---
kind: "section"
citation: "42 U.S.C. § 1395cc–6"
title: "42"
title_heading: "The Public Health and Welfare"
number: "1395cc–6"
heading: "Opioid use disorder treatment demonstration program"
release: "119-102"
date: "2026-07-12"
url: "https://uscodex.org/usc/42/1395cc-6"
units:
  - "Chapter 7 — Social Security"
  - "Subchapter XVIII — Health Insurance for Aged and Disabled"
  - "Part E — Miscellaneous Provisions"
---

# §1395cc–6. Opioid use disorder treatment demonstration program

- (a) **Implementation of 4-year demonstration program—**
  - (1) **In general—** Not later than January 1, 2021, the [Secretary](/usc/42/1301.md?p=a-6) shall implement a 4-year demonstration program under this subchapter (in this section referred to as the “Program”) to increase access of applicable beneficiaries to [opioid use disorder treatment services](/usc/42/1395x.md?p=jjj-1), improve [physical](/usc/42/1395x.md?p=g) and mental health outcomes for such beneficiaries, and to the extent possible, reduce expenditures under this subchapter. Under the Program, the [Secretary](/usc/42/1301.md?p=a-6) shall make payments under [subsection (e)](#e) to participants (as defined in [subsection (c)(1)(A)](#c-1-A)) for furnishing [opioid use disorder treatment services](/usc/42/1395x.md?p=jjj-1) delivered through opioid use disorder care teams, or arranging for such services to be furnished, to applicable beneficiaries participating in the Program.
  - (2) **Opioid use disorder treatment services—** For purposes of this section, the term “[opioid use disorder treatment services](/usc/42/1395x.md?p=jjj-1)”—
    - (A) means, with respect to an applicable beneficiary, services that are furnished for the [treatment](/usc/42/11851.md?p=11) of opioid use disorders and that utilize [drugs](/usc/42/1395x.md?p=t-1) approved under [section 355 of title 21](/usc/21/355.md) for the [treatment](/usc/42/11851.md?p=11) of opioid use disorders in an outpatient setting; and
    - (B) [includes](/usc/42/1301.md?p=b)—
      - (i) medication-assisted [treatment](/usc/42/11851.md?p=11);
      - (ii) [treatment](/usc/42/11851.md?p=11) planning;
      - (iii) psychiatric, psychological, or counseling services (or any combination of such services), as appropriate;
      - (iv) [social](/usc/42/1397j.md?p=20) support services, as appropriate; and
      - (v) care management and [care coordination services](/usc/42/701.md?p=b-3), [including](/usc/42/1301.md?p=b) coordination with other providers of services and [suppliers](/usc/42/1395x.md?p=d) not on an opioid use disorder care team.
- (b) **Program design—**
  - (1) **In general—** The [Secretary](/usc/42/1301.md?p=a-6) shall design the Program in such a manner to allow for the evaluation of the extent to which the Program accomplishes the following purposes:
    - (A) Reduces [hospitalizations](/usc/42/1301.md?p=a-7) and emergency department visits.
    - (B) Increases use of medication-assisted [treatment](/usc/42/11851.md?p=11) for opioid use disorders.
    - (C) Improves health outcomes of individuals with opioid use disorders, [including](/usc/42/1301.md?p=b) by reducing the incidence of infectious diseases (such as hepatitis C and HIV).
    - (D) Does not increase the total spending on items and services under this subchapter.
    - (E) Reduces deaths from opioid overdose.
    - (F) Reduces the utilization of inpatient residential [treatment](/usc/42/11851.md?p=11).
  - (2) **Consultation—** In designing the Program, [including](/usc/42/1301.md?p=b) the criteria under [subsection (e)(2)(A)](#e-2-A), the [Secretary](/usc/42/1301.md?p=a-6) shall, not later than 3 months after October 24, 2018, consult with specialists in the field of addiction, clinicians in the primary care community, and beneficiary groups.
- (c) **Participants; opioid use disorder care teams—**
  - (1) **Participants—**
    - (A) **Definition—** In this section, the term “participant” means an entity or individual—
      - (i) that is otherwise enrolled under this subchapter and that is—
        - (I) a [physician](/usc/42/1395x.md?p=r) (as defined in [section 1395x(r)(1) of this title](/usc/42/1395x.md));
        - (II) a group practice comprised of at least one [physician](/usc/42/1395x.md?p=r) described in [subclause (I)](#c-1-A-i-I);
        - (III) a [hospital](/usc/42/1395x.md?p=e) outpatient department;
        - (IV) a [federally qualified health center](/usc/42/1395x.md?p=aa-4) (as defined in [section 1395x(aa)(4) of this title](/usc/42/1395x.md?p=aa-4));
        - (V) a [rural health clinic](/usc/42/1395x.md?p=aa-2) (as defined in [section 1395x(aa)(2) of this title](/usc/42/1395x.md?p=aa-2));
        - (VI) a [community mental health center](/usc/42/1395x.md?p=ff-3-B) (as defined in [section 1395x(ff)(3)(B) of this title](/usc/42/1395x.md?p=ff-3-B));
        - (VII) a clinic certified as a certified community behavioral health clinic pursuant to section 223 of the Protecting Access to Medicare Act of 2014; or
        - (VIII) any other individual or entity specified by the [Secretary](/usc/42/1301.md?p=a-6);
      - (ii) that applied for and was selected to participate in the Program pursuant to an application and selection process established by the [Secretary](/usc/42/1301.md?p=a-6); and
      - (iii) that establishes an opioid use disorder care team (as defined in [paragraph (2)](#c-2)) through employing or contracting with health care practitioners described in [paragraph (2)(A)](#c-2-A), and uses such team to furnish or arrange for [opioid use disorder treatment services](/usc/42/1395x.md?p=jjj-1) in the outpatient setting under the Program.
    - (B) **Preference—** In selecting participants for the Program, the [Secretary](/usc/42/1301.md?p=a-6) shall give preference to individuals and entities that are located in areas with a prevalence of opioid use disorders that is higher than the national average prevalence.
  - (2) **Opioid use disorder care teams—**
    - (A) **In general—** For purposes of this section, the term “opioid use disorder care team” means a team of health care practitioners established by a participant described in [paragraph (1)(A)](#c-1-A) that—
      - (i) shall include—
        - (I) at least one [physician](/usc/42/1395x.md?p=r) (as defined in [section 1395x(r)(1) of this title](/usc/42/1395x.md)) furnishing primary care services or addiction [treatment](/usc/42/11851.md?p=11) services to an applicable beneficiary; and
        - (II) at least one eligible practitioner (as defined in [paragraph (3)](#c-3)), who may be a [physician](/usc/42/1395x.md?p=r) who meets the criterion in [subclause (I)](#c-2-A-i-I); and
      - (ii) may include other practitioners licensed under [State](/usc/42/1395x.md?p=x) law to furnish psychiatric, psychological, counseling, and [social](/usc/42/1397j.md?p=20) services to applicable beneficiaries.
    - (B) **Requirements for receipt of payment under program—** In order to receive payments under [subsection (e)](#e), each participant in the Program shall—
      - (i) furnish [opioid use disorder treatment services](/usc/42/1395x.md?p=jjj-1) through opioid use disorder care teams to applicable beneficiaries who agree to receive the services;
      - (ii) meet minimum criteria, as established by the [Secretary](/usc/42/1301.md?p=a-6); and
      - (iii) submit to the [Secretary](/usc/42/1301.md?p=a-6), in such form, manner, and frequency as specified by the [Secretary](/usc/42/1301.md?p=a-6), with respect to each applicable beneficiary for whom [opioid use disorder treatment services](/usc/42/1395x.md?p=jjj-1) are furnished by the opioid use disorder care team, data and such other information as the [Secretary](/usc/42/1301.md?p=a-6) determines appropriate to—
        - (I) monitor and evaluate the Program;
        - (II) determine if minimum criteria are met under [clause (ii)](#c-2-B-ii); and
        - (III) determine the incentive payment under [subsection (e)](#e).
  - (3) **Eligible practitioner defined—** For purposes of this section, the term “eligible practitioner” means a [physician](/usc/42/1395x.md?p=r) or other health care practitioner, such as a [nurse practitioner](/usc/42/1395x.md?p=aa-5-A), that—
    - (A) is enrolled under [section 1395cc(j)(1) of this title](/usc/42/1395cc.md?p=j-1); and
    - (B) is authorized to prescribe or dispense narcotic [drugs](/usc/42/1395x.md?p=t-1) to individuals for maintenance [treatment](/usc/42/11851.md?p=11) or detoxification [treatment](/usc/42/11851.md?p=11).
- (d) **Participation of applicable beneficiaries—**
  - (1) **Applicable beneficiary defined—** In this section, the term “applicable beneficiary” means an individual who—
    - (A) is entitled to, or enrolled for, benefits under part A and enrolled for benefits under part B;
    - (B) is not enrolled in a Medicare Advantage plan under part C;
    - (C) has a current diagnosis for an opioid use disorder; and
    - (D) meets such other criteria as the [Secretary](/usc/42/1301.md?p=a-6) determines appropriate.

    Such term shall include an individual who is dually eligible for benefits under this subchapter and subchapter XIX if such individual satisfies the criteria described in subparagraphs [(A)](#d-1-A) through [(D)](#d-1-D).

  - (2) **Voluntary beneficiary participation; limitation on number of beneficiaries—** An applicable beneficiary may participate in the Program on a voluntary basis and may terminate participation in the Program at any time. Not more than 20,000 applicable beneficiaries may participate in the Program at any time.
  - (3) **Services—** In order to participate in the Program, an applicable beneficiary shall agree to receive [opioid use disorder treatment services](/usc/42/1395x.md?p=jjj-1) from a participant. Participation under the Program shall not affect coverage of or payment for any other item or service under this subchapter for the applicable beneficiary.
  - (4) **Beneficiary access to services—** Nothing in this section shall be construed as encouraging providers to limit applicable beneficiary access to services covered under this subchapter, and applicable beneficiaries shall not be required to relinquish access to any benefit under this subchapter as a condition of receiving services from a participant in the Program.
- (e) **Payments—**
  - (1) **Per applicable beneficiary per month care management fee—**
    - (A) **In general—** The [Secretary](/usc/42/1301.md?p=a-6) shall establish a schedule of per applicable beneficiary per month care management fees. Such a per applicable beneficiary per month care management fee shall be paid to a participant in addition to any other amount otherwise payable under this subchapter to the health care practitioners in the participant’s opioid use disorder care team or, if applicable, to the participant. A participant may use such per applicable beneficiary per month care management fee to deliver additional services to applicable beneficiaries, [including](/usc/42/1301.md?p=b) services not otherwise eligible for payment under this subchapter.
    - (B) **Payment amounts—** In carrying out [subparagraph (A)](#e-1-A), the [Secretary](/usc/42/1301.md?p=a-6) may—
      - (i) consider payments otherwise payable under this subchapter for [opioid use disorder treatment services](/usc/42/1395x.md?p=jjj-1) and the needs of applicable beneficiaries;
      - (ii) pay a higher per applicable beneficiary per month care management fee for an applicable beneficiary who receives more intensive [treatment](/usc/42/11851.md?p=11) services from a participant and for whom those services are appropriate based on clinical guidelines for opioid use disorder care;
      - (iii) pay a higher per applicable beneficiary per month care management fee for the month in which the applicable beneficiary begins [treatment](/usc/42/11851.md?p=11) with a participant than in subsequent months, to reflect the greater time and costs required for the planning and initiation of [treatment](/usc/42/11851.md?p=11), as compared to maintenance of [treatment](/usc/42/11851.md?p=11); and
      - (iv) take into account whether a participant’s opioid use disorder care team refers applicable beneficiaries to other [suppliers](/usc/42/1395x.md?p=d) or providers for any [opioid use disorder treatment services](/usc/42/1395x.md?p=jjj-1).
    - (C) **No duplicate payment—** The [Secretary](/usc/42/1301.md?p=a-6) shall make payments under this paragraph to only one participant for services furnished to an applicable beneficiary during a calendar month.
  - (2) **Incentive payments—**
    - (A) **In general—** Under the Program, the [Secretary](/usc/42/1301.md?p=a-6) shall establish a performance-based incentive payment, which shall be paid (using a methodology established and at a time determined appropriate by the [Secretary](/usc/42/1301.md?p=a-6)) to participants based on the performance of participants with respect to criteria, as determined appropriate by the [Secretary](/usc/42/1301.md?p=a-6), in accordance with [subparagraph (B)](#e-2-B).
    - (B) **Criteria—**
      - (i) **In general—** Criteria described in [subparagraph (A)](#e-2-A) may include consideration of the following:
        - (I) Patient engagement and retention in [treatment](/usc/42/11851.md?p=11).
        - (II) Evidence-based medication-assisted [treatment](/usc/42/11851.md?p=11).
        - (III) Other criteria established by the [Secretary](/usc/42/1301.md?p=a-6).
      - (ii) **Required consultation and consideration—** In determining criteria described in [subparagraph (A)](#e-2-A), the [Secretary](/usc/42/1301.md?p=a-6) shall—
        - (I) consult with stakeholders, [including](/usc/42/1301.md?p=b) clinicians in the primary care community and in the field of addiction medicine; and
        - (II) consider existing clinical guidelines for the [treatment](/usc/42/11851.md?p=11) of opioid use disorders.
    - (C) **No duplicate payment—** The [Secretary](/usc/42/1301.md?p=a-6) shall ensure that no duplicate payments under this paragraph are made with respect to an applicable beneficiary.
- (f) **Multipayer strategy—** In carrying out the Program, the [Secretary](/usc/42/1301.md?p=a-6) shall encourage other payers to provide similar payments and to use similar criteria as applied under the Program under [subsection (e)(2)(C)](#e-2-C). The [Secretary](/usc/42/1301.md?p=a-6) may enter into a memorandum of understanding with other payers to align the methodology for payment provided by such a payer related to [opioid use disorder treatment services](/usc/42/1395x.md?p=jjj-1) with such methodology for payment under the Program.
- (g) **Evaluation—**
  - (1) **In general—** The [Secretary](/usc/42/1301.md?p=a-6) shall conduct an intermediate and final evaluation of the program. Each such evaluation shall determine the extent to which each of the purposes described in [subsection (b)](#b) have been accomplished under the Program.
  - (2) **Reports—** The [Secretary](/usc/42/1301.md?p=a-6) shall submit to Congress—
    - (A) a report with respect to the intermediate evaluation under [paragraph (1)](#g-1) not later than 3 years after the date of the implementation of the Program; and
    - (B) a report with respect to the final evaluation under [paragraph (1)](#g-1) not later than 6 years after such date.
- (h) **Funding—**
  - (1) **Administrative funding—** For the purposes of implementing, administering, and carrying out the Program (other than for purposes described in [paragraph (2)](#h-2)), $5,000,000 shall be available from the Federal Supplementary Medical Insurance Trust Fund under [section 1395t of this title](/usc/42/1395t.md).
  - (2) **Care management fees and incentives—** For the purposes of making payments under [subsection (e)](#e), $10,000,000 shall be available from the Federal Supplementary Medical Insurance Trust Fund under [section 1395t of this title](/usc/42/1395t.md) for each of [fiscal years](/usc/42/619.md?p=3) 2021 through 2024.
  - (3) **Availability—** Amounts transferred under this subsection for a [fiscal year](/usc/42/619.md?p=3) shall be available until expended.
- (i) **Waivers—** The [Secretary](/usc/42/1301.md?p=a-6) may waive any provision of this subchapter as may be necessary to carry out the Program under this section.

## Source credit

(Aug. 14, 1935, ch. 531, title XVIII, § 1866F, as added Pub. L. 115–271, title VI, § 6042, Oct. 24, 2018, 132 Stat. 3979; amended Pub. L. 117–215, title I, § 103(b)(4)(C), Dec. 2, 2022, 136 Stat. 2263; Pub. L. 117–328, div. FF, title I, § 1262(b)(7), Dec. 29, 2022, 136 Stat. 5682.)

## Notes

### Editorial Notes

### References in Text

Section 223 of the Protecting Access to Medicare Act of 2014, referred to in subsec. (c)(1)(A)(i)(VII), is section 223 of Pub. L. 113–93, which is set out as a note under section 1396a of this title.

### Amendments

2022—Subsec. (c)(3)(C). Pub. L. 117–328 struck out subpar. (C) which read as follows: “has in effect a waiver in accordance with section 823(h) of title 21 for such purpose and is otherwise in compliance with regulations promulgated by the Substance Abuse and Mental Health Services Administration to carry out such section.”

Pub. L. 117–215 substituted “823(h)” for “823(g)”.