Optum OTP Medicare Bundled Payments Policy Update

Coverage criteria and bundled payment rules

General coverage criteria

Covered when ALL of the following are met

Medicare enrollment and program eligibility: OTP is enrolled in Medicare and meets statutory requirements under section 1861(jjj) and 42 CFR 410.67

References SUPPORT Act and program rules

SAMHSA certification and accreditation: OTP has SAMHSA certification and accreditation by a SAMHSA-approved accrediting body per 42 CFR part 8

SAMHSA certification and accreditation required to furnish Medicare-covered OUD treatment services

Episode-level service provision: At least one OUD treatment service (drug or non-drug component) is furnished during the contiguous 7-day episode; for intensive outpatient services described by HCPCS G0137 a minimum of nine services in the 7-day period is required>=1 service per episode; >=9 services/7 days for G0137

Non-drug episode available when medication not administered (e.g., monthly injectables or implants)

General coverage for OTP bundled services

Covered when ALL of the following are met

Episode billing threshold: At least one OUD treatment service (drug or non-drug component) furnished during the week that corresponds to the episode of care>=1 service/week

For intensive outpatient services (G0137) the threshold is at least nine services over a 7-contiguous day period

Provider enrollment: Services furnished by a Medicare-enrolled Opioid Treatment Program (OTP)Medicare OTP enrollment

Only entities enrolled with Medicare as an OTP can bill the OTP bundled and add-on codes

Scope-of-practice: Counseling and therapy must be furnished by professionals authorized under state law and scope of practicestate authorization

Drug component coverage logic

Drug-component determination logic

Medication categories: Bundles vary by medication administered: methadone (oral), buprenorphine (oral, injectable, implant), and naltrexone (injectable)medication-specific bundles

New FDA-approved OUD medications use NOS code G2075; typical/average maintenance doses inform pricing

Dosage assumptions for pricing: Typical/average maintenance dosages are used to calculate drug costs (examples: methadone 100 mg/day; oral buprenorphine 16 mg/day; extended-release naltrexone 380 mg/month)specified doses

Used to determine the drug component of the bundled payment

Drug pricing methodology: Part B drug pricing uses ASP-based methodology where available; oral drugs use ASP or NADAC if ASP unavailable; methadone pricing updated using the Producer Price Index (PPI) beginning Jan 1, 2023

Non-drug component and add-on criteria

Non-drug component coverage and add-ons

Included services: Non-drug component includes counseling, individual and group therapy, toxicology testing, and drug dispensing/administration (if applicable)included in bundle

Toxicology testing includes presumptive and definitive tests and may use urine, hair, or other matrices

Testing frequency: OTPs must provide at least eight random drug abuse tests per year per patient in maintenance treatment>=8/year

Tests used for diagnosis, monitoring, and evaluating treatment progress

Add-on adjustments: Bundled payment rates may be adjusted using add-on codes for intake, periodic assessments, take-home supplies (methadone, oral buprenorphine, opioid antagonists), additional counseling beyond the individualized plan, intensive outpatient services, coordinated care/referral, patient navigation, and peer recovery support

Telehealth and billing constraints

Telehealth/site-of-service rules

Telehealth permissible services: OTPs may furnish substance use counseling, individual and group therapy, intake and periodic assessment add-ons via two-way interactive audio-video communications technology when clinically appropriate; audio-only is permitted when two-way AV is unavailable, and periodic assessments may be furnished audio-only beginning January 1, 2025 when AV is unavailabletelehealth authorization

Initiation of buprenorphine or methadone via telehealth allowed only to the extent DEA and SAMHSA authorize at time of service; audio-only initiation permitted in limited exception scenarios

Restrictions: Telemedicine must not expand scope of practice or permit practice in jurisdictions where provider is not licensed; counseling/therapy included in the bundle must not be separately billed by the practitioner furnishing itlicensure and billing restriction

OTPs providing intensive outpatient services shall not receive Part B payment if these services are furnished via AV or audio-only communications technology

Bundled payment composition

Bundled payment components and calculations

Bundle components: Bundled payments consist of a drug component (priced nationally using applicable drug-pricing methodology) and a non-drug component (calculated using a building-block methodology based on Medicare non-facility rates and adjusted for administration/dispensing)

Non-drug component varies by mode of administration (oral, injectable, implantable); oral dispensing fee approximated at $10.50

Duplicative payment policy

Duplication and recoupment rules

Duplicative medication payment: If the same medication for the same beneficiary on the same date of service is separately paid under Medicare Part B or Part D in addition to payment within an OTP bundle or add-on, CMS will consider that a duplicative payment and recoup the duplicate amount

Provision of the same kinds of services by both an OTP and a separate provider is not itself duplicative unless medication delivery/administration/dispensing was separately paid for the same date of service

Cost sharing

Cost sharing for beneficiaries

Cost sharing: Medicare Part B deductible applies to OUD treatment services; the copayment for OTP services furnished under fee-for-service Medicare Part B is $0

Rate adjustments and updates

Geographic and annual adjustments

Geographic adjustment: Geographic Adjustment Factor (GAF) is applied to the non-drug component of the OTP bundled payments and to add-on payments for non-drug services; the drug component receives no geographic adjustment under the ASP methodology

Annual update: Drug component payment amounts are updated using the applicable drug pricing mechanism data (e.g., ASP, NADAC, PPI for methadone as specified); the non-drug component and add-on payments are updated based on the Medicare Economic Index and other applicable adjustments

The Medicare OTP bundled payment applies only when services are furnished for the treatment of an opioid use disorder (OUD). The bundled payment includes FDA‑approved medications for OUD, plus associated dispensing/administration, substance use counseling, individual and group therapy, and toxicology testing; a separate non‑drug episode mechanism permits billing for non‑drug services in weeks when medication is not administered (for example, monthly injectable/implantable therapies).

Counseling and therapy included in the OTP bundle must be furnished by professionals who are authorized under State law and scope of practice. Services provided by individuals who are not authorized under state law to furnish therapy or counseling are not covered as OUD treatment services and therefore are excluded from payment under the OTP bundled benefit.

The provision of similar services by both an OTP and a separate provider does not, by itself, constitute a duplicative payment. CMS will, however, treat as duplicative and recoup any separately paid claim for the same medication delivery, administration, or dispensing to the same beneficiary on the same date of service that was already paid as part of an OTP bundled payment.

Services that are not furnished for the treatment of an opioid use disorder are not payable under the Medicare OTP bundled payment. The bundle is intended to cover OUD treatment items and services (drug and non‑drug components); services outside that clinical purpose should be billed under the appropriate Medicare benefit, not as an OTP bundle.

Telemedicine may be used for counseling and therapy included in the OTP bundle only in ways that do not expand a provider's licensed scope of practice or allow practice in jurisdictions where the provider is not licensed. Counseling or therapy furnished via communication technology as part of OTP services must not be separately billed by the practitioner because those services are paid through the OTP bundled payment.

HCPCS codes, POS, and coding thresholds

Covered HCPCS Codes (example called out)HCPCSCovered

G0137

OTP intensive outpatient services (minimum nine services/7-day period)

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; assessing periodically by an OTP practitioner and includes a review of MOUD dosing, treatment response, and other needs; 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 code for primary procedure

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1/2

Place of ServicePOS

58	Place of Service code 58 — Non-residential Opioid Treatment Facility

OTP bundled payment and add-on codesHCPCSCovered

HCPCS G-codes

G codes describing OTP bundled payments and add-on codes (specific G codes listed elsewhere)

OTP intensive outpatient minimum weekly services

Threshold>= 9 services per 7-day episode

Applies to codeHCPCS G0137 (OTP intensive outpatient services)

Qualifying servicesIndividual/group therapy, occupational therapy, services of social workers, trained psychiatric nurses, and other qualified staff as described in G0137

Episode duration

DefinitionAn episode of care is a contiguous 7-day period (one week)

Start dayMay start on any day of the week

Billing, enrollment, documentation, and operational requirements for OTPs

Billing Rule

Bundled payment and intensive outpatient billing

Payment for OUD treatment furnished by an OTP is through a Medicare bundled payment equal to 100% of the bundled rate for services furnished during an episode of care. Intensive outpatient services billed with HCPCS G0137 require a minimum of nine services over a contiguous 7‑day period to meet the episode threshold.

Bundled payment covers drug and non‑drug components (see code/grouping guidance).
G0137: Intensive outpatient services — bill only when minimum threshold (9 services in 7 contiguous days) is met.

Billing Rule

Billing and enrollment requirement

Only entities enrolled with Medicare as an Opioid Treatment Program (OTP) may bill the OTP bundled payment HCPCS G codes and the listed add‑on codes. OTPs are limited to billing only these bundled and add‑on codes for OTP services and may not bill for these services under the Physician Fee Schedule (PFS).

Level-of-care definitions and thresholds

Permitted treatment modalities included in the bundled payment

Medication-assisted treatment (MAT)

Medication-assisted treatment: Use of FDA-approved opioid agonist or antagonist medications (buprenorphine, methadone, naltrexone) included in the drug component of the bundled payment

Medications must be FDA-approved for OUD; includes oral, injected, and implanted formulations

Counseling and psychotherapy

Psychosocial services: Substance use counseling, individual and group therapy, and toxicology testing are included in the non-drug component of the bundle

Services may be furnished via two-way interactive audio-video and, when permitted, audio-only; providers must be authorized under state law to furnish these services

MOUD with counseling and testing (OTP bundled services)

Visit minimums and episode billing thresholds

OTP intensive outpatient services (G0137)

Minimum per weekMinimum 9 services

Associated codeG0137 — Intensive outpatient services

ContextUsed to determine eligibility to bill OTP intensive outpatient weekly bundle

Intensive outpatient services (G0137)

Service thresholdMinimum of nine services over a 7-contiguous day period

Examples of qualifying servicesIndividual/group therapy, occupational therapy, services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients

Billing note

Key definitions used in this policy

Episode of care

DefinitionA contiguous 7-day period

Also described asA one-week period that may start on any day

RelevanceDefines the duration of an episode of care for billing bundled payments

Opioid treatment program (OTP)

DefinitionAn entity that is an opioid treatment program as defined in 42 CFR 8.2 and meets participation requirements described in Section 30

RequirementMust meet SAMHSA certification and accrediting body requirements to furnish Medicare-covered OUD services

Billing implication

Policy background and statutory authority

The SUPPORT Act established the Medicare Part B benefit for OUD treatment services furnished by Opioid Treatment Programs (OTPs) effective January 1, 2020. Under section 1834(w) of the Act, Medicare pays an OTP 100% of a bundled payment for services the OTP furnishes to a beneficiary during a contiguous 7‑day episode of care.

OpenPayer

Opioid Treatment Program (OTP) Medicare Benefit — bundled payments and requirements