N.M. Admin. Code § 8.321.2.26 - INTENSIVE OUTPATIENT PROGRAM (IOP) FOR SUBSTANCE USE DISORDERS (SUD)
MAD pays for time limited IOP services utilizing a multi-faceted approach to treatment for an eligible recipient who requires structure and support to achieve and sustain recovery. IOP must utilize a research and evidence-based model approved through the process described in the BH policy and billing manual and target specific behaviors with individualized behavioral interventions.
A. Eligible
providers: Services must be delivered through an agency approved through the
application process described in the BH policy and billing manual. Prior to
medicaid enrollment the agency must demonstrate that the agency meets all the
requirements of IOP program services and supervision. See Subsection A and B of
8.321.2.9 NMAC for MAD general
provider requirements.
(1) IOP services are
provided through an integrated interdisciplinary approach including staff
expertise in both SUD and mental health treatment. This team may have services
rendered by non-independently licensed and non-licensed practitioners within
their scope of practice and under the direction of the IOP RLD board approved
clinical supervisor. See Subsection E of
8.321.2.9 NMAC for non-independent
and non-licensed practitioners and Subsection C of
8.321.2.9 NMAC for independently
licensed professionals eligible to conduct IOP clinical supervision.
(2) Each IOP program must have an
independently licensed RLD board approved clinical supervisor. Both clinical
services and supervision by independently licensed practitioners must be
conducted in accordance with respective licensing board regulations. An IOP
clinical supervisor must meet all the following requirements:
(a) have two or more years of relevant
experience with an IOP program or approved exception by submitting a request
through the process described in the BH policy and billing manual;
and
(b) have expertise in both
mental health and substance use disorder treatment.
(3) The IOP agency is required to develop and
implement a program outcome evaluation system which may include consumer
satisfaction surveys, retention into service rates, drop-out rates,
re-admittance or relapse and lapse rates, incarceration or hospitalization
data, or readily identifiable information and data specific to the
IOP.
(4) The agency must maintain
the appropriate state facility licensure and abide by all applicable state and
federal regulations if offering medication for opioid use disorder.
(5) The agency must hold an IOP approval
letter as described in the BH policy and billing manual and be enrolled by MAD
to render IOP services to an eligible recipient. In the application process
each IOP must identify if it is a youth program, an adult program, a
transitional age program, or multiple programs. Transitional age programs must
specify the age range of the target population. As described in the BH policy
and billing manual an IOP will receive provisional approval to begin rendering
IOP services prior to receiving full approval.
B.
Coverage criteria:
(1) An IOP is based on research and
evidence-based practice (EBP) models that target specific behaviors with
individualized behavioral interventions. All EBP services must be culturally
sensitive and incorporate recovery and resiliency values into all service
interventions. EBPs must be approved through the process described in the BH
policy and billing manual. A list of pre-approved EBPs is available through the
council, as are the criteria for having another model approved.
(2) Treatment services must address
co-occurring substance used and mental health disorders. Care coordination
should be available to ensure integrated care for medical conditions either by
referral or internally.
C.
Covered services:
(1) IOP core services must include:
(a) individual SUD related therapy;
(b) group therapy (group membership may not
exceed 15 in number); and
(c)
psychoeducation for the eligible recipient and their family or significant
other.
(2) Co-occurring
mental health and SUD: The IOP agency must accommodate the needs of an eligible
recipient with co-occurring substance use and mental health disorders.
Treatment services are provided through an integrated interdisciplinary team
and through coordinated, concurrent services with behavioral health
providers.
(3) Medication
management services must accessible either in the IOP agency or by referral to
oversee the use of psychotropic medications and medication assisted treatment
of SUD.
(4) The amount and
intensity of an eligible recipient's IOP intervention is typically three to six
months and between 9-19 hours for adults or 6-19 hours for adolescents per
week. The amount of weekly services per eligible recipient is directly related
to the goals specified in their IOP treatment plan and the IOP EBP in use.
Recipients must meet ASAM 2.1 level of care placement criteria and have been
diagnosed with a moderate or severe SUD to be eligible to receive SUD IOP
services.
(5) Other mental health
therapies: Outpatient therapies may be rendered in addition to the IOP
therapies of individual and group when the eligible recipient's co-occurring
disorder requires treatment services which are outside the scope of the IOP
therapeutic services. The eligible recipient's file must document the medical
necessity of receiving outpatient therapy services in addition to IOP
therapies. Such documentation includes, but is not limited to current
assessment, a co-occurring diagnosis, and inclusion in the treatment plan for
outpatient therapy services. An IOP agency may:
(a) render these services when it is enrolled
as a provider covered under Subsection D of
8.321.2.9 NMAC with practitioners
listed in Subsections C and E of
8.321.2.9 NMAC whose scope of
practice specifically allows for mental health therapy services; or
(b) refer the eligible recipient to another
provider if the IOP agency does not have such practitioners available; the IOP
agency may continue the eligible recipient's IOP services coordinating with the
new provider.
D.
Identified population:
(1) IOP services are provided to an eligible
recipient 11 through 17 years of age diagnosed with a substance use disorder or
with co-occurring disorders (mental illness and SUD) and that meet the American
society of addiction medicine (ASAM) patient placement criteria for level 2.1 -
intensive outpatient treatment; or have been mandated by the local judicial
system as an option of least restrictive level of care. Adolescents who turn 18
years old while in an IOP program may remain until appropriate discharge.
Services are not covered if the recipient is in detention or incarceration. See
eligibility rules
8.200.410.17 NMAC.
(2) IOP services are provided to an eligible
recipient of a transitional age program of which the age range has been
determined by the agency, and that have been diagnosed with substance use
disorder or with co-occurring disorders (mental illness and substance use) or
that meet the American society of addiction medicine's (ASAM) patient placement
criteria for level 2.1 - intensive outpatient treatment, or have been mandated
by the local judicial system as an option of least restrictive level of
care.
(3) IOP services are provided
to an eligible adult recipient 18 years of age and older diagnosed with
substance use disorders or co-occurring disorders (mental illness and substance
use) that meet the American society of addiction medicine's (ASAM) patient
placement criteria for level 2.1 - intensive outpatient treatment of have been
mandated by the local judicial system as an option of least restrictive level
of care.
(4) Prior to engaging in
an IOP program, the eligible recipient must have a treatment file containing:
(a) a diagnostic evaluation with a diagnosis
of a moderate or severe SUD;
(b) an
individualized IOP treatment plan that includes IOP and the EBP as the
intervention; and
(c) both a crisis
and safety plan developed with the recipient. The treatment, crisis, and safety
plans must be regularly updated in collaboration with the recipient.
E. Non-covered
services: IOP services are subject to the limitations and coverage restrictions
which exist for other MAD covered services see Subsection G of
8.321.2.9 NMAC for general
non-covered MAD behavioral health services and 8.310.2 NMAC for MAD general
non-covered services. MAD does not cover the following specific services billed
in conjunction with IOP services.
(1) acute
inpatient;
(2) residential
treatment services (i.e., ARTC, RTC, group home, and transitional living
services);
(3) partial
hospitalization;
(4) outpatient
therapies which do not meet Subsection C of
8.321.2.9 NMAC; or
(5) activity therapy.
F. Reimbursement: See Subsection H of
8.321.2.9 NMAC for MAD behavioral
health general reimbursement requirements.
(1) For IOP services, the agency must submit
claims for reimbursement on the CMS-1500 claim form or its successor.
(2) Core IOP services are reimbursed through
a daily rate. Medication assisted treatment and other mental health therapies
are billed and reimbursed separately from the daily rate.
(3) IOP services furnished by an IOP team
member are billed by and reimbursed to a MAD IOP agency whether the team member
is under contract with or employed by the IOP agency.
Notes
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