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.