As the opioid crisis continues to affect millions of Americans, the healthcare industry is welcoming a major policy change designed to expand treatment access. On January 1, new rules went into effect allowing Medicare to cover a broader range of opioid use disorder (OUD) treatment services for the first time.
Under these new regulations, Opioid Treatment Programs (OTPs) can now enroll in Medicare and be reimbursed for medication-assisted treatment (MAT) services, including the use of methadone and other therapies that were previously excluded from coverage.
This change marks a historic shift, particularly for Medicare Part B beneficiaries who previously faced limited treatment options for opioid addiction under the federal program.
Key Details of the New Medicare OUD Coverage
The expanded Medicare benefit enables OTPs to receive bundled payments for providing a range of services, including:
- Medication-assisted treatment with methadone, buprenorphine, and other approved medications.
- Counseling services, including telehealth counseling.
- Intake assessments and toxicology testing.
- Care coordination and other support services.
This is the first time that methadone—one of the most effective medications for treating opioid use disorder—has been covered by Medicare. Given the growing need for treatment among older adults, this coverage expansion has been widely praised by experts and advocates alike.
The Centers for Medicare & Medicaid Services (CMS) estimates that approximately 1,700 OTPs nationwide are eligible for Medicare enrollment under the new policy. However, few facilities have enrolled so far.
Why Aren’t More Providers Enrolling Right Away?
Despite the opportunities this new coverage presents, many treatment providers haven’t immediately jumped to enroll in Medicare. According to industry experts, this reluctance isn’t surprising.
“There’s just so much demand [for treatment services] currently and not enough capacity,” said Matt Sabbatino, a managing director with consulting firm L.E.K. Consulting. “I would suspect more and more clinics will start to enroll as Medicare providers, but it will take time.”
Sabbatino compared OTPs to bustling restaurants with full reservations every night. When providers are already at capacity, the incentive to take on the administrative burden of Medicare enrollment may not be strong—especially when those clinics are already filled with commercial insurance, Medicaid, and cash-pay patients.
Nevertheless, he predicts that many OTPs will eventually enroll once they fully understand the benefits and reimbursement rates offered under the new Medicare rules.
“I think it’s inevitable,” Sabbatino noted. “Assuming that the rates are reasonable, there’s no reason not to participate.”
Providers Exploring Medicare Enrollment
Some providers are already evaluating how to take advantage of the expanded Medicare coverage.
Symetria Recovery, an opioid addiction treatment provider based in Naperville, Illinois, is one example. The company operates 12 locations across Illinois and Texas, with plans to expand into 10 additional states.
“We are looking into their new benefits, as well as reexamining other insurance provider coverage options,” said Symetria President and CEO Chris Hassan. While the company doesn’t currently accept Medicare, it’s considering the opportunity.
Hassan praised the new Medicare policy as a step in the right direction for improving access to care.
“We are pleased that Medicare has introduced a more enlightened and comprehensive methodology that will increase access to care for thousands of Americans who struggle with this chronic medical condition,” he said.
The Growing Need for Opioid Treatment in Older Adults
The opioid epidemic has claimed hundreds of thousands of lives over the past two decades. According to the Centers for Disease Control and Prevention (CDC), nearly 400,000 Americans died from opioid overdoses between 1999 and 2017.
And contrary to some assumptions, older adults—many of whom are Medicare beneficiaries—are also vulnerable to opioid misuse and addiction.
In fact, 29% of Medicare beneficiaries, or about 13.4 million people, received opioids in 2018 alone, according to the U.S. Department of Health and Human Services Office of Inspector General.
This makes the expanded Medicare benefit not only timely, but essential.
Industry Leaders See Promise in New Coverage
Providers across the behavioral health industry are cautiously optimistic about the Medicare expansion.
Discovery Behavioral Health (DBH), based in Los Alamitos, California, operates 97 treatment centers across 12 states offering services for mental health, substance use, and eating disorders.
While DBH is not currently a Medicare provider, President and CEO John Peloquin said the organization is considering the opportunity.
“I can’t quantify it with you, but I do believe that with this new regulation, it is creating greater access,” Peloquin said.
He added that DBH is already exploring the steps needed to become Medicare-certified, with hopes to complete the process within the next year.
“One of the guiding pillars of our organization is access to treatment, and it seems clear to me that becoming Medicare-certified will allow us to reach more individuals in need of treatment,” he said. “It makes sense for us to pursue.”
The National Council for Behavioral Health’s Perspective
Chuck Ingoglia, CEO of the National Council for Behavioral Health, expressed similar optimism about the new Medicare benefit.
The National Council represents more than 3,300 behavioral health organizations nationwide, many of which provide substance use treatment to underserved populations.
“We’re glad that methadone is finally covered by Medicare, and we’re glad that [Medicare] is doing it as a bundled payment,” Ingoglia said. “It seems like they’re paying attention to the field in terms of adjusting the payment rates to be truly reflective of what’s needed.”
Ingoglia also acknowledged that it’s too early to predict how many providers will enroll, but emphasized that this is a crucial step toward removing barriers to care.
A Milestone for Addiction Treatment
For decades, Medicare beneficiaries with opioid use disorder had limited access to evidence-based treatment. The new Medicare benefit changes that by:
- Increasing access to life-saving medications like methadone and buprenorphine.
- Encouraging the use of telehealth counseling and other support services.
- Making it financially viable for providers to accept Medicare patients.
Providers like Peloquin say this change is long overdue.
“I think this is a good thing,” he said. “I have always advocated greater access to treatment since I’ve been in behavioral health. This is one more example of eliminating a barrier to treatment where more people can get access to the care they deserve.”
Looking Ahead
As more OTPs begin to take advantage of the new Medicare benefit, experts believe the industry will see a broader shift toward inclusive, accessible, and patient-centered addiction treatment.
The transition may take time—but for the millions of Americans affected by opioid addiction, this expanded Medicare coverage is a vital step toward recovery and healing.
