By Alison Knopf
The federal Center for Medicare and Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have started preparations for setting a rate for Medicare payment for people 65 and over, AT Forum has learned. Thanks to the “SUPPORT for Patients and Communities Act” signed into law last year by President Donald Trump, opioid treatment program (OTP) patients will be covered by Medicare, starting in 2020. This means that when patients turn 65 and lose their Medicaid or commercial insurance, getting Medicare instead, they will be able to stay in treatment.
“With regard to Medicare implementation, CMS/Medicare and SAMHSA representatives recently visited two OTPs to get a better sense of how they function and the services that are rendered,” Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), told AT Forum.
As we reported last fall, CMS is developing a weekly bundled rate. First, said Mr. Parrino, “they have to identify what the basic benefits will be and what the rate will be.” As the method of reimbursement becomes clearer, AATOD will offer an implementation webinar. It would be premature to do this at the present time, he said. But patients in treatment now, nearing their Medicare-eligible status, need not fear that they will lose coverage and have to drop out of treatment. AATOD spent more than a decade working to get this Medicare rate implemented.
The law creates a bundled payment for medication-assisted treatment (MAT), which by definition is a combination of medications and behavioral therapies to provide a holistic approach. The bundled payment will include the dispensing of methadone.
The law also requires private insurers who offer Medicare Part D prescription drug plans to implement “lock-in” programs, starting in 2022, that limit the number of pharmacies and prescribers used by enrollees identified as at risk of opioid misuse.
In adding OTPs to its covered programs, Medicare has to go through the same growing pains as all insurance companies. It will use the bundled approach, something Medicare already does for some other services. In the “bundled” approach, CMS combines payments for the physician and hospital or other services into a single amount, based on the expected costs during an episode of patient care.
Medicare covers items and services included in broad categories, such as hospital care, physician services, prescription drugs, and many other categories, but doesn’t explicitly list all reasonable and necessary items and services that treatment might require.
More to the point: until now, Medicare did not offer any explicit benefit to treat opioid use disorder (OUD), although many services considered part of OUD treatment are indeed covered under other categories, such as prescription drugs, psychologist services, physician services, and hospitalization.
Until now, Medicare did not recognize OTPs for reimbursement. And because methadone for OUD can be provided only in OTPs, it has not been covered by Medicare. Finally, it’s unusual for Medicare to group treatments to treat specific conditions or diagnoses in a bundle. But now, it will.
“Beginning on or after January 1, 2020, Medicare will pay OTPs 100% (less any beneficiary copayments) of a bundled payment for OUD treatment provided to Medicare beneficiaries during an episode of care (as defined by the Secretary),” according to the Congressional Research Service report on the SUPPORT Act’s Medicare implications. “The Secretary [of the Department of Health and Human Services] may implement one or more OTP payment bundles based on the medication dispensed, the scope of furnished services, beneficiary characteristics, and other factors the Secretary determines appropriate. In developing payment bundles, the Secretary may consider OTP payment rates for comparable services paid by Medicaid or TRICARE.”
Payment bundles for OTPs will be updated every year.