You may have added Medicare reimbursement opportunities to rejoice about come the new year.

In the final rule for the Medicare Physician Fee Schedule, CMS has plans to expand coverage for opioid use disorder (OUD) treatment services to increase access to treatment, including medication-assisted treatment (MAT Opioid Treatment Programs).

How to Get Paid for MAT Opioid Programs under New CMS Rule

Currently, opioid treatment programs (OTPs) are not recognized as Medicare providers. That means that beneficiaries who receive MAT for opioid use disorders must pay out of pocket, which could prevent many from seeking treatment. But starting Jan. 1, 2020, that’s set to change. According to the 2020 MPFS, CMS intends to:

• Reimburse OTPs for providing treatments outlined in section 2005 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, including MAT, toxicology testing, and counseling.
• Reimburse for those treatments provided via telemedicine. This includes the use of two-way interactive audio/visual communication technology.
• Pay OTPs a monthly bundled payment for counseling and management services involving MAT. The rate would vary depending on the medication and intensity of treatment.
• Add HCPCS codes to describe those bundled episodes of care to the list of CMS-approved telehealth services: GYYY1 (first month of counseling), GYYY2 (subsequent months of counseling), and GYYY3 (add on code for additional counseling).

Check You Meet These MAT Opioid Program Requirements

If you’re ready to reap the benefits of this new coverage, act quickly to ensure you’ve met all the qualifications to receive it:

• The OTP must be enrolled in Medicare.
• In order to enroll in Medicare, the OPT must first be fully certified by Substance Abuse and Mental Health Services Administration (SAMHSA). Providers may apply for a practitioner waiver to provide MAT in their practice.
• The OTP must also be accredited by a SAMHSA-approved accrediting body.

Beyond basic Medicare enrollment, there are a extra requirements that OTPs who wish to bill Medicare must meet:

• The OTP must submit a list of all providers who are legally authorized to prescribe, dispense, or order controlled substances on behalf of the OTP. CMS will then screen these providers to evaluate their qualifications and prescribing practices.
• The OTP must not employ/contract with any staff member who has been convicted of a federal or state felony that CMS “deem[s] detrimental to the best interests of the Medicare program and its beneficiaries.”
• The OTP must not employ/contract with any staff member who has had billing privileges revoked (under any government healthcare program), is on a preclusion list, or has had an adverse action imposed by a state oversight board for a “case or situation involving patient harm that CMS deems detrimental to the best interests of the Medicare program and its beneficiaries.”
• MAT patients also must receive counseling, which can include different forms of behavioral therapy. Learn more about medication and counseling treatment for substance use disorders.

According to CMS, more guidance regarding Medicare enrollment for opioid treatment programs will be available on the OTP website around Nov. 1, 2019.

Verify Your Practice Offers 5 Location Specifics

OTPs must meet certain practice setting criteria including:

1. Provide professional coverage for patient medical emergencies during hours when the practitioner’s practice is closed
2. Provide access to case-management services for patients including referral and follow-up services for programs that provide, or financially support, the provision of services
3. Use health information technology (health IT) systems such as electronic health records
4. Is registered for their State prescription drug monitoring program (PDMP)
5. Accept third-party payment for costs in providing health services, including written billing, credit, and collection policies and procedures, or Federal health benefits

Review Resources for MAT Opioid Requirements

Read the proposed Final Rule for Medicare Fee Schedule at https://www.cms.gov/Center/Provider-Type/All-Fee-For-Service-Providers/Downloads/OTP-Services.pdf

To meet other requirements for OTP certification, review 42 Code of Federal Regulations (CFR) 8

To obtain a waiver to treat OUD with MAT, see https://www.samhsa.gov/medication-assisted-treatment/training-materials-resources/apply-for-practitioner-waiver

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