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OTP Guidance specifc to MA plans

Guidance for MA plan OTP guidance


Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: December 15, 2020

Medicare Advantage


Are OTPs required to contract with Medicare Advantage Organizations (MAOs) in order to provide OTP services to their enrollees? 

OTPs are not required to contract with MAOs.  When an OTP chooses to contract with an MAO both parties negotiate the terms and conditions of payment.


If I work for a Medicare-enrolled OTP, do I have to enroll in Medicare separately?

No.  Medicare Advantage plans may contract with any Medicare-enrolled OTP.  Individual practitioners within an OTP do not need to enroll separately.


What are the basic MA access to services requirements for the OTP benefit? 

MA plans may:

  • Contract directly with a Medicare-enrolled OTP
  • Arrange for its enrollees to get the OTP benefit from non-contract Medicare enrolled OTPs 


An MA plan may require its enrollees to get OTP services only through contracted OTP facilities.  In these cases, the MA plan must ensure equitable access to contracted OTPs throughout its service area.


If enrollees use non-contract OTPs, MA plans must contact those OTPs to coordinate plan benefits and timely payment to the OTPs consistent with federal regulations.


Who can an OTP call for help with MA billing questions?

OTPs should contact MA plans and ask for “provider services” to help with questions about payment for OTP services under that MA plan.

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.