N.M. Admin. Code § 8.321.2.25

Current through Register Vol. 35, No. 21, November 5, 2024

Section 8.321.2.25 - INTENSIVE OUTPATIENT PROGRAM FOR SUBSTANCE USE DISORDERS (IOP)

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 by the IOP interdepartmental council, and target specific behaviors with individualized behavioral interventions.

A.Eligible providers: Services may only be delivered through a MAD approved agency after demonstrating that the agency meets all the requirements of IOP program services and supervision. See Subsections 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 addiction and mental health treatment. This team may have services rendered by non-independent practitioners under the direction of the IOP supervisor including LMSW, LMHC, LADAC, CADC, LSAA, and a master's level psych associates.

(2) Each IOP program must have a clinical supervisor. Both clinical services and supervision by licensed practitioners must be conducted in accordance with respective licensing board regulations. An IOP clinical supervisor must meet all the following requirements:

(a) be licensed as a MAD approved independent practitioner; see Subsection C of 8.321.2.9 NMAC;

(b) have two years relevant experience with an IOP program or approved exception by the interdepartmental council;

(c) have one year demonstrated supervisory experience; and

(d) have expertise in both mental health and substance abuse treatment.

(3) The IOP agency is required to develop and implement a program outcome evaluation system.

(4) The agency must maintain the appropriate state facility licensure if offering medication treatment or medication replacement services.

(5) The agency must hold an IOP interdepartmental council approval letter 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. A MAD IOP agency will be provisionally approved for a specified timeframe to render IOP services to an eligible recipient. During this provisionally approved time, MAD or its designee will determine if the IOP meets MAD IOP requirements and if so, the agency will receive an approval letter for IOP full enrollment.

B.Coverage criteria:

(1) An IOP is based on research and evidence-based practice models (EBP) 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 by the IOP interdepartmental council. A list of pre-approved EBPs is available through the council, as are the criteria for having another model approved. They are also listed in the BH policy and billing manual.

(2) Treatment services must address co-occurring mental health disorders, as well as substance use disorders, when indicated.

C.Covered services:

(1) IOP core services include:

(a) individual substance use disorder related therapy;

(b) group therapy (group membership may not exceed 15 in number); and

(c) psycho-education for the eligible recipient and his or her family.

(2) Co-occurring mental health and substance use disorders: 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 MAD behavioral health providers.

(3) Medication management services are available either in the IOP agency or by referral to oversee the use of psychotropic medications and medication assisted treatment of substance use disorders.

(4) The duration of an eligible recipient's IOP intervention is typically three to six months. The amount of weekly services per eligible recipient is directly related to the goals specified in his or her IOP treatment plan and the IOP EBP in use.

(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, and a statement from the IOP agency that to postpone such therapy until the completion of the eligible recipient's IOP services is not in the best interest of the eligible recipient. Such documentation includes, but is not limited to: current assessment, a co-occurring diagnosis, and the inclusion in service 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 substance abuse disorder or with co-occurring disorders (mental illness and substance abuse) or 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. 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 in a transitional age program of which the age range has been determined by the agency, and that have been diagnosed with substance abuse disorder or with co-occurring disorders (mental illness and substance abuse) 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 abuse disorders or co-occurring disorders (mental illness and substance abuse) 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.

(4) Prior to engaging in a MAD IOP program, the eligible recipient must have a treatment file containing:

(a) one diagnostic evaluation with a diagnosis of substance use disorder; and

(b) one individualized treatment service plan that includes IOP as an intervention.

E.Non-covered services: IOP services are subject to the limitations and coverage restrictions which exist for other MAD 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) ACT;

(4) partial hospitalization;

(5) outpatient therapies which do not meet Subsection C of 8.321.2.9 NMAC;

(6) multi-systemic therapy (MST);

(7) activity therapy; or

(8) psychosocial rehabilitation (PSR) group services.

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 bundled rate. Medication assisted treatment and other mental health therapies are billed and reimbursed separately from the bundled 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.

(4) IOP services not provided in accordance with the conditions for coverage as specified in 8.321.2 NMAC are not MAD covered services and are subject to recoupment.

N.M. Admin. Code § 8.321.2.25

Adopted by New Mexico Register, Volume XXX, Issue 23, December 17, 2019, eff. 1/1/2020, Adopted by New Mexico Register, Volume XXXII, Issue 15, August 10, 2021, eff. 8/10/2021