Medicaid Coverage Policy Variations for Chronic Pain and Opioid Use Disorder Treatment

Abstract

Importance: Co-occurring chronic pain and opioid use disorder (OUD) are associated with a high disease burden for the patient, requiring comprehensive treatment approaches, yet Medicaid benefit structures for evidence-based therapies vary substantially across states.

Objective: To develop a systematic framework for analyzing Medicaid coverage policy variations in behavioral and integrative health services for co-occurring chronic pain and OUD.

Design, setting, and participants: This systematic economic evaluation reviewed Medicaid coverage policies in California, Illinois, Texas, North Carolina, and New York from January 1, 2018, to December 31, 2023, representing states with a combined Medicaid enrollment of approximately 27.8 million beneficiaries in 2018 and growing to 35.9 million by 2023. Findings were applied to demonstrate methodology for future comparative policy effectiveness research.

Exposures: Medicaid coverage and co-occurring chronic pain and OUD.

Main outcomes and measures: Coverage status, authorization requirements, service limitations, and clinician qualifications for medications, behavioral health services, and integrative treatments.

Results: Five states covering approximately 35.9 million Medicaid beneficiaries at peak enrollment were analyzed. All states provided full coverage for core medication classes and basic interventional procedures, although with varying authorization requirements. Behavioral health coverage showed policy divergence: peer support services were universally covered but differently implemented, with Texas limiting coverage to 104 units per 6 months. Four states (80%) covered cognitive behavioral therapy with varying session limits. Physical therapy was universally covered, while only 2 states (40%) provided acupuncture coverage.

Conclusions and relevance: In this economic evaluation, substantial Medicaid implementation variations were documented across behavioral and integrative health services, establishing foundation methodology for future comparative effectiveness research to examine relationships between policy approaches and patient outcomes.