Medicare Part B covers opioid treatment programs (OTPs) for opioid use disorder (OUD). The government and an independent, government-approved accrediting body must certify the program.
Opioid use disorder (OUD) is a serious medical condition that affects people both psychologically and physically.
Medicare covers treatments for OUD with doctors and other healthcare professionals. However, if a person chooses treatment through an OTP, they may have fewer out-of-pocket expenses.
To be eligible for coverage through Medicare, the Substance Abuse and Mental Health Services Administration (SAMHSA) and an independent, SAMHSA-approved accrediting body must certify the OTP.
If a person receives Medicare-approved OTP services from a Medicare-enrolled facility, they will not typically have to pay any copayments. However, the Part B deductible will apply to OTP supplies and medications.
Individuals receiving the same services through a doctor or another healthcare professional will be required to pay the 20% Part B coinsurance after they have paid the $257 deductible.
People eligible for Medicare and Medicaid will pay $0 for the services they receive through their state Medicaid program.
A person with a Medicare Advantage plan will have the same coverage rules as someone with Original Medicare. However, based on their plan type, they may have specific network restrictions.
Medicare covers various services under its OTP benefit, including:
- FDA-approved OUD medications, including opioid agonists like methadone and opioid antagonists like naltrexone
- substance misuse counseling, with individual and group therapy options
- toxicology tests
- periodic assessments
- intensive outpatient programs
- coordinated care
- referral services
- peer recovery help services
Original Medicare Part B covers some prescription medications a doctor may prescribe. However, a person may need a Part D prescription drug plan for others.
If an individual has a Medicare Advantage plan, the plan must include drug coverage for some medications to be covered.
Anyone with OUD is eligible for an OTP, and doctors
The Centers for Disease Control and Prevention (CDC) states that clinicians should use a
Help is available
Seeking help for OUD may feel daunting or even scary, but several organizations can provide support.
If you believe that you or someone close to you is showing signs of OUD, you can contact the following organizations for immediate help and advice:
- Substance Abuse and Mental Health Services Administration (SAMHSA): 800-662-4357 (TTY: 800-487-4889)
- 988 Suicide & Crisis Lifeline: 988
Below are some common questions about OUD and OTP services.
Yes, both Original Medicare and Medicare Advantage plans pay for eligible costs relating to the diagnosis and treatment of OUD.
Medicare Part D prescription drug plans also cover the costs of some OUD medications.
Out-of-pocket costs may apply, and depending on their plan, a person may have to visit in-network doctors, healthcare professionals, and facilities.
In May 2023, the Food and Drug Administration (FDA) approved Brixadi (buprenorphine) extended-release injections to treat moderate to severe OUD.
Brixadi (buprenorphine) is available in either a weekly or monthly injection, and which one a doctor prescribes will depend on whether a person is new to the medication or not.
According to 2023 research, the “gold standard” evidence-based medication treatment for OUD is methadone, buprenorphine, or naltrexone.
Opioid treatment programs are purpose-led treatment regimens for OUD.
They typically consist of a combination of different therapies, including prescription medications, talking therapies, peer support, and periodic assessment.
If a person has Original Medicare, Part B covers Medicare-enrolled OTPs in full when a person has OUD and meets other eligibility requirements. People with Medicare Advantage plans will have the same coverage but may have to visit in-network doctors, healthcare professionals, or facilities.
People with OUD can recover, and help is available through SAMHSA at 800-662-4357 or through the 988 Suicide and Crisis Lifeline at 988.