Mental Health
Chapter 7
Section 3
Inpatient/Residential Substance
Use Disorder Rehabilitation Facilities (SUDRFs) Reimbursement
Issue Date: June 26, 1995
Revision: C-10, November 15, 2017
1.0 APPLICABILITY
1.1 This policy
is mandatory for reimbursement of services provided by either network
or non-network providers. However, alternative network reimbursement
methodologies are permitted when approved by the Defense Health
Agency (DHA) and specifically included in the network provider agreement.
1.2 The following reimbursement
methodology will be used for payment of all SUDRFs prior to implementation
of the reasonable cost method for Critical Access Hospitals (CAHs)
and implementation of Outpatient Prospective Payment System (OPPS).
Thereafter, this methodology will only be used in the reimbursement
of freestanding SUDRFs and other providers who are exempt from the
TRICARE OPPS and provide SUDRF services.
2.0 ISSUE
Reimbursement of SUDRFs. This
includes reimbursement for both inpatient and residential treatment of Substance Use Disorder (SUD) rehabilitation
care.
3.0 POLICY
3.1 Inpatient/Residential SUDRFs
Admissions to authorized SUDRFs
are subject to the Diagnosis Related Group (DRG)-based payment system.
3.2 Partial
Hospitalization
For
The
Treatment
Of
SUDs3.2.1 SUD rehabilitation
partial hospitalization services are reimbursed on the basis of prospectively
determined all-inclusive per diem rates. The per diem payment amount
must be accepted as payment in full for all institutional services
provided, including board, routine nursing services, ancillary services
(includes art, music, dance, occupational and other such therapies), psychological
testing and assessments, overhead and any other services for the
customary practice among similar providers is included as part of
the institutional charges.
3.3 Outpatient professional services shall be
reimbursed using the appropriate Healthcare Common Procedure Coding
System (HCPCS) code or Current Procedural Terminology (CPT) code. Payment
is the lesser of the billed charge or the CHAMPUS Maximum Allowable
Charge (CMAC).
3.4 Family therapy provided on
an inpatient or outpatient basis shall be
reimbursed under the CMAC for the procedure code(s) billed.
3.5 Cost-
Sharing
3.5.1 For date of service
prior to October 3, 2016, the cost-share for Active
Duty Dependents (ADDs) for inpatient SUD services
is $20.00 per day for each day of the inpatient admission. The $20.00 cost-share
amount also applies to SUD rehabilitation
care provided in a partial hospitalization setting. The inpatient
cost-share applies to the associated services billed separately
by the individual professional providers. For retirees and their
dependents, the cost-share is 25% of the allowed amount. Since inpatient
cost-sharing is being applied, no deductible is to be taken for
partial hospitalization regardless of sponsor status. The cost-share
for ADDs is to be taken from the partial hospitalization facility
claim.
3.5.2 For dates of
service on or after October 3, 2016, see Chapter 2, Addendum A for
cost-sharing requirements.
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