Opioid treatment programs (OTPs) have many patients—childless adults, mainly men—who have not been eligible for Medicaid. They are self-paying for their treatment. In these weeks before the Affordable Care Act (ACA) takes effect and self-paying patients can be covered under its Medicaid expansion provision, some OTPs are working feverishly to make sure that these patients are enrolled, and finally freed from the burden of paying out of pocket—something that will improve the chances that they will stay in treatment.
At Bay Area Addiction Research and Treatment (BAART), the focus is on implementing Medicaid expansion, said president Jason Kletter, PhD. BAART is based in California and has expanded into Arizona, North Carolina, Nebraska, and Vermont, serving more than 6,500 patients a day. BAART also provides primary medical care and mental health services through fixed sites and mobile vans.
“My organization has been certified as an enrollment entity, and we have about 30 people at sites around the state ready to enroll patients,” Dr. Kletter said. There have been logistical problems, but “we’ll get there eventually.” As in the rest of the country, technical hiccups in getting started are expected to be worked out well in advance of the January 1 ACA implementation date. “We currently have certified enrollment counselors who can’t do their job yet,” he said. The state’s exchange, Covered California, is managing the enrollment.
Dr. Kletter thinks the main advantage of Medicaid expansion will be to make sure current patients who are paying their own way will have insurance. “It’s a great benefit for these patients, because these are the folks who have a hard time staying in treatment.”
California Medicaid, called Medi-Cal, is still fee-for-service for treatment of substance use disorders (SUDs); many states are applying for federal waivers to put this population and health care providers under managed care. Instead, California went through a “realignment,” in which SUD treatment went from a centralized state management system to payment by the counties. “And they’ve added a lot of benefits to the Medicaid benefit, said Dr. Kletter—residential, intensive outpatient, and other services.
Medicaid money goes through the counties, and OTPs contract with each county, said Dr. Kletter. “After the realignment, I don’t see this being managed” by private insurance companies, he added.
But what about patients who already have commercial insurance—they have traditionally found it impossible to use their insurance to get reimbursed for treatment in an OTP, and they also had to pay out of pocket. That may be changing soon. “There’s been a recent change of heart, and managed care organizations are starting to reach out to OTPs in California,” said Dr. Kletter. The OTPs met with the state last year about this. “We think that the exclusion is discriminatory,” he said, referring to insurance policies that specifically excluded treatment with methadone in an OTP, or any treatment in an OTP. Of course it is discriminatory, under the ACA and the parity law. Any change in this would be a “great development,” Dr. Kletter believes, expanding OTP access not only to many people covered by Medicaid but also to people covered by private insurance.