Medicare, Medicaid, and commercial insurance—all three programs are putting up barriers to reimbursement for treatment in an opioid treatment program (OTP), but the situation is getting better, at least in states that expanded Medicaid.
Parity doesn’t apply to Medicare, so that presents a huge problem for patients who are covered by Medicare because of age or disability. “That’s a significant problem for Medicare and OTPs,” said Paul N. Samuels, JD, director and president of the Legal Action Center. But parity does apply to commercial insurance plans, and to Medicaid managed care plans.
Commercial Insurance
Until recently, commercial insurance companies didn’t even know what an OTP was; they had no understanding of methadone maintenance treatment, and little to no understanding of buprenorphine, said Mr. Samuels.
Likewise, many OTPs are not used to dealing with commercial insurance, he said.
“There are real problems with the language used, especially the whole concept of maintenance treatment.” Even in New York, one of the most progressive states in paying OTPs, there is a prevalent lack of understanding by private health plans about federal and state regulations and their requirements, he said.
There are other challenges that come to surface when OTPs bill commercial insurance companies as well, said Mark Parrino, MPH, president of AATOD. “The typical commercial insurance approach to allowing a finite number of service days does not fit well in treating chronic opioid dependence with maintenance medications,” he told AT Forum. “Some commercial insurers are also denying claims if patients have positive toxicology reports. OTPs clearly need to be in the position in educating such commercial carriers in addition to State Alcohol and Drug Abuse Directors.”
Mr. Samuels added that insurance companies need to be held to the parity law. “Many insurance companies have sent OTPs in New York contracts that are not compliant with the law,” he said. He explained that the insurance companies not only don’t understand OTPs, but don’t understand the law, despite the fact that the state’s Office of Alcoholism and Substance Abuse Services (OASAS) and the Department of Health have issued guidance to insurance plans and OTPs to try to insure that the rules are followed.
New Medicaid managed care plans were set to start in New York City October 1, rolling out in the rest of the state later. The good news is that the plans include OTPs. The transition to Medicaid managed behavioral health care for New York is expected to be rough, despite careful planning. Timely reimbursement will be key. OTPs have been used to fee-for-service with direct billing by OTPs to OASAS, so this is a “whole new ball game,” said Mr. Samuels.
OTPs in New York are fortunate to have the Legal Action Center in the state. There are no similar organizations in other states.
Medicaid
There are clearly parity violations taking place across the country when it comes to Medicaid and OTPs, and the Legal Action Center has been advocating for OTPs with the federal Department of Health and Human Services (HHS) and its Center for Medicare and Medicaid Services (CMS). “We are urging the [HHS] Secretary’s office and CMS to be as active as they can,” said Mr. Samuels.
“There are only two things the federal government can do about states that don’t want to reimburse OTPs for Medicaid services,” he said. “One is just to convince them of the wisdom of fighting this epidemic with one of the most effective tools there is. The other is this: parity does apply to Medicaid expansion states and to states where managed care runs Medicaid, and we’ve been urging the administration and CMS to do whatever is in their power to enforce the ACA and parity.”
States can enforce parity as well, but the federal government has the authority to do it, and “we’re hopeful that they will,” he said. “There’s a huge opportunity to move a lot more people into medication-assisted treatment, using the ACA.”
AATOD’s Role and Medicaid
The policy approach of the American Association for the Treatment of Opioid Dependence (AATOD) in terms of Medicaid is based on three elements: 1) the 17 to 19 states without Medicaid reimbursement have to want to change that; 2) the OTP providers in the states have to want to change it; and 3) the state alcohol and drug abuse administrator has to want to change it.
After it is determined that everyone wants to change it, all parties need to meet with the Medicaid authority, who then needs to agree. “Where AATOD comes in is to manage this process, and then to submit a proposed amendment to the state,” said Mr. Parrino, noting that a forthcoming paper by Kenneth Stoller, MD, will show that OTP utilization is 25 percent higher when Medicaid pays for patient care.
In states that have a long-entrenched policy of not allowing Medicaid to pay for OTP treatment, proprietary providers have opened up programs that are based on self-pay. These providers need to understand that it’s to their benefit to have Medicaid reimbursement, even though it will mean more paperwork in terms of billing (obtaining cash or a credit card from a patient seems easier). “Billing Medicaid is challenging but not nuclear physics,” said Mr. Parrino.
Even in states where Medicaid does cover OTP treatment, providers may prefer self-pay. But patients who are Medicaid-eligible want Medicaid to pay for their services; they don’t want the cost to come out of their food and shelter budget—and they’re right.
The bottom line: In many states, programs want to expand methadone treatment or add buprenorphine to their protocols, but there is no funding stream to do so, said Mr. Samuels. “It’s a real disconnect, and commercial insurance is being very difficult to deal with.”