CMS Issues Payer Guidance for Dually Eligible Beneficiaries Receiving Medicare Opioid Treatment Services

December 2019 ~

On December 17, CMS issued guidance to state Medicare agencies that Medicare will become the primary payer for opioid treatment programs (OTP) for dual-eligibles, including those who currently receive treatment through Medicaid, effective January 1, 2020.

Currently, CMS reimburses providers through bundled payment arrangements that cover medication-assisted treatment drugs, toxicology testing, and counseling. Starting January 1, Medicare will begin paying for OTPs through bundled payments for opioid use disorder (OUD) treatment services, including medication-assisted treatment (MAT) medications, toxicology testing, and counseling as authorized under the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act).

For dually-eligible beneficiaries who receive OTP services through Medicaid now, starting January 1, 2020, Medicare will become the primary payer for OTP services. In order to be reimbursed by Medicare, OTP providers will need to be enrolled as a Medicare provider. It is possible that not all providers will have completed the Medicare enrollment process and be able to bill Medicare as primary payer by this date.

In an effort to prevent any disruption in OTP treatment for dually-eligible beneficiaries, the agency has provided some background information on the enrollment of providers for this benefit and clarifying options available for states to consider regarding coordination of benefits/third party liability under Medicaid. That information can be viewed, here.

Source(s): Centers for Medicare & Medicaid Services; CIB: Guidance for State Medicaid Agencies on Dually Eligible Beneficiaries Receiving Medicare Opioid Treatment Services Effective January 1, 2020;