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White House Proposes Changes IMD Exclusion in 2021 Budget

The White House on Monday released a $4.8 trillion budget for 2021 that would modify Medicaid’s Institutions for Mental Diseases (IMD) exclusion to provide states with flexibility to provide inpatient mental health services to beneficiaries with serious mental illness (SMI).

The budget requests $94.5 billion for HHS, a 10-percent decrease from the 2020 enacted level. Although Congress is likely to reject President Trump’s proposal, the budget is significant for outlining the president’s top policy priorities as he seeks re-election in November. Notably for NABH, those priorities address mental health and addiction treatment services.

These provisions include changes to the IMD exclusion, which under current law states Medicaid cannot pay for certain inpatient stays at IMDs. The president’s budget would provide more than $5 billion in new federal funding to states to ensure the full continuum of care exists to provide help to people with SMI. These changes—which appear in summary tables at the end of the budget proposal—would exempt Qualified Residential Treatment Programs (QRTPs) from the IMD exclusion.

The budget also includes $225 million for Certified Community Behavioral Health Clinics (CCBHC) expansion grants, and would extend, through 2021, the CCBHC Medicaid demonstration programs to improve community mental health services for the eight states participating currently in the demonstration. In addition, the White House has proposed $25 million to expand primary healthcare services to address homelessness. These provisions, together with the changes to the IMD exclusion, are “part of a comprehensive strategy that includes improvements to community-based treatment,” the budget proposal noted.

Meanwhile, the president’s 2021 budget would continue 2020 funding to expand medication assisted treatment (MAT) from a small pilot program to half of all eligible Bureau of Prisons (BOP) facilities and provide an additional $37 million to complete MAT expansion to all eligible BOP facilities.

NABH will continue to analyze the Trump administration’s budget proposal and keep NABH apprised of any additional details regarding the IMD exclusion, MAT funding, and other topics related to the association’s policy priorities.

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ONDCP Issues 2020 National Drug Control Strategy and Treatment Plan

The Office of National Drug Control Policy (ONDCP) has issued its 2020 National Drug Control Strategy (Strategy) and accompanying National Treatment Plan (NTP) that includes action items for federal agencies and external stakeholders to increase access to care and close the addiction treatment gap.

The Strategy is presented using the domains of prevention, treatment and recovery, and supply-side strategies for reducing the availability and consumption of illicit drugs. These domains are established as ‘pillars’ that undergird the federal initiatives of expanding the early intervention, treatment and recovery infrastructure; improving the delivery system; and improving quality.

Specifically, the NTP calls for treatment expansion and improved quality by:

  • Developing protocols for medically managed withdrawal including MAT to prevent relapse and promote stabilization;
  • Increasing emergency department use of addiction medicine specialty services;
  • Exploring the inclusion of stimulant disorder treatment in opioid treatment programs;
  • Increasing access to all medication and psychosocial services, promoting syringe exchange, interim methadone, mobile methadone vans, and peer outreach. One objective of the federal Performance and Reporting System is to make sure 100% of all specialty providers offer MAT by 2020;
  • Adopting model state specialty SUD treatment licensing laws;
  • Developing mobile and online platforms with updated information on treatment slot availability with online appointment capacity;
  • Encouraging public and private payers to cover comprehensive services and improve reimbursement rates where out-of-network rates are higher;
  • Urging providers to subsidize and provide treatment scholarships; and
  • Exploring the idea of developing national consensus standards for addiction treatment to consolidate treatment quality standards.

If you have questions about the Strategy or NTP, please contact Sarah Wattenberg, NABH’s
director of quality and addiction services.

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CDC Reports U.S. Drug Overdose Death Rate Down, Opioid Overdose Death Rate Up in 2018

The age-adjusted rate of U.S. drug overdose deaths in 2018 was 4.6% lower than the rate in 2017, the Centers for Disease Control and Prevention reported Thursday.

New data from the National Vital Statistics System also show there were 67,367 drug overdose deaths in the United States in 2018, 4.1% fewer than the 70,237 deaths reported in 2017.

Despite the decline in overall drug overdose deaths, there was a 10% increase in the rate of drug overdose deaths involving synthetic opioids other than methadone, such as fentanyl, in 2018 compared with 2017.

Furthermore, the age-adjusted rate of overdose deaths involving cocaine more than tripled from 2012 through 2018, while the rate of deaths involving certain psychostimulants, such as methamphetamine, increased nearly five-fold.

The CDC also reported that decreases in life expectancy between 2014 and 2017 were driven mostly by deaths due to unintentional injuries, suicide, and Alzheimer’s disease.

Improvements in life expectancy between 2017 and 2018, meanwhile, were driven by decreases in  mortality from cancer, unintentional injuries, and chronic lower respiratory diseases. The positive contributions to the change in life expectancy were offset, in part, by the rising number of deaths by suicide, chronic liver disease, and cirrhosis.

Unintentional injuries and suicide remain in the top ten leading cause of death in the United States.

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NABH Sends CMS Recommendations to Reduce Administrative Burden

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NABH Supports Expanding Access to Inpatient Mental Health Act

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NABH Comments on CMS’ New Survey and Certification Process for Psychiatric Hospitals

WASHINGTONJan. 13, 2020 /PRNewswire/ — The Centers for Medicare & Medicaid Services (CMS) on Monday announced it has streamlined the process to survey the nation’s psychiatric hospitals to review for compliance with participation requirements in one comprehensive survey.

Beginning in March, CMS will send psychiatric hospitals one survey to evaluate their compliance with both general hospital and psychiatric hospital participation requirements. CMS is not making any changes to the special psychiatric Conditions of Participation (CoPs) in this process.

Under this change, CMS will move the interpretive guidelines from State Operations Manual (SOM) Appendix AA, or the special psychiatric CoPs, into Appendix A, the CoPs for general hospitals. Subsequently CMS will delete Appendix AA. This change will allow CMS to issue a single survey and report to hospitals, rather than two.

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NABH Urges Oversight Hearings on Parity Following GAO Report

WASHINGTONDec. 18, 2019 /PRNewswire/ — A key finding in a new Government Accountability Office (GAO) report on government oversight of compliance with parity underscores the need for federal lawmakers to proactively investigate the work of employer-sponsored group plans and ensure they are complying with the landmark 2008 parity law.

Late last week, GAO released a 67-page report that examined and evaluated the practices, policies, and guidance from the U.S. Health and Human Services (HHS) Department and the U.S. Labor Department (DOL), the two federal offices that oversee compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.

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CMS Releases Guidance on Coverage Transition for ‘Dual Eligibles’ Receiving OTP Services

The Centers for Medicare & Medicaid Services (CMS) released an Informational Bulletin on Tuesday that provides guidance on coverage for Medicare and Medicaid dual-eligible beneficiaries who receive opioid treatment program (OTP) services.

Revisions to the Physician Fee Schedule (CY 2020) allow for a new OTP bundled payment benefit under Medicare, which replaces Medicaid as the primary payer for OTP services for the dual-eligible population. The new benefit is effective January 1, 2020; however, not all OTP providers will have completed Medicare enrollment by that time.

To assure continuity of patient care, states must pay OTP claims for Medicaid state plan covered services for Medicaid enrolled providers while Medicare enrollments are being completed. The new guidance from CMS provides information to state Medicaid agencies about strategies for continuing to pay for OTP services, including continuing to pay for claims for a specified period, and advising OTPs to submit claims only after their Medicare enrollment has been approved.

CMS recommends that states communicate with Medicaid managed care plans that cover OTP benefits, as well as with providers to advise them to enroll in Medicare.

If you have questions, please contact Sarah Wattenberg, NABH’s director of quality and addiction services.

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Milliman Report Highlights Barriers to Accessing Behavioral Healthcare Services

WASHINGTONNov. 20, 2019 /PRNewswire/ — A report from Milliman, Inc. about disparities between physical and behavioral healthcare for both in-network access and provider reimbursement rates underscores NABH’s position that unnecessary barriers continue to deny access to behavioral healthcare for patients who need it.

The Bowman Family Foundation commissioned Milliman to produce Addiction and Mental Health vs. Physical Health: Widening disparities in network use and provider reimbursement, a 140-page report that shows the gap in disparities for employees and their families seeking mental health and addiction treatment versus treatment for physical health conditions widened in 2016 and 2017.

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NABH Analysis: OTP Provisions in 2020 Physician Fee Schedule

OTP Provisions in 2020 Physician Fee Schedule

CMS finalized provisions for the nation’s opioid treatment programs (OTPs) in the 2020 Physician Fee Schedule regulation that the agency released on Nov. 1.

This NABH Analysis provides a summary of those provisions, which provide for the treatment of opioid use disorders (OUDs) with new bundled service codes for OTPs, and for telehealth and opioid use treatment services in office-based settings. The final rule will be published in the Federal Register on Nov. 15.

The regulations implement requirements that were included in last year’s Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patient and Communities (SUPPORT) Act. NABH is pleased that the final rule addressed the following issues that NABH mentioned in its comment letter on Sept. 28:

  • CMS raised the non-drug bundle to 161.71, which aligns with NABH’s valuation. We used a building block methodology to demonstrate that the proposed non-drug bundle, based on the CMS PFS rates, was undervalued by 31-48 percent.
  • We also identified a range of indirect and direct services routinely performed by OTPs that CMS included in the final bundle.
  • NABH advocated for the elimination of the partial bundle and recommended a more gradual overall implementation of elements of the proposed rule. In the final rule, CMS temporarily eliminated the partial episode of care with the intent to engage in future rulemaking to more gradually phase in their bundled approach.
  • Comments and data were provided to CMS reflecting potential destabilization of the workforce relevant to the proposed service requirements. CMS addressed these issues through deference to state laws and scopes of service provisions, and a reduction of the number of services needed to bill the bundle.
  • In explanatory text, CMS made note of the NABH recommendation for a rural add-on rate of 17 percent and indicated it may be considered in future rulemaking to incentivize rural care.
  • NABH recommended consideration to permanently set a zero co-pay, and CMS indicated the intent to address the issue in future rulemaking.
  • We advocated to remove OTPs from the high-risk category. CMS finalized a compromise proposal that moves OTPs that have been fully and continuously certified by SAMSA since October 23, 2018 to moderate risk, while maintaining those without full and continuous certification in the high-level risk category, as they are newly-recognized Medicare providers.
  • NABH-supported telehealth codes were finalized.

Final Rule Highlights:

Opioid Treatment Programs

  • Definition of OUD Treatment Services
    • FDA-approved opioid agonist and antagonist treatment medications
    • Dispensing and administering of such medications (if applicable)
    • Substance use counseling
    • Individual and group therapy
    • Toxicology testing (both presumptive and definitive testing)
    • Intake activities
    • Periodic assessments
  • Bundled Rates/Episode of Care
    • Bundles reflect a weekly episode of care with no time limits.
    • Rates are a combination of a drug and non-drug component.
    • Full and partial episode construction was finalized to eliminate of partial episodes of care. Utilization will be monitored, intent is to create a partial bundle in the future.
    • One service must be furnished within a week to bill a weekly drug or non-drug bundle.
  • Drug component reflects drug dispensing/administration services; rates vary according to the specific drug (methadone-oral, buprenorphine-oral, buprenorphine-injection, buprenorphine-implant, naltrexone injection), and includes buprenorphine-only products.
    • Maintenance dosage and calculation for oral buprenorphine was increased from 10 mg to 16 mg daily.
    • Created an NOS code for new medications.
  • Non-drug component includes counseling, psychotherapy, toxicology testing and tracks with SAMHSA certification.
    • Does not require counseling and psychotherapy but defers to medical need and state laws relevant to scopes of practice.
    • Case/care management is not included as a bundled or add-on code. Intent to collaborate with OTPs to better understand services, with potential future rulemaking.
    • Rates were increased using building block methodology that values the services based on established Medicare PFS (non-facility) rates for similar services; the Medicare Clinical Laboratory Fee Schedule (CLFS); and state Medicaid programs.
    • Bundles include payment for presumptive and definitive drug testing, with no separate billing under CLFS. There is no add-on code in order to avoid incentive to test more frequently than needed.
  • Add-ons
    • Intake activities for new patients, including a physical examination
    • Periodic assessments during an episode of care, such as for pregnant or postpartum patients
    • Take homes for methadone/buprenorphine for up to 7 days of medication
    • Counseling 30-minutes when counseling or therapy substantially exceed the amount in the individual treatment plan

PFS Bundles for Office-based Services/Telehealth

  • Bundled Rates/Episode of Care
    • Codes for three new (monthly) OUD treatment bundles have been added to the telehealth list on a Category 1 basis for care coordination, individual and group therapy, and counseling through two-way interactive audio-video communication technology.
      • G2086, 70-minute psychotherapy, first month. Includes treatment planning, care coordination, individual and group psychotherapy and counseling
      • G2087, 60-minute psychotherapy, subsequent months. Includes care coordination individual and group psychotherapy and counseling
      • G2088, for each additional 30-minute service required beyond 120 minutes. Includes care coordination, individual and group psychotherapy, and counseling
    • To bill G2086 and G2087, one psychotherapy services must be furnished.
    • If no therapy is provided, the bundle may not be billed. Instead, existing CPT codes for care management 99484, 99492, 99493, 99494 and E/M codes may be used.
    • Psychotherapy codes 90832, 90834, 90837, 90853 may not be used by the same practitioner for the same beneficiary in same month that episode bundles are billed.
    • Rates do not include medications, as they are reimbursed under Medicare Part B or D or toxicology testing that is billed under CLFS.
    • Provider must be licensed in the jurisdiction/location of the patient.
    • The codes are not restricted to use by addiction specialists.
    • Additional telehealth services may be requested before February 10, 2020 for consideration for the following calendar year.
    • The rule notes the prior removal of geographic limitations for telehealth services for SUD or co-occurring mental health disorders.
    • The SUPPORT ACT permits services to be furnished at any originating site, including the patient’s home, and requires that no originating site facility fee is permitted when the individual’s home is the originating site.
    • OTP services are not considered physician/practitioner services, and as such may not bill these codes. Instead, services are covered through OTP bundled rates.

NABH will closely monitor and work with CMS and other stakeholders in the implementation of this benefit and provide updates to NABH members as necessary.

If you have questions, please contact Sarah Wattenberg, NABH’s director of quality and addiction services.

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