Substance Use Disorder (SUD) Services Opioid Treatment Programs (OTP)
Overview
Substance Use Disorder (SUD) Opioid Treatment Programs (OTPs) are specific programs utilizing U.S. Food and Drug Administration (FDA)-approved medications for opioid use disorder along with other supportive services. OTPs are federally licensed and regulated to deliver medication-assisted treatment (MAT) in combination with counseling and behavioral health services. OTPs can provide all three FDA-approved medications for opioid use disorder (methadone, naltrexone and buprenorphine). OTPs are the only level of care that dispenses methadone in an outpatient setting. This section of the Minnesota Health Care Programs (MHCP) Provider Manual specifically addresses OTP. Information regarding office-based opioid treatment (OBOT) for buprenorphine and naltrexone is available on the Medications for Opioid Use Disorder (MOUD) section of the MHCP Provider Manual.
Eligible Providers
OTP providers must meet all of the following to provide services, bill and receive payment from MHCP:
Programs providing OTP services and licensed according to Minnesota Statutes 245G.01 to 245G.17 and 245G.22, or applicable Tribal license, must certify their program’s ASAM levels of care by submitting a completed ASAM Certification Checklist (DHS-7325-ENG) and accompanying documents listed under the ASAM Certification heading on the ASAM resources for Minnesota SUD treatment providers webpage. Programs with an applicable Tribal license may certify their program’s ASAM level(s) of care.
Refer to information under the Licensed SUD Programs or Organizations Enrollment Requirements heading in the SUD Enrollment Criteria and Forms section of the MHCP Provider Manual for information about enrolling as an MHCP provider.
Eligible Members
SUD services are available to fee-for-service members with major programs MA, NM, IM and OO (Behavioral Health Fund) and MinnesotaCare (BB, KK, LL). Providers are encouraged to verify member eligibility in MN–ITS on a monthly basis. Clinical eligibility is determined via a comprehensive assessment. Refer members enrolled through a managed care organization (MCO) to their MCO health plans for details on coverage and accessing SUD services.
Fee-for-service members
MHCP fee-for-service members are eligible for OTP services if both of the following are met:
Providers should verify member eligibility through secure, online MN–ITS eligibility verification transaction or by contacting the Tribe or county of residence.
MCO members
MHCP members with coverage through an MCO must contact their MCO for coverage details for OTP services.
Behavioral Health Fund
If an individual needs OTP services and is not enrolled in MHCP, they may be eligible for services through Behavioral Health Fund (BHF) major program OO.
Incarcerated individuals who use methadone and meet financial eligibility guidelines are eligible for coverage through the BHF.
Covered Services
Covered Services are outlined in the Calendar Year Final Rule Payment Rates for Opioid Treatment Programs (DHS-8849).
Opioid Treatment Programs provide FDA-approved Medications for Opioid Use Disorder and substance use disorder treatment services that are reimbursed using the CMS Medicare rate structure. If the OTP is located in a residential treatment center, the services may also be included as an add-on to the residential treatment service per diem.
Information about Tribal MOUD programs that are not separately enrolled with SAMHSA/DEA as an OPT and use only buprenorphine products under a practitioner’s DEA registration is found in the MOUD section of the MHCP Provider Manual.
Substance Use Disorder treatment services in OTPs are reimbursed using the CMS Medicare rate structure and may also be included as an add-on to the residential treatment service per diem. Providers licensed as residential SUD programs must offer SUD-MOUD services on site or facilitate access to SUD-MOUD services off site. SUD-MOUD services may be provided through consultation off-site by a qualified practitioner and reimbursed through the member’s medical benefits.
Encounter payments are not available for self-administered medication when providers are paid the Indian Health Service encounter rate.
Noncovered Services
The following services are not covered:
Billing
Refer to the Calendar Year Final Rule Payment Rates for Opioid Treatment Programs (DHS-8849) for billing codes, definitions and assigned dollar values.
OTPs cannot bill both the OTP codes and outpatient substance use disorder codes for the same client, same provider, same day.
Billing for MCO members
Bill services provided to members enrolled in an MCO using Centers for Medicare and Medicaid Services (CMS) Healthcare Common Procedure Coding system (HCPC) procedure codes. Reimbursement amounts may be different.
Legal References
Minnesota Statutes, 245G.22 - Opioid Treatment Programs
Minnesota Statutes, 254B.121 - Rate Methodology; Substance Use Disorder Treatment Services with Medications for Opioid Use Disorder.
Code of Federal Regulations, title 42, section 410.67 - Medicare coverage and payment of opioid use disorder treatment services furnished by opioid treatment programs.
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