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April 27, 2018
Medicare Coverage of Opioid Addiction Treatment Services
Medication-Assisted Treatment (MAT) combines
medications, with counseling and behavioral therapies to
provide a holistic approach to treating substance abuse. The
federal government has taken steps to increase the
availability of MAT in response to a sharp increase in U.S.
opioid overdoses and deaths in recent years. Medicare
beneficiaries may have difficulty gaining access to
comprehensive MAT services, however, due to coverage
limits in the federal health care program.
Medicare does not have a distinct benefit category for
substance abuse treatment, although the program pays for
certain services deemed reasonable and necessary for
treatment of alcoholism and opioid abuse when provided in
settings certified by the Department of Health and Human
Services (HHS). For example, Medicare does not cover
MAT provided in federally registered opioid treatment
programs (OTPs or methadone clinics). Medicare may pay
for MAT drugs and counseling in other certified care
settings but coverage may be limited, enrollees may face
interruptions if they move between care settings, and cost-
sharing may vary. Congress and the Trump Administration
are considering proposals for broader Medicare MAT
coverage, such as a bundled provider payment for a set of
defined services and reimbursement for OTPs. This brief
provides background on MAT and Medicare policy.
How Does MAT Work?
According to the Substance Abuse and Mental Health
Services Administration (SAMHSA), MAT can provide a
safe and controlled level of medication to help patients
overcome opioid abuse. Research indicates that MAT is
most effective when it combines drug therapy with behavior
treatments and cognitive therapy (to challenge individual
thought patterns). MAT may be provided in an inpatient
hospital or treatment program; in the roughly 1,500 OTPs in
the United States; and, in certain cases, by specially trained
physicians or health care providers outside of OTPs.
The Food and Drug Administration (FDA) has approved
three medications for treating opioid dependence:
methadone, buprenorphine, and naltrexone. Methadone and
buprenorphine, which are opioids with the potential for
dependence, also may be prescribed for the treatment of
pain, outside of MAT. The drugs used in MAT may help to
stabilize brain chemistry, reduce or block the euphoric
effects of opioids, relieve physiological cravings, and
normalize body functions. Experts recommend that all three
drugs be available to people in MAT because certain
medications may be more appropriate for some patients.
Methadone and buprenorphine are regulated under the
Controlled Substances Act (CSA; 21 U.S.C. §§801 et seq.).
Under the CSA, methadone may be used to treat opioid
addiction within an inpatient setting, such as a hospital, or
in an OTP. An OTP may administer or dispense, but not
prescribe, methadone (see Table 1). Buprenorphine also
may be dispensed through an OTP. In addition, the Drug
Addiction Treatment Act of 2000 (DATA 2000; P.L. 106-
310) allows physicians and certain other health care
practitioners to obtain waivers to treat opioid addiction with
buprenorphine (but not with methadone) outside an OTP in
inpatient and outpatient settings. The FDA approved an
implantable version of buprenorphine in May 2016 that
lasts for three months, and an injectable version in
November 2017 that lasts for a month. The drug may also
be dispensed in other forms through a retail pharmacy.
Naltrexone, which is not an opioid, does not carry an
addiction risk and is not regulated under the CSA.
Naltrexone may be used in an OTP, or may be provided
outside an OTP by health care professionals who are
allowed to prescribe drugs, without federal DATA waivers.
Table I . Allowable Provision of MAT Druus
Data Waiver
OTPs Prescribers
Methadone
Buprenorphine
Naltrexone
Other
Prescribers
Yes No No
Yes Yes
Yes Yes
No
Yes
Source: CRS analysis based on 21 U.S.C. §801.
Opioid Use in Medicare
The federal Medicare program provides health coverage for
qualified individuals age 65 and older and individuals with
permanent disabilities. The program is expected to serve 60
million elderly and disabled in 2018. Medicare benefits are
provided through Part A, which covers hospital (inpatient)
services; Part B, which covers physician services and other
outpatient care; Part C, a managed care option that covers
Part A and B benefits (except hospice care); and Part D, a
voluntary program that provides coverage of outpatient
prescription drugs through private health plans.
Opioid overutilization is a significant issue in Medicare. A
November 2017 report by the HHS Office of Inspector
General (HHS OIG) found that one in three Part D enrollees
received an opioid prescription in 2016 (14.4 million out of
43.6 million enrollees). Nearly 500,000 Part D enrollees
received what the HHS OIG termed high levels of opioids
(a 120 morphine milligram equivalent [MME] average dose
for at least three months), a figure that did not include Part
D enrollees with cancer or in hospice care. A MME
measures the cumulative use of opioids over a 24-hour
period.](ViewImageLocal?handle=hein.crs/govzeb0001&div=1&collection=&method=preview&ext=.png&size=3)