Billing & Payment

Materials from Recent MAC Calls

In December, the Medicare Administrative Contractors (MACs) hosted calls to introduce themselves and educate OTPs on the functions MACs perform, especially around billing, claims processing, and payment.  The materials (PDF) from each of these calls are now available. 

Billing & Payment

Beginning January 1, 2020, Medicare will pay enrolled Opioid Treatment Programs (OTPs) bundled payments based on weekly episodes of care for services including:

  • FDA-approved treatment medications for the treatment of OUD
  • The dispensing and administration of such medications (if applicable)
  • Substance use counseling
  • Individual and group therapy
  • Toxicology testing

Medicare will also adjust payments for the bundled payment amount for intake activities and periodic assessments, which are required by SAMHSA, as well as for additional counseling and therapy, and take-home supplies of medications.

In 2020, there is NO copayment for OTP services for people with Medicare.

Review the OTP Medicare Billing & Payment Fact Sheet (PDF) to learn about:

  • Covered opioid use disorder (OUD) Treatment Services
  • Coding and submitting claims for OTP services
  • Payment and remittance advice (RA)

The CY2020 National Final Unadjusted Payment Rates for OTPs (PDF) document describes OTP HCPCS G-codes, bundled payments, and the total unadjusted payment assigned to each rate code. 

As discussed in the CY 2020 PFS Final Rule, CMS adjusted the non-drug component of the OTP bundled payments for geographic locality so payment rates will vary depending on the OTP’s location.  CMS will also geographically adjust the add-on payment adjustments for non-drug services (i.e., intake activities, periodic assessments, additional counseling and therapy).

Identifying Locality-Specific Payment Rates

1. In the Locality Key (PDF) document, find the locality and MAC numbers assigned to your OTP based on the State/Fee Schedule Area/County location of your practice

2. In the CY2020 National Final Unadjusted Payment Rates for OTPs (PDF) document, find the HCPCS code for the service of interest

3. In the Locality Adjusted Rates (PDF) document, find your locality and corresponding MAC numbers along with the HCPCS code to find the geographically-adjusted payment rate

 

Resources

Page Last Modified:
12/16/2019 10:03 PM