Mat With Methadone Service Code H0020 No Longer On The Medicare Exempt List
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Medication Assisted Treatment with Methadone, Service Code H0020, No Longer on the Medicare Exempt List
Effective January 1, 2020, the Centers for Medicare and Medicaid Services began covering MAT programs through Medicare. Please refer to the CMS final rule and letter to opioid treatment providers for additional information. As a result of this change in coverage, MaineCare’s MAT with Methadone has been removed from the Medicare exempt list and MIHMS was updated to reflect this on November 10, 2020.
Providers are now required to bill Medicare as the primary payor and MaineCare as the secondary payor when billing code H0020. H0020 claims for dual eligible Medicare members will deny without an attached Explanation of Benefits .
For providers who have previously submitted claims for dual eligible members that processed prior to billing Medicare, the Medicare payment information will not be reported on the claims. To correct payment for these members, providers must adjust the incorrectly paid claims and provide the Medicare payment information on the adjustment claim.
If you have any questions or need assistance, please contact Provider Relations Specialist, Rebecca Maranda, at .
Section 65 Behavioral Health Services, Intensive Outpatient Services Clarification
Drug Rates Update, CR 98011
See the spreadsheet for a list of codes with new rates which is available on the Codes & Rates webpage.
How Much Does Medicare Pay For Opioid Addiction Treatment
The coverage will be included under Medicare Part B. Part B is optional for all beneficiaries and comes with a standard premium of $144.60 per month in 2020, though some beneficiaries may pay a higher premium based on their income.
Beneficiaries will not pay any coinsurance for the OTP benefits after they have reached the annual Part B deductible of $198 in 2020.
Does Medicare Cover Mental Health Care
Mental health disorders affect people from all walks of life and all age groups. The coexistence of a mental health disorder and a substance use disorder is known as having co-occurring disorders. People with mental health disorders are more likely to also suffer from a substance use disorder. Approximately 9.2 million Americans have co-occurring disorders.6 When experiencing co-occurring disorders, you may have diagnoses of 2 or more substance use disorders as well as mental health disorder. Some drugs are more commonly abused by people who are struggling with co-occurring disorders, and these include:6
- Alcohol.
- Stimulants, like amphetamine and methamphetamine.
- Prescription drugs.
- Hallucinogens.
Under Medicare, if you experience a mental health disorder, Medicare Part A will help cover mental health services if you need an inpatient hospital stay or if you are admitted to a psychiatric hospital.7 Then, Medicare Part B will help cover mental health visits from a doctor or other services that you may need after you are released from your inpatient stay.7Under Part B, the following services related to mental health care are covered:7
- A depression screening and an alcohol misuse screening each year
- Individual or group psychotherapy
- Individual and group therapy
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Are Medicare And Medicaid The Same Thing
Medicare and Medicaid differ because Medicare is a health insurance coverage for older and disabled adults while Medicaid is a federal-state assistance program based on income.
Medicare is mainly for people over 65, but it also covers people with certain disabilities or who need dialysis. Eligibility is not income-based, and treatment is funded through money already contributed by beneficiaries. Enrollees contribute toward the cost of their treatment through deductibles, coinsurance and modest monthly premiums.
Medicaid pays for medical treatment for adults and children on low incomes, and beneficiaries are not usually required to contribute toward the cost of their care. Coverage varies widely between states, but coverage for certain treatments is mandatory for every state. Methadone treatment for opioid dependency is an example of a mandatory benefit for all Medicaid beneficiaries.
Some people have dual eligibility for Medicare and Medicaid, which means that they can enroll in both programs simultaneously. If you are enrolled in Medicare and Medicaid, Medicare will pay for treatment in the first instance if your treatment is covered. Medicaid may cover some or all of the costs you are liable for under Medicare, such as coinsurance payments. Furthermore, Medicaid may fund certain treatments not covered by Medicare.
Does Medicare Cover Methadone Clinics
Medicare is a federal healthcare provider that covers adults over the age of 65, children with severe disabilities, and others suffering from debilitating disease.
In general, Medicare is only likely to cover substance abuse treatment when its offered at a government approved, or Medicare certified, inpatient or outpatient treatment center, or if the treatment is medically necessary.
Medicare likely does not cover methadone clinics.
However, it may cover a stay at an approved inpatient treatment center that may administer methadone as a form of medication assisted treatment, or MAT.
But, reimbursement would only occur if methadone was listed as an eligible medication and was administered at the approved facility.
Whether or not Medicare even covers the cost of methadone, even at an approved facility, varies state by state. It may be best to contact your local Medicare agency for more information.
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Methadone Not Covered By Medicare
— One in three older Americans with Medicare drug coverage is prescribed opioid painkillers, but for those who develop a dangerous addiction there is one treatment Medicare won’t cover: methadone.
Methadone is the oldest, and experts say, the most effective of the three approved medications used to treat opioid addiction. It eases cravings without an intense high, allowing patients to work with counselors to rebuild their lives.
Federal money is flowing to states to open new methadone clinics through the 21st Century Cures Act, but despite the nation’s deepening opioid crisis, the Medicare drug program for the elderly covers methadone only when prescribed for pain.
Joseph Purvis, a former heroin and prescription painkiller user, said he went into a depressive tailspin because he initially feared he might have to stop methadone treatment when he went on Medicare at 65.
“I was terrified that I might have to leave the program. There’s no way I wanted to go back to addiction on the streets,” said Purvis, 66, of Gaithersburg, Maryland.
Methadone doesn’t meet the requirement of Medicare’s Part D drug program because it can’t be dispensed in a retail pharmacy.
Instead, in the highly regulated methadone system, patients first are assessed by a doctor, then show up daily at federally certified methadone clinics to take their doses of the pink liquid. Or, like Purvis in Maryland, they prove through repeated urine screens that they have earned the right to weekly take-home doses.
Government Programs: The Affordable Care Act
On March 23, 2010, President Obama signed the Affordable Care Act into law. The three main goals of the legislation were:
Many medical professionals praise the increase in availability of substance abuse treatment afforded by the ACA. Now considered an essential health benefit, insurers must cover services for the full spectrum of substance use disorders .
While rollbacks under the Trump administration have altered parts of the ACA, many core elements havent changed. In December 2017, Congress decommissioned the individual mandate, which required most to either enroll in health insurance or pay a penalty on their taxes. The open enrollment period for 2018 was shortened and funding for enrollment-assistance advertising was decreased. Still, some states have introduced their own healthcare laws in an effort to maintain stability should further cuts to the ACA be made.
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What Is Covered By Medicaid
Medicaid provides certain mandatory benefits for enrollees, meaning certain medically necessary treatments will always be funded by Medicaid regardless of where you live. For example, Medicaid will always fund inpatient and outpatient care in hospitals and certain home health services.
Coverage for some treatments is optional, and states can decide whether to fund them for Medicaid beneficiaries. For example, states can choose whether to cover dental treatment and prescription medications.
Increased Precautions Were Taking In Response To Covid
As updates on the impact of COVID-19 continue to be released, we want to take a moment to inform you of the heightened preventative measures we have put in place at CTC Programs to keep our patients, their families, and our employees safe. All efforts are guided by and in adherence to the recommendations distributed by the CDC.
In adherence to the social distancing recommendations provided by the CDC, we have implemented strict protocols at our clinic to ensure the safety of our patients and staff.
- Patients who have active symptoms of illness or a fever of 100 degrees or higher must call ahead to arrange after-hours dosing.
- The number of people allowed inside the building at any given time is restricted based on county, state, and federal guidelines.
- The number of people waiting in line is restricted based on county, state, and federal guidelines, and those present must maintain a minimum distance of six feet from one another.
- To maintain line restrictions, patients are asked to wait in their cars until direction is given.
For specific information regarding these changes and limitations, please contact us directly.
Please note that for the safety of our patients, their families, and our staff, there are certain restrictions in place regarding on-site visitation at CTC Programs.
For specific information regarding these changes and limitations, please contact us directly.
The CDC has provided a list of easy tips that can help prevent the spread of the coronavirus.
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How Long Does Medicare Cover Rehab
Treatment for substance abuse is designed to help people experiencing addiction by helping them to stop using drugs and return to productive, functioning lives. Most people that get into and remain in treatment can stop using drugs and see improvements in their occupational, social, and psychological functioning.8 How Effective is Drug Addiction Treatment?However, rehabilitation treatment plans must be individualized, and the type of treatment that you will receive depends on the extent and nature of your problem and the types of treatment services that will best help you to address underlying problems. Getting the best outcome from rehabilitation depends on your participation in a treatment plan of adequate duration to address your individual needs. The length of time needed varies by individual. Generally, for residential or outpatient treatment, treatment lasting longer than 90 days is recommended to achieve positive, lasting results.8 How Long Does Drug Addiction Treatment usually last?
Does Medicare Cover Methadone Treatment
Methadone is the oldest and best-known opioid treatment. If administered to an inpatient at a hospital, Part A covers methadone. For people who are not inpatient, methadone is a highly controlled prescription drug that you cant get at a regular pharmacy.
Patients must go to an opioid treatment center for daily doses of methadone. Medicare covers methadone and other opioid treatment services that enroll in Medicare.
Get A Free Quote
Find the most affordable Medicare Plan in your area
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Does Private Insurance Cover Methadone
Private insurance may or may not cover the cost of methadone clinics. Common private insurance plans include HMO and PPO plans.
HMO, or Health Maintenance Organization plans give a person access to doctors and other healthcare options within a particular network. The network is usually made up of a group of providers that have agreed on lower rates with the same standard of coverage and quality.
PPO, or Preferred Provider Organization plans allow more flexibility for the doctors patients can see and usually cost a little more than HMO plans.
Interested in learning more about methadone and medication-assisted treatment programs?
Our treatment specialists are standing by to answer any questions you may have.
Whether or not an HMO or PPO plan covers the cost of MMT depends on a variety of factors. It can come down to whether or not methadone treatment is medically necessary, or whether methadone is a covered medication included in the plan.
Some plans may cover the cost of methadone, but still require a co-payment.
The coverage of methadone is likely to vary from plan to plan, but a person with a PPO plan may have more options than someone with a more traditional, and less expensive, HMO plan.
There may also be private methadone clinics that deal directly with insurance companies, and may cover part, or all, of methadone maintenance therapy.
It may be best to contact your insurance provider for more information.
Medicare Advantage Coverage For Substance Abuse
Those with Medicare Advantage coverage have access to substance abuse treatment. Its essential to use an in-network doctor, or you risk paying out-of-pocket. Some Special Needs Plans help people with specific chronic issues such as mental health or substance abuse. Options for plans vary by county.
Get A Free Quote
Find the most affordable Medicare Plan in your area
Contact your health plan to find an in-network specialist.
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How Do I Find Insurance That Covers Methadone Treatment
If you want to get an insurance plan to cover a methadone program, youll get the best results with accurate information. Many insurance company websites have a directory of in-network providers. You can use this page and a clinics page to do preliminary research. After you find this information, we still recommend calling the insurance company and provider you have in mind. They will help you narrow down your search results and get accurate information on coverage.
How Long Does Medicare Pay For Rehab
Part A pays the full cost of 60 days of inpatient rehab in a semi-private room. For days 61 to 90, the coinsurance cost increases each day. After the 90th day, the coinsurance amount doubles, and you begin using lifetime reserve days.
Get A Free Quote
Find the most affordable Medicare Plan in your area
Medicare only allows 60 lifetime reserve days. If youve been inpatient for over 90 days and you dont have lifetime reserve days, Medicare wont pay for care.
A supplement plan can extend the number of days you have hospitalization coverage. If you get inpatient care at a psychiatric hospital, Medicare covers 190 days of lifetime care.
The limit on lifetime days is a problem if you need intensive mental health services or suffer a relapse. The limitation doesnt apply to care in a general hospital. For most people in rehab, an inpatient stay is the beginning of the journey. After discharge, Part B will continue to pay for counseling and medical care needed to stay on track.
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What Is Methadone Maintenance Therapy
Methadone maintenance therapy is a treatment option for people physically dependent to opioids. The therapy is likely to take place in a medical clinic that is fully staffed with physicians, nurses, and counselors.
Methadone maintenance therapy gives the person dependent to opioids a daily dose of methadone, usually in tablet or liquid form. The methadone dose will reduce their cravings for opioids, as well as ease their symptoms of opioid withdrawal.
While methadone is addictive like other opioids, its much safer than heroin, does not produce euphoria, and is only administered under medical supervision.
Research has shown that methadone maintenance therapy:
- reduces the number of deaths associated with opioid dependence
- reduces drug injecting and the spread of HIV
- reduces criminal activity relating to drug use
Initially, Methadone Maintenance Therapy starts out with a low dose. The size of the dose is then gradually increased until the patient reaches what physicians call the maintenance dose.
The maintenance dose is just the right amount of methadone needed to adequately relieve withdrawal symptoms, but not produce euphoria or feel-good effects.
Reaching the maintenance dose is likely to take days, and the entire MMT process can last months or even years.
MMT is usually a long-term outpatient treatment that may have patients travel to the methadone clinic once a day to receive their daily dose.
Find out if your insurance covers the cost of methadone maintenance
Does Medicare Cover The Cost Of Suboxone
Suboxone is a medication used during medication-assisted treatment for the treatment of an opioid use disorder. It is a combination of buprenorphine and naloxone which helps a person to reduce or quit the opioid drug of abuse, such as heroin or prescription opioid painkillers like oxycodone .
Buprenorphine may be covered by a Medicare drug plan if its considered medically necessary and if its on the plans formulary. If its not on the formulary an exception may possibly be made. In order for buprenorphine-based drugs to be covered they must be dispensed by a Medicare-certified program or facility for use during inpatient or detoxification services.
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Payment Assistance Options For Methadone Treatment
Medicaid can help pay for methadone treatment.
Medicaid Coverage
According to the Center for Medicaid & CHIP Services, state and federally sponsored Medicaid insurance offers low-income individuals a range of options for covering substance abuse-related treatment costs, including methadone treatment. In turn, some methadone clinics offer some form of assistance with applying for Medicaid for people who qualify for coverage.
Health Insurance Coverage
With the passing of the Affordable Care Act in 2008, all marketplace healthcare plans must provide coverage for substance abuse treatment as part of their standard policy offerings. This change means people who carry health coverage through an employer may well be able to cover a good portion of methadone treatment costs through their insurance plan, according to the Office of National Drug Control Policy. The year 2008 also saw the passing of the Mental Health Parity and Addiction Equity Act, which requires insurers to offer the same level of coverage benefits for both standard medical care and substance abuse treatment.
Sliding Fee Scale Option
Many methadone treatment clinics not only receive financial support from state and federal sources, but also nonprofit organizations and government grants. As a result, many clinics allow patients to cover treatment costs according to a sliding fee scale thats based on their monthly income earnings. Sliding fee scale costs typically vary depending on any one clinics available funding.
