Payment and Reimbursement

The pre-implementation planning team should identify all diagnostic and treatment codes relevant to medications and other treatments for OUD across Medicaid, Medicare, managed care organizations, and commercial payers. This includes billing codes from the Current Procedures Terminology (CPT) and International Classification of Diseases, Tenth and Eleventh Revisions (ICD-10 and ICD-11). Be sure to identify codes for screening and initial assessment, starting medication, maintenance visits, related clinical services (such as physical exams and lab tests), and any applicable mental health services. The National Council for Mental Wellbeing's Decision Support Tool and Billing Modules may be helpful in sorting out these issues.

Billing codes may differ based on whether the patient is new or established and the level of service provided. Some State Medicaid programs also limit which diagnosis codes are reimbursable for primary care providers.¹ Once you identify relevant billing codes, train staff how to use them.

Public and private health plans may have different rules about who is eligible to provide billable services. For instance, some plans limit which provider types can bill for mental health services.⁹ In models like the Nurse Care Manager Model, reimbursement for nursing visits is essential to viability. Check each payers definition of a qualified provider for OUD-related services. Depending on the health plan, payment may be structured as fee-for-service, bundled payments, or case rates.

Patients being treated for OUD in primary care often also receive care for chronic medical conditions at the same practice or organization. In integrated care settings, billing can be complicated if there are separate reimbursement systems for mental health and medical services. Some states prohibit providers from billing for both medical and mental health services on the same day. ² This restriction is often mistakenly believed to be based on federal policy, but no such federal prohibition exists.

Establish clear policies related to patient payment for medications and other services and set expectations with patients during the intake process. Unfortunately, patients may face barriers to promptly obtaining medications for OUD or discontinue treatment prematurely due to payment restrictions.⁸State Medicaid programs vary widely in how they cover and reimburse for medications for OUD and related services, but there are tools and strategies available to help your practice navigate these complexities.

Lack of Insurance: If patients do not have insurance, explore their eligibility for Medicaid or Medicare. Larger organizations may have case managers available to help patients enroll in health coverage. Smaller practices can identify and partner with community-based services that support uninsured individuals. In addition, some states have programs that provide MOUD free of charge or sliding scale models for those who are uninsured. For example, in New Mexico this program is provided by the New Mexico Department of Health.¹⁰In addition, grants such as the current SAMHSA State Opioid Response grants require that MOUD be provided regardless of the patients ability to pay.¹¹

Choice of Medications: All state Medicaid programs, and the District of Columbia cover some form of buprenorphine and naltrexone for OUD treatment, although coverage for injectable and implantable buprenorphine formulations remains inconsistent.¹² While medication selection should be guided by patient needs and preferences, insurance coverage must also be considered. Newer brand medications can be costly, and are less likely to be covered by insurance, creating potential barriers to treatment adherence.

If a clinically indicated and preferred medication is not covered by the patients insurance, consider helping the patient apply for pharmaceutical company-sponsored patient assistance programs, though clarify the patients out-of-pocket expense before prescribing. Some states also offer low-cost drug programs for individuals who fall below certain income thresholds but are not eligible for Medicaid.

Utilization Management Policies: Many payers—both public and private—employ benefit design limits and utilization management strategies to control costs. While intended to ensure appropriate treatment, these policies often delay or restrict access to necessary medications and services. It is worthwhile to learn what the relevant insurers policies are to avoid unpleasant surprises when bills are submitted.

Prior Authorization: Prior authorization requires providers to obtain advance approval before prescribing certain medications or services. Requirements for primary care providers prescribing medications for OUD can vary by state and insurer. Although prior authorization requirements for medications for OUD have declined across all insurers in recent years,¹³ they still represent a significant barrier to timely care. In 2023, 94% of physicians surveyed by the American Medical Association reported that prior authorizations caused care delays, and 80% reported that prior authorization could sometimes lead to treatment abandonment.¹⁴

As of 2024, 46 State and Washington, DC Medicaid programs no longer required prior authorization for at least one sublingual buprenorphine formulation.¹⁵ However, prior authorization requirements remain for other buprenorphine formulations¹⁶ and for higher doses, which are often used to treat fentanyl use.¹⁵ Prior authorization for buprenorphine monotherapy is often required due to its perceived higher potential for misuse or diversion,¹⁶ and more expensive medications are more likely to require prior authorization.¹⁷ Some providers manage these restrictions by treating patients with a covered medication while awaiting authorization for the preferred medication, then switching medications post-authorization.

Some payers may condition prior authorization approval on a patients participation in counseling or psychosocial treatment. In these cases, providers must submit evidence that the patient has been referred to or is engaging with psychosocial treatment before approval and reimbursement for medications are granted. Ideally, the decision to engage in counseling or psychosocial support should result from shared decision-making between patient and provider. While some patients may welcome this component of treatment, others may not feel ready, may not be able to accommodate it in their schedule, or may not view it as necessary for their recovery. Conditioning access to medication on participation in behavioral therapies conflicts with expert guidance, which recommends not restricting medication for patients who decline counseling or other psychosocial support.²

The timeline for prior authorization approval can vary significantly, from rapid turnaround to delays lasting several weeks. This is burdensome for both providers and patients. Timely access to treatment is essential for individuals experiencing withdrawal, or those newly motivated to begin treatment. Treatment delays can result in lost revenue for practices¹⁸ and lost opportunities to deliver needed care.

Establish internal processes and protocols to check prior authorization requirements before providing services or sending prescriptions to the pharmacy. Clearly define:¹⁸

• Who is responsible for managing prior authorizations;
• What documentation is needed in the medical record;
• How prior authorizations will be submitted and tracked to ensure timely approval; and
• How to appeal denials.

Despite efforts to automate the process prior authorization through EHRs and standardize requirements across payers, meaningful progress remains limited.¹⁸

Step therapy is another utilization management strategy in which patients must try a first-line medication before they can receive a second-line medication.² This approach can apply across medication types, formulations, or brands. For example, a fail first policy requires a patient to try a generic medication before a branded medication, or it might require someone to try naltrexone before buprenorphine or methadone may be prescribed. These policies are not evidence-based and can impede on patient-centered care approaches.

Insurers may also impose dosage and quantity restrictions,¹⁹ requiring more frequent prescription fills. While intended to control costs, these restrictions may conflict with clinical best practices and limit the flexibility needed for individualized care. Over time payers may be encouraged to adopt policies that better reflect the evidence base for effective treatment.