Majority of Medicaid MCOs Delegate SUD Treatment Benefits

“This [research] highlights that SUD services continue to be primarily segregated in Medicaid, with apparently more frequency than for mental health services, where carveout arrangements have shifted more recently to carve-in or integrated models,” said Jane Zhu, M.D., a primary care physician and associate professor of medicine in the Division of General Internal Medicine at Oregon Health & Science University, who was not involved in the study. Zhu is a co-author of a 2021 study published in Health Services Research that found that patients whose Medicaid managed care plans carved in behavioral health were more likely to access outpatient behavioral health services than patients whose plans carved out behavioral health.

Zhu said that carved in and carved out services have different trade-offs for different populations.

“Carve-in arrangements may rely more on broader networks of care—for example, primary care providers like myself—which in turn provide greater access to medical and behavioral health needs, including SUD in those with less complex conditions. But the trade-off is potentially less capacity or less training or specialization of care to address the needs of those with more serious or complex conditions,” Zhu explained. “In contrast, carveouts may offer access to more specialized care, but they also introduce more complexity for patients and providers.

“Regardless of the financing arrangement, policymakers should be focused on ensuring that barriers to SUD care are minimized across a continuum of services and settings, particularly as we grapple with a continued opioid epidemic,” Zhu added.

Silverman said that psychiatrists and other behavioral health professionals who participate in Medicaid should familiarize themselves with what is included in their patients’ plans before referring patients for services.

“If you’ve seen one Medicaid plan, you’ve seen one Medicaid plan,” Silverman said. “Don’t assume that one plan in your state will look like another plan in your state, or that something will be covered even if you’ve seen it covered on the plan before.”

Jeffrey DeVido, M.D., a former member of APA’s Council on Addiction Psychiatry, said that understanding the local Medicaid SUD treatment environment is critical to being able to help Medicaid patients navigate the system into treatment.

DeVido, chief of addiction services for the Marin County Department of Health and Human Services in California and behavioral health clinical director for Partnership HealthPlan of California, added that focusing locally is more manageable for the psychiatrist.

“Recognizing that the system may vary significantly from state to state, managed care organization to managed care organization, and even from ZIP code to ZIP code can help focus a psychiatrist’s learning curve such that they’re not trying to understand the system everywhere, but rather just the system of which they are a part,” DeVido said.

He added that the MCOs themselves often have care coordinators or other care navigators, and that in some systems, independent recovery coaches or case managers can also help shepherd patients to the correct treatment venue.

Silverman said that connecting patients with case managers, peer support specialists with lived experience working in the system, and other navigators may help ensure that patients get the help they need.

“Figuring all of this out on their own can be time-consuming if [patients] don’t know where to begin or what to look for. Some may feel it is too difficult, and some may not even realize they can get care,” she said.

The JSAT study was supported by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. The Health Services Research study was supported by the National Institute of Mental Health and the National Institute on Minority Health and Health Disparities. ■