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.