Coverage Changes for Opioid Treatment Services for Dually Eligible Individuals

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As of January 1, 2020, Medicare Part B covers a new Opioid Treatment Program (OTP) benefit.
In the 2018 Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, Congress expanded access to opioid use disorder (OUD) treatment services and authorized creation of the OTP benefit, which provides Medicare beneficiaries with access to methadone for medication-assisted treatment (MAT) in an out-patient setting.

This fact sheet describes the new OTP benefit and how it affects individuals dually eligible for Medicare and Medicaid.

What is the new Opioid Treatment Program benefit?

Under the new benefit, Medicare pays OTP providers a bundled payment for OUD treatment services for people with Medicare Part B. A new Medicare payment rule finalized last November outlines the bundled payment, which includes the following OUD treatment services delivered by a certified OTP provider:

• U.S. Food and Drug Administration (FDA)-approved opioid agonist and antagonist MAT
medications (including methadone), dispensing, and administration
• Substance use counseling
• Individual and group therapy
• Toxicology testing
• Intake activities
• Periodic assessments

Individuals enrolled in Original Medicare do not pay coinsurance for the new OTP benefit, meaning they have no cost-sharing for these services once they have met their Part B deductible ($198 in 2020). While Medicare Advantage (MA) plans are permitted to charge cost-sharing for the OTP benefit, Qualified Medicare Beneficiaries (QMBs) are exempt and protected by federal rules from improper billing for Medicare cost-sharing, including deductibles.

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