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On July 10, the Facilities for Medicare & Medicaid Providers (CMS) launched the Medicare Doctor Payment Schedule Proposed Rule (Proposed Rule) for the calendar 12 months 2025. The Proposed Rule would implement sure provisions of the Substance Use-Dysfunction Prevention that Promotes Opioid Restoration and Therapy for Sufferers and Communities Act (SUPPORT Act) and proposes new fee insurance policies regarding Opioid Use Dysfunction (OUD) remedy. Since enactment of the SUPPORT Act in 2018, CMS has constantly carried out reforms and added coated substance use dysfunction (SUD) remedy providers by way of its annual replace to the Medicare Doctor Payment Schedule. The Proposed Rule retains with that theme and builds on this progress. Buyers in and suppliers of SUD remedy providers ought to look at the impacts of the Proposed Rule and take into account submitting feedback to CMS — the deadline is September 9, 2024. The Proposed Rule options the next particular to SUD providers:
- Telecommunication Flexibilities for Periodic Evaluation and Initiation of Therapy with Methadone
- Establishing funds to Opioid Therapy Packages for Social Determinants of Well being threat assessments
- Establishing fee for brand spanking new U.S. Meals & Drug Administration (FDA)-approved Opioid Agonist and Antagonist Medicines
Everlasting Telecommunication Flexibilities
CMS proposed two adjustments which search to broaden entry and cut back obstacles for sufferers of Opioid Therapy Packages (OTPs) by completely permitting telecommunication applied sciences for sure providers.
First, CMS proposes that OTPs could furnish periodic assessments utilizing audio-only communications expertise when video will not be out there on a everlasting foundation starting January 1, 2025. This methodology had been allowed on a short lived foundation throughout COVID-19. By making this flexibility everlasting, CMS goals to advertise entry to care and forestall disruptions in remedy for Medicare beneficiaries as knowledge means that audio-only visits (or the demand therefor) will increase with age of the affected person, and lots of subpopulations of Medicare together with racial/ethnic minorities, twin enrollees in Medicare and Medicaid, and people with low broadband entry are extra probably to make use of audio solely telemedicine providers. As CMS acknowledged, telehealth providers by way of phone have turn into common providers choices for SUD remedy amenities for the reason that COVID-19 pandemic.
Second, CMS proposes allowing OTPs to make use of audio-visual telecommunication for initiation of remedy with methadone. Particularly, CMS proposes that an OTP consumption add-on service (HCPCS G2076) could also be furnished by way of two-way audio-video expertise. In February 2024, the Substance Abuse and Psychological Well being Providers Administration (SAMHSA) made a number of reforms to permit audio-visual telehealth initiation for any new affected person who will likely be handled by the OTP with methadone if a practitioner or main care supplier determines that an enough analysis of the affected person might be achieved by way of an audio-visual telehealth platform. The Proposed Rule would conform the Doctor Payment Schedule with SAMHSA reforms (beforehand mentioned in our current weblog publish: Opioid Therapy Packages: SAMHSA Makes Everlasting Regulatory Flexibilities) and permit for Medicare reimbursement. CMS hopes these reforms will cut back obstacles to care, promote optimistic well being outcomes, and advance well being fairness amongst Medicare beneficiaries.
Establishing Funds to Opioid Therapy Packages for Social Determinants of Well being Danger Assessments (Reforms to 42 C.F.R. Half 8)
The Proposed Rule consists of reforms to 42 C.F.R. Half 8 that might broaden protection beneath the Medicare OTP profit by establishing fee for Social Determinants of Well being (SDOH) threat assessments beneath a number of circumstances. Primarily, the SDOH threat evaluation should be a part of any consumption actions for remedy of OUD, the evaluation should be medically cheap and obligatory for the prognosis or remedy of OUD, and OTP suppliers should consider that unmet health-related social wants (HRSN) or the necessity for providers recognized within the evaluation may intervene with the OTP’s means to diagnose or deal with the affected person’s OUD.
Relatedly, CMS requests info associated to the fee of coordinated care and referrals to community-based organizations that handle unmet HRSN, present hurt discount providers, and/or present restoration help providers. CMS notes that beneath the Medicare OTP profit, fee has been established for some providers like overdose training furnished at the side of opioid antagonist remedy or social help by way of group remedy. CMS acknowledges that different forms of essential providers equivalent to any work the OTP could undertake to coordinate care or hyperlink sufferers to community-based organizations will not be at the moment reimbursed. Particularly, CMS requests info to grasp if OTPs incessantly work with transportation businesses, native help teams, syringe service applications, and nonprofits that present monetary helps and the forms of collaborative preparations an OTP could have with community-based organizations. CMS requests suggestions on whether or not OTPs already obtain funding for coordinated care or referral providers from different public or non-public providers.
Fee for New FDA-approved Opioid Agonist and Antagonist Medicines
Lastly, the Proposed Rule proposes the creation of fee codes for a number of new medication beneath the Medicare OTP profit, together with a brand new Nalmefene Hydrochloride product known as Opvee and a brand new injectable formulation of buprenorphine, Brixadi. Each of those merchandise had been just lately accredited by the FDA for OUD remedy and considerably broaden OUD remedy choices for sufferers.
Name to Motion
The Proposed Rule ought to be celebrated, by beneficiaries and suppliers alike, because it seeks to broaden Medicare protection and fee for SUD remedy providers. CMS will take into account stakeholder enter earlier than finalizing these essential reforms and can also be in search of details about collaborative preparations and funding for community-based suppliers to handle HRSNs. Stakeholders in SUD ought to take into account submitting feedback and responsive info to CMS to help continued reforms to broaden entry and fee pathways for SUD remedy providers.
Suppliers and scientific personnel desirous about adjustments to the behavioral well being codes for 2025 ought to take into account offering feedback to the proposed rule. The remark interval will shut on September 9, 2024, 5:00 p.m. ET. Anybody could submit feedback by way of digital submission at this hyperlink. Moreover, commenters could submit feedback by mail to:
- Common Mail: Facilities for Medicare & Medicaid Providers, Division of Well being and Human Providers, Consideration: CMS-1807-P, P.O. Field 8016, Baltimore, MD 21244-8016.
- Categorical or In a single day Mail: Facilities for Medicare & Medicaid Providers, Division of Well being and Human Providers, Consideration: CMS-1807-P, Mail Cease C4-26-05, 7500 Safety Boulevard, Baltimore, MD 21244-1850.
If submitting by way of mail, please permit time for feedback to be acquired earlier than the deadline.
Wish to Study Extra?
- Opioid Therapy Packages: SAMHSA Makes Everlasting Regulatory Flexibilities
- Well being-Associated Social Wants: Three Traits in Leveraging Neighborhood Partnerships
- Behavioral Well being: CMS Innovation Mannequin Outlines Modifications for the Supply of Built-in Behavioral and Bodily Well being Care
- 2023 Going Digital Well being’s Behavioral Well being Tech Convention: Key Funding Takeaways
For extra info on behavioral well being, substance use dysfunction remedy, psychological well being, and different well being improvements, together with the crew, publications, and consultant expertise, go to Foley’s Behavioral Well being and Substance Use Dysfunction group.
The publish Substance Use Dysfunction Therapy Providers: 2025 Doctor Payment Schedule Proposed Rule Would Broaden Entry and Medicare Protection appeared first on Foley & Lardner LLP.
