42 USC 1395cc-6 - Opioid use disorder treatment demonstration program

U.S Code last checked for updates: Oct 17, 2024

§ 1395cc–6.

Opioid use disorder treatment demonstration program

(a)

Implementation of 4-year demonstration program

(1)

In general

(2)

Opioid use disorder treatment services

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)

Program design

(1)

In general

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)

Consultation

(c)

Participants; opioid use disorder care teams

(1)

Participants

(A)

Definition

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)

Preference

(2)

Opioid use disorder care teams

(A)

In general

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)

Requirements for receipt of payment under program

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)

Eligible practitioner defined

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)

Participation of applicable beneficiaries

(1)

Applicable beneficiary defined

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.

Such term shall include an individual who is dually eligible for benefits under this subchapter and subchapter XIX if such individual satisfies the criteria described in subparagraphs (A) through (D).

(2)

Voluntary beneficiary participation; limitation on number of beneficiaries

(3)

Services

(4)

Beneficiary access to services

(e)

Payments

(1)

Per applicable beneficiary per month care management fee

(A)

In general

(B)

Payment amounts

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)

No duplicate payment

(2)

Incentive payments

(A)

In general

(B)

Criteria

(i)

In general

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)

Required consultation and consideration

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)

No duplicate payment

(f)

Multipayer strategy

(g)

Evaluation

(1)

In general

(2)

Reports

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)

Funding

(1)

Administrative funding

(2)

Care management fees and incentives

(3)

Availability

(i)

Waivers

(Aug. 14, 1935, ch. 531, title XVIII, § 1866F, as added Pub. L. 115–271, title VI, § 6042, Oct. 24, 2018, 132 Stat. 3979; amended Pub. L. 117–215, title I, § 103(b)(4)(C), Dec. 2, 2022, 136 Stat. 2263; Pub. L. 117–328, div. FF, title I, § 1262(b)(7), Dec. 29, 2022, 136 Stat. 5682.)

cite as: 42 USC 1395cc-6

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