Medicare Part B Covers Opioid Use Disorder Services Starting January 2020

Starting January 1, 2020, Medicare Part B will cover services to treat Opioid Use Disorder, including Medication Assisted Treatment (such as Suboxone and Buprenorphine treatment). In order to be covered by Medicare, the services must be delivered by Opioid Treatment Programs (OTPs) and these programs must become enrolled in Medicare. The federal government has established requirements for provider enrollment and reimbursement. Medicare beneficiaries who receive these covered services should have zero Medicare cost-sharing in 2020!


As many of our readers know, the Opioid Epidemic affects tens of thousands of people throughout Pennsylvania. The PA Department of Health has classified the prescription opioid and heroin overdose epidemic as "the worst public health crisis in Pennsylvania".  Older adults and people with disabilities on Medicare may be struggling with addiction themselves or have family members and friends who are addicted to opioids.


Dual eligibles in Pennsylvania, covered by both Medicare and Medicaid, who receive Medication Assisted Treatment have used their Medicaid coverage for these services. Now that Medicare will cover these services as of January, Medicare will become the primary payer for these services and Medicaid will become secondary. Providers of these services who enroll in Medicare will be paid a bundled rate by Medicare for treatment services including management of the condition, care coordination, individual and group psychotherapy, and substance use counseling.

As readers who work with dual eligibles know, it can be difficult for dual eligibles to find providers that take both their Medicare coverage and their Medicaid coverage. And, Medicaid is always the payer of last resort. To address concerns about continuity of care for dual eligibles who are getting treatment from a provider that is not yet enrolled in Medicare as of January 1, 2020, the federal government has issued the guidance to state Medicaid programs, like Pennsylvania. Please note that Pennsylvania's Medicaid program already covers services to treat Opioid Use Disorder, including Medication Assisted Treatment. The federal guidance says:

· Medicaid must pay for services to dual eligibles by OTPs who are enrolled in Medicaid but not yet enrolled in Medicare.

· Medicaid can recoup payments made to OTPs back to when the provider starts to bill Medicare and the OTP will in turn bill Medicare for those services.

The SUPPORT Act of 2018 included provisions that resulted in Medicare's coverage of these services. This law also mandated that all state Medicaid programs cover Opioid Treatment Programs as of October 2020. Again, Pennsylvania's Medicaid program already has been covering these services. More information about this law can be found here.

We'll keep readers updated about developments related to the new Medicare coverage for these important services in the new year. Dual eligibles who are having trouble accessing services for Opioid Use Disorder services are encouraged to call PHLP's Helpline at 1-800-274-3258.