Predictors of Medicaid managed care plan performance on opioid use disorder treatment quality metrics.

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Published in final edited form as: Drug Alcohol Depend. 2025 Jun 2;274:112742. doi: 10.1016/j.drugalcdep.2025.112742 Predictors of Medicaid managed care plan performance on opioid use disorder treatment quality metrics Maureen T Stewart a, b , Sage R Feltus a, b , Christina Andrews c , Dominic Hodgkin a , Cindy Parks Thomas a , Constance Horgan a Author information Article notes Copyright and License information a The Heller School for Social Policy and Management, Brandeis University b Department of Health Law, Policy and Management, Boston University School of Public Health c Arnold School of Public Health, University of South Carolina ✉ Corresponding Author: Maureen T. Stewart, PhD, Research Associate Professor, Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, stewartm@bu.edu Issue date 2025 Sep 1. PMC Copyright notice PMCID: PMC12306625  NIHMSID: NIHMS2089652  PMID: 40482519 The publisher's version of this article is available at Drug Alcohol Depend Abstract Introduction: Medicaid managed care plans (MCPs) and states play essential roles in supporting access to high-quality opioid use disorder (OUD) treatment services. This study aimed to identify MCP and state-level policies associated with better plan performance on indicators of quality OUD treatment. Methods: Publicly available data on Medicaid MCPs’ profit status, behavioral health contracting arrangements, market share, buprenorphine prior authorization and quantity limit policies and state Medicaid policies were linked with plan-level measures of OUD treatment quality from the National Committee on Quality Assurance (n=107). Regression analyses were used to examine associations between Medicaid MCP characteristics, MCP buprenorphine policies, and features of the state policy environment with plan-level rates of OUD treatment initiation and engagement. Results: The average OUD treatment initiation rate was 59.6% and engagement was 30.9%. MCPs with large market share had initiation and engagement rates 4.66 and 4.54 percentage points lower, respectively, than plans with small market share. Plans operating in states with 1115 SUD waivers had initiation and engagement rates 7.75 and 8.55 percentage points higher, respectively, than plans in states without waivers. Engagement rates among plans that required prior authorization for buprenorphine were 4.53 percentage points lower than plans without this restriction. Conclusions: Findings suggest state and MCP policies are important pathways to improve initial and sustained OUD treatment. Further research into these relationships is needed. Keywords: Opioid use disorder, Medicaid managed care, buprenorphine, medications for opioid use disorder (MOUD) 1. Introduction Medicaid is the largest source of public health insurance in the United States (US), enrolling nearly 80 million low-income or disabled people and pregnant women. Most state Medicaid programs contract with Medicaid managed care plans (MCPs) to manage benefits; 75% of Medicaid recipients are enrolled in MCPs ( Hinton et al., 2020 ). Medicaid MCPs serve over 1 million people with opioid use disorder (OUD) and can use benefit design to facilitate enrollee participation in the OUD care continuum, including prevention, diagnosis, treatment, and recovery support ( Maxwell, 2023 ; Williams et al., 2019 ). For MCP enrollees with OUD, treatment initiation and engagement with services are critical steps in the care continua ( Williams et al., 2019 ). One way to monitor MCP enrollee treatment initiation and engagement is to use Healthcare Effectiveness Data and Information Set (HEDIS ® ) 1 performance measures. These are validated measures of healthcare quality, supported by evidence for improved care outcomes, promulgated by the National Committee on Quality Assurance (NCQA). Two HEDIS OUD treatment quality metrics are associated with reduced odds of opioid-related overdose ( Weiner et al., 2024 ), reduced criminal-legal system involvement ( Garnick et al., 2007 , 2014 ), fewer admissions to withdrawal management ( Acevedo et al., 2016 ), and lower mortality ( Paddock et al., 2017 ; Watkins et al., 2016 ). These metrics map to the care continua in the treatment phase and are commonly used for monitoring and improving care quality including in payment models, 1115 demonstration waiver evaluations, and to share quality information publicly ( Kaye & Wilkniss, 2023 ). The objective of this study was to examine how plan and state-level factors were associated with Medicaid MCP performance on initiation and engagement in OUD treatment. MCP characteristics such as profit status, behavioral health contracting arrangement and state Medicaid market share may impact OUD treatment initiation and engagement. Prior research shows that enrollees in non-profit health plans had greater access to physical health care services than enrollees in for-profit plans ( Long, 2008 ). Enrollees in plans that managed behavioral health internally had greater access to outpatient services than plans not financially integrated ( Charlesworth et al., 2021 ). Five for-profit, publicly traded companies insure 50% of the US Medicaid managed care market ( Hinton & Raphael, 2023 ). Understanding how market share is associated with quality can inform state and MCP policy decisions. Medicaid MCPs must follow federal and state requirements regarding coverage of treatment services and medications for opioid use disorder (MOUD) but also have flexibility to develop their own policies. The Affordable Care Act and the federal parity law together require MCPs to cover most services included in the OUD quality measures including inpatient, outpatient, and partial hospital treatment ( Frank et al., 2014 ). The 2018 Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act mandated all MCPs cover buprenorphine, injectable naltrexone, and methadone for OUD ( H.R.6 – 115th Congress (2017–2018), 2018 ). Thus, coverage for treatment services and medications is not expected to vary substantially by plan. However, MCPs have discretion regarding utilization management policies ( Peterson et al., 2024 ). Prior authorization can be used to ensure appropriate clinical care ( Forrester, 2020 ) but may negatively impact OUD treatment initiation by creating delays. A recent survey found that 94% of physicians report care delays associated with prior authorization and 88% report prior authorization interferes with treatment engagement (not OUD-specific) ( American Medical Association, 2023 ). Another utilization management strategy, quantity limits, represent restrictions on the amount of a medication covered and may be employed to reduce over-use. Quantity limits could impact initiation if providers must obtain authorization for a higher covered dose or could impact engagement if the amount of medication covered is not sufficient for clinical need. Both prior authorization and quantity limits create administrative burden for providers which can reduce providers’ willingness to prescribe ( Leshner & Mancher, 2019 ; Mahone et al., 2023 ; McCollum et al., 2023 ). An estimated 65% of Medicaid enrollees accessing OUD treatment receive buprenorphine ( Maxwell, 2023 ). Removing prior authorization for buprenorphine has been associated with increased access ( Keshwani et al., 2022 ). Low initial doses of buprenorphine, which could result from quantity limit restrictions, are a risk factor for discontinuing treatment ( Samples et al., 2018 ). Utilization management requirements for buprenorphine are well documented in MCPs ( Abraham et al., 2022 ; Andrews et al., 2024 ; Peterson et al., 2024 ; Stewart et al., 2024 ); less is known about how these strategies are associated with quality of care for MCP enrollees. Features of the state Medicaid policy environment in which MCPs operate also may influence initiation and engagement in OUD treatment. To date thirty-seven states have obtained 1115 waivers to improve the SUD treatment continuum ( Substance Use Disorder Section 1115 Demonstration Opportunity, 2024 ). States with waivers may be required to track and report HEDIS performance measures. In California, Medicaid enrollee access to SUD treatment increased post waiver implementation ( Bass et al., 2023 ). States can also restrict the number of prescriptions an individual can fill per month while enrolled in a Medicaid MCP. In the eight states without a buprenorphine exception, this policy may impact an enrollee’s ability to refill buprenorphine prescriptions ( Hughto et al., 2022 ). The purpose of this study was to identify whether MCP characteristics and policies and the state policy environment in which plans operate are associated with plan-level rates of OUD treatment initiation and engagement. Understanding how plan and state-level policies are associated with OUD performance metrics can inform state approaches to contracting with MCPs and state and MCP development of policy strategies to improve OUD treatment. 2. Methods We identified all comprehensive Medicaid MCPs insuring adults 18–64 in states where MCPs retained responsibility for managing the pharmacy benefit in the 2021–2022 coverage year ( Centers for Medicare and Medicaid Services, 2021 ). 194 MCPs across 33 states and the District of Columbia (DC) met study inclusion criteria (see Supplement for details). We conducted a cross-sectional content analysis of publicly available insurance benefit documentation. MCP preferred drug lists were reviewed for buprenorphine coverage and utilization management policies and member handbooks were reviewed for plan behavioral health contracting details. Plan profit status was determined using publicly available documents from the Internal Revenue Service (IRS) ( Internal Revenue Service, 2024 ) and plan websites. We used CMS enrollment reports to record plan enrollment and calculate market share in the state ( Centers for Medicare and Medicaid Services, 2021 ). State Medicaid monthly prescription drug cap policies were obtained from a review of 2021 state Medicaid prescription policies ( Hughto et al., 2022 ). State opioid overdose mortality rates were obtained from a KFF analysis of Multiple Causes of Death Files, 1991–2021, from the Centers for Disease Control and Prevention ( KFF, 2021 ) (See Supplement for details). We linked our data with 2021 HEDIS Quality Compass data that included plan-level rates of initiation and engagement in OUD treatment obtained via a licensing agreement with the National Committee for Quality Assurance. One hundred thirty-nine plans matched across data sets based on plan name and state. After excluding plans with incomplete data and those that did not cover buprenorphine, the final sample size was 107 Medicaid MCPs across 28 states and the DC ( Supplement Figure 1 ). The Brandeis University Intuitional Review Board determined this study did not qualify as human subjects research and was therefore exempt from review. 2.1. Measures 2.1.1. Outcomes We examined two outcomes. The first HEDIS measure, Initiation of Substance Use Disorder Treatment – Opioid Use Disorder (hereafter referred to as ‘Initiation’), represents the proportion of plan members with newly documented OUD diagnosis who began treatment within 14 days of the diagnosis. Treatment was defined as a health insurance claim for any of the following services: inpatient hospital admission, outpatient psychosocial treatment, intensive outpatient program, partial hospitalization program, telehealth psychosocial appointment, or medication treatment with buprenorphine, injectable naltrexone, or methadone. The second HEDIS measure, Engagement in Substance Use Disorder Treatment – Opioid Use Disorder (hereafter referred to as ‘Engagement’) represents the proportion of plan members who met criteria for the initiation metric and had claims for two or more additional treatment services within 34 days of the initiation visit ( National Committee for Quality Assurance, 2019 , 2022 ). Plans calculate these measures using health insurance claims data for individual plan members and then calculate plan-level rates. 2.1.2. Independent variables Medicaid MCP characteristics included as predictors in the model were dichotomized variables for profit status (for-profit vs non-profit), behavioral health contracting arrangement (managed behavioral health benefit internally vs contracted with another entity to administer behavioral health services), market share, buprenorphine-naloxone utilization management policies. Market share was calculated as the number of plan enrollees divided by the state’s Medicaid managed care population, dichotomized at the 75 th percentile for interpretability, where one equals large market share in the state (≥ 24.9% of the state managed care population) and zero equals small market share in the state (<24.9% of the state managed care population). All MCPs in the sample included generic buprenorphine-naloxone sublingual tablets on the preferred drug list. Buprenorphine-naloxone utilization management policies were defined using two dichotomous variables that indicated whether the MCP employed prior authorization (yes/no) or quantity limit requirements (yes/no). The state Medicaid policy environment was operationalized using two dichotomous variables indicating whether the state capped the number of prescriptions Medicaid enrollees can receive in a month without an exception for buprenorphine_(yes/no) and whether the state had an approved 1115 waiver to expand access to SUD treatment services in 2021 (yes/no). We controlled for the state opioid overdose rate in 2021 using an indicator of opioid overdose deaths in the state per 100,000 population, dichotomized at the 75 th percentile for interpretability, where one equals a high overdose death rate (≥32.5 per 100,000 population) and zero equals a lower overdose death rate (<32.5 per 100,000 population). 2.2. Statistical Analyses We summarized the sample by calculating the number and percent of MCPs by plan characteristics, buprenorphine utilization management policies, and state Medicaid policies. We calculated the mean and standard deviation for plan-level rates of initiation and engagement in OUD treatment by plan characteristics, MCP buprenorphine policies, and state policies. We conducted t-tests to compare rates of initiation and engagement by study variables. We estimated two multivariable regression models with robust standard errors and 95% confidence intervals, with initiation and engagement in OUD treatment separately as dependent variables, with MCP characteristics, buprenorphine policies, and state policies as predictors, controlling for state overdose death rates in 2021. Multicollinearity was not a concern (all correlations less than 0.30). Coefficients, 95% confidence intervals, and p-values are reported. Data analysis was performed in Stata Version 18.0 from April-November 2024. Results were robust to alternative specifications. We tested using the 50 th percentile as a cutoff for opioid overdose death rates to ensure the dichotomization did not bias the estimates. We also tested using lagged opioid overdose death rates (2020) to ensure that the opioid overdose death rate had the opportunity to inform the outcomes of interest. In both cases, the pattern of findings remained the same. 3. Results Medicaid MCP characteristics, coverage and utilization management of buprenorphine, and the state Medicaid regulatory and policy environment are described in Table 1 . In our analytic sample, most plans were for profit, internally managed, and had small market share. Most plans covered buprenorphine without prior authorization (71%) and employed quantity limits (58%). Table 1. Sample characteristics by plan-level rates of initiation and engagement in OUD treatment # MCPs % MCPs Mean initiation rate % (SD) Mean engagement rate % (SD) Total 107 100 59.6 (10.7) 30.9 (11.4) Medicaid managed care plan (MCP) characteristics Profit status For-profit 67 63 58.8 (11.2) 29.6 (12.0) Non-profit 40 37 61.0 (9.9) 33.0 (10.0) Behavioral health contract Internally managed 85 79 59.6 (10.7) 31.3 (11.0) Not managed internally 22 21 59.6 (11.4) 29.3 (12.9) Market share Small 76 71 60.9 (10.2) 32.1 (11.8) Large 31 29 56.5 (11.6) 28.0 (9.7) MCP policies coverage and utilization management of buprenorphine Covered, prior authorization required 31 29 58.0 (10.7) 26.9 * (12.1) Covered, no prior authorization required 76 71 60.3 (10.8) 32.6 * (10.7) Covered, employs quantity limits 62 58 61.6 * (9.3) 33.3 * (10.2) Covered, no quantity limits 45 42 57.0 * (12.2) 27.6 * (12.2) State Medicaid policy environment Monthly cap on number of prescriptions Medicaid covers Yes 18 17 56.1 (13.0) 26.3 (10.7) No 89 83 60.4 (10.2) 31.8 (11.4) Section 1115 SUD waiver Yes 68 64 63.3 * (9.2) 35.1 * (9.5) No 39 36 53.2 * (10.4) 23.5 * (10.7) Overdose mortality Low 72 67 56.8 * (11.3) 28.0 * (11.5) High 35 33 65.5 * (6.5) 36.8 * (8.6) Open in a new tab Note . High overdose death rate refers to a state overdose death rate of ≥ 32.50 per 100,000 population (≥ 75 th percentile). Large market share refers to a plans’ market share in the state ≥24.89% (≥75 th percentile). * Represents a significant difference between groups based on a t-test The average plan-level OUD treatment initiation rate was 59.6% and the engagement rate was 30.9%. Initiation and engagement rates were higher in non-profit MCPs compared to for-profit and those with small market share vs large. MCPs that did not require prior authorization for buprenorphine had similar initiation rates, but higher OUD treatment engagement rates, compared to plans that required prior authorization (32.6% vs 26.9%). MCPs that employed quantity limits had higher rates of initiation (61.6% vs 57.0%) and engagement in treatment (33.3% vs 27.6%) compared to plans that did not put quantity limits on buprenorphine. MCPs in states with 1115 SUD waivers had higher rates of initiation and engagement compared to plans in states without these waivers (63.3% vs 53.2%, 35.1 vs 23.5%, respectively). 3.1. Initiation of OUD treatment In multivariable analyses, market share was significantly associated with MCP initiation rates; MCPs with a large market share had initiation rates 4.66 percentage points lower than plans with small market share ( p <.05, 95% CI =−9.22, −0.10) ( Figure 1 ). Other MCP characteristics were not significantly associated with initiation rates. MCP prior authorization and quantity limit requirements were not associated with initiation in OUD treatment. Turning to the state environment, 1115 SUD waivers and high opioid overdose death rates were significantly associated with MCP initiation rates. Initiation rates of MCPs in states with an 1115 SUD waiver were 7.75 percentage points higher than plans in states without waivers ( p <.05, 95% CI 3.48, 12.02). Initiation rates of MCPs in states with high opioid overdose death rates were 7.44 percentage points higher than plans in states with low opioid overdose death rates ( p <.001, 95% CI 3.70, 11.19) ( Figure 1 ). Figure 1. Open in a new tab Associations between MCP buprenorphine policies, plan characteristics, state policies with initiation of OUD treatment from regression analysis Note . Abbreviations: Bup. – buprenorphine, BH – behavioral health, Rx – prescription, SUD – substance use disorder. Interpretation: Dots represent estimates from the adjusted linear regression model and horizontal lines represent the 95% confidence intervals of the estimate. When an estimate and corresponding confidence intervals do not pass the vertical line (value =0), that predictor was statistically significant in the regression model. * and green text indicate significance at p < 0.05. High overdose death rate refers to a state overdose death rate of ≥ 32.50 per 100,000 population. 3.2. Engagement in OUD treatment In multivariable analyses, market share was significantly associated with MCP engagement rates; MCPs with a large market share had engagement rates 4.54 percentage points lower than plans with small market share ( p <.05, 95% CI = −8.54, −0.53). Engagement rates among plans that required buprenorphine prior authorization were 4.53 percentage points lower than plans that did not require prior authorization ( p <.05, 95% CI = −8.87, −0.20). Quantity limits were not significantly associated with rates of engagement. Regarding the state environment, 1115 SUD waivers and high opioid overdose death rates were also significantly associated with MCP engagement rates. Engagement rates of MCPs in states with 1115 SUD waivers were 8.55 percentage points higher than plans in states without waivers ( p <.001, 95% CI=4.47, 12.63). Engagement rates of plans in states with high opioid overdose death rates were 7.25 percentage points higher than plans in states with low rates ( p <.05, 95% CI = 2.78, 11.73) ( Figure 2 ). Figure 2. Open in a new tab Associations between MCP buprenorphine policies, plan characteristics and states policies with engagement in OUD treatment from regression analyses Note . Abbreviations: Bup. – buprenorphine, BH – behavioral health, Rx – prescription, SUD – substance use disorder. Interpretation: Dots represent estimates from the adjusted linear regression model and horizontal lines represent the 95% confidence intervals of the estimate. When an estimate and corresponding confidence intervals do not pass the vertical line (value =0), that predictor was statistically significant in the regression model. * and green text indicate significance at p < 0.05. High overdose death rate refers to a state overdose death rate of ≥ 32.50 per 100,000 population. 4. Discussion In a sample of 107 Medicaid MCPs across 28 states and the District of Columbia in 2021, we found evidence that MCPs’ large market share was associated with lower plan-level rates of enrollee initiation and engagement in treatment for OUD. MCPs’ use of prior authorization for buprenorphine was associated with lower plan-level rates of OUD treatment engagement. The finding that MCPs with large market share in their respective state had lower rates of both initiation and engagement in OUD treatment is novel and should be investigated further. In the broader US health insurance system, managed competition between health insurers is a key mechanism for improving the quality of care enrollees receive ( Gaynor, 2007 ) and one might expect better quality care in areas where plans have lower market share because they are competing for enrollees. In behavioral health, relationships may be more complex. An analysis from 2010 suggested that competition between insurers can lead to worse coverage of behavioral health services ( McGuire & Sinaiko, 2010 ), which may in turn impact service utilization. Plans with more competitors typically have smaller market share. However, there has been almost no recent published research about Medicaid MCP market share and subsequent impacts on care. While Medicaid MCP use of prior authorization for buprenorphine has been well documented ( Abraham et al., 2022 ; Andrews et al., 2024 ; Stewart et al., 2024 ), our findings are the first to our knowledge to suggest these policies may be associated with a plan performance metric associated with care outcomes. Buprenorphine is a critical tool for curbing the overdose crisis, yet rates of initiation and engagement in OUD treatment with buprenorphine among Medicaid enrollees have been low ( Samples et al., 2018 ; Williams et al., 2020 ). Prior authorization for buprenorphine has been highly scrutinized and identified as a major barrier to care ( Andrews et al., 2019 ; Priest & Gertner, 2019 ). Strong evidence suggests that the removal of prior authorization on buprenorphine increases buprenorphine receipt ( Keshwani et al., 2022 ; Mark et al., 2020 ). Buprenorphine receipt in the first 3 months of treatment is associated with reduced risk of overdose ( Wakeman et al., 2020 ). Our findings add to evidence that prior authorization for buprenorphine is a barrier to lifesaving treatment. Despite this, almost 30% of MCPs in the study sample required prior authorization for enrollees to receive buprenorphine. Finding that prior authorization requirements are associated with lower engagement rates but not with initiation rates may seem counterintuitive. However, this is not surprising because identifying OUD (thereby meeting the initiation measure) can occur at a single visit, prior to starting medication treatment. Meeting the engagement measure, however, requires at least two additional visits or medication use following the initiation visit, and this is where barriers to treatment may occur for people interacting with the treatment system and drop off along the cascade of care can happen. In addition, prior authorization may be required for dose adjustments, which are common early in treatment, and this requirement may interfere with enrollees’ sustained participation in treatment. Prior authorization is often an opaque process. In our review of MCP preferred drug lists we were not able to distinguish between one-time prior authorization and ongoing prior authorization. However, research on state Medicaid programs suggests that many states require prior authorization on an ongoing basis for dosage adjustments, and require additional steps for buprenorphine dosages beyond 16mg ( Nguemeni Tiako et al., 2023 ). Other prior authorization requirements might include urine drug screens (initial and random ongoing), proof of therapy receipt, or patient education ( Nguemeni Tiako et al., 2023 ). More research is needed to investigate the details of the prior authorization process and identify a nuanced approach to changing policies to improve treatment initiation and engagement. Quantity limits for buprenorphine may restrict the number of days’ supply that can be filled at one time and/or the daily dose (e.g., 24mg/day). In 2024, the FDA issued a notice encouraging modifications to buprenorphine medication labels, as target dose recommendations on the label have been misinterpreted as maximum doses and insurers may have limited coverage as a result ( U.S. Food and Drug Administration, 2024 ). In our analysis, quantity limits were not associated with rates of initiation or engagement in OUD treatment. It may be that quantity limits have a greater impact on other outcomes such as emergency department or inpatient service utilization, as has been documented in previous literature ( Axeen et al., 2024 ). Quantity limits warrant further investigation as providers argue higher doses of buprenorphine may be needed to effectively treat patients in the era of fentanyl and the rapidly evolving drug supply ( Axeen et al., 2024 ; National Institutes of Health, 2024 ; Providers Clinical Support System, 2023 ). MCPs operate within state environments with different approaches to Medicaid enrollment, funding and regulation, therefore it is important to account for state policies that could impact initiation and engagement in OUD treatment. In our sample, more than half of MCPs operated in states with 1115 SUD waivers, and this state policy was associated with higher MCP-level rates of both initiation and engagement in OUD treatment. Goals of these waivers include: to increase access to substance use disorder treatment and reduce overdose mortality, among other related priorities ( RTI International, 2022 ). States with waivers are required to monitor progress on these goals using measures including the HEDIS initiation and engagement in OUD treatment metric explored here ( Centers for Medicare & Medicaid Services, 2024 ). Our findings are aligned with previous research that shows increases in treatment access after waiver implementation in single states ( Bass et al., 2023 ; Cunningham et al., 2020 ; Sugarman et al., 2024 ). A more recent study of the effects of waiver implementation in 17 states found no significant increase in rates of OUD medication treatment using patientlevel data ( Lindner et al., 2024 ). More research is needed to understand the role of Medicaid MCPs in implementing changes allowable by 1115 SUD waivers and their effects on enrollee, plan, and state level treatment quality measures. As Medicaid policies change, it will be important to track how policy changes influence OUD medication treatment quality. We also examined caps on the number of prescriptions Medicaid enrollees can receive per month. People with OUD often have cooccurring health conditions requiring multiple daily medications ( Leshner & Mancher, 2019 ). State drug caps have been associated with fewer covered MOUD prescriptions in Medicaid ( Besaw & Fry, 2024 ). We observed higher mean rates of initiation and engagement in states without prescription drug caps in bivariate analyses, but in multivariable analyses, we did not find an association between cap policies and MCP initiation and engagement rates. Further research is needed to understand the impact of state prescription drug caps, among other state substance use and Medicaid policies on OUD treatment initiation and engagement. 4.1. Limitations This study has limitations. We included 44% of all comprehensive MCPs operating in 2021. Therefore, findings may not generalize to all Medicaid MCPs or beyond Medicaid. This was a cross-sectional study therefore no causality can be inferred from the relationships identified in this analysis. The plan-level outcome measures do not include information about OUD severity, therefore we cannot account for case mix variation in our models. However, MOUD are recommended for all individuals with OUD regardless of severity, and encounters for MOUD are accounted for in the outcome measures. We examined utilization management policies for one formulation of buprenorphine-naloxone – generic sublingual tablets – because it is the least expensive and least likely to be managed ( Andraka-Christou et al., 2023 ). Policies may differ for Injectable and film formulations. The five plans excluded for not covering generic buprenorphine-naloxone did not report covering any buprenorphine formulation. Medication is just one part of OUD treatment, and this study does not capture the impact of other important treatment services that MCPs cover and manage (e.g., counseling) that are included in the calculation of the outcome measures. However, because plans generally cover the treatment services and the medications, more variation is expected in utilization management for medications. We did not include the coverage and utilization management of methadone treatment and extended-release naltrexone although treatment with those medications is included in the HEDIS quality metrics. In 2021 65% of Medicaid enrollees receiving medication treatment for OUD were on buprenorphine ( Maxwell, 2023 ), therefore we focused the analyses on the MOUD enrollees were most likely to receive. Future research should examine whether Medicaid MCP methadone and naltrexone policies are associated with plan and enrollee-level outcomes and these analyses should be examined in larger samples of MCPs. 4.2. Policy implications Medicaid MCP performance on measures of initiation and engagement in OUD treatment are important indicators of enrollees’ access to quality treatment. Our results suggest that plan market share may influence plan performance on quality metrics. State Medicaid programs may consider contracting with a greater number of MCPs to encourage competition, which has been associated with better quality of care ( Gaynor, 2007 ). States may also consider enrollment procedures that more evenly distribute enrollee across plans to eliminate concentration. In the national Medicaid managed care landscape where mergers and acquisitions among MCPs are common, further analyses of how market share may impact quality of care is needed. State and Medicaid managed care plan policies that promote improvements to OUD treatment initiation and engagement rates are critical. States may consider identifying or creating incentives for plans to improve performance on these metrics. Access to MOUD is essential to increasing initiation and engagement rates. Medicaid MCPs should ensure they cover all FDA-approved MOUD to facilitate this. Offering low-barrier medication treatment, peer support services, and harm-reduction oriented services may lead to improved initiation and engagement rates ( Eddie et al., 2019 ; Reif et al., 2014 ; Samuels et al., 2018 ). Plans could ensure they reimburse at an adequate rate for these services or ensure capitated rates are high enough to cover costs of offering such services. Given the findings of the current study and growing evidence that prior authorization may be a significant barrier to buprenorphine use, reexamining and considering limits on prior authorization policies is warranted. While plans sometimes maintain discretion to set prior authorization policies independently, state Medicaid programs can opt to prohibit use of prior authorization in their contractual agreements with plans. States may also pass legislation that limits use of prior authorization for buprenorphine across all insurance plans operating in the state, as has been done in eight states to date. Supplementary Material Supplementary material NIHMS2089652-supplement-Supplementary_material.pdf (102.5KB, pdf) Highlights: Medicaid MCPs insuring a smaller proportion of a given states’ Medicaid population have higher rates of OUD treatment initiation and engagement. Medicaid MCPs in states with 1115 waivers have higher rates of OUD treatment initiation and engagement. Medicaid MCPs with prior authorization requirements for buprenorphine have lower OUD treatment engagement rates. State and Medicaid MCP policies are important potential pathways to initial and sustained OUD treatment. Acknowledgements: This work was completed while Dr. Stewart and Ms. Feltus were at the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University 415 South Street, MS 035, Waltham, MA 02453, both are now at Boston University School of Public Health. This research was supported by the National Institutes on Drug Abuse (R01DA049776, P30DA035772). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The source for certain health plan measure rates and benchmark (averages and percentiles) data (“the Data”) is Quality Compass ® [2022] and is used with the permission of the National Committee for Quality Assurance (“NCQA”). Any analysis, interpretation or conclusion based on the Data is solely that of the authors, and NCQA specifically disclaims responsibility for any such analysis, interpretation or conclusion. 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