Of the 21.7 million Americans that need substance use treatment, only 11% are able to receive it. Even as national policies aim at addressing this treatment gap, substance use deaths and the impacts of substance use disorders (SUDs) on long-term health care costs continue to rise.  Recovery support services are emerging as a possible solution to the costly treatment gap.
State Medicaid programs are the largest payers of substance use treatment costs. Thus, Medicaid has a strong interest in supporting approaches like recovery support services that help individuals maintain their substance use recovery. Despite the potential benefits of recovery support services to state Medicaid programs and their beneficiaries, these services are not offered by all Medicaid programs. Further, research examining the impact of recovery support services on health care costs and use have been very limited.
What are recovery support services?
Recovery support services are defined as “nonclinical services that assist individuals and families to recover from alcohol or drug problems.” Further, a recent Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) Issue Brief—based on a Medicaid coverage policy compilation conducted by RTI International under contract with MACPAC—classifies and defines recovery support services into five distinct service categories:
- comprehensive community supports – services that address barriers that impeded the development of skills necessary for independent functioning in the community;
- peer support services – supportive services delivered by a person in recovery from an SUD;
- skills training and development – services that help a beneficiary with an SUD acquire new skills, ranging from life skills to employment readiness and restoration to the community;
- supported employment – helps individuals achieve competitive employment in community settings; and
- supportive housing – evidenced-based intervention that combines housing assistance with wrap-around support services for people experiencing homelessness as well as other people with disabilities. 
What are Medicaid policies regarding recovery support services?
Major policy changes in the past decade brought by the Comprehensive Addiction and Recovery Act, the Affordable Care Act, and the Mental Health Parity and Addiction Equity Act of 2008 attempted to make coverage of behavioral health services and what payers such as Medicaid covered more equitable. In 2014 and 2015, the Centers for Medicare & Medicaid Services (CMS) developed the Medicaid Innovation Accelerator Program for SUDs and launched an initiative to encourage states to explore the possibility of expanding services and coverages for SUDs.  About 2 years later, CMS expanded its policy guidance to states by granting them more flexibility to offer Federal Medical Assistance Percentages for initiatives including recovery support services that target Medicaid enrollees with opioid use disorder (OUD) and other SUDs. In this guidance, CMS prioritized the continuum of care for OUD, including recovery and other support services. In light of these policy changes, state Medicaid programs have expanded coverage and recovery support services for SUDs considerably over the past few years.
What recovery support services does Medicaid cover?
Peer support services are the most commonly covered recovery support for Medicaid beneficiaries with an SUD; 38 Medicaid programs (75% of states) cover this service for beneficiaries with SUDs. The broad extent of this coverage comes as no surprise. In 2007, CMS released policy guidance to state Medicaid directors about the provision of peer supports for recovery of mental illness and substance use disorders. This guidance encouraged state Medicaid programs to not only begin covering peer recovery support services, but also served as a catalyst for states to explore certifying and enhancing the peer recovery support workforce. During the nearly 12 years since this guidance was released, states have expanded coverage of peer recovery supports. For some states, coverage of peer recovery support services extends beyond Medicaid and is provided as a service funded by the Substance Abuse and Mental Health Agency (SAMHSA) or other funders for all individuals with SUD, regardless of insurance status. 
Supportive housing is the least commonly covered recovery support service for Medicaid beneficiaries with an SUD; only four Medicaid programs covered this service as of October 2018. Coverage for housing support may increase as opportunities outlined in the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act or SUPPORT for Patients and Communities Act takes effect (P.L. 115-271). By providing technical assistance and reporting on innovative state housing-related services and support for Medicaid beneficiaries with SUDs, this Act shines a light on supportive housing as a service option for this Medicaid population.
The future of recovery support services
The majority of state Medicaid programs now cover some type of recovery support services, yet gaps in research make it challenging for policymakers to understand the impact of these services. Two areas of research would be beneficial: 1) examining the effects of recovery support services on Medicaid costs and health care services use; and 2) assessing the effectiveness of recovery support services available to Medicaid beneficiaries in preventing relapse. Both areas of research aim to help state Medicaid programs to use their resources more efficiently while helping more individuals with SUD stay in recovery.
Disclosure: This blog post was not written or approved by the Medicaid and CHIP Payment and Access Commission.
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