1. Medicaid Coverage for Opioid Treatment: Benefits for States
Paul N. Samuels, Legal Action Center
April 7, 2017

2. The Old Model: Grants and Client Fees
Unlike Rest of Health Care: Federal Block Grant, State Appropriations and Clients Fees
Disadvantages:
Highly Dependent on Political Environment
Highly Dependent on Economic Environment
Static: Doesn’t Grow with Need or Demand
Advantages:
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3. The New Model: Medicaid, Commercial Insurance and Parity
Parity required for most commercial insurance (large group and exchange) and Medicaid managed care and expansion
ACA private insurance enrollment: million enrollees
Medicaid plus Medicaid expansion:
Most states provide Medicaid reimbursement to OTPs
28 states and DC have elected to expand their Medicaid population (Federal government pays enhanced match for expansion population—100% through 2016, 90% in 2019 and beyond)

4. The New Model: Medicaid, Commercial Insurance and Parity (cont’d)
Advantages:
Funding flows with rest of health care
Since Medicaid an entitlement, funding increases with need/demand
Increased Medicaid funding frees up block grant and state appropriations for other (hopefully SUD) needs
Parity requires much better coverage for SUD
Disadvantages/Challenges:
Providers need to be able to bill and otherwise comply
Payors have to work with OTPs

5. Mental Health and Substance Use Disorder Parity
Mental Health Parity and Addiction Equity Act requires parity for SUD and MH with other medical conditions in:
Financial requirements
Quantitative treatment limitations
Non-quantitative treatment limitations
Applies to traditional Medicaid if managed care, all Medicaid expansion (managed care and fee-for-service), and most commercial insurance

6. Required Coverage of SUD and MH Services under the Affordable Care Act
The ACA dramatically improves coverage for and access to substance use disorder (SUD) and mental health (MH) services
Under the ACA, SUD and MH services are essential health benefits which must be covered at parity (Mental Health Parity and Addiction Equity Act) with other covered medical benefits
Successful advocacy by Coalition for Whole Health and others

7. Current Health Care Reform Debate
Much of the current structure, but not all, is being debated now, including:
Will Medicaid expansion continue?
Will SUD and MH coverage continue to be an “Essential Health Benefit” that must be covered at parity with other illnesses?
Opioid epidemic a major issue in the discussion
Parity for Medicaid managed care will remain the law
CMS has stated it will provide states more flexibility

8. Using Medicaid to Expand Access to Care for People in the Criminal Justice System
Huge opportunities
Recognition of the potential for cost-savings and improvement of health and criminal justice outcomes
Range of options to improve coverage and access around the country
Coverage for SUD and MH care at parity
Great opportunity for many newly Medicaid-eligible individuals who are justice-involved but also significant work in states not currently expanding their Medicaid population

9. Criminal Justice Opportunities: Seamless Medicaid Coverage
Medicaid can be suspended during incarceration
The federal government (CMS) has encouraged states to suspend not terminate Medicaid
States that suspend Medicaid upon an individual’s incarceration:
CA, CO, FL, IA, MD, MN, NY, NC, OH, OR, TX, WA
The enhanced federal Medicaid share in expansion states presents an even greater opportunity for cost-savings
Reforming state policies to promote seamless Medicaid coverage will significantly help with continuity of care into the community

10. Medicaid, Incarcerated Beneficiaries, and the Inpatient Exclusion
Medicaid can pay for services when the incarcerated individual is a “patient in a medical institution”
When they’ve been admitted as an inpatient in a community- based hospital, nursing facility, juvenile psychiatric facility, or intermediate care facility for at least 24 hours
All medically necessary Medicaid covered services provided to that individual while admitted can be billed to Medicaid
Federal Medicaid dollars can pay for these services if the state’s policies allow for that

11. State Cost-Savings by Billing Medicaid for Inpatient Care
States that bill Medicaid for inpatient care:
AR, CA, CO, DE, LA, MI, MS, NE, NY, NC, OK, PA, VT, WA
A number of states have recognized the huge potential for cost savings when they bill for inpatient care
North Carolina saved $10 million in the first year (2011)
California saved about $31 million in FY 2013
New York estimated in 2012 that it could save $20 million annually if the state billed Medicaid for eligible inpatient care
CSG Justice Center brief:
content/uploads/2013/12/ACA-Medicaid-Expansion-Policy- Brief.pdf

12. Medicaid Eligibility and Enrollment for Justice-Involved Individuals
Although federal rules prohibit payment for services for incarcerated individuals, this has no effect on Medicaid eligibility or enrollment
There is no federal prohibition against screening for eligibility and enrolling during incarceration
HHS has clarified “corrections department employees…are not precluded from serving as an authorized representative of incarcerated individuals for purposes of submitting a (Medicaid) application on such an individual’s behalf”
Enrollment can and should happen at all stages of justice system involvement

13. Health Homes and the Criminal Justice System
Twenty-six states (and DC) have an approved Health Home State Plan Amendment or are working with CMS toward approval
Includes ten states that are not currently expanding their Medicaid population
New York is working to include justice-involved individuals through their initiative
Rhode Island is focusing on substance use disorders, including opioid use disorders

14. Benefits of Using Medicaid for Opioid Medication-Assisted Treatment
Better Health Outcomes: Reduced drug use
Better Public Safety Outcomes: Reduced recidivism and incarceration
Reduced Health Care Costs: Washington State study findings that costs of SUD treatment offset by health care savings in first year and overall savings in subsequent years

15. Maximizing the Opportunities Before Us
Critical need for payors, regulators and providers to work closely together: State Medicaid agency, the SSAs for SUD and MH, and OTPs
Huge interest in criminal justice system – drug courts and other community courts, jails, prisons, reentry and community supervision programs – in better engaging with the SUD and MH service provider network
Goal: Expand care by learning from early adopters, sharing best practices, and shaping existing models to work for each system

16. We Are Here to Help
Legal Action Center
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