Form CMS-10728 Beneficiary Notification

VALUE IN TREATMENT TEMPLATES FOR BENEFICIARY NOTICE AND BENEFICIARY AGREEMENT FORM

INSTRUCTIONS

Beneficiary Notice Heading: Value in Treatment participants must include their name and address in the heading of the beneficiary notice. Value in Treatment participants also may include their logo in the heading of the beneficiary notice, if desired.

Typeface: The typeface must be Times New Roman, 12 point or larger. This size requirement is based on a legal settlement related to readability. Except in the heading of the beneficiary notice, the Centers for Medicare & Medicaid Services (CMS) will not consider font colors other than black. Since readability for beneficiaries is a priority, CMS recommends black text on white paper.

Process for finalizing beneficiary notice, Beneficiary Agreement Form, and Beneficiary Frequently Asked Questions (FAQs) templates: Items inside the “<” and “>” signs are to be completed by Value in Treatment participants. Once completed, please send a copy of your final beneficiary notice, Beneficiary Agreement Form, and Beneficiary FAQs to the Value in Treatment Demonstration mailbox at ValueinTreatment@cms.hhs.gov. Items outside of the “<” and “>” signs must not be changed or rewritten. If you want to propose changes, send them to the Value in Treatment Demonstration mailbox at ValueinTreatment@cms.hhs.gov. You will receive a response within 10 business days. Consider your printing timelines and this 10-day timeframe as you plan your submission.

Process for submitting beneficiary notice to eligible beneficiaries and obtaining participation and data-sharing agreement: Value in Treatment participants are required to obtain beneficiary consent 1) for the beneficiary to participate in the demonstration and receive opioid use disorder (OUD) treatment services from the Value in Treatment participant; and 2) for CMS to share the beneficiary’s health care information with the Value in Treatment participant. Participants must use the enclosed templates for the beneficiary notice, Beneficiary Agreement Form, and Beneficiary FAQs to obtain the beneficiary’s consent for these purposes. Once completed, this beneficiary notice, Beneficiary Agreement Form, and Beneficiary FAQs may be provided only to eligible beneficiaries and must be provided together. Value in Treatment participants may provide the beneficiary notice, Beneficiary Agreement Form, and Beneficiary FAQs to eligible beneficiaries during a face-to-face visit, or via mail or email. Regardless of the delivery method, a signature by the beneficiary or his or her authorized representative on the Beneficiary Agreement Form is required to confirm the beneficiary’s consent to participate in Value in Treatment and receive OUD treatment services from the Value in Treatment participant and, if applicable, to confirm the beneficiary’s agreement to share his or her health care information with the Value in Treatment participant. It is not necessary for a beneficiary to agree to share his or her health care information with the Value in Treatment participant in order for the beneficiary to consent to participate in Value in Treatment.

<ViT Participant Name> <OPTIONAL: ViT Participant Logo>

<Address> <OPTIONAL: PCP/Practice Name>

<City, State, Zip Code> <OPTIONAL: PCP/Practice Logo>

<Phone Number>

NEWS FOR YOU: OPTION TO PARTICIPATE IN VOLUNTARY MEDICARE OPOID USE DISORDER (OUD) TREATMENT DEMONSTRATION PROGRAM

Dear Beneficiary, [May remove if not letter form]

The Centers for Medicare & Medicaid Services (CMS) is implementing a new four-year initiative, the Value in Opioid Use Disorder Treatment Demonstration Program (Value in Treatment).¹ Value in Treatment’s primary goal is to provide eligible beneficiaries who elect to participate with increased access to enhanced opioid use disorder (OUD) treatment services to help achieve their recovery goals and, to the extent possible, reduce Medicare program costs. Enhanced OUD treatment services will be offered under Value in Treatment between [CMS TO INSERT DATE] through December 31, 2024.

This notice is to inform you that your doctor or health care provider, <Participant Name>, is voluntarily taking part in Value in Treatment. You are receiving this letter because <Participant Name> thinks you might benefit from participation in Value in Treatment.

How do I agree to participate?

Participation in Value in Treatment is voluntary for eligible beneficiaries. To be eligible to participate in Value in Treatment, you must:

• Be entitled to, or enrolled for, benefits under Medicare Part A and enrolled for benefits under Medicare Part B;

• Not be enrolled in a Medicare Advantage Plan; and

• Have a current diagnosis for an opioid use disorder.

If you meet these criteria and wish to participate in the demonstration program and receive OUD treatment services from <Participant Name>, please complete the enclosed Beneficiary Agreement Form. This form must be completed by yourself or your authorized representative (an individual legally authorized to make health care decisions on your behalf in the state in which you reside). Your health care professional should not complete this form for you.

On the Beneficiary Agreement Form, you will also have the opportunity to agree to have Medicare share your health care information with <Participant Name> for the sole purposes of developing and implementing activities related to coordinating care and improving the quality and efficiency of your care. You are not required to agree to share your health care information with <Participant Name> in order to participate in Value in Treatment and receive OUD treatment services from <Participant Name>.

Once completed, either hand deliver the Beneficiary Agreement Form to <Participant Name>, email it to <email address>, fax it to <fax number>, or mail it to <mailing address>.

No changes to your current Medicare benefits.

Whether or not you complete the enclosed Beneficiary Agreement Form, you will remain eligible to receive the same Medicare benefits and you still have the right to use any doctor, hospital, or other health care provider that accepts Medicare, at any time. If you have questions feel free to ask your doctor or other health care professional, call <Participant Name> at <phone number>, or call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

No one is allowed to attempt to influence your choice to complete the Beneficiary Agreement Form, or to agree to share your health care information, by offering or withholding anything in exchange for you to complete or not complete the form or agreeing to share your health care information. If you feel pressured to sign or not sign this form, please call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

What can I expect from participating in Value in Treatment?

• Enhanced OUD treatment services. Value in Treatment will enable <Participant Name> to furnish, or arrange to be furnished, enhanced OUD treatment services, including: medication-assisted treatment; treatment planning; psychiatric, psychological, or counseling services (or any combination of such services), as appropriate; social support services, as appropriate; and care management and care coordination services, including coordination with other providers of services and suppliers not on an opioid use disorder care team.

• No Cost Sharing on Medicare Services Received from OTPs. You will not be asked to pay any cost-sharing for OUD treatment services you receive as part of Value in Treatment. In addition, while participating in Value in Treatment, any OUD treatment services you receive from opioid treatment programs (OTPs) outside of Value in Treatment also will not be subject to any cost-sharing requirements.

• Enhanced OUD treatment services offered through < Participant Name >. As a participant in Value in Treatment, <Participant Name> is able to offer you these enhanced OUD treatment services:

[insert benefit]

<insert information>

[insert benefit]

<insert information>

What if I no longer want to participate in Value in Treatment?

Participating in Value in Treatment is voluntary. You have the option to terminate your participation at any time. If you change your mind later about whether you wish to participate in Value in Treatment, it is your responsibility to inform <Participant Name> in writing that you no longer wish to participate in Value in Treatment.

If you choose to switch to another health care provider participating in the demonstration, you will need to sign a new Beneficiary Agreement Form agreeing to participate in Value in Treatment and receive OUD treatment services from that health care provider.

What if I change my mind about Medicare sharing my health information?

If you decide you no longer want your health care information shared with <Participant Name>, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users may call 1-877-486-2048.

Where can I learn more?

You can learn more about Value in Treatment by:

• Reading the enclosed frequently asked questions (FAQs) sheet.

• Calling <Participant Name> by phone at <phone number>, <extension or dial in options>.

• Emailing <Participant Name> at <email>.

• Sending a letter to <Participant Name> at <mailing address>

<Sincerely, [may remove if not a letter form]>

<Participant Name>

<Participant Signature>

Value in Opioid Use Disorder Treatment Demonstration Program (Value in Treatment)

BENEFICIARY AGREEMENT FORM

The Centers for Medicare & Medicaid Services (CMS) is the agency within the U.S. Department of Health and Human Services (HHS) that is charged with administering the Medicare and Medicaid programs. CMS is implementing the Value in Opioid Use Disorder Treatment Demonstration Program (Value in Treatment) under section 1866F of the Social Security Act, as added by section 6042 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act).

<Participant Name> is an individual or entity enrolled in Medicare, who has established an opioid use disorder (OUD) care team, and who is located at <Address> (“Participant”). Participant applied for and was selected to participate in Value in Treatment.

__________________________ [print beneficiary’s name as shown on beneficiary’s Medicare card] (the “Beneficiary”) agrees to participate in Value in Treatment and to receive OUD treatment services from Participant. The Beneficiary is identified by the following Medicare ID: ________________ [insert number on the Beneficiary’s Medicare card].

Please select one of the following:

• The Beneficiary hereby authorizes CMS and its designees to release his or her health care information to the Participant, as necessary for the sole purpose of developing and implementing activities related to coordinating care and improving the quality and efficiency of the Beneficiary’s care under Value in Treatment.

• The Beneficiary does not authorize CMS or its designees to release his or her health care information to the Participant.

This Agreement will become effective when it is signed by the Beneficiary, or by the Beneficiary’s authorized representative, and will expire on December 31, 2024, or such earlier date as the Beneficiary either terminates his or her participation in Value in Treatment or signs a new Beneficiary Agreement Form agreeing to receive OUD treatment services from a different health care provider participating in Value in Treatment. The Beneficiary may terminate his or her participation in Value in Treatment at any time by informing the Participant in writing that the Beneficiary wishes to terminate his or her participation in Value in Treatment. The Beneficiary may terminate his or her authorization for CMS to share his or her health care information with Participant by calling Medicare at 1-800-MEDICARE (1-800-633-4227; TTY users may call 1-877-486-2048).

Person signing this form (select one):

• Beneficiary

• Authorized representative (e.g., Attorney, Guardian, Conservator, Power of Attorney)

Name:

Relationship to Beneficiary:

Address:

Phone Number:

Signature: Date Signed:

^{Value in Opioid Use Disorder Treatment Demonstration Program (Value in Treatment)}

^{Beneficiary Frequently Asked Questions (FAQs)}

What is the Value in Opioid Use Disorder Treatment Demonstration Program (Value in Treatment)?

The Centers for Medicare & Medicaid Services (CMS) is starting a new four-year initiative, the Value in Opioid Use Disorder Treatment Demonstration Program (Value in Treatment). Value in Treatment’s primary goal is to provide eligible beneficiaries who elect to participate with increased access to enhanced opioid use disorder (OUD) treatment services to help achieve their recovery goals and, to the extent possible, reduce Medicare program costs.

When does the Value in Treatment demonstration start and end?

Value in Treatment services are scheduled to begin on April 1, 2021 and will be offered through December 31, 2024. Should you agree to participate, the start date of your participation in Value in Treatment is the date you or your authorized representative signs the Beneficiary Agreement Form. Your participation in the demonstration will expire on either December 31, 2024, or on the date you terminate your participation in Value in Treatment, whichever is earlier.

How will participating in Value in Treatment benefit me?

Value in Treatment’s primary goal is to give eligible beneficiaries who agree to participate access to enhanced OUD treatment services, including OUD treatment services that are otherwise not covered by Medicare, to help such beneficiaries reach their recovery goals.

Does participating in Value in Treatment change my Medicare benefits?

No. Whether or not you agree to participate in Value in Treatment, you will remain eligible to receive the same Medicare benefits and you still have the right to use any doctor, hospital, or other health care provider that accepts Medicare, at any time. If you have questions feel free to ask your doctor or other health care professional, call <Participant Name> at <phone number>, or call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

What should I do if I agree to participate?

Be engaged and committed as best as you can! By engaging with your doctor or other health care professional in setting your treatment plan, following your treatment plan, and showing up to scheduled visits, <Participant Name> is better able to help you reach your recovery goals. <Participant Name> will work closely with you to ensure your treatment plan and Value in Treatment services are appropriate for you.

If my Medicare health care provider is participating in Value in Treatment, am I automatically enrolled in Value in Treatment?

No. Your participation in Value in Treatment is voluntary. All health care providers participating in Value in Treatment are required to use the Beneficiary Agreement Form to obtain a beneficiary’s agreement to participate in Value in Treatment and receive OUD treatment services from the participant.

What if I agree to participate in Value in Treatment, but change my mind later?

Your participation in Value in Treatment is voluntary. You have the option to terminate your participation at any time. It is your responsibility to inform your health care provider in writing if and when you decide you no longer want to participate in Value in Treatment.

What are the enhanced opioid use disorder treatment services available to me under Value in Treatment?

Participating health care providers have flexibility in the types of OUD treatment services they can offer you under Value in Treatment. Those services will vary by participating health care provider. As a participant in Value in Treatment, <Participant Name> is able to offer you these enhanced OUD treatment services:

• <insert benefit>

<insert information>

• <insert benefit>

<insert information>

Please contact <Participant Name> for further questions regarding these new benefits at <phone number> or <email>.

What if I want to remain in Value in Treatment, but want to switch to another health care provider?

Value in Treatment services are only offered by Medicare health care providers participating in the demonstration. It is possible that <Participant Name> is the only health care provider in your area offering Value in Treatment services. To view a list of Value in Treatment participants, go to <CMS to insert website>. If you choose to switch to another health care provider participating in Value in Treatment, you will need to sign a new Beneficiary Agreement Form agreeing to receive OUD treatment services from that health care provider.

What can I do if I do not want to share my health care information with a participating provider?

We will only share your data with the participant if you opt into data sharing. You have the opportunity to opt into data sharing through the Beneficiary Agreement Form. If you have elected to share your health care information and later change your mind, you may call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

1 Value in Treatment is authorized under section 1866F of the Social Security Act (42 U.S.C. § 1395cc-6), added by section 6042 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act).