CMS MEDICARE OTP FINAL RULE Federal Register CMS1715

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CMS MEDICARE OTP FINAL RULE Federal Register CMS-1715 -P First Glance

CMS MEDICARE OTP FINAL RULE Federal Register CMS-1715 -P First Glance

CMS Final Rule: Weekly Bundles ■ CMS is finalizing an OTP reimbursement structure utilizing

CMS Final Rule: Weekly Bundles ■ CMS is finalizing an OTP reimbursement structure utilizing full weekly bundles for all FDA-approved medications. ■ They will NOT be using partial bundles at this time. ■ Bundles have Drug components and Non-drug components. ■ The bundled payment rates would vary by the medication used, amount of services, and geographic location where services are provided.

CMS Final Rule: Duration of Bundle ■ A weekly bundle consists of 7 days

CMS Final Rule: Duration of Bundle ■ A weekly bundle consists of 7 days ■ In order to accommodate guest dosing and patients that attend OTP treatment less than once per week, CMS has added an add-on take-home medication code.

CMS Final Rule: Weekly Bundles ■ The drug component is the cost of the

CMS Final Rule: Weekly Bundles ■ The drug component is the cost of the medication only. ■ The non-drug component may consist of medication administration and/or a combination of services, including counseling/individual and group therapy and/or toxicology. ■ The drug and non-drug components are billed together as a unified bundled payment. ■ Services in the weekly non-drug component are determined according to individualized treatment plan ■ The weekly bundle is eligible to be billed as long as any component of the bundle is provided during the week. ■ CMS confirms that services can be delivered by a licensed professional as allowed for OTPs by the laws and scope of practice within the state

CMS Final Rule: Co-share ■ The Support Act specifies that Medicare will pay 100%

CMS Final Rule: Co-share ■ The Support Act specifies that Medicare will pay 100% of the cost of OTP services. ■ CMS finalizes a $0 copay for a time-limited duration and will consider adjustments in future rulemaking. ■ The standard Part B annual deductible would apply (currently $185). CMS discusses State options for deductibles for dualeligible beneficiaries.

CMS Final Rule: Add-on Codes ■ For patients requiring additional counseling or therapy, CMS

CMS Final Rule: Add-on Codes ■ For patients requiring additional counseling or therapy, CMS is creating an add-on payment (HCPCS G 2080 for each additional 30 -minute session in a week, with such need being documented in the treatment plan). ■ CMS has created add-on codes for the intake activities based on E/M Code value 99204 (moderate to high severity) plus toxicology.

OTP Definitions ■ CMS considered comments on the broader scope of OTP services but

OTP Definitions ■ CMS considered comments on the broader scope of OTP services but will not additional services this year. ■ Amongs services mentioned for consideration in future are case management/care coordination ■ The use of telehealth is finalized for all counseling services , which may be delivered to the patient’s home, with proper equipment/platform.

CMS Final Rule Medications ■ CMS adjusted the average dose of oral buprenorphine from

CMS Final Rule Medications ■ CMS adjusted the average dose of oral buprenorphine from 10 mg to 16 mg. ■ CMS included buprenorphine and buprenorphine/naloxone in the oral buprenorphine bundle

CMS Final Rule Payment for Bundles ■ CMS responded to public comments regarding the

CMS Final Rule Payment for Bundles ■ CMS responded to public comments regarding the insufficiency of the proposed reimbursement and concerns over using Tricare as the framework. ■ CMS is finalized a payment rule for the non-drug component based on a building block methodology using the Medicare payment rates for similar services. ■ CMS acknowledges that establishing a methodology in which Medicare payments would be less than State Medicaid programs would create unnecessary barriers to care.

CMS OTP Final Payment Bundles HCPCS Descriptor OTP Code Descriptors and Proposed Approximate Payment

CMS OTP Final Payment Bundles HCPCS Descriptor OTP Code Descriptors and Proposed Approximate Payment Amounts Drug Cost** Full weeks NOTE added: services listed are for CMS valuation purposes only Non-drug Cost*** Total Cost G 2067 Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicareenrolled Opioid Treatment Program) $35. 28 $172. 21 $207. 49 G 2068 Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) $86. 26 $172. 21 258. 46 G 2069 Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) $1, 578. 64 $178. 65 1757. 29 See Final Rule for code G 2070 -G 2075, injectables and implants

CMS OTP Proposed Payment Bundles OTP Code Descriptors and Proposed Approximate Payment Amounts HCPCS

CMS OTP Proposed Payment Bundles OTP Code Descriptors and Proposed Approximate Payment Amounts HCPCS Descriptor Intensity Add-On Codes Drug Cost** Non-drug Cost*** Total Cost $179. 46 110. 28 G 2076 Intake Activities: Physical exam OR Intake Treatment plan/comprehensive psycho-social evaluation- G 2077 Periodic assessment- by qualified personnel to determine appropriate combination of Tx G 2078 Take-home supply of methadone- up to 7 days $35. 28 0 35. 28 G 2079 Take home supply of buprenorphine (oral) up to 7 days 86. 26 0 86. 26 G 2080 Additional 30 minutes of counseling 0 30. 94

CMS Regional Adjustments made to non-drug component of weekly bundle and add-on payments Medicare

CMS Regional Adjustments made to non-drug component of weekly bundle and add-on payments Medicare Administrative Contractor 13202 13292 13282 State Locality Number NY NY NY 01 02 03 04 99 Medicare Locality MANHATTAN NYC SUBURBS/LONG ISLAND POUGHKPSIE/N NYC SUBURBS QUEENS REST OF NEW YORK 2019 GAF* 1. 134 1. 162 1. 053 1. 164 0. 960 Percent 2020 GAF Change (2019 -2020) 1. 144 0. 9% 1. 173 0. 9% 1. 068 1. 4% 1. 178 1. 2% 0. 963 0. 3% 2021 GAF 1. 155 1. 185 1. 082 1. 193 0. 965 Percent Change (2019 -2021) 1. 9% 2. 0% 2. 8% 2. 5% 0. 5%

CMS OTP Implementation Issues and Next steps ■ CMS will work with states to

CMS OTP Implementation Issues and Next steps ■ CMS will work with states to ensure a smooth transition. ■ CMS will issue guidance to States regarding dual-eligible beneficiaries and wants to ensure that services continue without interruption. ■ January 1, 2020 is the date for OTP coverage. ■ Not all OTPs will be enrolled in Medicare on January 1. ■ Medicaid will continue to pay claims until Medicare can begin payments. ■ CMS notes that Medicare Advantage plans are obligated to provide all Part A and Part B benefits to their enrollees (which now includes OTP coverage).

COALITION OF MEDICATION-ASSISTED TREATMENT PROVIDERS AND ADVOCATES Please contact Allegra Schorr at aschorr@compa-ny. org

COALITION OF MEDICATION-ASSISTED TREATMENT PROVIDERS AND ADVOCATES Please contact Allegra Schorr at aschorr@compa-ny. org for further info. ■ The final rule is scheduled to be published in the Federal Register on November 15, 2019 and is available online at https: //www. federalregister. gov/documents/2019/11/15/201924086/medicare-program-cy-2020 -revisions-to-payment-policiesunder-the-physician-fee-schedule-and-other and on govinfo. gov ■ CMS Opioid Treatment Programs: Enrolling in Medicare Call on Tue, Nov 12, 3: 00 pm ■ REGISTER for November 12 call