CMS focuses on new bundled payment opportunities for opioid use disorder treatment services



December 05, 2019

Health Care Alert

Author(s): Jena M. Grady

This alert was co-authored by Gabriela Illa.

On November 15, 2019, the Centers for Medicare and Medicaid Services (“CMS”) published in the Federal Register its final rule to address new ways under Medicare for opioid treatment programs (“OTPs”) and practitioners to deliver and seek reimbursement for opioid use disorder (“OUD”) treatment services. We discuss the two new bundled payment models available to these providers starting January 1, 2020 below.

New bundled payment model for opioid use disorder treatment services provided by opioid treatment programs

The new bundled payment model for opioid treatment services for OTPs comes as a result of the requirement under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act) for CMS to implement as a new Medicare Part B benefit OUD treatment services furnished by OTPs. Nixon Peabody’s alert about the SUPPORT Act is available here.

CMS is finalizing the below OUD treatment services provided by OTPs to be eligible for bundled payment to include the following:

  • FDA-approved treatment medications for the treatment of OUD, including methadone,
  • the dispensing and administration of such medication,
  • substance use counseling,
  • individual and group therapy with a physician or psychologist (or other mental health professional if allowed under applicable state law), and
  • toxicology testing.

Payment for the services above will be a bundled payment for episodes of care for a period of one week in duration. The bundled payment will be stratified into several codes in order to address for differences in a Medicare beneficiary’s clinical needs.

In order to receive the weekly bundled payment, an OTP is required to provide at least one service, administration of the drug, individual therapy, group therapy, substance use counseling, or toxicology testing, during the week. While intake activities (e.g., preparation of a treatment plan) and periodic assessment are included in the definition of OUD treatment services, CMS noted that it will establish payment adjustments when these services are provided rather than these services being included in the bundled payment for OTPs. There will also be additional payment adjustments for counseling and therapy services that substantially exceed the amount specified in a beneficiary’s individualized treatment plan and take-home supplies of medication.

Notably, Medicare beneficiaries will not be required to have a copayment for OUD treatment services provided by OTPs in 2020. CMS seeks to have this copayment at zero for a limited time and will possibly evaluate the amount for the copayment in future rulemaking if deemed appropriate.

In order for OTPs to be eligible for reimbursement under this new bundled payment program, OTPs will be required to enroll in Medicare. Medicare enrollment will require in part the OTP to have a current certification with the Substance Abuse and Mental Health Services Administration and Drug Enforcement Administration registration. CMS started to enroll OTPs in Medicare on November 1, 2019.

CMS is also finalizing a policy to permit counseling and therapy services that are part of the bundled payment to be provided via two-way interactive audio-video communication technology as clinically appropriate. It is CMS’s hope that this flexibility will assist beneficiaries that live in rural areas that have been hit the hardest by the opioid crisis to obtain treatment services.

New bundled payment model for opioid use disorder treatment services under the Medicare Physician Fee Schedule

CMS also established a new bundled payment under the Medicare Physician Fee Schedule (“PFS”) furnished by practitioners in an office or an outpatient setting. CMS hopes that the addition of a bundled payment program for OUD treatment services under the PFS will incentivize practitioners to provide more counseling and care coordination services for beneficiaries with OUD in their offices.

CMS is finalizing OUD treatment services eligible for bundled payment under PFS to include the following HCPCS codes:

  • HCPCS Code G2086: Office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month.
  • HCPCS Code G2087: Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month.

Payment for the codes above will be a bundled payment for episodes of care for a period of one month in duration. For the purposes of valuation of the above codes, CMS assumed that there would be two individual psychotherapy sessions per month and four group psychotherapy sessions per month. However, CMS noted that it realizes the number of counseling and therapy sessions furnished per month will vary among beneficiaries and over time based on a beneficiary’s needs.

There will also be an add-on code for practitioners to receive additional reimbursement in part for when extra services are required because beneficiaries may have additional needs that are not usually seen for a typical patient and/or when there are psychosocial stressors that need to be addressed that were not identified at the beginning when the treatment plan was developed.

CMS also noted that unlike the OUD treatment services bundled payment for OTPs, CMS does not have the statutory authority to eliminate copayment requirements for the bundled OUD treatment services under the PFS.

CMS also authorized the above HCPCS codes, including the add-on code for additional services outside the bundled payment, to be provided via telehealth. As enacted by the SUPPORT Act, patients will be able to obtain these OUD treatment services via telehealth from their own homes.

The foregoing has been prepared for the general information of clients and friends of the firm. It is not meant to provide legal advice with respect to any specific matter and should not be acted upon without professional counsel. If you have any questions or require any further information regarding these or other related matters, please contact your regular Nixon Peabody LLP representative. This material may be considered advertising under certain rules of professional conduct.

Back to top