PRIA, Government Policy, Made Personal

Summary

The Secretary must start a 4-year demo program by January 1, 2021 to make it easier for certain Medicare patients to get opioid use disorder treatment, help their physical and mental health, and try to lower Medicare spending. The program pays selected providers for giving or arranging outpatient opioid treatment through special care teams and for meeting performance goals like keeping patients in treatment and using proven medication-based care. Key terms (one line each): opioid use disorder treatment services — outpatient care that uses drugs approved under 21 U.S.C. 355 and can include medication-assisted treatment, treatment planning, counseling or psychiatric care, social supports, and care coordination; participant — a Medicare-enrolled provider or clinic (examples: physicians, group practices, hospital outpatient departments, federally qualified health centers, rural health clinics, community mental health centers, certified community behavioral health clinics, or others the Secretary allows) that applies, is chosen, and sets up a care team; opioid use disorder care team — a team that must include at least one physician and one other eligible practitioner and may include counselors and social service providers; eligible practitioner — a Medicare-enrolled clinician authorized to prescribe or dispense narcotics for maintenance or detoxification; applicable beneficiary — a person on Medicare Parts A and B (not in Medicare Advantage) with a current opioid use disorder diagnosis who agrees to join the program. Up to 20,000 beneficiaries may take part at once and they may leave anytime. The Secretary must consult addiction and primary care experts within 3 months after October 24, 2018 and give preference to providers in areas with higher-than-average opioid problems. Payments include a monthly per-beneficiary care management fee (which can be higher for more intensive care or the first month) plus performance-based incentives tied to measures like engagement and use of evidence-based treatment; only one participant gets paid for a beneficiary in a month. The Secretary will run intermediate and final evaluations and must report to Congress not later than 3 years and 6 years after the program starts. Funding: $5,000,000 from the Federal Supplementary Medical Insurance Trust Fund for running the program (except payments), and $10,000,000 from that Trust Fund for each of fiscal years 2021 through 2024 for payments. The Secretary may waive Medicare rules if needed and may work with other payers to align payments.

Title 42, §1395cc–6

The Public Health and Welfare, Source: USLM XML via OLRC

(a)(1)Not later than January 1, 2021, the Secretary shall implement a 4-year demonstration program under this subchapter (in this section referred to as the “Program”) to increase access of applicable beneficiaries to opioid use disorder treatment services, improve physical and mental health outcomes for such beneficiaries, and to the extent possible, reduce expenditures under this subchapter. Under the Program, the Secretary shall make payments under subsection (e) to participants (as defined in subsection (c)(1)(A)) for furnishing opioid use disorder treatment services delivered through opioid use disorder care teams, or arranging for such services to be furnished, to applicable beneficiaries participating in the Program.

(2)For purposes of this section, the term “opioid use disorder treatment services”—

(A)means, with respect to an applicable beneficiary, services that are furnished for the treatment of opioid use disorders and that utilize drugs approved under section 355 of title 21 for the treatment of opioid use disorders in an outpatient setting; and

(B)includes—

(i)medication-assisted treatment;

(ii)treatment planning;

(iii)psychiatric, psychological, or counseling services (or any combination of such services), as appropriate;

(iv)social support services, as appropriate; and

(v)care management and care coordination services, including coordination with other providers of services and suppliers not on an opioid use disorder care team.

(b)(1)The Secretary shall design the Program in such a manner to allow for the evaluation of the extent to which the Program accomplishes the following purposes:

(A)Reduces hospitalizations and emergency department visits.

(B)Increases use of medication-assisted treatment for opioid use disorders.

(C)Improves health outcomes of individuals with opioid use disorders, including by reducing the incidence of infectious diseases (such as hepatitis C and HIV).

(D)Does not increase the total spending on items and services under this subchapter.

(E)Reduces deaths from opioid overdose.

(F)Reduces the utilization of inpatient residential treatment.

(2)In designing the Program, including the criteria under subsection (e)(2)(A), the Secretary shall, not later than 3 months after October 24, 2018, consult with specialists in the field of addiction, clinicians in the primary care community, and beneficiary groups.

(c)(1)(A)In this section, the term “participant” means an entity or individual—

(i)that is otherwise enrolled under this subchapter and that is—

(I)a physician (as defined in section 1395x(r)(1) of this title);

(II)a group practice comprised of at least one physician described in subclause (I);

(III)a hospital outpatient department;

(IV)a federally qualified health center (as defined in section 1395x(aa)(4) of this title);

(V)a rural health clinic (as defined in section 1395x(aa)(2) of this title);

(VI)a community mental health center (as defined in section 1395x(ff)(3)(B) of this title);

(VII)a clinic certified as a certified community behavioral health clinic pursuant to section 223 of the Protecting Access to Medicare Act of 2014; or

(VIII)any other individual or entity specified by the Secretary;

(ii)that applied for and was selected to participate in the Program pursuant to an application and selection process established by the Secretary; and

(iii)that establishes an opioid use disorder care team (as defined in paragraph (2)) through employing or contracting with health care practitioners described in paragraph (2)(A), and uses such team to furnish or arrange for opioid use disorder treatment services in the outpatient setting under the Program.

(B)In selecting participants for the Program, the Secretary shall give preference to individuals and entities that are located in areas with a prevalence of opioid use disorders that is higher than the national average prevalence.

(2)(A)For purposes of this section, the term “opioid use disorder care team” means a team of health care practitioners established by a participant described in paragraph (1)(A) that—

(i)shall include—

(I)at least one physician (as defined in section 1395x(r)(1) of this title) furnishing primary care services or addiction treatment services to an applicable beneficiary; and

(II)at least one eligible practitioner (as defined in paragraph (3)), who may be a physician who meets the criterion in subclause (I); and

(ii)may include other practitioners licensed under State law to furnish psychiatric, psychological, counseling, and social services to applicable beneficiaries.

(B)In order to receive payments under subsection (e), each participant in the Program shall—

(i)furnish opioid use disorder treatment services through opioid use disorder care teams to applicable beneficiaries who agree to receive the services;

(ii)meet minimum criteria, as established by the Secretary; and

(iii)submit to the Secretary, in such form, manner, and frequency as specified by the Secretary, with respect to each applicable beneficiary for whom opioid use disorder treatment services are furnished by the opioid use disorder care team, data and such other information as the Secretary determines appropriate to—

(I)monitor and evaluate the Program;

(II)determine if minimum criteria are met under clause (ii); and

(III)determine the incentive payment under subsection (e).

(3)For purposes of this section, the term “eligible practitioner” means a physician or other health care practitioner, such as a nurse practitioner, that—

(A)is enrolled under section 1395cc(j)(1) of this title; and

(B)is authorized to prescribe or dispense narcotic drugs to individuals for maintenance treatment or detoxification treatment.

(d)(1)In this section, the term “applicable beneficiary” means an individual who—

(A)is entitled to, or enrolled for, benefits under part A and enrolled for benefits under part B;

(B)is not enrolled in a Medicare Advantage plan under part C;

(C)has a current diagnosis for an opioid use disorder; and

(D)meets such other criteria as the Secretary determines appropriate.

(2)An applicable beneficiary may participate in the Program on a voluntary basis and may terminate participation in the Program at any time. Not more than 20,000 applicable beneficiaries may participate in the Program at any time.

(3)In order to participate in the Program, an applicable beneficiary shall agree to receive opioid use disorder treatment services from a participant. Participation under the Program shall not affect coverage of or payment for any other item or service under this subchapter for the applicable beneficiary.

(4)Nothing in this section shall be construed as encouraging providers to limit applicable beneficiary access to services covered under this subchapter, and applicable beneficiaries shall not be required to relinquish access to any benefit under this subchapter as a condition of receiving services from a participant in the Program.

(e)(1)(A)The Secretary shall establish a schedule of per applicable beneficiary per month care management fees. Such a per applicable beneficiary per month care management fee shall be paid to a participant in addition to any other amount otherwise payable under this subchapter to the health care practitioners in the participant’s opioid use disorder care team or, if applicable, to the participant. A participant may use such per applicable beneficiary per month care management fee to deliver additional services to applicable beneficiaries, including services not otherwise eligible for payment under this subchapter.

(B)In carrying out subparagraph (A), the Secretary may—

(i)consider payments otherwise payable under this subchapter for opioid use disorder treatment services and the needs of applicable beneficiaries;

(ii)pay a higher per applicable beneficiary per month care management fee for an applicable beneficiary who receives more intensive treatment services from a participant and for whom those services are appropriate based on clinical guidelines for opioid use disorder care;

(iii)pay a higher per applicable beneficiary per month care management fee for the month in which the applicable beneficiary begins treatment with a participant than in subsequent months, to reflect the greater time and costs required for the planning and initiation of treatment, as compared to maintenance of treatment; and

(iv)take into account whether a participant’s opioid use disorder care team refers applicable beneficiaries to other suppliers or providers for any opioid use disorder treatment services.

(C)The Secretary shall make payments under this paragraph to only one participant for services furnished to an applicable beneficiary during a calendar month.

(2)(A)Under the Program, the Secretary shall establish a performance-based incentive payment, which shall be paid (using a methodology established and at a time determined appropriate by the Secretary) to participants based on the performance of participants with respect to criteria, as determined appropriate by the Secretary, in accordance with subparagraph (B).

(B)(i)Criteria described in subparagraph (A) may include consideration of the following:

(I)Patient engagement and retention in treatment.

(II)Evidence-based medication-assisted treatment.

(III)Other criteria established by the Secretary.

(ii)In determining criteria described in subparagraph (A), the Secretary shall—

(I)consult with stakeholders, including clinicians in the primary care community and in the field of addiction medicine; and

(II)consider existing clinical guidelines for the treatment of opioid use disorders.

(C)The Secretary shall ensure that no duplicate payments under this paragraph are made with respect to an applicable beneficiary.

(f)In carrying out the Program, the Secretary shall encourage other payers to provide similar payments and to use similar criteria as applied under the Program under subsection (e)(2)(C). The Secretary may enter into a memorandum of understanding with other payers to align the methodology for payment provided by such a payer related to opioid use disorder treatment services with such methodology for payment under the Program.

(g)(1)The Secretary shall conduct an intermediate and final evaluation of the program. Each such evaluation shall determine the extent to which each of the purposes described in subsection (b) have been accomplished under the Program.

(2)The Secretary shall submit to Congress—

(A)a report with respect to the intermediate evaluation under paragraph (1) not later than 3 years after the date of the implementation of the Program; and

(B)a report with respect to the final evaluation under paragraph (1) not later than 6 years after such date.

(h)(1)For the purposes of implementing, administering, and carrying out the Program (other than for purposes described in paragraph (2)), $5,000,000 shall be available from the Federal Supplementary Medical Insurance Trust Fund under section 1395t of this title.

(2)For the purposes of making payments under subsection (e), $10,000,000 shall be available from the Federal Supplementary Medical Insurance Trust Fund under section 1395t of this title for each of fiscal years 2021 through 2024.

(3)Amounts transferred under this subsection for a fiscal year shall be available until expended.

(i)The Secretary may waive any provision of this subchapter as may be necessary to carry out the Program under this section.

Notes & Related Subsidiaries

Editorial Notes

References in Text

section 223 of the Protecting Access to Medicare Act of 2014, referred to in subsec. (c)(1)(A)(i)(VII), is section 223 of Pub. L. 113–93, which is set out as a note under section 1396a of this title.

Amendments

2022—Subsec. (c)(3)(C). Pub. L. 117–328 struck out subpar. (C) which read as follows: “has in effect a waiver in accordance with section 823(h) of title 21 for such purpose and is otherwise in compliance with

Regulations

promulgated by the Substance Abuse and Mental Health Services Administration to carry out such section.” Pub. L. 117–215 substituted “823(h)” for “823(g)”.

§1395cc–6 Opioid Use Disorder Treatment Demonstration Program