The 660-page opioid bill that passed Congress and was signed October 24 by President Trump has important provisions for opioid treatment programs (OTPs). The most significant provision expands coverage to Medicare patients. Starting in 2020, Medicare will be required to pay a bundled rate for medication-assisted treatment (MAT) in an OTP. 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.
Other aspects of H.R. 6, also called “Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act,’’ or the ‘‘SUPPORT for Patients and Communities Act,” have ramifications for OTPs as well (see below).
Opening the Door to Medicare for OTP Patients
The OTP Consortium has expressed its support for this measure since last February, when Rep. George Holding (R-North Carolina) first put forward the measure under House Resolution 5080, the Comprehensive Opioid Management and Bundled Addiction Treatment (COMBAT) Act of 2018. “Congressman Holding’s legislation opens the door to patient access for a vulnerable Medicare population that currently lacks coverage for Opioid Use Disorder (OUD) treatment provided by OTPs. I commend Congressman Holding and his colleagues for crafting a bill that will certainly improve our nation’s response to the opioid crisis by filling this treatment gap and assisting this population on their Road to Recovery,” stated Peter Morris, Group President of Acadia Healthcare.
That measure became incorporated into H.R. 6.
A Major Victory
“The bill is a major victory for patients who are Medicare eligible and who are about to be eligible,” said Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD). “CMS Medicare will construct the rate, and I expect it to be a weekly bundled rate, which will include all three federally approved medications, in addition to lab testing and clinical services,” he told AT Forum. “For the present time, I will be informing programs about how to prepare, and will develop a webinar in order to provide technical assistance.”
The bill “is an extraordinary opportunity for patients, and I do not see any part that is a threat to treatment,” said Mr. Parrino.
“We are extremely pleased that Congress has included Medicare coverage of OTPs in the just-passed opioid package,” said Jason Kletter, PhD, president of BayMark Health Services. “This coverage will, once implemented, provide immediate benefit to the roughly 20,000 Medicare beneficiaries currently receiving treatment in OTPs, as well as create treatment access for the 300,000 beneficiaries with a diagnosis of opioid use disorder,” Dr. Kletter told AT Forum. “In addition, Medicare coverage will likely result in greater coverage of OTP services by commercial health plans, exponentially increasing access to high quality, evidence-based MAT across the country.”
The Need is Clear, and Methadone Works
OTPs provide not only medications—methadone, buprenorphine, and naltrexone—but support services, which may include counseling, toxicology screening and lab services, case management, primary care, and mental health services.
The FDA-approved medication methadone, as part of a MAT program, has been recommended by the National institutes of Health as the most effective treatment option for OUD. OTPs provide medically supervised access to this medication as well as buprenorphine and naltrexone, along with support services.
Medicare beneficiaries show a clear need for OUD treatment: 300,000 beneficiaries have been diagnosed with OUD, Medicare hospitalizations due to complications of opioid misuse increased 10% a year, and 30% of Medicare Part D enrollees used prescription opioids in 2015.
Success—After 10 Years’ Work
It has taken Mark Parrino more than 10 years to get this legislation passed. It was impossible for the Centers for Medicare and Medicaid Services to make the change on its own: Congress needed to act in order to approve the bundled rate. The Senate side had proposed a demonstration project, which would have covered a fraction of Medicare patients at greater cost.
According to the Congressional Budget Office, the full Medicare benefit will cost $243 million, which, if it covers all 300,000 Medicare beneficiaries with an OUD, would cost $810 per person.
The Medicare provision is Section 2005 of H.R. 6.
Now, it’s up to OTPs to gear up to bill Medicare, once CMS sets the bundling rate and codes.
From the bill, below are the Medicare provisions for OTPs:
All opioid agonist and antagonist treatment medications (including oral, injected, or implanted versions) that are approved by the Food and Drug Administration for use in the treatment of opioid use disorder would be covered, including dispensing and administration.
Counseling, including individual and group therapy, for substance use would be covered to the extent authorized by state law.
Toxicology testing would be covered.
Medicare will pay OTPs an amount which is equal to 100% of a bundled payment for OUD treatment services, starting January 1, 2020.
Other aspects of the bill with relevance to OTPs:
- Demonstration project to increase substance use provider capacity under the Medicaid program.
- Guidance to improve care for infants with neonatal abstinence syndrome and their mothers; GAO study on gaps in Medicaid coverage for pregnant and postpartum women with substance use disorder.
- Medicaid health homes for substance-use-disorder Medicaid enrollees.
- More flexibility with respect to medication-assisted treatment for opioid use disorders.
- Medication-assisted treatment for recovery from substance use disorder.
- Grants to enhance access to substance use disorder treatment.
- Access expansion under the Medicare program to addiction treatment in Federally Qualified Health Centers and rural health clinics.
- Review required of quality measures relating to opioids and opioid use disorder treatments furnished under the Medicare program and other federal health care programs.
- Report on addressing maternal and infant health in the opioid crisis.
- Comprehensive opioid recovery centers , which would provide inpatient and outpatient treatment with all FDA-approved medications, including methadone.
For the bill, go to https://docs.house.gov/billsthisweek/20180924/HR6.pdf