Opioid Treatment Programs (OTPs)
The Centers for Medicare & Medicaid Services (CMS) began paying Medicare-enrolled Opioid Treatment Programs (OTPs) through bundled payments for Opioid Use Disorder (OUD) treatment services (PDF) for Medicare beneficiaries, effective Jan. 1, 2020.
Effective Jan. 1, 2021, CMS began covering hospital outpatient OTPs submitting claims on the 837i or UB-04 (CMS-1450). CMS also established two new add-on codes HCPCS codes for take-home supply of naloxone: G2215 nasal naloxone and G2216 injectable naloxone.
Refer to CMS’s OTP webpage and the CY 2020 Physician Fee Schedule Final Rule for enrollment, coding, and claims information.
Under the 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)
- Take-home supply of methadone, oral buprenorphine, nasal naloxone and injectable naloxone
- Substance use counseling
- Individual and group therapy
- Toxicology testing
- Intake activities
- Periodic assessments
Opioid treatment provider requirements:
1. Get certified/accredited: OTPs must be certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and accredited by an independent, SAMHSA-approved accrediting body. For SAMHSA certification, OTPs must comply with all pertinent state laws and regulations, and all regulations enforced by the Drug Enforcement Administration. For more information on the accreditation process, visit SAMHSA’s Certification of Opioid Treatment Programs (OTPs) webpage.
2. Get enrolled: Certified, accredited providers must enroll in Medicare to bill OTP services under Medicare Part B. Refer to the OTP Medicare Enrollment Fact Sheet (PDF) to learn more about the enrollment process and the documentation you’ll need to get started.
3. Get contracted: Medicare-enrolled OTPs must contract with Magellan to serve Medicare Advantage plans that we manage. If you are already contracted with Magellan for the Medicare network, then you’ll need to have your contract amended to add the OTP services. If you are not already contracted with Magellan for the Medicare network, you’ll need to complete the Medicare enrollment process first and then complete the credentialing and contracting process to become an in-network provider for OTP services.
Magellan’s next steps
Magellan is covering the OTP services for members of our Medicare Advantage and dual-eligible behavioral health plans. We are sending contracts to SAMHSA-certified OTPs in areas where we support Medicare Advantage members. View answers to frequently asked questions (PDF), or contact your field network representative to learn more. If you’re unsure who your field network representative is, contact our Provider Services Line at 1-800-788-4005.