Opioid Treatment Providers Praise New Medicare Coverage Opportunities

On January 1, new rules went into effect establishing expanded Medicare coverage for opioid use disorder (OUD) treatment.

Under the new benefit, opioid treatment programs (OTPs) will be able to enroll in — and be reimbursed by — Medicare for providing medication-assisted treatment (MAT) services that were not previously covered.

Medicare will pay enrolled OTPs through bundled payments for the services, which will be provided to eligible Medicare Part B beneficiaries. The new rules also allow OTPs to be reimbursed for methadone and certain MAT support services — such as telehealth counseling — for the first time ever.


While CMS estimates about 1,700 OTPs nationwide are eligible for Medicare enrollment, few currently seem to be taking advantage of the new option. But experts expect that to change, predicting the new opportunity will prompt treatment companies to expand their services and further propel the MAT boom in the years to come.

“There’s just so much demand [for treatment services] currently and not enough capacity,” Matt Sabbatino, a Boston-based managing director for global management consulting firm L.E.K. Consulting, told Behavioral Health Business. “[The new rules] only went into effect January 1st, so I would suspect more and more clinics will start to enroll as Medicare providers [and take] those patients.”

The question is when that will happen. Currently, there’s no dearth of demand for MAT providers’ current services. As such, some might not feel compelled to capitalize on the new coverage right away.


Sabbatino compared such providers to busy restaurants.

Such eateries — with consistently full houses and long lines of customers waiting to be seated — don’t really need to add new offerings, he explained, especially if doing so takes time and resources away from current services.

“There’s not enough [MAT clinics],” Sabbatino told BHB. “And they’re already busy enough with commercial Medicaid and out-of-pocket patients.”

As such, many might opt to forgo or delay the administrative burden that comes with enrolling as a Medicare provider. However, that, Sabbatino says, could change.

“I think why not?” he said. “It just doesn’t make sense that they wouldn’t [pursue the opportunity], assuming that the rates are reasonable.”

Operator outlook

In line with Sabbatino’s predictions, a number of substance abuse treatment providers are exploring the possibility of pursuing the new Medicare benefit in the future.

Take Naperville, Illinois-based Symetria Recovery, for example.

“We are looking into their new benefits, as well as reexamining other insurance provider coverage options,” president and CEO Chris Hassan told BHB, noting Symetria does not currently accept Medicare. “We hope to be able to bring our unique form of treatment to additional patients in the near future.”

Symetria is an opioid addiction treatment provider that operates 12 facilities in Illinois and Texas, with plans to open new centers in 10 additional states.

“We are pleased that Medicare has introduced a more enlightened and comprehensive methodology that will increase access to care for thousands of Americans who struggle with this chronic medical condition,” Hassan said.

Opioid abuse has been a problem since before the dawn of the new millennium, but has become especially deadly in recent years.

Nearly 400,000 Americans died between 1999 and 2017 from overdosing on various types of opioids, according to the Centers for Disease Control and Prevention. And of the more than 70,000 drug overdose deaths in 2017, nearly 68% were from opioids.

Older populations — and, in turn, Medicare beneficiaries — aren’t immune to the opioid epidemic. In fact, they may be especially susceptible, with 29% of Medicare beneficiaries, or 13.4 million people, receiving opioids in 2018, according to the U.S. Department of Health and Human Services Office of Inspector General.

That makes the new Medicare coverage opportunities even more important.

John Peloquin, who is the president and CEO of Los Alamitos, California-based Discovery Behavioral Health (DBH), believes that the new rules are having an obvious — if not yet measurable — industry impact.

“I can’t quantify it with you, but I do believe that with this new regulation, it is creating greater access,” Peloquin told BHB. “I don’t see any downside because it’s something that will only help people to get into treatment that they need.”

DBH operates 97 locations across 12 states and provides mental health and eating disorder treatment in addition to substance treatment services. The provider accepts Medicaid and some private payments, but like Symetria, it currently is not a Medicare-certified provider.

Peloquin says DBH is also exploring setting up a structure to accept Medicare payments, which he anticipates will be up and running within a year.

“One of the guiding pillars of our organization is access to treatment, and it seems clear to me that becoming Medicare-certified will allow us to reach more individuals in need of treatment,” he noted. “Becoming Medicare certified seems to make sense for us to pursue.”

Meanwhile, National Council of Behavioral Health CEO Chuck Ingoglia, whose organization represents more than 3,300 providers, previously told BHB he doesn’t know how many of his members will ultimately take advantage of the new Medicare benefit. However, he too is hopeful about the opportunities it creates.

“We’re glad that methadone is finally covered by Medicare, and we’re glad that [Medicare] is doing it as a bundled payment,” Ingoglia told BHB. “It seems like they’re paying attention to the field in terms of adjusting the payment rates to be truly reflective of what’s needed.”

Provider executives like Peloquin agree.

“I think this is a good thing,” he said. “I have always advocated greater access to treatment since I’ve been in behavioral health. This is one more example of eliminating a barrier to treatment where more people can get access to treatment they deserve.”

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