The Centers for Medicare & Medicaid Services (CMS) has taken a significant step in addressing the opioid crisis by expanding coverage for Medicaid beneficiaries suffering from opioid use disorder (OUD). The recently finalized 2020 Physician Fee Schedule introduces new benefits, including a specialized enrollment category for providers offering OUD treatment programs. Additionally, the rule establishes bundled payment codes and expands telehealth services for OUD treatment. This expansion highlights the growing recognition of the need for accessible and comprehensive addiction treatment within government healthcare programs.
Key Changes in Coverage
The finalized rule brings several important changes designed to improve access to medication-assisted treatment (MAT) and therapy for Medicaid beneficiaries. These changes include:
- A New Enrollment Category for OUD Treatment Providers
- This new classification enables healthcare providers who specialize in OUD treatment to enroll more easily in Medicaid, making it simpler for patients to access their services.
- Bundled Payment Codes for OUD Treatment
- CMS has introduced new payment codes that bundle services for MAT, including medication, therapy, and counseling. These bundled payments are designed to streamline reimbursement and encourage integrated care.
- Expanded Telehealth Billing Options
- Starting January 1, 2020, providers will be able to bill for specific telehealth services using newly designated codes. These changes acknowledge the increasing role of telemedicine in providing accessible care, especially for those in rural or underserved areas.
Breakdown of the New HCPCS Codes
The new rule introduces three new Healthcare Common Procedure Coding System (HCPCS) codes that will allow providers to bill for telehealth treatment as part of a bundled care episode for OUD:
- HCPCS Code G2086: Covers at least 70 minutes of office-based treatment for opioid use disorder. This includes:
- Development of a treatment plan
- Care coordination
- Individual therapy
- Group therapy
- Counseling services
- HCPCS Code G2087: Covers at least 60 minutes of treatment in the subsequent month, including:
- Office-based OUD treatment
- Care coordination
- Various therapy and counseling services
- HCPCS Code G2088: Covers each additional 30-minute increment beyond the first two hours for ongoing office-based OUD treatment, therapy, and counseling.
The Growing Need for Medicare and Medicaid Coverage for OUD
Medicaid has traditionally been the primary payer for behavioral health treatments, including substance use disorder services. However, Medicare’s role in substance abuse treatment has grown significantly in recent years. The finalized rule acknowledges this shift by expanding Medicare coverage options, particularly for older adults struggling with OUD.
According to CMS data, the Medicare population has the fastest-growing prevalence of OUD compared to the general adult population. In 2014 alone, more than 300,000 Medicare beneficiaries were diagnosed with OUD. This trend underscores the need for increased access to treatment options under Medicare, alongside Medicaid expansions.
The Impact of Bundled Payments on OUD Treatment
One of the key aspects of the new rule is the introduction of bundled payments for OUD treatment. Bundled payments simplify the reimbursement process for healthcare providers by consolidating multiple services into a single payment. This system is expected to have several positive effects:
- Encouraging Integrated Care
- By bundling medication-assisted treatment with therapy and counseling, CMS promotes a holistic approach to OUD treatment.
- Reducing Administrative Burdens
- Providers no longer need to bill separately for different components of OUD care, streamlining the claims process.
- Incentivizing Treatment Providers
- The new payment structure makes it financially viable for more healthcare providers to offer comprehensive OUD treatment, potentially increasing patient access.
The Role of Telehealth in OUD Treatment
Telehealth has emerged as a crucial tool in addressing access barriers to behavioral health care. Stigma, geographical limitations, and provider shortages have historically made it difficult for many individuals to receive timely OUD treatment. The new CMS rule expands the ability of healthcare providers to deliver and bill for OUD treatment via telehealth, a move that is expected to:
- Improve Access in Rural Areas: Many patients in remote locations struggle to find specialized addiction treatment providers. Telehealth services enable them to receive care without long travel distances.
- Reduce Wait Times: By allowing patients to connect with providers virtually, telehealth can mitigate the issue of long appointment wait times.
- Lower Barriers to Treatment: Telehealth reduces the stigma of seeking help by allowing patients to receive treatment discreetly from their homes.
Potential Challenges and Considerations
While the CMS expansion of Medicaid coverage for OUD treatment is a significant step forward, some challenges remain:
- Provider Shortages: Even with improved payment structures and telehealth options, the shortage of addiction treatment providers may continue to limit access.
- State Variability in Medicaid Expansion: Since Medicaid programs are administered at the state level, variations in implementation could impact the effectiveness of the new policies.
- Technology and Accessibility Barriers: Some patients, particularly older adults or those in low-income communities, may face difficulties accessing telehealth services due to a lack of technology or internet connectivity.
Conclusion
The CMS expansion of Medicaid coverage for OUD treatment represents a significant step in addressing the opioid epidemic. By creating a new provider enrollment category, establishing bundled payment codes, and expanding telehealth options, CMS is working to improve access to effective treatment for Medicaid and Medicare beneficiaries.
These changes reflect a growing recognition of the need for comprehensive, accessible addiction treatment services. While challenges remain, the finalized 2020 Physician Fee Schedule is expected to enhance care coordination, reduce administrative burdens, and ultimately improve patient outcomes. As healthcare providers and policymakers continue to navigate the evolving landscape of addiction treatment, these changes serve as a foundation for further innovations and improvements in care delivery.
