Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs
Dear Opioid Treatment Program Sponsors and State Opioid Treatment Authorities:
Starting January 1, 2020, under the Calendar Year (CY) 2020 Physician Fee Schedule final rule, the Centers for Medicare & Medicaid Services (CMS) will pay Opioid Treatment Programs (OTPs) through bundled payments for opioid use disorder (OUD) treatment services in an episode of care provided to people with Medicare Part B (Medical Insurance).
Under the new OTP benefit, Medicare covers:
- U.S. Food and Drug Administration (FDA)-approved opioid agonist and antagonist medication-assisted treatment (MAT) medications
- Dispensing and administration of MAT medications (if applicable)
- Substance use counseling
- Individual and group therapy
- Toxicology testing
- Intake activities
- Periodic assessments
With the release of the final rule, OTPs fully-certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and accredited by a SAMHSA-approved accrediting body can start enrolling in the Medicare program so they can bill for services starting January 1, 2020. We encourage OTPs to begin the enrollment process as soon as possible, and to open the doors to Medicare patients who may use this benefit to cover their OUD treatment services.
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. CMS will issue 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. Briefly, 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.
OTP providers should enroll in Medicare now to be able to bill Medicare for OTP services beginning January 1, 2020.
Medicare Advantage plans must also include the OTP benefit as of January 1, 2020, and can contract with OTP providers in their service area. In covering the OTP benefit, Medicare Advantage plans must use only OTP providers that meet the same requirements as those providing services under Medicare Part B (including enrollment with Medicare).
SAMHSA Certification and Accreditation
To enroll in Medicare, OTPs must be fully certified by the SAMHSA and accredited by a SAMHSA-approved accrediting body. Medicare will not accept provisional SAMHSA certifications during the Medicare enrollment process.
For more information on the accreditation process, visit SAMHSA’s Certification of Opioid Treatment Programs (OTPs) webpage.
Enroll in Medicare
Enroll in Medicare using the Provider Enrollment, Chain, and Ownership System (PECOS). PECOS lets you complete most of your enrollment activities online, including submitting your enrollment application and changing existing Medicare enrollment record information. PECOS expedites the enrollment process because it verifies enrollment information online then electronically sends it to your Medicare Administrative Contractor (MAC) for processing. If you can’t enroll electronically, you can complete a paper application and mail it to your MAC, however, this process takes longer than the online submission.
Read our Enrollment Fact Sheet (PDF) to learn more about the enrollment process and the documentation you’ll need to get started.
Get to Know Your MAC
As a newly eligible Medicare provider, you should get to know your MAC. CMS contracts with MACs to process enrollment applications and Medicare Fee-For-Service (FFS) claims (also known as Medicare Part A and Part B claims). Each MAC processes FFS claims (including claims for OTP services) for certain areas of the country called jurisdictions. If you deliver OTP services in multiple jurisdictions, you might work with more than one Medicare A/B MAC. MACs also communicate information about the Medicare FFS Program to health care providers enrolled in the Medicare program.
Participate in a Call with CMS Experts
On Tuesday, November 12, we will host a Medicare Learning Network® call to help OTPs navigate the enrollment process and understand the details of the new benefit. Register for our Opioid Treatment Programs: Enrolling in Medicare call.
Stay Connected
Bookmark our OTP webpage for the most current information, education, and upcoming events on the new benefit.