Email UpdatesLearn how to navigate the financial aspects of delivering MOUD, including reimbursement strategies and sustainability planning and view practical advice for assessing your financial landscape, understanding payer policies, and adapting to evolving funding requirements.
North Star
The practice assesses the financial landscape for providing MOUD-related services by identifying the relevant policies, processes, and requirements related to service delivery and reimbursement across public and private payers in their state. The implemented MOUD treatment model is sustainable within the limitations of the available resources and financial landscape.
Financial Sustainability
Regrettably, funding for primary care1 in general, and for treatment of OUD specifically,2 is not generous and is rarely considered to be adequate.3 That said, there are a diverse array of funding models.4 It is impossible to provide a single strategy to achieve financial sustainability given the widespread differences in payer policies for primary care and OUD treatment.4 Devising a strategy will require a careful review of your baseline financial status, patient mix, payer mix, and associated policies.
Because this is a complex set of issues, it may be wise to consider reaching out to an experienced practice facilitator who understands what care models and reimbursement options are available in your state and area. Some states have organized practice facilitation organizations designed specifically to help improve the operations and effectiveness of primary care providers. If no such organization is available in your state, consider consulting with similarly situated professional colleagues or professional associations. For example, your state primary care association5 (especially for FQHCs and community health clinics) or your state health agency6 may be helpful.
Payment and Reimbursement
Payment and reimbursement policies vary across public and private payers in each state. Coverage, coding, and definitions of qualified providers may differ by payer—and these policies can change over time. Stay informed about current requirements and how they may impact your practice.
The National Council for Mental Wellbeing has developed a very helpful resource that provides extensive information about fee-for-service billing and reimbursement for integrated services. While largely focused on mental health agencies and on Medicare and Medicaid, it is also applicable to primary care providers and includes a module specific to decision support and billing for MOUD. The MOUD module was current as of November 2022, while the larger decision support tool was last updated in 2024. This is an area that is subject to relatively rapid change, so reliance on a tool of this sort is no substitute for more careful investigation of current rules and rates applicable to your state, setting, and payer mix.
Consider the following questions:
- Which medications and formulations to treat OUD are included on the medication formularies?25
- Does your state's Medicaid program or commercial payers have additional requirements for MOUD services, including restrictions on who can deliver them?25
- Are there alternative payment models (APMs) in your state and payer mix, such as bundled payments or Medicaid opioid health homes for OUD treatment?
- Do any of the payers your patients are enrolled with have requirements or rules for continuation in treatment? For example, some may call for ending treatment if patients continue to use multiple substances despite expert guidance recommending treatment intensification rather than termination.2
OUD affects people across all income levels, but is more common among those with lower incomes, who often rely on public insurance or lack coverage altogether. In 2019, roughly 84% of people with OUD had health insuranceMedicare, Medicaid, or private.3 Medicaid is the largest payer for medications for OUD, covering 40% of adults under 65 receiving medications for OUD.4,5 In 2021, approximately 1.5 million Medicaid enrollees had an OUD diagnosis (nearly 2% of the total Medicaid population that year).4 Of those, more than 1 million received medications for OUD that year through Medicaid or Medicare (for those dually eligible).4 Among the Medicaid fee-for-service population, 2.8% (about 591,000 individuals) had OUD in 2018.6 Due to stigma, some people may also choose to pay out of pocket to keep their OUD diagnosis private.7,8
To ensure financial sustainability, begin planning early, starting in the pre-implementation phase. Include a representative from the billing or revenue cycle team on the pre-implementation planning team, as financial factors can shape your choice of service model.42 Flexibility in your MOUD reimbursement strategy is often recommended. Ultimately, sustainability will depend on state reimbursement policies, your payer mix,4 available resources, infrastructure, and payment rates.
Identify your payer mix. Most primary care practices serve patients with different insurance coverage. Some of the payers may include:
- Medicare fee-for-service;
- Medicare Advantage plans;
- Medicaid fee-for-service;
- Medicaid managed care organizations;
- Private insurers; and
- Private pay.
Investigate the relevant policies of each of the payers for your patient mix and learn what and how much they will reimburse for necessary services and which staff members must provide them. Note that in some circumstances it may be necessary or preferable to create staff roles that will provide non-reimbursable services. For example, a patient engagement specialist or care coordinator may take on the responsibility of patient outreach and follow up but allow other providers to practice at the top of their license and spend more time billing for their services.
For uninsured patients with OUD, 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.7 In addition, grants such as the current SAMHSA State Opioid Response require that MOUD be provided regardless of the patient's ability to pay.8
When planning to provide medications for OUD, consider how to make it financially sustainable over time, including the stability of program funding sources. For example, grant funding can be vital toward an initial investment to start an OUD treatment practice, but it is temporary. It can be very helpful in covering costs associated with transitioning to an alternate service delivery model but cannot cover ongoing operational costs over time.
The configuration of a clinical and support team, salaries, overhead costs, and reimbursement rates are all important considerations. In addition, financial sustainability often depends on the scale of the practice, that is, the number of patients the practice will be treating. These sorts of analyses are based on program- and state- specific assumptions of personnel salaries and other programmatic expenses, as well as payers' reimbursement rates for services provided to patients served.
As you develop your office-based practice to treat OUD, you might want to develop your own financial sustainability model,9 similar to those from the Medicaid Innovation Accelerator Program | Medicaid that reflects salary, cost, and reimbursement data for your practice. You will need to work with your budgeting and financial staff to develop such models, in collaboration with clinical staff, so that models are designed to meet the needs of the patients served.
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 payer's 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.10 In addition, grants such as the current SAMHSA State Opioid Response grants require that MOUD be provided regardless of the patient's 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 patient's insurance, consider helping the patient apply for pharmaceutical company-sponsored patient assistance programs, though clarify the patient's 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 insurer's 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 patient's 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.