Providers say Medicare Advantage hinders new methadone benefit

There are about 1,900 opioid treatment programs in the United States. While some lawmakers and addiction experts have called for making methadone available outside of opioid treatment programs, for now, those programs are the only outpatient settings that can dispense methadone, which has been shown to reduce opioid use and overdose deaths and curb withdrawal symptoms.

Prior authorization

Advantage plans, also known as Medicare Part C, were established in 1997 to administer Medicare benefits at a lower cost than the government. But the tactics that they argue reduce unnecessary care and lower health care costs, like prior authorization, have been criticized across the board by physicians and providers, including opioid treatment programs. 

“It’s really an important issue to make sure that people have immediate access to treatment. As soon as you put prior authorization on it, you’re delaying that access,” said Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates of New York, which represents 108 opioid treatment programs in the state. 

Under federal regulations, Medicare Advantage plans can take up to 72 hours to respond to an urgent request or up to 14 days for nonurgent requests. But that is time wasted when someone with opioid use disorder needs to begin treatment, experts say. Sometimes those requests are denied with no explanation or providers must resubmit requests after a few months of treatment. 

Schorr said she is also increasingly seeing plans require physician referrals for opioid treatment programs, which can also lead to delays, especially if someone doesn’t already have a primary care doctor.