Medicaid payment policies for methadone maintenance treatment for opioid use disorder, 2020-2025.

BACKGROUND: The potential of methadone maintenance treatment (MMT) to address the opioid crisis has been limited by restrictive federal and local policies that require frequent clinic visits for medication. Unprecedented federal regulatory changes started in early COVID-19 and were made permanent in 2024, allowing clinics increased flexibility in granting take-home medication to patients. Medicaid payment policies can profoundly shape provider behaviors but may not align with regulatory changes. METHODS: We conducted a systematic synthesis of Medicaid MMT payment and billing policies among 40 states over March 2020-July 2025. RESULTS: More than half of the states continued to adopt a per-dose or per-diem approach to paying for methadone dosing and a per-service approach to paying for addiction counseling, thus tying Medicaid revenue closely to clinic visits. More than one-quarter maintained a flat bundled payment dating back to prepandemic era that provided little incentive for granting patients more than 1 week of take-home medication. Adoption of a 2-tiered bundled payment modeled after Medicare's payment increased over time but remained limited. CONCLUSION: Medicaid payment policies for MMT saw limited changes over the 5 years following initial federal regulatory changes. Practice changes toward more flexible and patient-centered care may be hindered without compatible changes in payment approaches.