3.1 Freestanding methadone OTPs
(which also provide opioid partial agonists and antagonists) shall
be reimbursed the lower of the billed charge or a weekly all-inclusive
rate.
3.1.1 The weekly
all-inclusive rate shall include the cost of the drug and all related
services (i.e., the costs related to initial intake/assessment,
drug dispensing and screening, and integrated psychosocial and medical
treatment and support services).
3.1.2 The weekly all-inclusive rate
shall be accepted as payment-in-full.
3.1.3 The weekly all-inclusive rate
is subject to the outpatient cost-sharing provisions in
32 CFR 199.4(f). Services shall be cost-shared
on a weekly basis (e.g., one $12 cost-share applies to a full week of
methadone OTP services for a Prime retiree).
3.1.4 The initial Fiscal Year (FY)
2017 national weekly all-inclusive rate is $126. This rate is based upon
an estimated drug cost of $3 per day, and $15 per day for medical
services. The national rate was determined to be $126 after an analysis
of the payments made by other payers.
3.1.5 The weekly all-inclusive rate
shall be wage-adjusted by the CHAMPUS Maximum Allowable Charge (CMAC)
locality adjustment factors.
3.1.6 The national weekly all-inclusive
rate shall be updated annually, on October 1 of each year, by the
Medicare update factor used for the Medicare Inpatient Prospective
Payment System (IPPS) (see
Section 1, paragraph 3.5.3 for the list of
update factors).
3.1.7 The weekly all-inclusive rate shall be posted
to the DHA website by October 1 of each year. DHA shall retain three
years of reimbursement rates for methadone OTPs on the DHA website.
3.1.8 The weekly all-inclusive set
of services shall be billed utilizing Healthcare Common Procedure
Coding System (HCPCS) code H0020 [Alcohol and/or drug services].
Only one occurrence of this code shall be reimbursed in a given
week (seven day period). Services that are incorporated into the
weekly all-inclusive rate (e.g., HCPCS code J1230 for the methadone)
shall not be separately reimbursed.
3.1.9 Psychotherapy sessions and
non-mental health related medical services not normally included
in the evaluation and assessment for OTPs, provided by authorized
independent providers who are not employed by, or under contract
with, the OTP for the purposes of providing clinical patient care
are not included in the weekly bundled rate and may be billed separately.
This includes ambulance services when medically necessary for emergency
transport.
3.2 OTP
reimbursement of other medications (e.g., buprenorphine and naltrexone)
provided in freestanding OTPs shall be made on a fee-for-service
basis (i.e., separate payments will be allowed for both the medication
and accompanying support services).
3.2.1 Buprenorphine. HCPCS code
H0047 shall be utilized to reflect the medical intake and assessment,
drug dispensing and monitoring, and counseling services. H0047 shall
be reimbursed in accordance with the CMAC methodology; see
Chapter 5, Section 3. The appropriate HCPCS
code shall be utilized to bill for the medication. The National
Drug Code (NDC) shall be reported to the contractor, along with
the dosage and acquisition cost. The drug shall be reimbursed in
accordance with the
Chapter 1, Section 15.
3.2.2 Naltrexone. HCPCS code H0047
shall be utilized to reflect the medical intake and assessment,
monitoring and counseling services. Current Procedural Terminology
(CPT) code 96372 shall be utilized to report the administration
fee. H0047 and 96372 shall be reimbursed in accordance with the
CMAC methodology; see
Chapter 5, Section 3.
HCPCS code J2315 shall be utilized for the prescribed medication,
along with the number of milligrams used. The drug shall be reimbursed
in accordance with
Chapter 1, Section 15.
In general, naltrexone is provided as an injection every four weeks.
Contractors shall review more frequent administration to ensure
services are medically necessary and appropriate.
3.2.3 Participation Agreement
3.2.3.1 In order
for the services of an OTP to be authorized, the OTP must sign a
Participation Agreement. See the TRICARE Policy Manual (TPM),
Chapter 11, Addendum H.
3.2.3.2 The agreement
requires the OTP to accept the TRICARE determined rate as payment
in full and collect from the beneficiary or the family of the beneficiary
those amounts that represent the beneficiary’s liability, as defined
by 32 CFR 199, and charges for services and supplies that are not
a benefit.
3.2.4 Cost-Sharing
Services provided under
paragraph 3.2 are subject
to the outpatient cost-sharing provisions in
32 CFR 199.4(f). Cost-sharing shall be applied
on a per-visit basis.