How is Medicare responding to the opioid crisis?

You have probably heard, read or seen on the news that there is an opioid abuse epidemic running rampant in the United States. According to the Center for Medicare and Medicaid Services (CMS), Opioids killed more than 47,000 people in 2017. That is 130 people per day. Sadly, 36% of all opioid overdose deaths involved a prescription opioid. It is estimated that three out of four people who used heroin misused prescription opioids first, and over two million people currently have an opioid use disorder and only 20% are currently receiving treatment.

In an effort to address this widespread crisis, on Oct. 26, 2018, President Donald Trump signed into law the Substance Use-Disorder Prevention Act that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities (H.R. 6). In response to this legislation, CMS is using a multi-pronged approach which includes addressing prevention, treatment provision, use of data, and providing resources. Addressed under prevention are goals to stop improper prescribing of opioids, enhancing the diagnosis of opioid use disorders, and promotion of non-opioid pain treatment and therapies.

There are treatment options available for opioid abuse and Medicare is actively responding in numerous ways. To enhance treatment options, Medicare is working to make certain that people can access treatment and have treatment choices, and is providing support for innovative approaches. Medicare is using data to identify and understand opioid use patterns, promote data sharing, and watching trends to evaluate existing solutions success. Medicare is also working on providing resources for beneficiaries, providers and pharmacists to ensure that opioid abuse is prevented if possible and treated when necessary.

One change that has recently become accessible is the coverage of Opioid Treatment programs under Part B of Medicare. As of January 1, 2020, The Centers for Medicare and Medicaid Services (CMS) will pay for Opioid Treatment Programs (OTPs) through bundled payments for opioid use disorder (OUD) treatment services when you have Medicare Part B. Although OTPs are also known as Methadone Clinics, they may provide additional medications and services to treat opioid abuse. These clinics are certified by the Substance Abuse and Mental Health Services Administrations and provide certain medications as part of medication-assisted treatment. Medicare Part B is covering numerous services provided by the OTPs including:

the three currently FDA-approved medications: methadone, buprenorphine, and naltrexone

Dispensing and administration of the medications if necessary

Substance use counseling

Individual and group therapy to form healthy interpersonal relationships with individuals who can become a part of their post-treatment support network.

Toxicology testing – testing the urine for the presence of illicit drugs

Intake activities

Periodic assessments to evaluate the success of treatment

These services are covered under Part B of Medicare at 80% after the 2020 deductible of $198 has been satisfied. Patients are responsible for the residual 20% unless they have a secondary coverage such as a Medicare Supplement (Medigap) plan, retiree coverage, or Medicaid. In order to qualify for reimbursement, the OTP must be enrolled with Medicare.

While there is much work to be done to address this epidemic, some successes already have been recognized. CMS sent out 24,000 letters in 2017 and 2018 to Medicare physicians letting them know that they were prescribing higher levels of opioids than their peers to incentivize safe prescribing practices. Due to these safer prescribing practices, the number of Medicare beneficiaries receiving higher than recommended doses from multiple physicians fell by 40% in 2017. In order to improve access to treatment, Medicare is encouraging OTPs to enroll as Medicare Providers. Medication assisted treatment is now available for Medicaid recipients as well. Medicare’s use of data has helped identify areas where opioid use is high in order to provide additional interventions.

If you have questions about Opioid Treatment Programs available in your area, speak with your physician. If you have questions about how Medicare will cover these treatment programs, call the Medicare Information Office at 1-800-478-6065, toll-free in Alaska.

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Nila Morgan is a Certified Medicare Counselor who works at the Anchorage Senior Activity Center.

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