In Lieu of Services (ILOS) are services that have been approved by Texas Health & Human Services Commission (HHSC) to be medically appropriate, clinically appropriate, and cost-effective substitutes for covered services under Texas Medicaid.
Texas Medicaid Providers in network with managed care programs can use ILOS an alternative to traditional Medicaid services or settings. This approach aims to reduce health disparities and address unmet health-related social needs (HRSNs).
ILOS are only available to Members enrolled in Texas Medicaid programs, including:
- STAR
- STAR+PLUS
- STAR Kids
- Medicare-Medicaid Dual Demonstration
Examples of ILOS include:
- Partial Hospitalization Program (PHP): A structured outpatient program offering behavioral health services such as group therapy, medication management, and nursing services.
- Intensive Outpatient Program (IOP): An outpatient program focused on structured therapy, educational services, and life skills training.
- Coordinated Specialty Care (CSC): A team-based treatment approach for individuals with newly diagnosed psychosis.
What you should know about ILOS:
- Request ILOS when appropriate, ensuring the request aligns with the Member’s comprehensive treatment plan.
- Engage Members in discussions about ILOS to ensure they understand their options and can make informed decisions.
- ILOS may be limited to Members who meet certain criteria. For example, the ILOS may only be available to people who are a specific age.
- ILOS may be limited in quantity or duration. It may also be limited to a specific setting.
- Members have the right to request or decline these services.
- Maintain documentation of the Member’s choice to receive ILOS and make it available upon request.
ILOS are not a replacement for regular services or treatments covered by Community First. They are services substituted for Medicaid State Plan services or settings, as allowed by Medicaid guidelines.
Billing
| PHP | IOP | CSC | |
| Mental Health Services | H0035 | S9480 | H2040 |
| SUD Services | S0201 | H0015 | H2041 |
Refer to HHSC’s Uniform Managed Care Manual (UMCM), chapter 16.3, for procedure codes for PHP, IOP, and CSC.
Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6294. You can also contact your Provider Relations Representative directly.
To access all Provider alerts:
- Log into the Community First Provider Portal
- Go to CommunityFirstHealthPlans.com/Provider-News
- Sign up for the Community First Provider eNewsletter