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.