N.M. Admin. Code § 8.321.2.26

Current through Register Vol. 35, No. 23, December 10, 2024

Section 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.

(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 § 8.321.2.26

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, Adopted by New Mexico Register, Volume XXXV, Issue 23, December 10, 2024, eff. 12/10/2024