The Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (the Innovation Center) is implementing a new initiative, Value in Opioid Use Disorder Treatment (Value in Treatment). Value in Treatment is a 4-year demonstration program authorized under section 1866F of the Social Security Act (Act), which was added by section 6042 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act). The purpose of the demonstration, as stated in the statute, is to “increase access of applicable beneficiaries to opioid use disorder treatment services, improve physical and mental health outcomes for such beneficiaries, and to the extent possible, reduce [Medicare program expenditures].” Value in Treatment was implemented April 1, 2021.
The United States is in the midst of a national opioid crisis that has substantial health, economic, and societal costs. In 2017, more than 47,000 Americans died from drug overdoses related to prescription and illegal opioids – an almost two-fold increase compared to opioid-related deaths a decade earlier (2007). The epidemic is widespread, with nearly every state having experienced increases in opioid-related deaths since 2000. ED visits for opioid overdoses rose 30% from July 2016 through September 2017. The associated costs are borne disproportionately by public insurance: in 2015, public insurance covered a total of 72.1% of opioid-related inpatient stays (31.9% Medicare, 40.2% Medicaid) and 60.6% of opioid-related ED visits (16.1% Medicare, 44.5% Medicaid). Medicare has experienced the largest annual increase in the number of opioid-related hospital stays over the past two decades, and currently pays for one-third of opioid-related hospital stays. Nationally, Medicare beneficiaries with OUD cost 1.6 times more ($15,464 PBPY in 2017) than Medicare beneficiaries without OUD ($9,558 PBPY in 2017).
The statute stipulates that a maximum of 20,000 applicable beneficiaries may participate in Value in Treatment at any given time, and makes available $10,000,000 from the Federal Supplementary Medical Insurance Trust Fund under section 1841 of the Act available each of fiscal years 2021-2024 for care management fees and incentive payments under Value in Treatment. Specifically, as required by statute, Value in Treatment created two new payments for OUD treatment services furnished to applicable beneficiaries participating in the demonstration program:
- A per beneficiary per month care management fee (CMF), which the participant may use to “deliver additional services to applicable beneficiaries, including services not otherwise eligible for payment under [Title XVIII]”; and
- A performance-based incentive, that will be payable based on the participant’s performance with respect to criteria specified by CMS, which may include evidence-based medication-assisted treatment (MAT), as well as patient engagement and retention in treatment.
Services furnished under Value in Treatment must be based on an applicable beneficiary’s individualized OUD treatment plan, aligned with OUD treatment services defined in statute and with other services furnished to the beneficiary for purposes of treating his or her OUD, and have a reasonable expectation of improving or maintaining the health or overall function of applicable beneficiaries.
The following applicable beneficiaries and eligible participants are eligible to participate in the demonstration:
- Is entitled to, or enrolled for, benefits under Medicare Part A and enrolled for benefits under Medicare Part B;
- Is not enrolled in a Medicare Advantage plan under Medicare Part C; and
- Has a current diagnosis for an opioid use disorder.
Applicable beneficiaries include those who are dually eligible for Medicare and Medicaid, if the criteria listed above are also met. While the statute authorizes CMS to establish additional criteria for applicable beneficiaries, CMS is not establishing any such criteria at this time.
Entities and individuals enrolled in Medicare, who applied for and are selected to participate in the demonstration program under an application and selection process established by CMS, who establish an OUD care team and uses such team to furnish or arrange for OUD treatment services in the outpatient setting under the demonstration, and who are one of the following types of individuals or entities:
- Group practice comprised of at least one physician
- Hospital outpatient department
- Federally qualified health center
- Rural health clinic
- Community mental health center
- Clinic certified as a certified community behavioral health clinic pursuant to section 223 of the Protecting Access to Medicare Act of 2014
- Opioid treatment program (entity specified by the Secretary)
- Critical Access Hospital (entity specified by the Secretary)
Value in Treatment will test whether the demonstration: reduces hospitalizations and emergency department (ED) visits; increases use of medication assisted treatment (MAT) for OUD; improves health outcomes for individuals with OUD, including reducing the incidence of infectious diseases such as Human Immunodeficiency Virus (HIV) and hepatitis C (HCV); reduces deaths from opioid overdose; reduces utilization of inpatient residential treatment; and reduces Medicare program expenditures to the extent possible.
If you have questions or additional inquiries please email: ValueinTreatment@cms.hhs.gov.
- Value in Treatment Press Release - April 8, 2021
- Value in Treatment Selected Participants (PDF)
- Federal Register (Link to provide public comment)
- PRA Listing: CMS-10728 Value in Opioid Use Disorder Treatment Demonstration (ZIP) (Link to access demonstration documents)
- Request for Application (PDF) - document overviewing the demonstration, applicant eligibility, and application submission and participation requirements
- Request for Application Guidance (PDF)
- Appendix A and B (RFA questions and checklist)
- Attachment 1 (XLS) [OUD Care Team Roster that was required for submission along with the application]
- Attachment 2 (XLS) [prevalence rates data used by applicants to complete the “Proposed Demonstration Region” section of the application]