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 OTPs as a covered benefit to the TRICARE
Basic program. This added level of care improves the availability
of SUD services. The intent is to provide a needed service and to
allow more efficient use of resources for needed SUD care.
2.0 DESCRIPTION
OTPs are service settings for opioid treatment,
either freestanding or hospital based, that adhere to the Department
of Health and Human Services’ (DHHS’) regulations at 42 CFR Part
8 and use medications indicated and approved by the Food and Drug
Administration (FDA). Treatment in OTPs provides a comprehensive,
individually tailored program of medication therapy integrated with psychosocial
and medical treatment and support services that address factors
affecting each patient, as certified by the Center for Substance
Abuse Treatment (CSAT) of the DHHS’ Substance Abuse and Mental Health
Services Administration (SAMHSA). Treatment in OTPs can include
management of withdrawal symptoms (detoxification) from opioids
and medically supervised withdrawal from maintenance medications.
Patients receiving care for substance use and co-occurring disorder
care can be referred to, or otherwise concurrently enrolled in,
OTPs. Medication Assisted Treatment (MAT) is a TRICARE covered benefit
(see
Section 3.18) provided in OTPs by TRICARE
authorized providers when medically and psychologically necessary.
MAT is a combination of pharmacotherapy, medical treatment, and
individually tailored psychosocial and support services.
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 OTP services. Preauthorization
is not required for OTP services.
However, if the
OTP 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 TRICARE adopts the treatment
standards, including criteria for determining medical or psychological
necessity, for OTP services, that are set forth in 42 CFR Part 8.
3.4 All services,
supplies, equipment, and space necessary to fulfill the requirements
of each patient’s individualized diagnosis and treatment plan are
included in the reimbursement approved for an authorized OTP.
3.5 Authorized
OTPs must enter into participation agreements for services and supplies
that are included in the reimbursement approved for an authorized
OTP.
3.6 OTPs will be reimbursed in accordance with
the TRICARE Reimbursement Manual (TRM),
Chapter 7, Section 5.
4.0 EXCLUSION
The programmed use of physical measures, such
as electric shock, alcohol, or other drugs as negative reinforcement
(aversion therapy) is not covered, even if recommended by a physician.