CurrentOptumPolicy N/A

Medicare coverage and payment rules for Opioid Treatment Programs (OTPs)

Defines Medicare Part B benefit, covered OUD treatment services, OTP certification/accreditation requirements, episode-based bundled payments, and payment treatment for mobile units; applies to OTPs furnishing services to Medicare beneficiaries.

Policy Summary

PayerOptum

PolicyMedicare coverage and payment rules for Opioid Treatment Programs (OTPs)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument that at least one OUD treatment service was furnished during the 7-day episode and for G0137 document at least nine services in that period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 weekepisode of care duration

≥9min services for G0137

100%bundled payment to OTP

3 FDA drugsFDA-approved OUD drugs

IncludedOTP mobile units

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Covered OTP services and episode rules

Covered when ALL of the following are met

Medicare OTP bundling coverage: Services are covered when furnished by an OTP that meets Medicare participation requirements (enrolled in Medicare, SAMHSA-certified, SAMHSA-accredited, and with a provider agreement under 42 CFR 489) and when services are for treatment of opioid use disorder and are medically reasonable and necessary.

Includes drug and non-drug components as defined; bundled payment applies per 7-day episode.

Included services in bundle: Bundle includes FDA-approved OUD medications, dispensing/administration, substance use counseling, individual and group therapy, and toxicology testing.

Drug and non-drug components have separate payment methodologies combined into full bundled rate.

Telehealth/remote provision: Periodic assessments and counseling/therapy may be furnished via two-way audio-video; in certain circumstances and dates specified, audio-only telephone may be used when video is unavailable or beneficiary cannot consent to video.

Specific PHE-origin flexibilities made permanent for some services and expanded in Jan 2025 for audio-only periodic assessments when no video access.

Intensive outpatient coverage: Beginning Jan 1, 2024, OTP intensive outpatient services furnished by OTPs that meet the criteria (minimum 9 hours/week and certified plan of care) are covered as part of OTP services but do not include FDA-approved opioid agonist/antagonist medications, opioid antagonist medications for emergency overdose treatment, or toxicology testing.Minimum 9 hours/week and minimum 9 services per 7-day episode for G0137

Must be certified and documented in plan of care by physician or NPP as permitted by state law.

Episode of Care Coverage Criteria

Covered when ALL of the following are met

Episode billing threshold: At least one OUD treatment service (drug or non-drug component) was furnished to the patient during the week corresponding to the episode of care; for intensive outpatient services furnished by OTPs (HCPCS G0137) the threshold is a minimum of nine services over a 7-day period.see node

Non-drug-only episode exists for weeks without medication (e.g., monthly injectables/implants).

Drug Component Eligibility

Covered when ONE of the following medication conditions is met

Medication category: Medication used is one of: methadone (oral), buprenorphine (oral, injectable, implant), or naltrexone (injectable); if medication is new and FDA-approved but not specified, bill G2075 (medication NOS) and CMS will price using typical/average maintenance dose.medication type

Drug component payment uses typical/average maintenance dosages and pricing methodologies described in document.

Non-Drug Component Coverage

Covered non-drug services included in the bundle

Non-drug component: Includes counseling, individual and group therapy, toxicology testing (including at least eight random tests/year for maintenance), dispensing and/or administration costs, and related services; these services are included in the bundled payment and not separately billable outside add-on/primary codes.>=8 tests/year

OTPs must provide adequate substance use counseling and professionals must operate within state law/scope of practice.

OTP intensive outpatient services do not include FDA-approved opioid agonist or antagonist medications, emergency opioid antagonist medications for overdose treatment, or toxicology testing. Intensive outpatient services are treated as part of the OTP bundle but the drug component (FDA‑approved medications) and toxicology testing are identified separately in the bundled payment methodology and are not considered part of the intensive outpatient service definition for purposes of exclusions.

Counseling or therapy furnished via communication technology or otherwise as part of OUD treatment services by an OTP must not be separately billed by the practitioner providing those counseling or therapy services because these services are already paid through the OTP bundled payment. Only entities enrolled with Medicare as an OTP may bill the OTP bundled payment codes; telemedicine cannot be used to expand a provider’s scope of practice or permit practice in a jurisdiction where the provider is not licensed.

Payment for medications that are delivered, administered, or dispensed to a beneficiary as part of an OTP bundled payment is considered duplicative if that same medication for the same beneficiary on the same date of service is separately paid under Medicare Part B or Part D. In such cases, CMS will recoup the duplicative payment made to the OTP.

Payments under the Medicare OTP benefit must be for the treatment of an opioid use disorder. Services furnished for indications other than OUD treatment are not payable under the OTP benefit; to bill an episode the OTP must meet the episode requirements (at least one OUD treatment service during the 7‑day episode, or for intensive outpatient G0137 a minimum of 9 services over a contiguous 7‑day period).

Therapy or counseling services furnished by individuals who are not authorized under State law and scope of practice to provide such services would not be covered as OUD treatment services. OTPs must ensure professionals furnishing counseling and therapy are permitted by state law (for example, licensed professional counselors, licensed clinical alcohol and drug counselors, licensed marriage and family therapists, or other state‑authorized practitioners).

Coding and billing codes

OTP intensive outpatient HCPCSHCPCS

G0137

OTP intensive outpatient services (HCPCS code referenced for intensive outpatient threshold)

Covered HCPCS codes for OTP bundled and add-on servicesHCPCSCovered

G2067	Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed
G2068	Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed
G2069	Medication assisted treatment, buprenorphine (injectable) administered on a monthly basis; bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed
G0533	Medication assisted treatment, buprenorphine (injectable) administered on a weekly basis; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed
G2073	Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed
G2074	Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed
G2075	Medication assisted treatment, medication not otherwise specified; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed
G2076	Intake activities, including initial medical examination and preparation of a care plan; list separately in addition to each primary code
G2077	Periodic assessment; list separately in addition to each primary code
G2078	Take-home supply of methadone; up to 7 additional day supply; list separately in addition to primary procedure

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OTP Place of ServicePOS

58	Place of Service code 58: Non-residential Opioid Treatment Facility-a location that provides treatment for OUD on an ambulatory basis. Services include methadone and other forms of MAT

OTP bundled payment and add-on G codesHCPCSCovered

G codes

HCPCS G codes describing OTP bundled payments and add-on codes (specific G codes not listed in this excerpt)

Intensive outpatient services threshold — G0137

ThresholdMinimum of 9 services over a contiguous 7-day period to bill an intensive outpatient episode (HCPCS G0137).

Applicable codeG0137 (Intensive outpatient services).

Included service types that may meet thresholdIndividual and group therapy, occupational therapy, social worker services, trained psychiatric nurses, and other qualifying intensive outpatient services per §410.67(b)(ix).

Episode duration

Episode durationOne-week contiguous (7-day) period (may start any day of the week).

Billing periodWeekly episode corresponds to the contiguous 7-day period during which services were furnished.

Non-drug exceptionsFor some medications furnished monthly (e.g., monthly injectables/implants), non-drug-only episodes may be billed for weeks without medication administration.

Intensive outpatient services threshold

Minimum servicesMinimum of nine services over a contiguous 7-day period to meet the billing threshold for intensive outpatient episode (G0137).

Qualifying servicesServices may include individual and group therapy, occupational therapy, social work, nursing, and other intensive outpatient services specified in the G0137 descriptor.

Documentation requirementOTPs must document the services furnished during the 7-day period to support billing the intensive outpatient threshold.

Oral dispensing fee approximation

Approximate fee$10.50 (approximation of average dispensing fees under state Medicaid programs used to determine the non-drug component for oral drugs).

ContextUsed because there is no Medicare Part B rate for oral MAT drugs; applied in building-block methodology for non-drug component.

Applies toDispensing oral medications (oral MAT) included in non-drug component of the weekly bundle.

Provider requirements, billing and documentation actions

Billing Rule

Bundled episode billing / G0137 threshold

Payment for OTP episodes is a weekly bundled episode. For standard episodes the threshold to bill is that at least one OUD treatment service (drug or non-drug component) was furnished during the contiguous 7-day episode. For intensive outpatient services reported with HCPCS G0137, the billing threshold is a minimum of nine services furnished over a contiguous 7-day period.

Weekly episode = contiguous 7-day period
General episode threshold = >=1 OUD treatment service during the week
G0137 intensive outpatient threshold = minimum 9 services in same 7-day period

Prior Authorization

Eligibility and enrollment requirements

Only entities enrolled with Medicare as an Opioid Treatment Program (OTP), certified by SAMHSA, accredited by a SAMHSA‑approved accrediting body, and having a Medicare provider agreement may bill OTP-specific bundled and add-on HCPCS G codes. OTPs must be enrolled in Medicare and maintain SAMHSA certification and SAMHSA-approved accreditation per federal requirements.

Must be enrolled in Medicare as an OTP
Must have SAMHSA certification for the OTP
Must be accredited by a SAMHSA-approved accrediting body
Must have a valid provider agreement under 42 CFR 489
Only Medicare-enrolled OTPs can bill OTP-specific G codes

Denial Risk

Duplicative medication payment recoupment

CMS will recoup duplicative medication payments. If a medication delivered, administered, or dispensed to a beneficiary as part of an OTP bundled payment (or an adjustment) is separately paid under Medicare Part B or Part D for the same beneficiary on the same date of service, that separate payment is considered duplicative and will be recouped.

Duplicative payment definition: same medication, same beneficiary, same date of service, paid under Part B or Part D and also included in OTP bundle
CMS recoups the duplicative payment from the OTP

Billing Rule

Medication NOS billing

If an OTP furnishes MAT using a new FDA-approved opioid agonist or antagonist medication that is not specified in existing codes, bill the episode using the medication not otherwise specified (NOS) HCPCS code G2075. Contractors will determine drug cost using a typical or average maintenance dose and add that to the appropriate non-drug component payment based on the drug administration mode.

Use HCPCS G2075 for medication NOS (new FDA‑approved OUD medications not otherwise coded)
CMS uses typical/average maintenance dose to price the drug component for NOS
Combine NOS drug cost with non-drug component for total bundled rate

Billing Rule

Mode-based non-drug payment

The non-drug component payment is determined by a building-block methodology that groups services by mode of drug administration (oral, injectable, implantable). The non-drug component uses Medicare payment rates for similar non-facility services, with adjustments to account for administration or dispensing costs specific to the mode (for oral dispensing an approximation of state Medicaid dispensing fees is used; injectable bundles include Medicare administration rates). The same building-block approach is used to set the non-drug component for NOS medications based on their mode of administration.

Non-drug component uses building-block methodology using Medicare non-facility rates
Adjustments applied for administration/dispensing costs by mode: oral, injectable, implantable
Oral dispensing approximation uses $10.50 (state Medicaid approximation) when no Part B oral MAT rate exists
Injectable bundles include Medicare administration non-facility rate
Medication NOS non-drug component determined by mode of administration

Definitions and key terms

Episode of care — definition

DefinitionEpisode of care means a one-week (contiguous 7-day) period.

Starts/endsA contiguous 7-day period that may start on any day of the week and constitutes the bundled episode duration.

Billing implicationAt least one OUD treatment service must be furnished during the week to bill an episode; intensive outpatient episodes require meeting the nine-service threshold within the week.

Opioid treatment program (OTP)

DefinitionOpioid treatment program (OTP) means an entity that is an OTP as defined in 42 CFR 8.2 that meets the requirements described in Section 30.

Certification requirementOTPs must meet SAMHSA certification and other regulatory requirements as described in Section 30.

Medicare enrollmentOTPs must be enrolled in Medicare to receive payment for covered OUD treatment services.

OUD treatment service — definition and components

DefinitionOUD treatment service includes FDA‑approved opioid agonist/antagonist medications (oral, injected, implanted), dispensing/administration, substance use counseling, individual and group therapy, toxicology testing, intake and periodic assessments, emergency opioid antagonist and overdose education, and OTP intensive outpatient services (beginning Jan 1, 2024).

FDA-approved medicationsExamples: buprenorphine, methadone, naltrexone (three FDA‑approved drugs noted).

Telehealth allowanceCounseling and periodic assessments may be furnished via two-way audio‑video and, in certain circumstances and dates, via audio‑only telephone when video is unavailable and requirements are met.

OTP Mobile Units

Payment recognitionServices furnished via OTP mobile units will be considered for determining payments to OTPs if medically reasonable and necessary and furnished per SAMHSA and DEA guidance.

Geographic adjustmentFor geographic adjustment, services furnished via an OTP mobile unit are treated as if furnished at the OTP's registered physical location.

Effective dateMobile unit services considered beginning January 1, 2023.

Episode of care — bundled period and components

Bundle definitionAn episode of care is a weekly bundled period (contiguous 7-day) where at least one OUD treatment service (drug or non-drug component) was furnished; for some medications furnished monthly, non-drug-only weekly episodes may be billed when no medication was administered that week.

Drug and non-drug componentsCMS developed separate payment methodologies for the drug component and the non-drug component (dispensing/administration, counseling, therapy, toxicology testing).

Intensive outpatient noteFor intensive outpatient services (G0137) the bundle threshold is nine services over the 7-day episode.

Non-drug component — what is included

Included servicesNon-drug component includes counseling, individual and group therapy, toxicology testing, and drug dispensing/administration costs (excluding the medication itself).

Toxicology testing frequencyOTPs are required to provide at least eight random drug abuse tests per year per patient in maintenance treatment.

Payment treatmentThese non-drug services and dispensing/administration costs are included in the bundled payment and not separately billable except via specified add-on codes.

Non-residential Opioid Treatment Facility (OTP) — POS 58

Place of Service codePlace of Service code 58 (Non-residential Opioid Treatment Facility).

Usage expectationCMS expects POS 58 to be noted on claims submitted for the HCPCS G codes describing OTP services; G codes can only be billed by OTPs.

ScopePOS codes may be used by other payers; POS 58 describes ambulatory OTP locations providing MAT such as methadone and other forms of MAT.

Level of care and intensity criteria

Outpatient / Intensive Outpatient (OTP services)

Enrollment and certification: OTP must be enrolled in Medicare, have SAMHSA certification, be accredited by a SAMHSA-approved accrediting body, and have a provider agreement under 42 CFR 489 to furnish Medicare-covered OUD treatment services.

Failure to meet these requirements prevents Medicare payment to the OTP.

Periodic assessment modality: Periodic assessments required under 42 CFR 8.12(f)(4) may be furnished face-to-face or via two-way audio-video communication; beginning Jan 1, 2025, if beneficiary lacks video access these may be furnished via audio-only telephone if other requirements are met.

Document clinical appropriateness and compliance with requirements.

Outpatient / OTP

Intake activities: Intake includes an initial medical examination by an appropriately licensed practitioner and preparation of a care plan (HCPCS G2076); intake may be furnished via two-way audio-video and in specific scenarios via audio-only as permitted by DEA/SAMHSA and applicable rules.documented intake and care plan

List G2076 separately in addition to primary code when billed.

Periodic assessments (HCPCS G2077) include review of MOUD dosing, treatment response, and other SUD treatment needs; may be furnished via two-way audio-video and, beginning Jan 1, 2025, via audio-only when beneficiary lacks video access and requirements are met.periodic as clinically appropriate

List G2077 separately in addition to primary code when billed.

Treatment modalities included in OTP service

Medication-Assisted Treatment (MAT)

MAT medications: Use of FDA-approved medications (buprenorphine, methadone, naltrexone) as part of OTP services; dispensing and administration are included in the bundle.

Document which FDA-approved opioid agonist/antagonist medication is used when dispensing pharmacotherapy; billing for new medications may use G2075 (NOS).

Counseling / Psychotherapy

Counseling and therapy: Substance use counseling, individual and group therapy are covered when furnished by professionals authorized under state law; these services may be provided via two-way audio-video (and in some cases audio-only) as clinically appropriate.

Therapy/counseling provided by individuals not authorized under state law would not be covered as OUD treatment services.

Intensive Outpatient Program (IOP)

IOP inclusion: Intensive outpatient services (G0137) may include individual and group therapy, occupational therapy, social worker services, trained psychiatric nurses, drugs/biologicals for therapeutic purposes (excluding FDA-approved opioid agonist/antagonist meds), and diagnostic services (excluding toxicology testing).>=9 services/7 days

IOP services must meet definition requirements and be certified and documented in plan of care.

Recovery Support and Care Coordination

Peer and navigation services: Coordinated care/referral (G0534), patient navigation (G0535), and peer recovery support services (G0536) are add-on billable services when applicable requirements are met; list separately in addition to primary code.per 30 minutes for G0534/G0535/G0536

These add-ons adjust bundled payment rates when furnished.

Medication for OUD (MAT)

Mode of administration: Non-drug component payment varies by mode of medication administration (oral, injectable, implantable) and uses a building-block methodology; oral dispensing fees use an approximation of $10.50.

CMS uses typical/average maintenance dosages to calculate drug component and combines with non-drug component to determine bundled payment.

Visit limits and supply rules

Any OUD treatment service required to bill an episode

Minimum services to bill an episodeMinimum 1 OUD treatment service (drug or non-drug) furnished during the 7-day episode is required to bill an episode of care.

Episode periodPer 7-day episode (contiguous week).

DocumentationOTPs must document that at least one OUD treatment service was furnished during the 7-day episode to support billing.

OTP intensive outpatient services — G0137 threshold

IOP billing thresholdMinimum 9 services over a contiguous 7-day period are required to meet the G0137 intensive outpatient billing threshold.

Relevant codeG0137 must be listed separately in addition to primary procedure when applicable.

Service examplesIncludes individual and group therapy and other intensive outpatient services described in the G0137 descriptor per §410.67(b)(ix).

Take-home opioid antagonist medications — frequency limit

Take-home antagonist adjustmentAdjustment for take-home opioid antagonist medications (e.g., naloxone or nalmefene) is limited to once every 30 days unless additional dispensation is medically reasonable and necessary and documented in the medical record.

Documentation requirementOTPs must document reasons in the medical record when dispensing take-home opioid antagonists more frequently than once every 30 days.

Add-on codingTake-home supplies are billed using the specified HCPCS add-on codes (e.g., G2215, G2216, G1028, G0532) listed as separate additions to the primary code.

OpenPayer

Medicare coverage and payment rules for Opioid Treatment Programs (OTPs)

Coverage criteria for OTP services

Coding and billing codes

Provider requirements, billing and documentation actions

Policy background

Definitions and key terms

Level of care and intensity criteria

Treatment modalities included in OTP service

Visit limits and supply rules