Provider Notice Issued 02/26/2020

​

Date:    February 26, 2020

To:       All Medical Assistance Program Providers

Re:      Opioid Treatment Programs Medicare Coverage Effective January 1, 2020

This notice informs providers of new coverage under the Medicare program that began January 1, 2020, for Opioid Treatment Programs (OTPs).

Starting January 1, 2020, under the Calendar Year (CY) 2020 Physician Fee Schedule final rule, the Centers for Medicare & Medicaid Services (CMS) will pay Opioid Treatment Programs (OTPs) through bundled payments for opioid use disorder (OUD) treatment services in an episode of care provided to people with Medicare Part B. OTPs must enroll in the Medicare program in order to receive reimbursement when these services are provided to Medicare patients.

For dually eligible beneficiaries (those enrolled in both Medicare and Medicaid) who get OTP services through Medicaid now, starting January 1, 2020, Medicare became the primary payer for OTP services. As an effort to promote continuity of care for dually eligible beneficiaries, HFS will continue to pay OTP providers that are not yet enrolled in Medicare until July 1, 2020.

Effective July 1, 2020 Medicaid will discontinue payments to OTP providers for dual eligible beneficiaries enrolled in both Medicare and Medicaid to uphold Medicaid responsibilities as the payer of last resort.

Under the new OTP benefit, Medicare covers:

•         U.S. Food and Drug Administration (FDA)-approved opioid agonist and antagonist medication assisted treatment (MAT) medications

•         Dispensing and administration of MAT medications (if applicable)

•         Substance use counseling

•         Individual and group therapy

•         Toxicology testing

•         Intake activities

•         Periodic assessments

With the release of the final rule, OTPs fully-certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and accredited by a SAMHSA-approved accrediting body can start enrolling in the Medicare program, so they can bill for services starting January 1, 2020.

HFS strongly encourages OTPs to begin the Medicare enrollment process as soon as possible. Read the CMS Enrollment Fact Sheet to learn more about the enrollment process and the documentation providers need to get started.

Resources:

• OTPs Medicare Enrollment fact sheet: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/OTP-enrollment-factsheet-MLN6325432.PDF
• OTPs Medicare Billing and Payment fact sheet: https://www.cms.gov/files/document/otp-billing-and-payment-fact-sheet.pdf
• Opioid Treatment Programs: Enrolling in Medicare Webcast Training: https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2019-11-12-OTP

Questions regarding provider enrollment for Medicare Part B services may be directed to the Medicare enrollment Helpline at 877-908-8476. Additional questions regarding this notice may be directed to the Bureau of Managed Care at 217-524-7478 or HFS.MMAI@illinois.gov.

Kelly Cunningham

Acting Medicaid Director