance use disorder services provided in many locations, including schools. However, officials said the state was still building the telehealth infrastructure, and services had not yet been provided at the time of our review. Officials were unsure whether OUD services would be delivered via telehealth in schools under the new policy once implementation began.

State officials and subject matter experts that we spoke with also reported a range of potential benefits and challenges associated with providing substance use disorder services, including OUD services, in schools via telehealth. (See table 1.)

There have also been federal efforts to emphasize the use of telehealth to improve access to OUD services for children. For example, these efforts include the following: In June 2018, CMS issued guidance emphasizing the use of telehealth as a means of improving access to OUD services and noted that states need not necessarily submit a change to their state plan to begin delivering covered Medicaid services through telehealth. Similar to what we heard from experts, this guidance suggests that leveraging technology to provide such services might help with addressing provider shortages, particularly in rural areas.

In July 2019, CMS and SAMHSA jointly issued guidance on addressing mental health and substance issues in schools. The guidance states that telehealth for mental health services in schools has been found to be effective. This guidance also emphasizes that telehealth can be helpful for ensuring that Medicaid services are provided to Medicaid beneficiaries who are in rural areas or in areas where qualified practitioners are scarce.

HRSA officials we spoke with also described several different HRSA programs from which funds could be used to facilitate or deliver substance use disorder services via telehealth, including in some school-based health centers; however, the officials were not able to determine whether telehealth is being utilized to deliver OUD services in school-based health centers, specifically.

The SUPPORT Act also includes a provision for HHS to issue guidance to states on Medicaid coverage of substance use disorder services delivered via telehealth, including in school-based health centers, by fall of 2019.

Agency Comments

We provided a draft of this report to HHS for review. HHS provided technical comments, which we incorporated as appropriate.

We are sending copies of this report to the Secretary of Health and Human Services, the Administrator of the Centers for Medicare & Medicaid Services, the Health Research and Services Administration, the Substance Abuse and Mental Health Services Administration, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact Jessica Farb at (202) 512-7114 or farbj@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 II.

Appendix I: State Reported Medicaid Coverage of Opioid Use Disorder Services Delivered through Telehealth in Schools

Appendix II: GAO Contact and Staff Acknowledgements

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Rashmi Agarwal (Assistant Director), Kaitlin McConnell (Analyst-in-Charge), Arushi Kumar, Kimberly Lloyd Perrault, Jennifer Rudisill, and Emily J. Weisenberger made key contributions to this report. Also contributing were Drew Long and Ethiene Salgado-Rodriguez.

Related GAO Products

Medicaid: Additional CMS Data and Oversight Needed to Help Ensure Children Receive Recommended Screenings. GAO-19-481. Washington, D.C.: August 16, 2019.

Opioid Crisis: Status of Public Health Emergency Authorities. GAO-18- 685R. Washington, D.C.: September 28, 2018.

Adolescent and Young Adult Substance Use: Federal Grants for Prevention, Treatment, and Recovery Services and for Research. GAO- 18-606. Washington, D.C.: September 4, 2018.

Newborn Health: Federal Action Needed to Address Neonatal Abstinence Syndrome. GAO-18-32. Washington, D.C.: October 4, 2017.

Drug Control Policy: Information on Status of Federal Efforts and Key Issues for Preventing Illicit Drug Use. GAO-17-766T. Washington, D.C.: July 26, 2017.

Medicaid Expansion: Behavioral Health Treatment Use in Selected States in 2014. GAO-17-529. Washington, D.C.: June 22, 2017.

Health Care: Telehealth and Remote Patient Monitoring Use in Medicare and Selected Federal Programs. GAO-17-365. Washington, D.C.: April 14, 2017.

School Based Health Centers: Available Information on Federal Funding. GAO-11-18R. Washington, D.C.: October 8, 2010.