Medicaid

Medicaid

In addition to the creation of the OTP benefit, the SUPPORT Act also mandates all states cover OTP in their Medicaid programs effective October 2020 subject to an exception process as defined by the Secretary.

For dually eligible beneficiaries (those enrolled in both Medicare and Medicaid) who get OTP services through Medicaid now, starting January 1, 2020, Medicare will be the primary payer for OTP services. OTP providers need to enroll as a Medicare provider in order to bill Medicare. It is possible that not all providers will complete the Medicare enrollment process and be able to bill Medicare as primary payer by this date.  In this situation, Medicaid:

• Must pay for services delivered to these beneficiaries by OTP providers who are not yet enrolled in Medicare but are enrolled in Medicaid, to the extent the service is covered in the state plan.
• Will later recoup those Medicaid payments made to the OTP, back to the date the provider can begin billing Medicare (30 days prior to the effective date of the OTP’s Medicare enrollment), and the OTP will then bill Medicare for those services.

CMS issued guidance to states to clarify how Medicaid can pay OTP providers that are not yet enrolled in Medicare, so State Medicaid Agencies can uphold their responsibilities as the payer of last resort while promoting continuity of care for dually eligible beneficiaries.  Read the Informational Bulletin for more information about the options available for states regarding coordination of benefits/third party liability under Medicaid.

Read the New Tip Sheet on State Coverage of Medicare Part B Deductible for Dually Eligible Patients
The Medicare Part B annual deductible applies to opioid use disorder treatment services. For the majority of individuals dually eligible for Medicaid and Medicare, state Medicaid agencies are liable for the Medicare Part B deductible, subject to certain limits. The new Tip Sheet for Opioid Treatment Program (OTP) Providers Serving Dually Eligible Individuals: State Coverage of the Medicare Part B Deductible (PDF) gives an introduction to the Part B deductible and how OTPs can get Medicaid payment for this deductible when treating dually eligible individuals. It also gives information about enrolling in Medicare and Medicaid, the Medicare claims crossover process, and how to find additional information.

Ensuring Continuity of Care for Dually Eligible Medicare Advantage
On January 2, 2020, CMS released a Health Plan Management System (HPMS) Memo (PDF) to all Medicare Advantage organizations addressing continuity of care for dually eligible enrollees currently receiving OTP services through Medicaid.

Find Medicare-Enrolled OTPs
A list of Medicare-enrolled OTPs is now available and includes the OTP number assigned by the Substance Abuse and Mental Health Services Administration, the National Provider Identifier or NPI, address, and the date they enrolled in Medicare.  We will update the list every two weeks. 

Coverage of Medication-Assisted Treatment (MAT)
Read the CMS State Health Officials (SHO) 20-005 letter for information on Medicaid state plan coverage of MAT.