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1 1 (June 04, 2020)

handle is hein.crs/govdarr0001 and id is 1 raw text is: FF.ri E.$~ & Updated June 4, 2020 Medicare Coverage of Medication Assisted Treatment (MAT) for Opioid Addiction Medicare covers certain reasonable and necessary services provided by Medicare-enrolled health care practitioners for treating substance abuse disorders, such as alcoholism and opioid and other drug abuse. Medication Assisted Treatment (MAT) combines medication with counseling and behavioral therapies to provide comprehensive substance abuse treatment. Congress and the federal government have taken steps to increase the availability of MAT in response to a sharp increase in U.S. opioid overdoses and deaths in recent years. Effective January 1, 2020, the Support for Patients and Communities Act (SUPPORT; P.L. 115-271) added a Medicare benefit category for treating opioid use disorder, which includes comprehensive MAT services provided in the roughly 1,700 Substance Abuse Mental Health Services Administration (SAMHSA)-certified Opioid Treatment Programs (OTPs), also known as methadone clinics. OTP services include management, care coordination, psychotherapy, and counseling, as well as telehealth services and dispensing and administration of MAT drugs, including methadone. This brief provides background on MAT and Medicare coverage of MAT for opioid abuse treatment. According to SAMHSA, MAT can provide a safe and controlled level of medication to help patients overcome or live with their opioid drug addiction. Research indicates that opioid use disorder treatment is most effective when drugs are used in combination with behavioral treatments and cognitive therapy (to challenge habitual individual behavior patterns). The Food and Drug Administration (FDA) has approved three MAT medications for treating opioid dependence: methadone, buprenorphine, and naltrexone. Methadone and buprenorphine are opioid drugs with potential for dependence but also may be prescribed outside of MAT in different formulations for treating chronic pain. MAT drugs help to reduce or block an opioid drug's euphoric effects, relieve physiological cravings, and normalize body functions. Experts recommend that all three drugs be available for 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, when used for treating opioid abuse, may be administered as part of a hospital admission; otherwise, this medication may only be administered and dispensed by OTPs (see Table 1). OTPs may prescribe and dispense buprenorphine and naltrexone. The Drug Addiction Treatment Act of 2000 (DATA 2000; P.L. 106-3 10) allows physicians and certain other health care practitioners to obtain waivers to treat opioid addiction by prescribing buprenorphine, but not methadone, outside an OTP in other health care settings. In May 2016, FDA approved an implantable buprenorphine product that is effective for three months, and in November 2017, FDA approved an injectable formulation that is effective for one month. Implanted and injected buprenorphine formulations are administered in physician offices and other outpatient settings. Other buprenorphine formulations, such as pills, may be dispensed by retail pharmacies. Naltrexone, a nonopioid drug, does not carry an addiction risk and is not regulated under the CSA. Naltrexone may be prescribed and dispensed in OTPs. It also may be prescribed by health care practitioners (without DATA 2000 waivers), who are licensed to prescribe drugs, and then dispensed by pharmacies. Table I. MAT Drug Practitioner Authority MAT Practitioners Authorized to Medication Prescribe/Dispense MAT Drugs OTPs DATA 2000 Other Waiver Practitioners Methadone Yes No No Buprenorphine Yes Yes No Naltrexone Yes Yes Yes Source: CRS analysis based on 21 U.S.C. §801. ,p dAbse'- The federal Medicare program provides health coverage for qualified individuals age 65 and older and permanently disabled individuals about 63 million in 2020. Medicare benefits are provided through Part A, which covers inpatient hospital services; Part B, which covers physician services and other outpatient care; Part C, a managed care service delivery option that covers Parts A and B benefits (except hospice care); and Part D, a voluntary optional benefit that covers outpatient prescription drugs through private prescription drug plans. Opioid overutilization is a significant issue in Medicare. A May 2020 Department of Health and Human Services Office of Inspector General (HHS OIG) report found that most of the 71,260 Part D enrollees at serious opioid abuse risk in 2017 received high opioid doses in 2018. Even though it appeared fewer of these Part D enrollees were doctor shopping or receiving extreme opioid doses, they had what the HHS OIG termed high opioid levels a 120 gognpo goo g , q 'S a X 11LULANJILiN,

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