New Behavioral Health in-lieu-of services programs

Effective December 1, 2024, Wellpoint may offer eligible Medicaid members the option of in-lieu-of services and settings when medically appropriate and cost-effective. Partial Hospitalization Services and Intensive Outpatient Program (IOP) Services will be offered in lieu of acute care inpatient hospital services for behavioral health treatment. In addition, for members aged 21 to 64, Wellpoint may offer up to 15 calendar days per month inpatient services at an Institution of Mental Disease (IMD) in lieu of an acute care inpatient hospital setting to treat acute psychiatric conditions.

The use of in-lieu-of services or settings is not required and is the member’s choice. All in-lieu-of services and settings require a prior authorization (PA) and member agreement of the in-lieu-of service or setting. Providers must document the member’s choice of an in-lieu-of service or setting in the member’s record and must make the documentation available to Wellpoint upon request. Once a member agrees, providers may request an in-lieu-of service or setting by contacting Provider Services at 833-731-2162. Information on PA requirements is available by calling Provider Services or on our provider website > Resources > Prior Authorization Requirements.

Behavioral health in-lieu-of services and settings are not available to members with dual Medicaid and Medicare coverage or to Nursing Facility members with STAR+PLUS. Wellpoint will not offer outpatient services in-lieu-of inpatient hospital services for members who are at immediate risk of harming themselves or others.

Partial Hospitalization Services provide a structured day program of outpatient behavioral health services. Partial Hospitalization Programs (PHPs) may provide services for mental health, substance use disorder (SUD), or both. These services resemble highly structured, short-term hospital inpatient programs. The treatment level is more intense than outpatient day treatment or psychosocial rehabilitation.

Intensive Outpatient Program Services, also referred to as IOP services, are used to treat behavioral health issues that do not require detoxification or 24-hour supervision. IOPs are generally less intensive than PHPs. They may be delivered for mental health, SUD, or both.

IOP services are organized nonresidential services providing structured group and individual therapy, educational services, and life skills training, which consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day.

Inpatient services in an IMD setting are to treat acute psychiatric conditions and are allowed for up to 15 calendar days per month for members aged 21 to 64 only.

PHP and IOP will be contracted to and provided by Licensed Hospital Facilities enrolled in Medicaid and able to meet the requirements in the link below with a multidisciplinary team approach to patient care under the direction of a physician. Wellpoint will allow inpatient services in an IMD setting with Medicaid-enrolled IMD facilities. Qualifications are outlined within the Health and Human Services Commission (HHSC) document Uniform Managed Care Manual 16.3 "In-Lieu-of-Covered Services and Settings" (hhs.texas.gov).

Providers and members may request these in-lieu-of services. Contact Provider Services at 833‑731‑2162 for assistance in submitting an authorization request.