People eligible for both Medicare and Medicaid experience co-occurring substance use disorders and chronic pain at rates that are two to six times higher than those for Medicare-only beneficiaries or Medicaid-only adults with disabilities, which puts them at higher risk for opioid misuse or addiction. Health plans serving dually eligible individuals play a key role in treatment and recovery by providing care management for their members, who may be receiving services from multiple sources. However, legal restrictions, such as those that protect patient confidentiality by regulating the ability of substance use disorder treatment providers to share patient information, make it challenging for plans to provide good care management.

Recently, the health plans participating in Promoting Integrated Care for Dual Eligibles (PRIDE), a national initiative led by the Center for Health Care Strategies and supported by The Commonwealth Fund, collaborated with Manatt Health to develop and respond to a set of commonly asked questions about working within the law to get the information needed to help members with opioid use disorder while maintaining confidentiality.

The issues surrounding the legality of information sharing faced by the Medicare-Medicaid Plans and Dual Eligible Special Needs Plans in the PRIDE project are likely also encountered by other types of plans serving other populations. The strategies discussed here may be useful in providing good care management for all health plan enrollees with opioid use disorder.

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