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.