In 2018, responding to a wave of overdose deaths, Congress passed legislation requiring Medicare to pay for services at opioid treatment programs for the first time.
But two years after Medicare began covering those programs, which use methadone and other medications to help reduce opioid use and overdose deaths, providers say their efforts are being hindered by Medicare Advantage — private insurance companies that administer benefits to about half of the Medicare population.
They say the tactics Medicare Advantage has long used to control health care costs can also delay or block access to patient care, which can be especially dangerous or deadly for someone with a substance use disorder.
“Once a patient reaches out for treatment, they’re not going to sit around and wait. If you don’t get people into treatment that day, you’ve kind of lost them to the street, and that’s what is the most concerning,” said Jay Higham, CEO of Behavioral Health Group, which operates 120 opioid treatment programs in 24 states.
Opioid treatment programs say they usually must first get approval from Medicare Advantage plans for their services to be paid for, a process that can take several days or weeks. Patients have been told they must pay for a portion of their care and get referrals from primary care doctors before starting treatment.
Programs also say Medicare Advantage plans are slow to issue payments, if they pay at all, and also make it difficult to get on a list of covered providers called a network.
Such obstacles have led some opioid treatment programs to be more selective about which Advantage plans they work with.
“It’s basically a benefit without being a benefit,” said Gary Houle, CEO of the North Charles Mental Health Research and Training Foundation, a nonprofit that operates an opioid treatment program in Cambridge, Massachusetts. “They say they provide reimbursement for methadone treatment, but they don’t really. There are so many roadblocks, it’s impossible.”
He said his program has had to stop accepting some Advantage plans because of nonpayments or difficult prior authorization practices.
The opioid crisis remains acute: A record-high 80,000 people died of opioid overdoses in 2021, a 15% increase over 2020.
There are about 1,900 opioid treatment programs in the United States. While some lawmakers and addiction experts have called for making methadone available outside of opioid treatment programs, for now, those programs are the only outpatient settings that can dispense methadone, which has been shown to reduce opioid use and overdose deaths and curb withdrawal symptoms.
Prior authorization
Advantage plans, also known as Medicare Part C, were established in 1997 to administer Medicare benefits at a lower cost than the government. But the tactics that they argue reduce unnecessary care and lower health care costs, like prior authorization, have been criticized across the board by physicians and providers, including opioid treatment programs.
“It’s really an important issue to make sure that people have immediate access to treatment. As soon as you put prior authorization on it, you’re delaying that access,” said Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates of New York, which represents 108 opioid treatment programs in the state.
Under federal regulations, Medicare Advantage plans can take up to 72 hours to respond to an urgent request or up to 14 days for nonurgent requests. But that is time wasted when someone with opioid use disorder needs to begin treatment, experts say. Sometimes those requests are denied with no explanation or providers must resubmit requests after a few months of treatment.
Schorr said she is also increasingly seeing plans require physician referrals for opioid treatment programs, which can also lead to delays, especially if someone doesn’t already have a primary care doctor.
If a person is in withdrawal and can’t get treatment, they might return to illicit drugs and overdose, said Schorr, who is also vice president of West Midtown Medical Group, an opioid treatment program in New York City.
In 2022, 85% of Medicare Advantage enrollees were in plans that require prior authorization for coverage of opioid treatment programs, according to a Kaiser Family Foundation analysis.
That includes UnitedHealthcare, which covers about 28% of Medicare Advantage enrollees, making it the dominant insurer in the market, according to a Kaiser Family Foundation analysis.
A UHC spokesperson did not respond to a request for comment.
Some plans don’t make clear when prior authorization is necessary, leaving providers to find out that it is when they don’t get paid for a service or their claims are denied.
Unpaid claims
Other opioid treatment programs say their claims for payment are often denied without reason.
North Charles Mental Health Research and Training Foundation has had to rely on seeking payments for treating some Advantage enrollees through a state program that reimburses care for uninsured or underinsured patients.
“It’s a barrier to care, is what it is. They’re never going to admit it’s intentional, but it sure does seem like it,” Houle said. “If we’re out to save lives and treat people as quickly as we can when they present themselves, these Advantage plans are not helpful.”
Dave Kneessy, regional director of the Central Florida Treatment Center, said there is little to no guidance from Medicare Advantage plans about how to get in network, whether they require prior authorization and what documentation and billing codes they need.
“It’s not like they go, ‘Congratulations, you’re now in network with UnitedHealthcare Medicare Advantage plan. Let us walk you through how to bill.’ It’s a crapshoot. You just start processing through denials and changing things and they won’t tell you how to fix them,” Kneessy said.
“You keep trying and applying and submitting and getting denied and changing things one piece at a time until you find the magic formula that actually works. And some of them just don’t work. They just don’t pay.”
All of those hoops take time to jump through, during which Central Florida Treatment Center tries to continue seeing patients with Medicare Advantage plans.
“We do everything we can to work with the patient, but there comes a point we can’t treat multiple people for free,” Kneessy said.
Copays
Many Medicare Advantage programs require patients to pay for a portion of their own treatment called a copay.
Studies have long shown copays can be a barrier to care.
“If a plan imposes a copay every time they show up, that’s completely unreasonable,” said Jason Kletter, president of BayMark Health Services, which has 116 opioid treatment programs in 37 states. Patients typically must visit opioid treatment programs several times a week for treatment.
“Even if it’s just five bucks — if you’ve got to do that 30 days a month, it’s unreasonable.”
Traditional Medicare doesn’t require copays for opioid treatment program services, noting in a 2020 rule that it wanted to “minimize barriers to patient access” to treatment services.
But Advantage plans are allowed by law to set copays, with the intention of reducing health care costs by making patients reconsider whether they need a service or doctor’s visit.
Proposed rules
CMS did not make a representative available for an interview after asking for a list of questions.
In written responses, a CMS spokesperson said the agency is “committed to ensuring that Medicare Advantage enrollees have access to all Medicare-covered services, including the critical services provided by (opioid treatment programs).”
The agency in December proposed two rules related to Medicare Advantage that could have an impact on opioid treatment programs.
CMS is proposing that Advantage plans use Medicare coverage rules when determining whether a request is “medically necessary.” Currently, plans can create their own rules for making prior authorization decisions, and those criteria are often shielded from the public.
A report released in April by the Health and Human Services Office of Inspector General found that of prior authorization requests denied by Medicare Advantage plans, 13% were for services that would have been covered by traditional Medicare.
CMS also wants to require that prior authorization approvals be valid for the duration of the course of treatment and for plans to clearly state when prior authorization is necessary. Plans would have to state any needed documentation for those requests and explain their reasons for any denials to providers and patients.
The agency has not proposed changing the 72-hour timeline for urgent requests.
CMS is also proposing prohibiting “misleading” marketing around Medicare Advantage that experts say has contributed to increased enrollment in those plans.
When evaluating whether a plan’s network is adequate, CMS also wants to start considering whether there are enough opioid treatment programs available and whether they are accessible to enrollees.
The Medicare Rights Center, American Society of Addiction Medicine, National Association for Behavioral Healthcare and others had called on CMS to update network adequacy requirements to address substance-use-specific facilities like opioid treatment programs and provide better oversight of Advantage plans.
“We’re very concerned that when people ask for care and they are denied, that is a terrible outcome that can be a life-changing or life-ending decision for that person,” said Julie Carter, federal policy associate for the Medicare Rights Center. “Things may get really out of control after that point, and we want to make sure people get the care they need in the moment they’re able to.”
This article was written with the support of a journalism fellowship from The Gerontological Society of America, the Journalists Network on Generations and the NIHCM Foundation.
