Visante 
ASP PRICING FILE- JANUARY 1, 2021 - MARCH 30, 2021
HOSPITAL OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (CMS MLN Booklet, March 2020)
BACKGROUND: Authorized by Social Security Act (SSA) § 1833(t), the Centers for Medicare & Medicaid Services (CMS) started the OPPS to pay for:
- Designated hospital outpatient items and services
- Certain Medicare Part B services for hospital inpatients when Medicare cannot pay Part A
- Community Mental Health Centers (CMHCs) partial hospitalization services and certain inpatient hospital services paid by Medicare Part B
- Home Health Agency-furnished hepatitis B vaccines and their administration, splints, casts, and antigens for patients not under a home health plan of care or for hospice patients for treatment of non-terminal illness or related conditions
- Comprehensive Outpatient Rehab Facility (CORF)-furnished hepatitis B vaccines and their administration
- An Initial Preventive Physical Examination (IPPE) within the first 12 months of Medicare Part B coverage
PAYMENT: APCs are the OPPS unit of payment in most cases. CMS assigns individual services (HCPCS codes) to APCs based on similar clinical characteristics and similar costs. The APC payment rate and calculated copayment apply to each service within the APC. Medicare pays some services separately, including some drugs, biologicals and radiopharmaceuticals.
A critical OPPS feature is “packaging,” or grouping integral, ancillary, supportive, dependent and adjunctive services into the payment for the associated primary procedure or service. Packaging encourages better use of hospital resources. Medicare makes no separate packaged service payments. 42 CFR § 419.2(b) describes some types of packaged items and services including:
- Inexpensive drugs under a per-day drug threshold packaging amount ($130 cost per day for FY20, and Proposed for FY21)
- Drugs, biologicals, and radiopharmaceuticals functioning as supplies, including diagnostic radiopharmaceuticals, contrast agents, stress agents, implantable biologicals, and skin substitutes
The above information pertains to Medicare, but many State Medicaid Programs and Third-Party Payers follow similar methodologies.