With the opioid crisis still raging, reliable access to treatment options is vital. Many patients with opioid use disorder (OUD) face obstacles to treatment, including stigma, limited local care providers, and financial concerns.
Private insurance sometimes covers OUD treatment options, alleviating some of the financial burden, but not everyone has these insurance plans. Patients with OUD who are on Medicaid also need accessible, affordable care, and coverage can vary by state. In New York, Medicaid does cover most medications for addiction treatment.
Prevalence of OUD among Medicaid beneficiaries
Over two million people in the United States have OUD. Certain groups of people are disproportionately represented among those affected by OUD, including Medicaid beneficiaries. A cross-sectional study published in the Journal of the American Medical Association (JAMA) in 2023 found that the prevalence of OUD among Medicaid beneficiaries ranged from 0.6% to 9.7% between states based on claims data. By comparison, the Centers for Disease Control and Prevention (CDC) found that 3.7% of adults aged 18 and over needed OUD treatment based on responses to the 2022 National Survey on Drug Use and Health.
The question is whether Medicaid covers drug treatment services like those for patients with OUD. Generally, Medicaid does cover treatment for substance use disorders, but exact requirements differ across states. Someone on Medicaid living in a rural community might struggle to find a Medicaid-approved OUD treatment option in their area. By comparison, Medicaid-approved Suboxone® treatment in NYC is much easier to find, leading to discrepancies in access to care (important safety information).
What are the NY State guidelines for covering medications for addiction treatment (MAT)?
As of October 2021, the New York Department of Health established a single statewide list of covered medications for addiction treatment (MAT). Suboxone is on the list of preferred opioid dependence agents for NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) recipients. Generic buprenorphine and combination buprenorphine/naloxone tablets are also on the list.
Medicaid limits Suboxone coverage to three sublingual tablets or films each day, up to 90 total, as part of a 30-day supply. As of March 22, 2022, care providers no longer need to seek prior authorization for Medicaid coverage of MAT, as long as they stick to generally accepted national professional guidelines for treating a substance use disorder when prescribing. However, patients on established opioid dependence therapy need prior authorization to get coverage to start using one of these medications. Generic MAT options, like the buprenorphine/naloxone film, also require prior authorization for Medicaid coverage.
It’s important to note that Ophelia’s care teams tailor treatments to the individual patient’s needs, which includes dosage. Our intake coordinators can help with insurance questions to be sure your care is covered.
To make treatment even more accessible, the New York Department of Health has the Buprenorphine Assistance Program (BUPE-AP). This program covers the cost of buprenorphine for qualifying patients without any insurance or sufficient coverage to pay for the medication.
Other OUD treatment coverage
New York State Medicare also covers Narcan, as well as the generic opioid agonists naloxone and naltrexone. Naloxone rapidly reverses opioid overdoses, saving lives by giving emergency responders more time to arrive and administer further treatment. It’s available in injectable and nasal spray forms. Narcan®, a common brand-name naloxone medication, is a nasal spray. Sublocade® and Vivitrol®, two injectable opioid dependence agents, are also covered under NY State Medicare.
NY Medicaid telehealth treatment
During the COVID-19 pandemic, telehealth utilization grew tremendously. Even after the pandemic, telehealth use has decreased somewhat but remained much higher than pre-pandemic levels.
However, insurance coverage for telehealth visits and treatment can be different from in-person treatment coverage in some cases. In New York State, Medicaid covers four types of telehealth services:
- Audio-only visits: Electronic audio-only two-way calls between telehealth providers and patients in different locations.
- Audio and visual visits: Two-way synchronous electronic calls with both audio and visual communication between the patient and telehealth provider.
- Remote patient monitoring: Telehealth providers using digital technologies to collect medical data and health information about patients from different locations.
- Store-and-forward: Telehealth providers pre-record videos or images with the patient’s health information, then transmit them electronically and asynchronously to the patient.
Suboxone treatment for addiction in New York is covered by NYS Medicaid, including telehealth treatment. Retention in telehealth treatment with buprenorphine for OUD is high. In one study, the program retained 56.4% of patients over 180 days and 48.3% of patients over 365 days.
Access affordable OUD treatment through Ophelia
Everyone should have access to the care they need for OUD. Telehealth OUD treatment helps break down barriers to reach more patients. However, even with telehealth services, some patients may worry about being able to access treatment due to financial concerns.
That’s why Ophelia is committed to making OUD care affordable for as many patients as possible. Ophelia accepts New York State Medicaid and a growing set of other insurance plans for our telehealth Suboxone treatment. Use our free insurance checker to determine whether your treatment might be covered, or get in touch with our team to dig deeper into your coverage and costs. After that, the next step to getting started with Ophelia is a quick welcome call to determine your eligibility.
Sources
