CMS Proposes to Expand Behavioral Healthcare Access in 2024 OPPS Rule
The Centers for Medicare & Medicaid Services (CMS) on Friday proposed expanding access to behavioral healthcare services through coverage of intensive outpatient services.
Currently, Medicare covers and pays for various behavioral healthcare services, including inpatient psychiatric hospitalizations, partial hospitalizations services, and outpatient therapeutic services; however, there is a gap in coverage when Medicare beneficiaries require levels of services more frequent than individual outpatient therapy visits, but less intensive than a partial hospitalization program.
The agency’s 2024 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule includes proposals to implement provisions of the
Consolidated Appropriations Act, 2023 (CAA, 2023) that created a new benefit category for Intensive Outpatient Program (IOP) services. CMS proposed to establish payment and program requirements for the benefit across various settings, including hospital outpatient departments, Community Mental Health Centers (CMHCs), Federally Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs) effective Jan. 1, 2024.
CMS also proposed to establish payment for IOP services provided by Opioid Treatment Programs (OTPs) effective Jan. 1, 2024, and is clarifying that these intensive behavioral healthcare services are available for individuals with mental health conditions and for individuals with substance use disorders.
“This proposed rule reflects CMS’ commitment to ensure Medicare is comprehensive in its ability to address patient needs, filling gaps in the health care system including behavioral health,” Meena Seshamani, M.D., deputy administrator and director for CMS’ Center for Medicare, said in a news release. “Through these proposals, we will ensure people get timely access to quality care in their communities, leading to improved outcomes and better health.”
CMS provided the following details about the scope of benefits for IOP and its proposals for each setting:
Scope of Benefits for IOP:
CMS proposed a scope of benefits for IOP services that the CAA, 2023 mandates. The agency noted an IOP is a distinct and organized outpatient program of psychiatric services provided for individuals who have an acute mental illness or substance use disorder, consisting of a specified group of behavioral healthcare services paid on a per-diem basis under the OPPS or other applicable payment system when furnished in hospital outpatient departments, CMHCs, FQHCs and RHCs. CMS proposed to base the per-diem costs of items and services included in IOP that have been, and are, paid for by Medicare either as part of the PHP benefit or under the OPPS more generally.
Physician Certification and Plan of Treatment Requirements for IOP:
The CAA, 2023 requires that a physician determine that each patient needs a minimum of nine hours of IOP services per week, and this determination must occur no less frequently than every other month. CMS proposes to codify this requirement in regulation for IOP provided in all settings and is soliciting comments on the recertification period.
IOP Payment Rates and Policy in Hospital Outpatient Departments and CMHCs:
CMS proposed to establish two IOP ambulatory payment classifications for each provider type: one for days with three services per day and one for days with four or more services per day.
For CY 2024, CMS proposed to calculate hospital-based and CMHC IOP payment rates for three services per day and four or more services per day based on cost per day using a broader set of OPPS data that includes PHP days and non-PHP days.
CMS noted that while no Medicare IOP benefit currently exists, the agency believes using the broader OPPS data set would allow us to capture data from hospital claims that are not identified as IOP, but that include the service codes and intensity required for an IOP day.
Opioid Treatment Program (OTP) Settings:
CMS proposed to extend IOP coverage to include OTPs. The agency also proposed to establish a weekly payment adjustment via an add-on code for IOP services furnished by OTPs for the treatment of opioid use disorder (OUD) and to revise the definition of OUD treatment services to include IOP services.
The payment adjustment would also be updated based on the Medicare Economic Index and receive the Geographic Adjustment Factor if finalized. CMS proposed that Medicare would pay for IOP services that OTPs provide as long as each service is medically reasonable and necessary, and not duplicative of any service paid for under any bundled payments billed for an episode of care in a given week.
For an OTP to receive the additional payment adjustment for IOP services, a physician must certify that the beneficiary requires a higher level of care intensity compared to existing OTP services, and the certification, plan of care, and all other applicable requirements are met. CMS said it believes that payment for IOP services that OTPs provide would improve continuity of care between different treatment settings and levels of care, expand access to treatment for Medicare beneficiaries with an OUD and further promote health equity for racial/ethnic populations and older beneficiaries.
RHCs and FQHCs:
For CY 2024, CMS proposed to make conforming regulatory text changes to applicable RHC and FQHC regulations related to the scope of IOP benefits and services, certification and plan of care requirements, and special payment rules for IOP services as the CAA, 2023 mandates.
The scope of IOP benefits and certification and plan of care requirements will be the same for RHCs and FQHCs as described above for hospitals. CMS proposed to pay for three IOP services/day, and according to the statute, payment is based on the hospital rate. This means RHCs would be paid the three-services per day payment amount for hospital outpatient departments.
For FQHCs, payment would be the lesser of a FQHC’s actual charges or the three-services per day payment amount for hospital outpatient departments. For grandfathered tribal FQHCs, payment would be the Medicare outpatient per visit rate as the Indian Health Service has established when furnishing IOP services, and payment is based on the lesser of a grandfathered tribal FQHC’s actual charges or the Medicare outpatient per-visit rate.
Regarding OPPS payment rates, CMS proposed updating OPPS payment rates for hospitals by 2.8%. This update is based on the projected hospital market basket percentage increase of 3.0%, reduced by a 0.2 percentage point for the productivity adjustment.
CMS Includes Behavioral Healthcare Provisions in Proposed 2024 Physician Fee Schedule
CMS on Thursday included a provision to extend OTP periodic assessment flexibilities via audio-only telehealth through the end of 2024 in the agency’s proposed 2024 Physician Fee Schedule rule.
CMS noted it will continue to consider the value of extending this flexibility permanently. For mental healthcare, the agency’s proposed rule included implementing the CAA, 2023’s requirements that marriage and family therapists (MFTs) and mental health counselors (MHCs) can bill through the Medicare program.
The agency also proposed HCPCS codes for crisis psychotherapy services, and proposed permitting Behavior Assessments and Intervention to be performed and billed by clinical social workers, MFTs and MHCs. Increases for timed PFS behavioral health services will be implemented over four years, according to CMS.
988 Suicide & Crisis Line Adds New Services as One-Year Anniversary Approaches
This week the Biden administration announced it has added Spanish text and chat services as well as specialized services for LGBTQI+ youth and young adults to the nation’s 988 Suicide & Crisis Lifeline following a successful pilot test.
This Sunday marks the one-year anniversary of 988’s launch, and the Biden administration reports the Lifeline has answered nearly 5 million contacts in the past year—2 million more than were received in the previous 12 months—following a $1 billion investment from the administration.
Meanwhile, in June the National Alliance on Mental Illness (NAMI) released its
988 Suicide & Crisis Lifeline Tracker that found familiarity with 988 remains low despite increasing overall awareness since it launched last July. NAMI found that 63% of Americans report at least hearing something about 988, up 19% percentage points since September 2022 and up 41 percentage points since May 2022. Still, only 17% of Americans say they are very or somewhat familiar with it, while only 4% say they are very familiar with it.
The study also found Americans 49 and under are more likely than older Americans to report having heard of 988, and LGBTQ+ Americans are twice as likely to say they are familiar with it than non-LGBTQ+ Americans.
White House Releases National Response Plan to Address Emerging Threat of Fentanyl Combined with Xylazine
The White House Office of National Drug Control Policy this week released a
national response plan to combat the dangerous and deadly combination of xylazine mixed with fentanyl.
Earlier this year, the Biden administration used its executive designation authority for the first time when it declared xylazine mixed with fentanyl as an emerging threat in the United States.
“Since we announced the emerging drug threat earlier this year, we’ve been working tirelessly to create the best plan of attack to address this dangerous and deadly substance head-on,” Rahul Gupta, M.D., director of the White House Office of National Drug Control Policy (ONDCP), said in an announcement. “Now, with this National Response Plan, we are launching coordinated efforts across all of government to ensure we are using every lever we have to protect public health and public safety and save lives.”
The plan outlines action steps and key responsibilities for departments and agencies across the federal government and directs them to develop and submit an Implementation Report to the White House in 60 days.
As required by statute in the
SUPPORT Act and the Criteria for Designating Evolving and Emerging Drug Threats (Dir. No. 2022-002), the national response plan’s goal is to terminate fentanyl combined with xylazine as an emerging threat. This will require a 15% reduction (compared with 2022 as the baseline year) of xylazine positive drug poisoning deaths in at least three of four U.S. census regions by 2025.
NABH Members Highlight Behavioral Health EMR Gap in Health Affairs Commentary
A recent
Health Affairs commentary explores the 2009
HITECH Act’s failure to include behavioral healthcare providers in its $19 billion of meaningful use incentives and the resulting lag in electronic medical record (EMR) adoption in the behavioral healthcare segment.
“There was no clear rationale for this exclusion beyond implicit prioritization of physical health over mental health in the competition for funding dollars. And this disparity continues to this day,” wrote the article’s authors William Shrank, M.D., Christopher Hunter, M.B.A., and Andrew Lynch, Ph.D., adding that EMR use has exceeded 95% since 2014 but only 6% of outpatient behavioral healthcare facilities and 29% of substance use disorder treatment centers use EMRs. Shrank is a venture partner at Andreeseen Horowitz; Hunter is CEO at NABH member Acadia Healthcare, and Lynch serves as Acadia’s chief strategy officer.
The article reviews earlier legislative attempts to bridge the EMR gap, including the
bill Rep. Doris Matsui (D-Calif.) introduced last year.
Reminder: Provider Relief Fund Reporting Portal Now Open for Period 5
The Health Resources and Services Administration has announced that the Provider Relief Fund (PRF) Reporting Portal is now open for Reporting Period 5.
Recipients who received one or more General Distribution, Targeted Distribution, or ARP Rural Distribution payments exceeding $10,000, in the aggregate, from Jan. 1, 2022 to June 30, 2022 are required to report on the use of their payments during Reporting Period 5.
This latest reporting period will close at 11:59 p.m. ET on Sept. 30, 2023. Click
here to learn more.
In Case You Missed It: NABH Education & Research Foundation Workforce Resources
If you missed the 2023 Annual Meeting, be sure to access the workforce resources that the NABH Education and Research Foundation featured at the meeting and are available on the Foundation’s
Resources page.
First, watch speaker John Pallasch’s
presentation and listen to the question-and-answer period from NABH members.
Pallasch, founder and CEO of workforce consultancy One Workforce Solutions, served previously as the Senate-confirmed assistant secretary for employment and training at the U.S. Labor Department. Pallasch’s presentation challenged attendees to think beyond recruitment and retention and instead focus on re-designing the U.S. workforce system. He offered practical ideas for how NABH members can get involved in this process.
Also be sure to use the
workforce resource guide that the Foundation co-branded with One Workforce Solutions. The guide includes links to state workforce agencies, workforce development boards, and more.
Reminder: Please Submit Data to Enhance NABH’s Managed-Care Advocacy Efforts
Thank you to all members who have submitted data to NABH’s denial-of-care portal!
We are still seeking data from additional members to support advocacy on health plan denials and prior-authorization timeliness. If you are a new participant, please e-mail NABH Administrative Coordinator
Emily Wilkins for support.
Fact of the Week:
The Centers for Disease Control and Prevention
estimates that 109,940 people died of an overdose between February 2022 and February 2023, compared with 110,063 people in the same period the previous year. ONDCP
cited the seizure of illicit drugs at the nation’s borders and access to naloxone as reasons for the continued flattening in the overdose rate.
For questions or comments about this CEO Update, please contact Jessica Zigmond