Does Medicare Cover Opioid Treatment Programs?
Opioid use disorder (OUD) is a severe medical condition that can affect people psychologically and physically.
Help is available from many healthcare professionals, clinics, and facilities, with some offering OTPs.
Medicare covers eligible treatments for OUDs. However, if you choose an OTP, you may have fewer out-of-pocket costs.
Medicare coverage and opioid treatment programs (OTPs)
For an OTP to be eligible for coverage through Medicare, it must be Substance Abuse and Mental Health Services Administration (SAMHSA) certified and have accreditation from a SAMHSA-approved body.
If you receive Medicare-approved OTP services from a facility or healthcare professional enrolled in Medicare, you will not typically have to pay any copayments. However, you must pay the Part B deductible for OTP supplies and some medications.
If you receive the same services through a doctor or another healthcare professional, you must pay the 20% Part B coinsurance after you've paid the $257 deductible.
If you're eligible for both Medicare and Medicaid, you will pay $0 for the services you receive through your state Medicaid program.
If you have a Medicare Advantage plan, you will have the same coverage rules as Original Medicare. However, you may have network restrictions based on your plan type.
Medicare's OTP services
Medicare covers different services under its OTP benefit, including:
Food and Drug Administration (FDA)-approved medications, including opioid agonists like methadone and opioid antagonists like naltrexone
substance misuse counseling, including individual and group sessions
periodic assessments
intensive outpatient programs
peer recovery help services
toxicology tests
referral services
coordinated care
Original Medicare Part B will cover some of the prescription medications you may be given. However, you may need a Part D prescription drug plan for others.
If you have a Medicare Advantage plan, your plan must include drug coverage for some medications to be covered.
Medicare and OTP eligibility
Anyone with OUD is eligible for an OTP, and doctors look for specific symptoms when diagnosing the condition.
The Centers for Disease Control and Prevention (CDC) states that healthcare professionals should confirm a diagnosis of OUD using a checklist. This list derives from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR).
You may also require blood or urine screenings that check for opioids and assess whether you are at risk of addiction.
»Learn more: Risk Factors for OUD
Support for opioid use disorder
Seeking help for addiction can feel daunting or even scary, but several organizations are there to help.
If you believe that you or someone close to you is displaying signs of addiction, you can contact the following organizations for immediate help and advice:
SAMHSA: 800-662-4357 (TTY: 800-487-4889)
988 Suicide & Crisis Lifeline: 988
Frequently asked questions
Below are some common questions about OUD and OTP treatment services.
Does Medicare pay for opioid treatment?
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, you may have to visit in-network doctors and facilities.
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, you may have to visit in-network doctors and facilities.
What is the new treatment for opioids?
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. Which one a doctor gives you will depend on whether you are new to the medication.
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. Which one a doctor gives you will depend on whether you are new to the medication.
What is the gold standard treatment for opioid use disorder?
Research from 2023 confirms that the 'gold standard' evidence-based medication treatment for OUD is methadone, buprenorphine, or naltrexone.
Research from 2023 confirms that the 'gold standard' evidence-based medication treatment for OUD is methadone, buprenorphine, or naltrexone.
What are opioid treatment programs?
Opioid treatment programs are purpose-driven treatment plans for OUD.
OTPs typically involve a combination of different therapies, including talking therapies, prescription medications, periodic assessments, and peer support.
Opioid treatment programs are purpose-driven treatment plans for OUD.
OTPs typically involve a combination of different therapies, including talking therapies, prescription medications, periodic assessments, and peer support.
Summary
If you have Original Medicare, Part B covers opioid treatment programs (OTPs) in full if you have opioid use disorder (OUD) and meet eligibility requirements. People with Medicare Advantage plans have the same coverage but may need to visit in-network doctors or healthcare facilities.
If you have OUD, you can recover, and help is available through your healthcare team, Substance Abuse and Mental Health Services Administration (SAMHSA) at 800-662-4357, or through the 988 Suicide & Crisis Lifeline at 988.
The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
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