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.