1.0 BACKGROUND
With the implementation of the Final Rule,
Federal Register, Volume 81, No 171, September 2, 2016, TRICARE
mental health and Substance Use Disorder (SUD) treatment, the Defense
Health Agency (DHA) added IOPs, both for mental health and SUDs,
as covered benefits to the TRICARE Basic program. This added level
of care improves the availability of mental health and SUD services.
The intent is to provide availability of adequate step down care
from inpatient/residential or partial hospitalization care and increase
beneficiaries’ access to medically or psychologically necessary
intensive outpatient care in all geographic areas.
2.0 DESCRIPTION
IOP is an outpatient level of care that provides
an organized day or evening program for the treatment of mental
health and/or SUDs. Mental health and/or SUD IOP level care typically
consists of between six and nine or more hours a week of treatment
services (minimum two hours per treatment day) which includes assessment,
treatment, and rehabilitation for individuals requiring a lower
level of care than mental health or SUD Partial Hospitalization
Program (PHP), inpatient/residential Substance Use Disorder Rehabilitation
Facility (SUDRF) care, Residential Treatment Care (RTC) care, or
acute inpatient psychiatric or SUD hospitalization. The program
structure is regularly scheduled, individualized and shares monitoring
and support with the beneficiary’s family and support system. IOPs
provide therapies as clinically indicated, and includes case management
to link beneficiaries and their families with community-based support
systems. An IOP may be appropriate to transition from other levels
of care, when medically and psychologically necessary.
3.0 POLICY
3.1 In order
to qualify for mental health benefits, the patient must be diagnosed
by a licensed, qualified mental health professional to be suffering
from a mental disorder, according to the criteria listed in the
current edition of the Diagnostic and Statistical Manual for
Mental Disorders (DSM) or a mental health diagnosis in the
International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) for diagnoses made before the mandated date, as directed
by Health and Human Services (HHS), for the International Classification
of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) implementation,
after which the ICD-10-CM diagnoses must be used. No benefits are
payable for “Conditions Not Attributable to a Mental Disorder,”
or ICD-9-CM V codes, or ICD-10-CM Z codes.
Co-occurring mental and SUDs are common and assessment should proceed
as soon as it is possible to distinguish the substance related symptoms
from other independent conditions. In order for treatment of a mental
disorder to be medically or psychologically necessary, the patient
must, as a result of a diagnosed mental disorder, be experiencing
both physical or psychological distress and an impairment in his
or her ability to function in appropriate occupational, educational
or social roles. It is generally the degree to which the patient’s
ability to function is impaired that determines the level of care
(if any) required to treat the patient’s condition.
3.2 A
Primary Care Manager (PCM) referral is required for IOP services. Preauthorization
is not required for admission to an IOP.
However,
if the IOP provider is a network provider, a request for preauthorization
from the network provider to the contractor may be accepted in lieu
of PCM referral. Contractors remain responsible for
ensuring covered care is medically and psychologically necessary and
appropriate.
See Sections 3.5 and 3.8 regarding referral and preauthorization
requirements.
3.3 Criteria for determining medical
or psychological necessity of IOP services. IOP services will be considered
necessary only if all of the following conditions are present:
3.3.1 The patient
is suffering significant impairment from a mental disorder to include
SUD (as defined in
32 CFR 199.2)
which interferes with age appropriate functioning.
3.3.2 The patient
is in need of crisis stabilization, treatment of partially stabilized
mental health or SUD, or services as a transition from an inpatient
program.
3.3.3 The admission into the IOP is based on the
development of an individualized diagnosis and treatment plan expected
to be effective for that patient and permit treatment at a less
intensive level.
3.4 Authorized IOPs must enter
into participation agreements to provide multi-disciplinary programs
in exchange for all-inclusive per diem reimbursement. Professional
services provided by a qualified mental health provider that do
not duplicate treatment provided in an IOP may be billed separately.