The SUPPORT Act mandates all states cover OTP in their Medicaid programs effective October 1, 2020, subject to an exception process as defined by the Secretary.

For dually eligible patients (those enrolled in both Medicare and Medicaid) who get OTP services through Medicaid now, Medicare is the primary payer for OTP services, as of January 1, 2020. OTP providers need to enroll as a Medicare provider to bill Medicare.

We issued guidance to states to clarify how Medicaid can pay OTP providers that aren’t 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 patients. In this situation, Medicaid:

  • Must pay when OTP providers who aren’t yet enrolled in Medicare but are enrolled in Medicaid provide services to their patients, 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 before the effective date of the OTP’s Medicare enrollment), and the OTP will then bill Medicare for those services

For more information, read the Guidance to State Medicaid Agencies on Dually Eligible Beneficiaries Receiving Medicare Opioid Treatment Services bulletin.

State Coverage of Medicare Part B Deductible for Dually Eligible Patients

The Part B annual deductible applies to OUD treatment services. For the majority of people dually eligible for Medicaid and Medicare, state Medicaid agencies are liable for the Part B deductible, subject to certain limits.

View Opioid Treatment Program (OTP) Providers Serving Dually Eligible Individuals: State Coverage of the Medicare Part B Deductible (PDF) for:

  • An introduction to the Part B deductible
  • How OTPs can get Medicaid payment for this deductible when treating dually eligible patients

Ensuring Continuity of Care for Dually Eligible Medicare Advantage

Read the January 2, 2020, Health Plan Management System (HPMS) Memo (PDF) to all Medicare Advantage organizations (MAOs) addressing continuity of care for dually eligible enrollees currently getting OTP services through Medicaid.

Coverage of Medication-Assisted Treatment (MAT)

View the CMS State Health Officials (SHO) 20-005 letter (PDF) for information on Medicaid state plan coverage of MAT.

Find Medicare-Enrolled OTPs

Page Last Modified:
09/06/2023 04:51 PM