Medicare, the federal health insurance program primarily for individuals ages 65 and older, provides coverage for certain aspects of medication-assisted treatment.
Medication for Addiction Treatment (MAT) is primarily used to treat opioid use disorder (OUD) and alcohol use disorder (AUD). MAT coverage provided by Medicare includes the use of medications to treat OUD, such as methadone, buprenorphine, Suboxone and naltrexone.
In 2020, approximately 1 million Medicare beneficiaries were diagnosed with OUD, demonstrating a significant need for treatment in this population.
How Does Medicare Cover Treatment for OUD?
Medicare provides coverage for the treatment of OUD to its eligible beneficiaries through various provisions and programs. MAT coverage for Medicare includes medications like Suboxone, methadone or buprenorphine as well as counseling, individual and group therapy, regular assessments, drug testing and educational workshops.
MAT coverage is available through these Medicare programs:[4,6-8]
Medicare Part A
Medicare Part A covers methadone for OUD when a patient is an inpatient in a hospital setting.
Medicare Part B
Medicare Part B covers outpatient services for addiction treatment, such as counseling and therapy sessions delivered by licensed professionals including psychologists, clinical social workers and licensed professional counselors.
Medicare Part D
Medicare Part D is their prescription drug coverage program. It offers coverage of buprenorphine and naltrexone prescribed to treat OUD. They’re usually covered under the “prescription drugs” portion of Part D plans. Copays and limitations in coverage may differ among plans, so it’s wise to discuss your personal plan with medical billing staff at your treatment program in advance.
Medicare Advantage (Part C)
Medicare-approved private insurers offer this plan, which includes coverage similar to Parts A and B as well as prescription drug coverage from Part D. Depending on which company backs the plan, there may also be benefits available for substance misuse treatment services included.
Opioid Treatment Programs
Medicare Part B covers some services provided by Opioid Treatment Programs (OTPs) for beneficiaries who can demonstrate that these services are medically necessary. OTPs are usually inpatient facilities that offer MAT, counseling services and other specialized treatment solutions for people who have had no success with outpatient or medication-only approaches to OUD in the past.
What Medications Does Medicare Cover for MAT?
Medicare covers medications prescribed to treat OUD as part of MAT.[2,8]
These are some of the medications most commonly covered by Medicare to treat OUD:[4,6,8-10]
Methadone is a long-acting opioid agonist medication used to treat OUD by decreasing cravings and withdrawal symptoms. Methadone is typically prescribed in clinics called Opioid Treatment Programs (OTPs) since it usually isn’t approved for take-home doses.
Medicare Part B covers some services provided by OTPs, including methadone treatment, and in some cases, methadone may be covered by Medicare Part A if it is given to an inpatient in a hospital setting.
Buprenorphine is a partial opioid agonist prescribed to treat OUD. Buprenorphine comes in various forms, such as sublingual tablets or films (Suboxone), or extended-release injections (Sublocade).
Medicare Parts B and D offer coverage of the drug when prescribed to treat OUD. Medicare Advantage plans (Part C) may also cover it when prescribed for OUD.
Naltrexone is an opioid antagonist medication that blocks opioids’ euphoric effects. It is used to help people with OUD avoid relapse. It’s available as either an oral tablet (ReVia) or a long-acting injectable (Vivitrol). Both forms may be covered under Medicare Parts B and D plans.
What Is Excluded From Medicare Coverage?
Medicare excludes certain types of addiction treatment, such as experimental treatments and some types of intensive residential and outpatient treatment.
Check Your Coverage
It’s important to note that Medicare Part D provides coverage for prescription drugs, including medications used in MAT. However, coverage specifics can vary among different Part D plans.
Each plan maintains its own list of covered drugs. It’s a good idea to review your specific Medicare Part D plan to determine which MAT medications are covered and to understand any associated copayments or cost-sharing requirements.
In most cases, your treatment provider can check this coverage for you. They can confirm any out-of-pocket costs that are your responsibility, so there won’t be surprises down the road.
Does Medicare Cover Telehealth Addiction Treatment?
Yes, Medicare covers telehealth treatment services for addiction care, including treatment of OUD.[11-12]
This means you can meet with your treatment provider virtually, no matter where you live. This is particularly important for those who live in rural areas with limited access to in-person treatment providers.
What Is the SUPPORT for Patients & Communities Act?
The SUPPORT for Patients and Communities Act was passed in 2018 as a comprehensive piece of legislation designed to combat opioid use disorder in the U.S. and expand resources available for affected patients. The bill includes a number of provisions that aim to support people who want to stop using drugs by increasing their access to treatment services.
The SUPPORT for Patients and Communities Act includes these features:[3-5]
Expanded Access to MAT
One way that the law increases resources for those who are struggling with OUD is by expanding access to MAT.
This treatment approach combines the use of FDA-approved medications with counseling and behavioral treatments. The law also loosened the restrictions on the prescription of buprenorphine and increased funding to make it more readily available to those who need it.
More Research for Pain Management
Through the SUPPORT Act, funding was designated to research additional pain management techniques that don’t involve addictive drugs. The hope is that addiction rates will decrease as will rates of diversion of pain medications.
If fewer people start taking prescription opioids because there are other pain management options available, fewer people will end up with OUD.
Prescription drug monitoring programs (PDMPs) are how states can track who is prescribing what to whom and in what amount. This helps to prevent multiple doctors prescribing addictive drugs to the same person.
Unfortunately, it’s not a perfect system, so the SUPPORT Act identified ways to improve the system and make sure that medical professionals are putting it to good use.
Increased Funding for Prevention & Treatment Programs
Grants were created or expanded through the SUPPORT Act for prevention and treatment programs. In some cases, funds were designated to open more treatment locations, expanding access to treatment in areas where it may not be available.
Support for Pregnant Women & New Babies
Pregnant [people and babies born with neonatal abstinence syndrome (NAS) receive better treatment services and expanded access to treatment due to grants created and expanded through the SUPPORT Act.
Greater Focus on Education & Awareness
Though education about the risks of OUD and options for treatment has grown in the past decade, there is room for improvement. The SUPPORT Act specified the need to increase awareness campaigns and training programs for medical professionals who prescribe addictive drugs. Prevention efforts go a long way in reducing rates of OUD and opioid overdose.
Reviewed By Peter Manza, PhD
Peter Manza, PhD received his BA in Psychology and Biology from the University of Rochester and his PhD in Integrative Neuroscience at Stony Brook University. He is currently working as a research scientist in Washington, DC. His research focuses on the role ... Read More
- Information about medication-assisted treatment (MAT). U.S. Food & Drug Administration. Published May 2023. Accessed September 22, 2023. https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat
- Many Medicare beneficiaries are not receiving medication to treat their opioid use disorder. Office of the Inspector General, U.S. Department of Health and Human Services. Published December 15, 2021. Accessed September 22, 2023. https://oig.hhs.gov/oei/reports/OEI-02-20-00390.asp
- H.R.6 – SUPPORT for Patients and Communities Act. Congress.gov. 2018. Accessed September 22, 2023. https://www.congress.gov/bill/115th-congress/house-bill/6
- Opioid use disorder treatment services. Medicare.gov. Accessed September 22, 20223. https://www.medicare.gov/coverage/opioid-use-disorder-treatment-services
- Prescription Drug Monitoring Programs (PDMPs). Centers for Disease Control and Prevention. Published May 2021. Accessed September 22, 2023. https://www.cdc.gov/drugoverdose/pdmp/index.html
- Medicare coverage of medication assisted treatment (MAT) for opioid addiction. Congressional Research Services. Published June 4, 2020. Accessed September 22, 2023.https://crsreports.congress.gov/product/pdf/IF/IF10875
- Opioid Treatment Programs (OTP). Center for Medicare & Medicaid Services. Published April 2023. Accessed September 22, 2023. https://www.cms.gov/medicare/medicare-fee-for-service-payment/opioid-treatment-program
- Mark TL, Parish WJ, Weber EM, Steinberg DG, Henretty K. The cost of opioid use disorder-related conditions in Medicare. Drug and Alcohol Dependence. 2023;244:109778. doi:https://doi.org/10.1016/j.drugalcdep.2023.109778
- New for 2023. Centers for Medicare & Medicaid Services. Published September 11, 2023. Accessed September 23, 2023. https://www.cms.gov/medicare/payment/opioid-treatment-program
- Medicare coverage of buprenorphine-naloxone film surrounding generic entry. AJMC. Published August 23, 2023. Accessed September 23, 2023. https://www.ajmc.com/view/medicare-coverage-of-buprenorphine-naloxone-film-surrounding-generic-entry
- Waiver Elimination (MAT Act). Substance Abuse and Mental Health Services Administration. Published September 18, 2023. Accessed September 23, 2023. https://www.samhsa.gov/medications-substance-use-disorders/waiver-elimination-mat-act
- Telehealth. Medicare.gov. Accessed September 23, 2023. https://www.medicare.gov/coverage/telehealth
- Molfenter T, Brown R, O’Neill A, Kopetsky E, Toy A. Use of telemedicine in addiction treatment: Current practices and organizational implementation characteristics. Int J Telemed Appl. 2018;2018:3932643. Published 2018 Mar 11. doi:10.1155/2018/3932643
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