Does Insurance Cover Medication-Assisted Treatment?

Medication-assisted treatment (MAT) utilizes modern advances in treating substance abuse and mental health related issues by providing effective medications and counseling options to help you begin your road to recovery. MAT can become a part of your inpatient treatment care or can be provided by way of intensive outpatient care. As the opioid epidemic continues to rise, insurance companies are rising to the task of providing coverage opportunities for their clients to help make MAT more affordable and available for those seeking addiction treatment throughout the US.

Does Medicaid Cover Opioid Treatment?

With opioid deaths exceeding 47,000 and over 2,000,000 cases of opioid use disorder reported (OUD) reported in 2017, the need for insurance coverage for millions of Americans has become more prominent, now more than ever. More recently, Medicaid has risen to the call for insurance coverage for MAT programs. However, there are some limitations that are included in their expansion. In some states, coverage is still limited, if not available at all. For those in the States where coverage is available, Medicaid coverage is available to adults who reach an income of up to 138% of the federal poverty level.

Medicaid currently offers the below list of services for those suffering from substance abuse disorder. Kaiser Health News has more information regarding Medicaid coverage of MAT services on a state-by-state basis. Medicaid currently offers the below services in select states:

Inpatient Detoxification
Residential Rehabilitation
Outpatient Detoxification
Buprenorphine for Medication Assisted Treatment (MAT)
Oral Naltrexone for Medication Assisted Treatment (MAT)
Injectable Naltrexone for Medication Assisted Treatment (MAT)
Methadone for Medication Assisted Treatment (MAT)
Suboxone Treatment
Intensive Outpatient Treatment for Substance Use Disorder
Smoking and Tobacco Use Cessation Counseling (Excluding Mandatory Coverage for Pregnant Women)

As of January of this year (2020), Medicaid covers MAT programs as long as they include behavioral health services: services which include mental health treatment and substance use disorders.

Medicare and MAT

As of October of 2018, Medicare joined the ranks of insurance companies that now offer services for substance use disorders related MAT. Opioid Bill H.R. 6: Support for Patients and Community Act was passed to ensure Federal support for men and women struggling with opioid and substance use disorders through the US. Under this act there are a few limitations:

“(Sec. 2002) The initial examination for new enrollees and annual wellness visits under Medicare must include a substance-use disorder screening and a review of any current opioid prescriptions.”
“(Sec. 2003) In general, prescriptions for controlled substances that are covered drugs under Medicare must be transmitted through electronic prescription programs.”
“(Sec. 2004) Medicare prescription drug plan sponsors must establish drug-management programs for at-risk beneficiaries.”
“(Sec. 2005) The bill also requires coverage for services provided by certified opioid-treatment programs under Medicare.”

What Medications Are Used in MAT?

There are three medications currently used in many MAT programs that are usually covered by most insurance companies. These medications are:

Methadone
Buprenorphine
Naloxone

MAT Medications Covered by Insurance

With treatment facilities now able to accept Medicare, access to evidence-based MAT programs will increase nationwide for those who may previously have been unable to afford the treatment. Medicare covers the following FDA-approved medications:

More and more treatment facilities are able to accept Medicare and Medicaid for MAT programs. Along with coverage for substance use disorders (namely, opioid addiction), both Medicaid and Medicaid provide coverage for the below medications commonly used in MAT programs:

Methadone – Methadone is one of the most common medications used in MAT programs over the years. Methadone can treat both chronic pain and opioid addiction. However, Methadone is only covered by insurance if prescribed as part of a holistic care plan involving mental health services and substance use treatment administered by a clinical facility. The good news is that Methadone is currently only available in MAT programs that abide by strict medication management regulations.
Buprenorphine – Buprenorphine is another common medication used to treat opioid use disorders. Buprenorphine is similar to Methadone, but can be prescribed by your family doctor or physician. In order for Buprenorphine to be covered by Medicaid or Medicare, the individual must be evaluated for opioid use disorder and enroll in behavioral therapy programs (mental health or substance use treatment).
Naltrexone/Vivitrol® – Naltrexone differs from Buprenorphine and Methadone as it is not an opioid or narcotic medication. Naloxone is currently covered by most insurance companies and can be prescribed by your local doctor, physician, as well as take part in your MAT program.

Freedom Now uses a combination of both Buprenorphine and Naloxone called Suboxone. Suboxone is currently covered by Medicaid and Medicare as well as many other insurance companies.

Medication-Assisted Treatment Guidelines

In many cases, guidelines for MAT programs are unique to the insurance company you are with. In most cases where Medicaid and Medicare provide coverage for MAT, a prior authorization by a medical professional is required. This may mean that you are required to pay the full amount to begin your treatment or to be evaluated by a doctor. In this case, Medicaid and Medicare will reimburse a certain amount if a co-pay is required. State-wide coverage for opioid use may have other limitations established, such as: quantity of drugs prescribed, dose limitations, and requirements involving therapeutic treatments for any additional underlying issues. If you have any more questions regarding whether or not your insurance company covers MAT programs, contact your provider to learn more about their services.