Providers say Medicare Advantage hinders new methadone benefit

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.

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