American Society of Addiciton Medicine

Cover It: Insurance for Addiction Treatment

National Advocacy

Cover It: Insurance for Addiction Treatment

ASAM identifies and advocates for policies and practices that ensure equitable access to, and coverage for, comprehensive, high-quality addiction care for all.

ASAM’s federal advocacy works to ensure mental health and addiction treatment services are covered on par with medical and surgical services by both public and private payers and are not subject to arbitrary limits or unfair utilization controls. For example, a robust body of research shows that medications for addiction treatment, such as buprenorphine, naltrexone, and methadone, are highly effective for the treatment of OUD. However, utilization management techniques – such as prior authorization – restrict patient access to these life-saving treatments. A delay of just one day is enough time for a patient to relapse, overdose, or suffer other consequences that can adversely affect their treatment outcome.

National Initiatives

Medicare OTP Bundled Payment 

In the 2020 Medicare Physician Fee Schedule (MPFS), CMS finalized a methodology to implement the new Medicare Part B benefit for OUD treatment services furnished by OTPs that was established by the SUPPORT Act. Starting January 1, 2020, CMS pays OTPs through bundled payments for OUD treatment services in an episode of care provided to people with Medicare Part B.  Read more.

Medicare OUD Demonstration

As a result of the SUPPORT Act, the Centers for Medicare & Medicaid Services (CMS) launched the Value in Opioid Use Disorder Treatment Demonstration, also known as the Value in Treatment Demonstration. Starting in April 2021, this 4-year demonstration tests whether a new care management fee and performance-based incentive for opioid use disorder (OUD) treatment services can cut hospitalizations and improve health outcomes for individuals with OUD.   Read more.

H.R. 955/S. 285 - Medicaid Reentry Act

ASAM supports the Medicaid Reentry Act,  which would grant states limited new flexibility to restart benefits for Medicaid-eligible incarcerated individuals 30 days prior to release.

H.R. 3514/S. 1821 - Humane Correctional Health Care Act

ASAM supports the  Human Correctional Health Care Act, which would repeal the Medicaid Inmate Exclusion and allow states to cover individuals, who are incarcerated, under Medicaid.

H.R. 1364 - Parity Enforcement Act

ASAM supports the Parity Enforcement Act, which would amend the Employee Retirement Income Security Act (ERISA) to give the U.S. Department of Labor the authority to levy civil monetary penalties against health insurers and plan sponsors for parity violations. This act would provide USDOL a critical tool to ensure health plan compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008. 

H.R. 3450/S. 1727 - Medicaid Bump Act

ASAM supports the  Mediciad Bump Act, which would incentivize states to expand coverage of behavioral health services, including mental health and substance use services, by providing a corresponding increase in the Federal Medical Assistance Percentage (FMAP) matching rate to 90% for these services.

H.R. 6 - SUPPORT for Patients and Communities Act

The SUPPORT for Patients and Communities Act was signed into law on October 24, 2018. The bill contains many provisions designed to promote coverage for addiction treatment. You can read a section-by-section summary of the bill  here

  • OUD outpatient treatment demo in Medicare
    • Effective January 2021    
    • Emphasis on care coordination & bio-psychological-social model of care    
    • Enhances reimbursement and focuses on accountability metrics        
  • Medicare coverage of OTPs beginning January 2020
    • OTPs previously not covered by Medicare
    • Bundled payments for holistic services and coverage of methadone
    • Fee schedule updated yearly
  • Medicaid Reentry Act
    • Law currently prohibits payment, but not enrollment for those in criminal justice settings   
    • HR 6 requires HHS to convene stakeholders to develop best practices for transitioning back into the community upon release    
  • October 2020 – September 30, 2025: Required coverage of OUD treatment medication in Medicaid, subject to some allowable exceptions.
  • Telehealth/telemedicine
    • Requires CMS to issue guidance to state Medicaid programs about the federal options for reimbursement of services delivered via telehealth
    • Waives requirement for the beneficiary to be located in a county outside of a Metropolitan Statistical Area (MSA) or in a rural Health Professional Shortage Area (HPSA) located in a rural census tract beginning July 2019
    • Directs the Attorney General, with the Secretary of Health and Human Services, to issue final regulations by October 2019 to provide further guidance about the special registration process
  • Added testing of incentive payments for behavioral health providers that use certified-electronic health records as a priority for HHS
  • Requires the use of e-prescribing for schedule II-V controlled substances covered under a Medicare Part D prescription drug plan, or a Medicare Advantage prescription drug plan starting January 2021
  • Controlled Substances Act has been changed to allow implantable or injectable medications which are controlled substances and are for the purposes of maintenance or detoxification treatment, to be delivered via specialty pharmacies

P-COAT Alternative Payment Model

ASAM and the American Medical Association (AMA)  jointly released a conceptual alternative payment model entitled the "Patient-Centered Opioid Addiction Treatment (P-COAT) Alternative Payment Model." The model is designed to increase the utilization of office-based treatment of opioid use disorder by providing adequate financial support to successfully treat patients and broaden the coordinated delivery of medical, psychological, and social support services.

Section 1115 Waiver

ASAM works with its state chapters and CMS to secure approval of section 1115 waivers to ensure appropriate funding and coverage of addiction treatment.

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