Medicare covers people with opioid addiction through treatment services like counseling, medication, individual and group therapy, drug testing, periodic assessments, and intake activities.
Here Medicare pays the doctors and other health care providers in charge of office-based opioid use disorder treatment, such as psychotherapy, management, counseling activities, and care coordination.
However, the billing situation is actually different from the typical Original Medicare billing. You will not be required to pay for any of these services, as long as they are deemed medically necessary by your doctor and given by an opioid health care provider approved by Medicare.
To get the best of these services, make sure that you communicate with your doctor or other health care provider. Also, you can visit Medicare.gov/talk-to-someone and select “Opioid Treatment Program Services” to find the nearest available program.
To start, Medicare pays health care providers to provide Opioid Use Disorder (OUD) treatment for people with Medicare Part B under this new program.
A new Medicare payment rule includes different OUD treatment services that a certified Opioid Treatment Program (OTP) provider should deliver upon payment by Medicare. Some of which consist of the following;
- Individual and group therapy
- Substance use counseling
- Intake activities
- Periodic assessments
- Toxicology testing
A person with dual eligibility is known to be eligible or qualified for both Medicare and Medicaid. Since January 1,2020, Medicare is the primary or main payer for OUD treatment services.
This is actually why Medicare & Medicaid treatment Services issue a guide for OTP providers. This guide makes sure that dually eligible individuals can receive these OUD treatment services without experiencing interruptions or disruptions in care.
However, one concern that has been consistent and persistent over time is the delay in the OTPs that Medicaid beneficiaries use in completing their Medicare provider enrollment process.
Medicare Advantage has a procedure that enables dual-eligible beneficiaries to continue seeing their current OTP providers using the CMS’s guidelines. At the same time, they assist the individual in transitioning to a new network provider. This is so even if the health care provider is not within the MAPD network.
This guide can also protect Qualified Medicare Beneficiaries from inappropriate billing due to dual eligibility.
To facilitate treatment access for beneficiaries having dual eligibility, Medicare beneficiaries who want to receive OUD treatment services need to be familiar with the following;
- OTP providers are prohibited from billing Medicare beneficiaries qualified to share Medicare costs for OTP services. This can actually mean that individuals who enroll in Original Medicare are not required to pay for OTP services as long as they have met their Part B deductible.
- States, providers, and MA plans should follow the guide to make sure continuity of care for beneficiaries who are dually eligible and receiving OTP services.
- The state Medicaid programs cannot exclude or deny dual-eligible beneficiaries transportation coverage to Medicare-covered benefits such as OTP services.
In the section below, we’ll explain and explore briefly the different Parts of Medicare and what each covers.
Generally, Medicare Part A covers inpatient hospital services, like drug abuse treatment in psychiatric or other qualified, certified and competent hospitals. Currently, Medicare Part A hospital coverage has a $1,556 deductible per occurrence with a $0 coinsurance for days 1-60, then $389/day for days 61-90 and finally $778/day for each lifetime reserve day (up to 60 days over your lifetime.
Medicare Part A covers FDA-approved medications administered during a hospital stay.
Medicare Part B covers physician and professional services, including psychiatric care, for outpatient hospitalization services like therapy and treatment services.
Since January 1, 2020, OTPs and authorized outpatient locations, such as community health centers or doctors’ offices, have been covered under Medicare Part B.
Here Medicare beneficiaries are responsible for Part B monthly premiums; however, they have no Part B copays or coinsurance for opioid treatment beyond the Part B deductable.
This treatment program includes all services under Medicare Parts A and B and may consist of outpatient drug prescription coverage under Medicare Part D.
Medicare Part C coverage includes services given or provided by participating in Medicare OTPs because these services are covered under Medicare Part B.
If you are on a Medicare Advantage Plan, you need to make sure that your current opioid treatment program is Medicare-enrolled so that you can commence complete treatment without interruption or disturbance at all. If this is not the case, you may have to switch to a Medicare-enrolled opioid treatment program.