Medicare Coverage of Medication Assisted Treatment (MAT) for Opioid Addiction

Medicare Coverage of Medication Assisted Treatment (MAT) for Opioid Addiction

link to page 1

Updated June 4, 2020
Medicare Coverage of Medication Assisted Treatment (MAT)
for Opioid Addiction
Medicare covers certain reasonable and necessary services
The Drug Addiction Treatment Act of 2000 (DATA 2000;
provided by Medicare-enrolled health care practitioners for
P.L. 106-310) allows physicians and certain other health
treating substance abuse disorders, such as alcoholism and
care practitioners to obtain waivers to treat opioid addiction
opioid and other drug abuse. Medication Assisted
by prescribing buprenorphine, but not methadone, outside
Treatment (MAT) combines medication with counseling
an OTP in other health care settings. In May 2016, FDA
and behavioral therapies to provide comprehensive
approved an implantable buprenorphine product that is
substance abuse treatment. Congress and the federal
effective for three months, and in November 2017, FDA
government have taken steps to increase the availability of
approved an injectable formulation that is effective for one
MAT in response to a sharp increase in U.S. opioid
month. Implanted and injected buprenorphine formulations
overdoses and deaths in recent years. Effective January 1,
are administered in physician offices and other outpatient
2020, the Support for Patients and Communities Act
settings. Other buprenorphine formulations, such as pills,
(SUPPORT; P.L. 115-271) added a Medicare benefit
may be dispensed by retail pharmacies.
category for treating opioid use disorder, which includes
comprehensive MAT services provided in the roughly
Naltrexone, a nonopioid drug, does not carry an addiction
1,700 Substance Abuse Mental Health Services
risk and is not regulated under the CSA. Naltrexone may be
Administration (SAMHSA)-certified Opioid Treatment
prescribed and dispensed in OTPs. It also may be
Programs (OTPs), also known as methadone clinics. OTP
prescribed by health care practitioners (without DATA
services include management, care coordination,
2000 waivers), who are licensed to prescribe drugs, and
psychotherapy, and counseling, as well as telehealth
then dispensed by pharmacies.
services and dispensing and administration of MAT drugs,
including methadone. This brief provides background on
Table 1. MAT Drug Practitioner Authority
MAT and Medicare coverage of MAT for opioid abuse
treatment.
MAT
Practitioners Authorized to
Medication
Prescribe/Dispense MAT Drugs
How Does MAT Work?

DATA 2000
Other
According to SAMHSA, MAT can provide a safe and
OTPs
Waiver
Practitioners
controlled level of medication to help patients overcome or
live with their opioid drug addiction. Research indicates
Methadone
Yes
No
No
that opioid use disorder treatment is most effective when
Buprenorphine
Yes
Yes
No
drugs are used in combination with behavioral treatments
and cognitive therapy (to challenge habitual individual
Naltrexone
Yes
Yes
Yes
behavior patterns).
Source: CRS analysis based on 21 U.S.C. § 801.
The Food and Drug Administration (FDA) has approved
Opioid Abuse in Medicare
three MAT medications for treating opioid dependence:
The federal Medicare program provides health coverage for
methadone, buprenorphine, and naltrexone. Methadone and
qualified individuals age 65 and older and permanently
buprenorphine are opioid drugs with potential for
disabled individuals—about 63 million in 2020. Medicare
dependence but also may be prescribed outside of MAT in
benefits are provided through Part A, which covers
different formulations for treating chronic pain. MAT drugs
inpatient hospital services; Part B, which covers physician
help to reduce or block an opioid drug’s euphoric effects,
services and other outpatient care; Part C, a managed care
relieve physiological cravings, and normalize body
service delivery option that covers Parts A and B benefits
functions. Experts recommend that all three drugs be
(except hospice care); and Part D, a voluntary optional
available for MAT because certain medications may be
benefit that covers outpatient prescription drugs through
more appropriate for some patients.
private prescription drug plans.
Methadone and buprenorphine are regulated under the
Opioid overutilization is a significant issue in Medicare. A
Controlled Substances Act (CSA; 21 U.S.C. §§801 et seq.).
May 2020 Department of Health and Human Services
Under the CSA, methadone, when used for treating opioid
Office of Inspector General (HHS OIG) report found that
abuse, may be administered as part of a hospital admission;
most of the 71,260 Part D enrollees at serious opioid abuse
otherwise, this medication may only be administered and
risk in 2017 received high opioid doses in 2018. Even
dispensed by OTPs (see Table 1). OTPs may prescribe and
though it appeared fewer of these Part D enrollees were
dispense buprenorphine and naltrexone.
doctor shopping or receiving extreme opioid doses, they
had what the HHS OIG termed high opioid levels —a 120
https://crsreports.congress.gov

link to page 2 Medicare Coverage of Medication Assisted Treatment (MAT) for Opioid Addiction
morphine milligram equivalent (MME) average dose for at
Source: CRS review of Medicare coverage and the SUPPORT Act.
least three months. MME measures an individual’s
cumulative opioid use over a 24-hour period.
Medicare Part A generally covers inpatient services,
including substance abuse treatment in psychiatric or other
As required under the Comprehensive Addiction and
qualified hospitals. (Medicare Part A covers up to 190 days
Recovery Act of 2016 (CARA; P.L. 114-198), the Centers
of inpatient psychiatric hospital services during an
for Medicare & Medicaid Services (CMS) established a
enrollee’s lifetime.) Part A covers FDA-approved drugs,
Part D opioid overutilization monitoring system (OMS) to
including all MAT medications, when administered during
help plans monitor opioid prescribing. CMS developed
a hospital admission. Medicare beneficiaries are responsible
maximum dosage thresholds to identify potential opioid
for applicable Part A deductibles and copayments.
overutilization based on Centers for Disease Control and
Prevention opioid prescribing guidelines. Under the OMS
Medicare Part B covers physician and professional
program, Part D plans are required to review and provide
services and may cover psychiatric services (partial
case management for at-risk enrollees (with some
hospitalization services) including therapy, drugs, and
exclusions). MAT drugs are not counted in OMS dosage
counseling. Beginning January 1, 2020, Part B covers MAT
criteria. Beginning January 1, 2019, Part D plans could
services provided in OTPs and may cover MAT—other
limit the number of prescribers and pharmacies used by
than methadone treatment—in approved outpatient settings,
enrollees at risk of overutilization of commonly abused
such as community health centers or physician offices. Part
drugs. Part D plans are required to impose these limits in
B began covering insertion and removal of buprenorphine
2022, but most plans (99%) had implemented these
implants January 1, 2018. Medicare beneficiaries generally
restrictions in 2019.
are responsible for Part B monthly premiums, an annual
deductible ($198 in 2020), and coinsurance (20% of service
Medicare Coverage of MAT
cost). However, Medicare beneficiaries have no Part B cost-
Prior to January 1, 2020, Medicare did not include an OTP
sharing or MAT services except the deductible.
service benefit category, although some beneficiaries, with
supplemental health coverage or who were enrolled in a
Medicare Part C plans must cover MAT services available
Medicare Advantage plan, may have had coverage for some
under Parts A and B and may offer outpatient prescription
OTP services. Some Medicare beneficiaries also may have
drug coverage under Medicare Part D. Part C plans must
paid for OTP services themselves. To receive Medicare
cover services provided by Medicare-participating OTPs
payment, OTPs must meet certain conditions, such as
because the services are covered under Part B.
entering into a standard Medicare provider agreement,
paying an application fee, and satisfying other OTP-specific
Medicare Part D covers prescribed outpatient drugs that
requirements. OTPs could begin enrolling in Medicare in
may be dispensed in retail pharmacies for medically
November 2019. As shown in Table 2, Medicare covers
accepted indications. Part D plans may cover methadone
MAT services as a comprehensive benefit under Medicare
when prescribed for pain, but not methadone when used in
Parts A, B, and C, as well as some MAT under Part D.
MAT. Medicare Part D plans must cover other self-
administered MAT drugs, either on their formularies (a list
Table 2. Medicare MAT Coverage Summary
of covered drugs) or through a coverage exception
Medicare
requested by an enrollee. Under Medicare statute, each plan
Covered MAT Services
Part
must cover at least two drugs in each class or category,
except in six protected classes where plans must cover all
Inpatient services, including counseling, and MAT
drugs. CMS approves plan formularies and encourages
Part A
drugs administered during a covered stay in a
plans to facilitate enrollment and limit restrictions for
Medicare-approved hospital or inpatient facility.
beneficiaries who require MAT. Beneficiaries are
responsible for Part D monthly premiums and cost sharing.
Outpatient counseling, physician services, and MAT
Cost sharing varies depending on the plan formulary and
drugs, including methadone administered or
the beneficiary’s required drugs.
Part B
dispensed in OTPs and some buprenorphine
formulations, such as injections and implants,
Medicare MAT Coverage Demonstration
administered by practitioners with DATA 2000
The President’s FY2021 budget request provides for
waivers.
implementation of an Innovation Center model required by
Required Parts A and B covered services and Part
the SUPPORT Act. The model would test whether a care
management fee and performance-based provider financial
Part C
D drugs if the Part C plan covers prescription
drugs. For years beginning January 1, 2020, plans
incentives would improve outcomes for beneficiaries being
are required to cover OTP services.
treated for opioid use disorder. The model could be
expanded nationwide if it were found to be effective.
MAT drugs prescribed by participating Medicare
practitioners and dispensed by retail pharmacies,
including some buprenorphine formulations, such
Cliff Binder, Analyst in Health Care Financing
Part D
as film or pil s, and naltrexone. Methadone when
Johnathan H. Duff, Analyst in Health Policy
prescribed for pain, depending on the plan.
IF10875
Methadone for MAT is not covered.

https://crsreports.congress.gov

Medicare Coverage of Medication Assisted Treatment (MAT) for Opioid Addiction

Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permissio n of the copyright holder if you
wish to copy or otherwise use copyrighted material.

https://crsreports.congress.gov | IF10875 · VERSION 3 · UPDATED