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 3.17) 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 The contractor
shall be responsible for ensuring covered care is medically and
psychologically necessary and appropriate. 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.
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.