H.R. 5083, Expanding Access to Evidence-Based Opioid Treatment for Seniors Act

Bill Summary:  H.R. 5083, the Expanding Access to Evidence-Based Opioid Treatment for Seniors Act, would allow Medicare beneficiaries suffering from opioid use disorders to access treatment at opioid treatment programs (OTPs), which provide medication-assisted treatment (MAT). Dating back to the 1960s, MAT is the most effective treatment for opioid use disorder, sustaining long-term recovery by combining medications (i.e., methadone, buprenorphine, and naltrexone) with counseling and behavioral therapies.

• There are approximately 1,500 OTPs across the United States, caring for roughly 400,000 patients. These programs provide a full range of services to support those struggling with opioid use disorders. Because opioid use disorder is a chronic, relapsing disease, treatment is a long-term process with the ultimate goal of transitioning individuals to recovery so they can lead healthy, productive lives.

• Medicaid and some private payers cover OTPs as a treatment option for those with opioid use disorders, however, Medicare does not. The lack of Medicare coverage for this critical therapy has not gone unnoticed.  For instance, the National Governor’s Association noted the absence of coverage for methadone in OTPs as a gap that must be addressed in its 2018 recommendations.

• Though not frequently discussed, the opioid epidemic is particularly problematic for the Medicare population, with one-third of beneficiaries enrolled in Medicare’s drug program (Part D) receiving an opioid prescription in 2016.   Among Medicare beneficiaries under age 65 who qualify on the basis of disability, nearly 50 percent are receiving opioid prescriptions. The lack of Medicare coverage for OTPs means that a critical treatment option for Medicare beneficiaries with opioid use disorders is unavailable. This access issue hurts recovery prospects. 

• The legislation would enable Medicare to pay for opioid use disorder treatment provided to Medicare beneficiaries in OTPs. This payment, like most Medicaid and private insurance reimbursement mechanisms, would be for a package of services – a “bundle” to include medication administration, care coordination, social services, and other services provided to beneficiaries. The legislation also provides for an annual audit of OTP billing by the Inspector General of the Department of Health and Human Services for the first five years to ensure compliance with program policies and procedures; these audits would continue as necessary in subsequent years.