West Virginia has been disproportionately impacted by the opioid epidemic, consistently reporting one of the highest opioid overdose fatality rates in the nation. In 2017 alone, the state recorded about 58 opioid overdose deaths per 100,000 people.  As the crisis escalated, Cindy Beane, West Virginia’s Medicaid director, recognized Medicaid’s critical role in addressing the needs of individuals and families affected by substance use disorder (SUD).

In 2018, Ms. Beane led the state’s efforts to secure an 1115 waiver aimed at expanding and improving SUD treatment through Medicaid. This effort coincided with her time as a Fellow in CHCS’ Medicaid Leadership Institute (MLI), where she made it her leadership goal to obtain CMS approval for the waiver. Her experience highlights valuable lessons in tackling the opioid crisis through innovative Medicaid policies and leadership.

Background

In 2018, West Virginia Medicaid sought to systematically address the opioid epidemic by developing an 1115 demonstration waiver to expand behavioral health services and better meet the needs of Medicaid members with SUD. Prior to the waiver, the scope of services and capacity to serve West Virginians with SUD were limited, with only grant funded or cash-only based programs available. An 1115 demonstration waiver would give the state flexibility to improve behavioral health services by including a comprehensive set of treatments that was previously limited due to strained resources and system capacity.

West Virginia is a small Medicaid agency that, in 2018, had fewer than 100 employees. As a result, West Virginia Medicaid relied heavily on contractors for routine operations. Ms. Beane explained that obtaining approval for an 1115 waiver demonstration from CMS was an intimidating process, requiring substantial staff bandwidth and expertise that the bureau was unsure it possessed. Despite these challenges, the potential of an 1115 waiver for enhanced SUD services offered hope in combatting the devastation caused by the opioid epidemic in West Virginia.

Initially, two key questions emerged: (1) What should the waiver include to address the immediate needs of West Virginians with SUD? and (2) How could they ensure support from key stakeholders, such as SUD providers and sister agencies, including the Bureau for Behavioral Health? Ms. Beane and her team recognized the importance of gaining support from the provider stakeholder community for the transformation of Medicaid-led SUD treatment services. They also sought expertise on the population’s needs from stakeholders and national experts on SUD prevention and treatment.

Prior to 2018, SUD care delivery for Medicaid members in West Virginia was funded through grants or private out-of-pocket payments services. The Bureau for Behavioral Health needed to develop a stakeholder engagement plan that included providers and policymakers since Medicaid-led SUD services would require increased provider accountability as well as new administrative processes and knowledge for providers to bill Medicaid. Additionally, it would require the adoption of evidence-based care, such as harm reduction, which had previously been limited in the state and faced opposition from many policymakers. For example, at the time, medications for addiction treatment (MAT) were stigmatized by some policymakers and providers due to a perception that MAT substituted one substance for another. Some stakeholders worried that this stigma could result in pressure to limit access to MAT and/or restrict the types of MAT offered. Ms. Beane and her team needed to build trust and assure stakeholders that the Medicaid agency was committed to facilitating access to all evidence-based treatment options, including MAT. Building that trust was essential to gain support for a robust, evidence-based SUD policy in the waiver demonstration.

Implementing a Strategy for Stakeholder Buy-In

Under Ms. Beane’s leadership, West Virginia Medicaid sought to collaborate with behavioral health stakeholders in the state — including the West Virginia Department of Health and Human Resources, Bureau for Behavioral Health; the Governor’s Counsel on Substance Abuse; advocates; providers; among others — who had long been invested in identifying solutions to address the opioid epidemic in West Virginia. Central to these efforts was an acknowledgment of Medicaid’s vital role in the continuum of care: it is the primary source of coverage for adults with opioid use disorder (OUD), covering 47 percent of all nonelderly adults with OUD. Among those receiving treatment, Medicaid also covers approximately two-thirds (64 percent) of adults engaged in outpatient treatment and peer support services. Ms. Beane emphasized the importance of recognizing the Medicaid bureau as an equal stakeholder and integral part of SUD care in West Virginia, given its unique reach and capacity to deliver critical services statewide.

Under Ms. Beane’s leadership, West Virginia Medicaid sought to collaborate with behavioral health stakeholders in the state — including the West Virginia Department of Health and Human Resources, Bureau for Behavioral Health (BBH); the Governor’s Counsel on Substance Abuse; advocates; providers; among others — who had long been invested in identifying solutions to address the opioid epidemic in West Virginia. Ms. Beane emphasized the importance of recognizing the Medicaid bureau as an equal stakeholder and integral part of SUD care in West Virginia, given its extensive capacity to provide services to individuals with SUD across the state. 

Building trust among the state’s behavioral health stakeholder community required sensitivity, mutual respect, and a shared commitment to saving lives and alleviating the burden on people managing a challenging disease. Ms. Beane and her team also needed to develop a strong partnership with BBH so the two bureaus could align on a shared vision to increase access to SUD services.

In collaboration with BBH, a leader in addressing SUD across the state, West Virginia Medicaid’s stakeholder engagement approach included conducting an extensive statewide “roadshow” to understand additional perspectives. The roadshow aimed to understand the types and levels of care provided by grant-funded organizations to avoid duplicating services covered by Medicaid. Additionally, it sought to build awareness and buy-in for the two bureaus’ shared vision that, under the waiver, all Medicaid-enrolled behavioral health providers would offer MAT as part of their treatment options.

Developing An 1115 Waiver: A New
Leadership Challenge

West Virginia had never pursued an 1115 waiver, which presented a new policy and leadership challenge for Ms. Beane. The peers in her MLI Fellowship cohort helped her better understand the waiver submission and negotiation process with CMS, which enabled her to respond more effectively to CMS’ questions during the review of the waiver submission. Ms. Beane recalls being better able to answer nuanced questions because of MLI peer support, such as in negotiating the terms and conditions of the waiver, and presenting the waiver implementation timeline.

Through MLI, Cindy and her team received technical assistance from subject matter experts, including the American Society of Addiction Medicine (ASAM). CMS guidance required compliance with SUD quality of care standards, including for placement, continued service, and transfer of patients with SUD and co-occurring conditions. The West Virginia provider community needed appropriate training to meet these SUD quality of care standards. ASAM helped West Virginia Medicaid consider how to implement specific aspects of the SUD treatment program, such as residential care, into the 1115 waiver.

Defining Success

By prioritizing stakeholder engagement, Ms. Bean helped West Virginia’s Medicaid agency build strong partnerships across the behavioral health agency and provider stakeholders invested in addressing SUD in West Virginia. Together, SUD stakeholders developed a strategy to expand access and broaden treatment options for SUD.  Stakeholders — including the behavioral health agency, advocacy groups, and current grant‑funded partners — met to co‑design the continuum of care. Together, they worked through key waiver elements, such as the number of treatment beds and the scope of peer‑support services. Since the waiver was implemented, member access to and use of SUD treatment services has grown substantially:

• As of 2022, over 295,000 Medicaid members in West Virginia have received SUD treatment. 
• As of 2025, West Virginia has about 1,800 inpatient residential treatment beds that are reimbursed by Medicaid; prior to the waiver the state did not pay for residential treatment.
• West Virginia added 330 behavioral health peer support professionals across the state that are reimbursable by Medicaid under the waiver.
• Access to MAT increased from 247,305 treatments administered in 2017 to 586,073 treatments in 2022 — a 137 percent increase in treatments administered. The number of distinct MAT recipients also increased from 15,277 in 2017 to 24,715 in 2022 — a 62 percent increase.

Like many states, the COVID-19 pandemic exacerbated SUD rates because of high levels of COVID illness and isolation. Thanks in part to the dedicated work of West Virginia Medicaid, by 2022, West Virginia was one of seven states where overdose deaths declined. This shift represented a meaningful step forward in a place that has long been at the epicenter of the crisis — an early sign of progress in the face of significant challenges. That progress has continued: the West Virginia Department of Human Services reports an almost 38 percent drop in overdose deaths for the 12 months ending November 2024 — well above the national average of about 27 percent. Current data shows an almost 42 percent decrease in overdose deaths from January to August 2024 compared to the same period in 2023. This progress means 468 more lives saved and continuing on the path to recovery.

As West Virginia Medicaid embarks on renewal of the 1115 waiver, Ms. Beane and her team hope to add community integration and employment support services for people in substance use recovery to continue to improve outcomes and reduce fatalities. These additional supports will help individuals in substance use recovery successfully reintegrate into society and lead stable, fulfilling lives within their communities.