TITLE
8 SOCIAL SERVICES
CHAPTER
321 SPECIALIZED BEHAVIORAL HEALTH
SERVICES
PART
2 SPECIALIZED BEHAVIORAL
HEALTH PROVIDER ENROLLMENT AND REIMBURSEMENT
8.321.2.1 ISSUING AGENCY: New Mexico Human
Services Department (HSD).
[8.321.2.1
NMAC - Rp, 8.321.2.1 NMAC, 8/10/2021]
8.321.2.2 SCOPE: The rule applies to
the general public.
[8.321.2.2
NMAC - Rp, 8.321.2.2 NMAC, 8/10/2021]
8.321.2.3 STATUTORY AUTHORITY: The New Mexico medicaid program and other health care programs are
administered pursuant to regulations promulgated by the federal department of
health and human services under Title XIX of the Social Security Act as amended
or by state statute. See Section 27-2-12
et seq., NMSA 1978.
[8.321.2.3
NMAC - Rp, 8.321.2.3 NMAC, 8/10/2021]
8.321.2.4 DURATION: Permanent.
[8.321.2.4
NMAC - Rp, 8.321.2.4 NMAC, 8/10/2021]
8.321.2.5 EFFECTIVE DATE: August 10, 2021,
unless a later date is cited at the end of a section.
[8.321.2.5
NMAC - Rp, 8.321.2.5 NMAC, 8/10/2021]
8.321.2.6 OBJECTIVE: The objective of
these rules is to provide instruction for the service portion of the New Mexico
medical assistance programs (MAP).
[8.321.2.6
NMAC - Rp, 8.321.2.6 NMAC, 8/10/2021]
8.321.2.7 DEFINITIONS: [RESERVED]
8.321.2.8 MISSION STATEMENT: To transform
lives. Working with our partners, we
design and deliver innovative, high quality health and human services that
improve the security and promote independence for New Mexicans in their
communities.
[8.321.2.8
NMAC - Rp, 8.321.2.8 NMAC, 8/10/2021]
8.321.2.9 GENERAL PROVIDER INSTRUCTION:
A. Health care to
New Mexico eligible recipients is furnished by a variety of providers and
provider groups. The reimbursement for
these services is administered by the HSD medical assistance division (MAD). Upon approval of a New Mexico MAD provider
participation agreement (PPA) a licensed practitioner, a facility or other
providers of services that meet applicable requirements are eligible to be
reimbursed for furnishing MAD covered services to an eligible recipient. A provider must be approved before submitting
a claim for payment to the MAD claims processing contractors. Information necessary to participate in
health care programs administered by HSD or its authorized agents, including
New Mexico administrative code (NMAC) program rules, program policy manuals,
billing instructions, supplements, utilization review (UR) instructions, and
other pertinent materials is available on the HSD website, on other program
specific websites or in hard copy format.
When approved, a provider receives instructions on how to access these
documents. It is the provider’s
responsibility to access these instructions, to understand the information
provided and to comply with the requirements.
The provider must contact HSD or its authorized agents to obtain answers
to questions related to the material or not covered by the material. To be eligible for reimbursement, providers
and practitioners must adhere to the provisions of his or her MAD PPA and all
applicable statutes, regulations, rules, and executive orders. MAD or its selected claims processing
contractor issues payment to a provider using the electronic funds transfer
(EFT) only. Providers must supply necessary information as
outlined in the PPA for payment to be made.
B. Services
must be provided within the licensure for each facility and scope of practice
for each provider and supervising or rendering practitioner. Services must be in
compliance with the statutes, rules and regulations of the applicable
practice act. Providers must be eligible
for reimbursement as described in 8.310.2 NMAC and 8.310.3 NMAC.
C. The
following independent providers with active licenses (not provisional or
temporary) are eligible to be reimbursed directly for providing MAD behavioral
health professional services unless otherwise restricted or limited by NMAC
rules:
(1) a
physician licensed by the board of medical examiners or board of osteopathy who
is board eligible or board certified in psychiatry, to
include the groups they form;
(2) a
psychologist (Ph.D., Psy.D. or Ed.D.) licensed as a clinical psychologist by
the New Mexico regulation and licensing department’s (RLD) board of
psychologist examiners, to include the groups they form;
(3) a
licensed independent social worker (LISW) or a licensed clinical social worker
(LCSW) licensed by RLD’s board of social work examiners, to include the groups
they form;
(4) a
licensed professional clinical counselor (LPCC) licensed by RLD’s counseling
and therapy practice board, to include the groups they form;
(5) a
licensed marriage and family therapist (LMFT) licensed by RLD’s counseling and
therapy practice board, to include the groups they form;
(6) a
licensed alcohol and drug abuse counselor (LADAC) licensed by RLD’s counseling
and therapy practice board or a certified alcohol and
drug abuse counselor (CADC) certified by the New Mexico credentialing board for
behavioral health professionals (CBBHP).
Independent practice is for alcohol and drug abuse diagnoses only. The LADAC or CADC may provide therapeutic
services that may include treatment of clients with co-occurring disorders or
dual diagnoses in an integrated behavioral health setting in which an
interdisciplinary team has developed an interdisciplinary treatment plan that
is co-authorized by an independently licensed counselor or therapist. The treatment of a mental health disorder
must be supervised by an independently licensed counselor or therapist; or
(7) a
clinical nurse specialist (CNS) or a certified nurse practitioner (CNP)
licensed by the New Mexico board of nursing and certified in psychiatric
nursing by a national nursing organization, to include the groups they form,
who can furnish services to adults or children as his or her certification
permits; or
(8) a licensed professional art therapist
(LPAT) licensed by RLD’s counseling and therapy practice board, and certified
for independent practice by the art therapy credentials board (ATCB); or
(9) an out-of-state provider rendering a
service from out-of-state must meet his or her state’s licensing and certification
requirements which are acceptable when deemed by MAD to be substantially
equivalent to the license.
D. The following
agencies are eligible to be reimbursed for providing behavioral health
professional services when all conditions for providing services are met:
(1) a
community mental health center (CMHC);
(2) a
federally qualified health center (FQHC);
(3) an
Indian health service (IHS) hospital, clinic or FQHC;
(4) a PL 93-638 tribally operated
hospital, clinic or FQHC;
(5) to the extent not covered by
Paragraphs (3) and (4) of Subsection D of 8.321.2.9 NMAC above, an “Indian
Health Care Provider (IHCP)” defined in 42 Code of Federal Regulations
§438.14(a).
(6) a children,
youth and families department (CYFD) facility;
(7) a hospital and its outpatient
facility;
(8) a core service agency (CSA);
(9) a CareLink
NM health home (CLNM HH);
(10) a crisis triage center licensed by
the department of health (DOH);
(11) a behavioral health agency (BHA);
(12) an opioid treatment program in a
methadone clinic;
(13) a political subdivision of the
state of New Mexico; and
(14) a crisis services community
provider as a BHA.
(15) a school based health center with
behavioral health supervisory certification.
E. A behavioral
health service rendered by a licensed practitioner listed in Paragraph (2) of
Subsection E of 8.321.2.9 NMAC whose scope of licensure does not allow him or
her to practice independently or a non-licensed practitioner listed in
Paragraph (3) of Subsection E of 8.321.2.9 NMAC is covered to the same extent
as if rendered by a practitioner licensed for independent practice, when the
supervisory requirements are met consistent with the practitioner’s licensing
board within his or her scope of practice and the service is provided through
and billed by one of the provider’s agencies listed in numbers one through nine
of Subsection D of 8.321.2.9 NMAC, when the agency has a behavioral health
services division (BHSD) supervisory certificate, and Paragraphs (10) through (15)
of Subsection D of 8.321.2.9 NMAC. All
services must be delivered according to the medicaid
regulation and current version of the behavioral health policy and billing
manual. If the service is an evaluation,
assessment, or therapy service rendered by the practitioner and supervised by
an independently licensed practitioner, the independently licensed
practitioner’s practice board must specifically allow him or her to supervise
the non-independent practitioner.
(1) Specialized
behavioral health services, other than evaluation, assessment, or therapy
services, may have specific rendering practitioner requirements which are
detailed in each behavioral health services section of 8.321.2.9 NMAC.
(2) The
non-independently licensed rendering practitioner with an active license which
is not provisional or temporary must be one of the following:
(a) a
licensed master of social work (LMSW) licensed by
RLD’s board of social work examiners;
(b) a
licensed mental health counselor (LMHC) licensed by RLD’s counseling and
therapy practice board;
(c) a
licensed professional mental health counselor (LPC) licensed by RLD’s
examiner board;
(d) a
licensed associate marriage and family therapist (LAMFT) licensed by RLD’s
examiner board;
(e) a
psychologist associate licensed by the RLD’s psychologist examiners board;
(f) a
licensed substance abuse associate (LSAA) licensed by RLD’s counseling and
therapy practice board will be eligible for reimbursement aligned with each
tier level of designated scope of practice determined by the board;
(h) a
licensed physician assistant certified by the state of New Mexico if supervised
by a behavioral health physician or DO licensed by
RLD’s examiner board.
(3) Non-licensed
practitioners must be one of the following:
(a) a
master’s level behavioral health intern;
(b) a
psychology intern including psychology practicum students, pre-doctoral
internship;
(c) a
pre-licensure psychology post doctorate student;
(d) a
certified peer support worker;
(e) a
certified family peer support worker; or
(f) a
provisional or temporarily licensed masters level
behavioral health professional.
(4) The rendering practitioner must be enrolled as a MAD
provider.
F. An eligible
recipient under 21 years of age may be identified through a tot to teen health
check, self-referral, referral from an agency (such as a public school, child care provider or other practitioner) when he or she is
experiencing behavioral health concerns.
G. Either as a
separate service or a component of a treatment plan or a bundled service, the
following services are not MAD covered benefits:
(1) hypnotherapy;
(2) biofeedback;
(3) conditions
that do not meet the standard of medical necessity as defined in NMAC MAD
rules;
(4) educational
or vocational services related to traditional academic subjects or vocational training;
(5) experimental
or investigational procedures, technologies or non-drug therapies and related
services;
(6) activity
therapy, group activities and other services which are primarily recreational
or diversional in nature;
(7) electroconvulsive
therapy;
(8) services
provided by a behavioral health practitioner who is not in compliance with the
statutes, regulations, rules or renders services outside his or her scope of
practice;
(9) treatment
of intellectual disabilities alone;
(10) services
not considered medically necessary for the condition of the eligible recipient;
(11) services
for which prior authorization is required but was not obtained; and
(12) milieu
therapy.
H. All behavioral
health services must meet with the current MAD definition of medical necessity
found in 8.302.1 NMAC. Performance of a
MAD behavioral health service cannot be delegated to a provider or practitioner
not licensed for independent practice except as specified within this rule,
within his or her practice board’s scope and practice and in accordance with
applicable federal, state, and local statutes, laws and rules. When a service is performed by a supervised
practitioner, the supervision of the service cannot be billed separately or
additionally. Other than agencies as
allowed in Subsections D and E of 8.321.2.9 NMAC, a behavioral health provider
cannot himself or herself as a rendering provider bill for a service for which
he or she was providing supervision and the service was in part or wholly performed
by a different individual. Behavioral
health services are reimbursed as follows, except when otherwise described
within a particular specialized service’s reimbursement section.
(1) Once
enrolled, a provider receives instructions on how to access documentation,
billing, and claims processing information.
Reimbursement is made to a provider for covered services at the lesser
of the following:
(a) the
MAD fee schedule for the specific service or procedure; or
(b) the
provider’s billed charge. The provider’s
billed charge must be its usual and customary charge for services (“usual and
customary charge” refers to the amount that the individual provider charges the
general public in the majority of cases for a specific
procedure or service).
(2) Reimbursement
is made for an Indian health service (IHS) agency, a PL 93-638 tribal health
facility, a federally qualified health center (FQHC), any other “Indian Health Care Provider (IHCP)” as defined in 42 Code
of Federal Regulations §438.14(a), rural health clinic, or
hospital-based rural health clinic by following its federal guidelines and
special provisions as detailed in 8.310.4 and 8.310.12 NMAC.
I. All behavioral
health services are subject to utilization review for medical necessity and
program compliance. Reviews can be
performed before services are furnished, after service is furnished but before
a payment is made, or after the payment is made; see 8.310.2 NMAC. The provider must contact HSD or its
authorized agents to request UR instructions.
It is the provider’s and practitioner’s responsibility to access these
instructions or ask for paper copies to be provided, to understand the
information provided, to comply with the requirements, and to obtain answers to
questions not covered by these materials.
When services are billed to and paid by a coordinated services
contractor authorized by HSD, the provider must follow that contractor’s
instructions for authorization of services.
A specialized behavioral health service may have additional prior
authorization requirements listed in that service’s prior authorization
subsection. All prior authorization
procedures must follow federal parity law.
J. For an eligible
recipient to access behavioral health services, a practitioner must complete a
diagnostic evaluation, progress and treatment notes and teaming notes, if
indicated. Exceptions to this whereby a
treatment or set of treatments may be performed before a diagnostic evaluation
has been done, utilizing a provisional diagnosis based on screening results are
outlined in 8.321.2.14, 8.321.2.18 and 8.321.2.34 NMAC and in the behavioral
health (BH) policy and billing manual.
For a limited set of treatments, (i.e. four or less), no treatment plan
is required. All documentation must be
signed, dated and placed in the eligible recipient’s file. All documentation must be made available for
review by HSD or its designees in the eligible recipient’s file (see the BH
policy and billing manual for specific instructions).
K. For recipients
meeting the NM state definition of serious mental illness (SMI) for adults or
severe emotional disturbances (SED) for recipients under 18 years of age or a
substance use disorder (SUD) for any age, a comprehensive assessment or
diagnostic evaluation and service plan must be completed (see the BH policy and
billing manual for specific instructions).
(1) Comprehensive
assessment and service plan can only be billed by the agencies listed in
Subsection D of 8.321.2.9 NMAC.
(2) Behavioral health service plans can
be developed by individuals employed by the agency who have Health Insurance
Portability and Accountability Act (HIPAA) training, are working within their
scope of practice, and are working under the supervision of the rendering
provider who must be a NM independently licensed clinician.
(3) A
comprehensive assessment and service plan cannot be billed if care coordination
is being billed through bundled service packages such as case rates, value
based purchasing agreements, high fidelity wraparound or CareLink
NM (CLNM) health homes.
L. For out-patient,
non-residential recipients meeting the NM state definition of serious mental
illness (SMI) for adults or severe emotional disturbance (SED) for recipients
under 18 years of age or a moderate to severe substance use disorder (SUD) for
any age, where multiple provider disciplines are required and engaged either
for co-occurring conditions, or other social determinants of health, an update
to the service plan may be made using interdisciplinary teaming. MAD covers service plan updates through the
participation of interdisciplinary teams.
(1) Coverage,
purpose and frequency of interdisciplinary team meetings:
(a) provides
the central learning, decision-making, and service integrating elements that
weave practice functions together into a coherent effort for helping a
recipient meet needs and achieve life goals; and
(b) covered
team meetings resulting in service plan changes or updates are limited to an
annual review, when recipient conditions change, or at critical decision points
in the recipient’s progress to recovery.
(2) The
team consists of:
(a) a
lead agency, which must be one of the agencies listed in Subsection D of
8.321.2.9 NMAC. This agency has a
designated and qualified team lead who prepares team members, convenes and
organizes meetings, facilitates the team decision-making process, and follows
up on commitments made;
(b) a
participating provider that is a MAD enrolled provider that is either already
treating the recipient or is new to the case and has the expertise pertinent to
the needs of the individual. This
provider may practice within the same agency but in a differing discipline, or
outside of the lead agency;
(c) other
participating providers not enrolled with MAD, other subject matter experts,
and relevant family and natural supports may be part of the team, but are not
reimbursed through MAD; and
(d) the
recipient, who is the subject of this service plan update, must be a
participating member of every teaming meeting.
(3) Reimbursement:
(a) only
the team lead and two other MAD enrolled participating providers or agencies
may bill for the interdisciplinary team update.
When more than three MAD enrolled providers are engaged within the
session, the team decides who will bill based on the level of effort or change
within their own discipline.
(b) when
the team lead and only one other provider meet to update the service plan, the
definition of teaming is not met and the service plan
update may not be billed using the interdisciplinary teaming codes.
(c) the
six elements of teaming may be performed by using a variety of media (with the
person’s knowledge and consent) e.g., texting members to update them on an
emergent event; using email communications to ask or answer questions; sharing
assessments, plans and reports; conducting conference calls via telephone;
using telehealth platforms conferences; and, conducting face-to-face meetings
with the person present when key decisions are made. Only the last element, that is, conducting
the final face-to-face meeting with the recipient present when key decisions
that result in the updates to the service plan, is a billable event.
(d) when
the service plan updates to the original plan, that was developed within the
comprehensive assessment, are developed using the interdisciplinary teaming
model described in the BH policy and billing manual, service codes specific for
interdisciplinary teaming may be billed.
If the teaming model is not used, only the standard codes for updating
the service plan can be billed. An
update to the service plan using a teaming method approach and an update to the
service plan not using the teaming method approach, cannot both be billed.
(e) billing
instructions are found in the BH policy and billing manual.
M. For recipients
with behavioral health diagnoses and other co-occurring conditions, or other
social determinants of health meeting medical necessity, and for whom multiple
provider disciplines are engaged, MAD covers service plan development and one
subsequent update per year for an interdisciplinary team.
(1) The
team consists of:
(a) a
lead MAD enrolled provider that has primary responsibility for coordinating the
interdisciplinary team, convenes and organizes meetings, facilitates the team
decision-making process, and follows up on commitments made;
(b) a
participating MAD enrolled provider from a different discipline;
(c) other
participating providers not enrolled with MAD, other subject matter experts,
and relevant family and natural supports may be part of the team, but are not
reimbursed through MAD; and
(d) the
recipient, who is the subject of this service plan development and update, must
be a participating member of each team meeting.
(2) Reimbursement:
(a) only
the team lead and one other MAD enrolled participating provider may bill for a
single session. When more than two MAD
enrolled providers are engaged with the session, the team decides who will bill
based on the level of effort or change within their own discipline;
(b) this
service plan development and subsequent update to the original plan can only be
billed twice within one year; and
(c) billing
instructions are found in the BH policy and billing manual.
N. All specialized behavioral health services should be
delivered in the least restrictive setting.
Least restrictive settings will differ between services and facilities,
and are generally defined as a physical setting which places the least restraint
on the client’s freedom of movement and opportunity for independence and
enables an individual to function with as much choice and self-direction as
safely appropriate. In addition, access
to or receipt of one service may not be contingent on requiring an individual
to obtain or utilize any other service; for example, a housing service may not
require a treatment component, nor may an outpatient treatment service require
participation in housing. Multiple
services may be encouraged, under appropriate circumstances, but may not be
required.
[8.321.2.9
NMAC - Rp, 8.321.2.9 NMAC, 8/10/2021]
8.321.2.10 ADULT ACCREDITED RESIDENTIAL TREATMENT CENTER (AARTC) FOR ADULTS WITH
SUBSTANCE USE DISORDERS: To help an eligible recipient 18 years of age
and older, who has been diagnosed as having a substance use disorder (SUD), and
the need for AARTC has been identified in the
eligible recipient’s diagnostic evaluation as meeting criteria of the American
society of addiction medicine (ASAM) level of care three for whom a less
restrictive setting is not appropriate, MAD pays for services furnished to him
or her by an AARTC accredited by the joint commission (JC), the commission on
accreditation of rehabilitation facilities (CARF) or the council on
accreditation (COA).
A. Eligible facilities:
(1) To
be eligible to be reimbursed for providing AARTC services to an eligible
recipient, an AARTC facility:
(a) must
be accredited by JC, COA, or CARF as an adult (18 and older) residential
treatment facility;
(b) must be certified through an application
process with the behavioral health services division which includes a
supervisory certificate (see BH policy and billing manual for details on the
supervisory certificate);
(c) must have written policies and
procedures specifying ASAM level of care three criteria as the basis for
accepting eligible recipients into the sub-level treatment program;
(d) must
meet ASAM treatment service requirements for the ASAM level of care three
recipients it admits into each sub-level of care;
(e) must
provide medication assisted treatment (MAT) for SUD, as indicated; and
(f) all practitioners shall be
trained in ASAM principles and levels of care.
(2) An
out-of-state or MAD border AARTC must have JC, CARF or COA accreditation, use
ASAM level three criteria for accepting recipients, and be licensed in its own
state as an AARTC residential treatment facility.
B. Coverage criteria:
(1) Treatment
must be provided under the direction of an independently licensed
clinician/practitioner as defined by ASAM criteria level three for the
sub-level of treatment being rendered.
(2) Treatment
shall be based on the eligible recipient’s individualized treatment plans
rendered by the AARTC facility’s practitioners, within the scope and practice
of their professions as defined by state law, rule or regulation. See Subsection B of 8.321.2.9 NMAC for
general behavioral health professional requirements.
(3) The
following services shall be performed by the AARTC agency to receive
reimbursement from MAD:
(a) diagnostic
evaluation, necessary psychological testing, and development of the eligible
recipient’s treatment plan, while ensuring that evaluations already performed
are not repeated;
(b) provision
of regularly scheduled counseling and therapy sessions in an individual, family
or group setting following the eligible recipient’s treatment plan, and
according to ASAM guidelines for level three, residential care, and the
specific sub-level of care for which that client meets admission criteria;
(c) facilitation
of age-appropriate life skills development;
(d) assistance
to the eligible recipient in his or her self-administration of medication in
compliance with state statute, regulation and rules;
(e) maintain
appropriate staff available on a 24-hour basis to respond to crisis situations,
determine the severity of the situation, stabilize the eligible recipient, make
referrals as necessary, and provide follow-up to the eligible recipient; and
(f) consultation
with other professionals or allied caregivers regarding the needs of the
eligible recipient, as applicable.
(4) Admission
and treatment criteria based on the sub-levels of ASAM level three criteria
must be met. The differing sub-levels of
ASAM three are based on the intensity of clinical services, particularly as
demonstrated by the degree of involvement of medical and nursing
professionals. The defining
characteristic of level three ASAM criteria is that they serve recipients who
need safe and stable living environments to develop their recovery skills. They are transferred to lower levels of care
when they have established sufficient skills to safely continue treatment
without the immediate risk of relapse, continued use, or other continued problems,
and are no longer in imminent danger of harm to themselves or others.
(5) Levels of care without withdrawal
management:
(a) clinically
managed low-intensity residential services as specified in ASAM level of care
3.1 are covered for recipients whose condition meets the criteria for ASAM 3.1:
(i) is often a step down from a higher level of care and
prepares the recipient for transition to the community and outpatient services;
and
(ii) requires
a minimum of five hours per week of recovery skills development.
(b) clinically
managed population-specific high-intensity residential services as specified in
ASAM levels of care 3.3 and 3.5 are covered for recipients whose condition
meets the criteria of ASAM level 3.3 or 3.5:
(i) level 3.3 meets the needs of
recipients with cognitive difficulties needing more specialized individualized
services. The cognitive impairments can
be due to aging, traumatic brain injury, acute but lasting injury, or
illness. These recipients need a slower
pace and lower intensity of services;
(ii) level
3.5 offers a higher intensity of service not requiring medical monitoring.
(c) medically
monitored intensive inpatient services as specified in ASAM level of care 3.7
are covered for recipients whose condition meets the criteria for ASAM level 3.7:
(i) 3.7 level is an organized service
delivered by medical and nursing professionals which provides 24-hour
evaluation and monitoring services under the direction of a physician or
clinical nurse practitioner who is available by phone 24-hours a day;
(ii) nursing
staff is on-site 24-hours a day;
(iii) other
interdisciplinary staff of trained clinicians may include counselors, social
workers, emergency medical technicians with documentation of three hours of
annual training in substance use disorder, and psychologists available to
assess and treat the recipient and to obtain and interpret information
regarding recipient needs.
(6) Withdrawal
management (WM) levels of care:
(a) clinically
managed residential withdrawal management services as specified in ASAM level
of care 3.2WM for recipients whose condition meets the criteria for ASAM 3.2WM:
(i) managed by behavioral health
professionals, with protocols in place should a patient’s condition deteriorate
and appear to need medical or nursing interventions;
(ii) ability
to arrange for appropriate laboratory and toxicology tests;
(iii) a
range of cognitive, behavioral, medical, mental health and other therapies
administered on an individual or group basis to enhance the recipient’s
understanding of addiction, the completion of the withdrawal management
process, and referral to an appropriate level of care for continuing treatment;
(iv) the
recipient remains in a level 3.2WM program until withdrawal signs and symptoms
are sufficiently resolved that he or she can be safely managed at a less
intensive level of care; or the recipient’s signs and symptoms of withdrawal
have failed to respond to treatment and have intensified such that transfer to
a more intensive level of withdrawal management services is indicated; and
(v) 3.2WM’s
length of stay is typically 3 - 5 days, after which transfer to another level
of care is indicated.
(b) medically
monitored residential withdrawal management services as specified in ASAM level
of care 3.7WM for recipients whose condition meets the criteria for ASAM 3.7WM:
(i) services are provided by an
interdisciplinary staff of nurses, counselors, social workers, addiction
specialists, peer support workers, emergency medical technicians with
documentation of three (3) hours of annual training in substance use disorder,
or other health and technical personnel under the direction of a licensed
physician;
(ii) monitored
by medical or nursing professionals, with 24-hour nursing care and physician
visits as needed, with protocols in place should a patient’s condition
deteriorate and appear to need intensive inpatient withdrawal management
interventions;
(iii) ability
to arrange for appropriate laboratory and toxicology tests;
(iv) a range of
cognitive, behavioral, medical, mental health and other therapies administered
on an individual or group basis to enhance the recipient’s understanding of
addiction, the completion of the withdrawal management process, and referral to
an appropriate level of care for continuing treatment; and
(v)
the recipient remains in a level 3.7WM program until withdrawal signs and
symptoms are sufficiently resolved that he or she can be safely managed at a
less intensive level of care; or the recipient’s signs and symptoms of
withdrawal have failed to respond to treatment and have intensified such that
transfer to a more intensive level of withdrawal management service is
indicated;
(vi) 3.7WM
typically last for no more than seven days.
C. Covered
services: AARTCs treating all
recipients meeting ASAM level three criteria.
MAD covers residential treatment services which are medically necessary
for the diagnosis and treatment of an eligible recipient’s condition. A clinically-managed AARTC facility
must provide 24-hour care with trained staff.
D. Non-covered
services: AARTC services are subject
to the limitations and coverage restrictions that exist for other MAD
services. See Subsection G of 8.321.2.9
NMAC for general MAD behavioral health non-covered services or activities. MAD does not cover the following specific
services billed in conjunction with AARTC services to an eligible recipient:
(1) comprehensive
community support services (CCSS), except when provided by a CCSS agency in discharge
planning for the eligible recipient from the facility;
(2) services
for which prior approval was not requested and approved;
(3) services
furnished to ineligible individuals;
(4) formal
educational and vocational services which relate to traditional academic
subjects or vocational training; and
(5) activity
therapy, group activities, and other services primarily recreational or
diversional in nature.
E. Treatment plan: The treatment plan must be developed by a
team of professionals in consultation with the eligible recipient and in
accordance with ASAM and accreditation standards. The interdisciplinary team must review the
treatment plan at least every 15 days.
F. Prior authorization: Prior authorization is not required for up to
five days for eligible recipients meeting ASAM level three criteria to
facilitate immediate admission and treatment to the appropriate level of
care. Within that five day period, the
provider must furnish notification of the admission and if the provider believes
that continued care beyond the initial five days is medically necessary, prior
authorization must be obtained from MAD or its designee. For out-of-state AARTCs prior authorization
is required prior to admission. Services
for which prior authorization was obtained remain subject to utilization review
at any point in the payment process. All
MAD services are subject to utilization review for medical necessity,
inspection of care, and program compliance.
Follow up auditing is done by the accrediting agency per their
standards.
G. Reimbursement: An AARTC agency must submit claims for
reimbursement on the UB-04 form or its successor. See Subsection H of 8.321.2.9 NMAC for MAD
general reimbursement requirements and see 8.302.2 NMAC. Once enrolled, the agency receives
instructions on how to access documentation, billing, and claims processing
information.
(1) MAD
reimbursement covers services considered routine in the residential
setting. Routine services include, but
are not limited to, counseling, therapy, activities of daily living, medical management,
crisis intervention, professional consultation, transportation, rehabilitative
services and administration.
(2) Services
which are not covered in routine services include other MAD services that an
eligible recipient might require that are not furnished by the facility, such
as pharmacy services, primary care visits, laboratory or radiology
services. These services are billed
directly by the applicable providers and are governed by the applicable sections
of NMAC rules.
(3) MAD
does not cover room and board.
(4) Detailed
billing instructions can be accessed in the BH policy and billing manual.
[8.321.2.10
NMAC - Rp, 8.321.2.10 NMAC, 8/10/2021]
8.321.2.11 ACCREDITED RESIDENTIAL TREATMENT CENTER (ARTC) FOR
YOUTH:
To help an eligible recipient under 21 years of age when the need for
ARTC has been identified in the eligible recipient’s tot to teen health check
screen (EPSDT) program (42 CFR section 441.57) or other diagnostic evaluation,
and for whom a less restrictive setting is not appropriate, MAD pays for
services furnished to him or her by an ARTC accredited by the joint commission
(JC), the commission on accreditation of rehabilitation facilities (CARF) or
the council on accreditation (COA). A
determination must be made that the eligible recipient needs the level of care
(LOC) for services furnished in an ARTC.
This determination must have considered all environments which are least
restrictive, meaning a supervised community placement, preferably a placement
with the juvenile’s parent, guardian or relative. A facility or conditions of treatment that is
a residential or institutional placement should only be utilized as a last
resort based on the best interest of the juvenile or for reasons of public
safety.
A. Eligible facilities:
(1) In
addition to the requirements of Subsections A and B of 8.321.2.9 NMAC, in order
to be eligible to be reimbursed for providing ARTC services to an eligible
recipient, an ARTC facility:
(a) must
provide a copy of its JC, COA, or CARF accreditation as a children’s
residential treatment facility;
(b) must
provide a copy of its CYFD ARTC facility license and certification; and
(c) must
have written utilization review (UR) plans in effect which provide for review
of the eligible recipient’s need for the ARTC that meet federal requirements;
see 42 CFR Section 456.201 through 456.245;
(2) If
the ARTC is operated by IHS or by a federally recognized tribal government, the
youth based facility must meet CYFD ARTC licensing requirements, but is not
required to be licensed or certified by CYFD.
In lieu of receiving a license and certification, CYFD will provide MAD
copies of its facility findings and recommendations. MAD will work with the facility to address
recommendations. Details related to
findings and recommendations for an IHS or federally recognized tribal
government’s ARTC are detailed in the BH policy and billing manual; and
(3) In
lieu of New Mexico CYFD licensure, an out-of-state or MAD border ARTC facility
must have JC, COA or CARF accreditation and be licensed in its own state as an
ARTC residential treatment facility.
B. Covered
services: MAD covers accommodation
and residential treatment services which are medically necessary for the
diagnosis and treatment of an eligible recipient’s condition. An ARTC facility must provide an
interdisciplinary psychotherapeutic treatment program on a 24-hour basis to the
eligible recipient. The ARTC will
coordinate with the educational program of the recipient, if applicable.
(1) Treatment
must be furnished under the direction of a MAD board eligible or certified
psychiatrist.
(2) Treatment
must be based on the eligible recipient’s individualized treatment plans
rendered by the ARTC facility’s practitioners, within the scope and practice of
their professions as defined by state law, rule or regulation. See Subsection B of 8.321.2.9 NMAC for
general behavioral health professional requirements.
(3) Treatment
must be reasonably expected to improve the eligible recipient’s condition. The treatment must be designed to reduce or
control symptoms or maintain levels of functioning and avoid hospitalization or
further deterioration is acceptable expectations of improvement.
(4) The
following services must be performed by the ARTC agency to receive
reimbursement from MAD:
(a) performance
of necessary evaluations, psychological testing and development of the eligible
recipient’s treatment plans, while ensuring that evaluations already performed
are not repeated;
(b) provide
regularly scheduled counseling and therapy sessions in an individual, family or
group setting following the eligible recipient’s treatment plan;
(c) facilitation
of age-appropriate skills development in the areas of household management,
nutrition, personal care, physical and emotional health, basic life skills,
time management, school attendance and money management to the eligible
recipient;
(d) assistance
to the eligible recipient in his or her self-administration of medication in
compliance with state statute, regulation and rules;
(e) maintain
appropriate staff available on a 24-hour basis to respond to crisis situations,
determine the severity of the situation, stabilize the eligible recipient, make
referrals, as necessary, and provide follow-up to the eligible recipient;
(f) consultation
with other professionals or allied caregivers regarding the needs of the
eligible recipient, as applicable;
(g) non-medical
transportation services needed to accomplish the eligible recipient’s treatment
objective; and
(h) therapeutic
services to meet the physical, social, cultural, recreational, health
maintenance and rehabilitation needs of the eligible recipients.
C. Non-covered
services: ARTC services are subject
to the limitations and coverage restrictions that exist for other MAD
services. See Subsection G of 8.321.2.9
NMAC for general MAD behavioral health non-covered services or activities. MAD does not cover the following specific
services billed in conjunction with ARTC services to an eligible recipient:
(1) CCSS,
except when provided by a CCSS agency in discharge planning for the eligible
recipient from the facility;
(2) services
for which prior approval was not requested and approved;
(3) services
furnished to ineligible individuals; ARTC and group services are covered only
for eligible recipients under 21 years of age;
(4) formal
educational and vocational services which relate to traditional academic
subjects or vocation training; and
(5) activity
therapy, group activities, and other services primarily recreational or
diversional in nature.
D. Treatment plan: The treatment plan must be developed by a
team of professionals in consultation with the eligible recipient, his or her
parent, legal guardian and others in whose care he or she will be released
after discharge. The plan must be
developed within 14 calendar days of the eligible recipient’s admission to an
ARTC facility. The interdisciplinary team
must review the treatment plan at least every 30 calendar days. In addition to the requirements of Subsection
K of 8.321.2.9 NMAC, all supporting documentation must be available for review
in the eligible recipient’s file. The
treatment plan must also include a statement of the eligible recipient’s
cultural needs and provision for access to cultural practices.
E. Prior
authorization: Before any ARTC
services are furnished to an eligible recipient, prior authorization is
required from MAD or its designee.
Services for which prior authorization was obtained remain subject to utilization
review at any point in the payment process.
F. Reimbursement: An ARTC agency must submit claims for
reimbursement on the UB-04 form or its successor. See Subsection H of 8.321.2.9 NMAC for MAD
general reimbursement requirements and see 8.302.2 NMAC. Once enrolled, the agency receives
instructions on how to access documentation, billing, and claims processing
information.
(1) The
MAD fee schedule is based on actual cost data submitted by the ARTC
agency. Cost data is grouped into
various cost categories for purposes of analysis and rate setting. These include direct service, direct service
supervision, therapy, admission and discharge planning, clinical support,
non-personnel operating, administration and consultation.
(a) The
MAD fee schedule reimbursement covers those services considered routine in the
residential setting. Routine services
include, but are not limited to: counseling, therapy, activities of daily
living, medical management, crisis intervention, professional consultation,
transportation, rehabilitative services and administration.
(b) Services
which are not covered in routine services include other MAD services that an
eligible recipient might require that are not furnished by the facility, such
as pharmacy services, primary care visits, laboratory or radiology services,
are billed directly by the applicable providers and are governed by applicable
sections of NMAC rules.
(c) Services
which are not covered in the routine rate and are not a MAD covered service
include services not related to medical necessity, clinical treatment, and
patient care.
(2) A
vacancy factor of 24 days annually for each eligible recipient is built in for
therapeutic leave and trial community placement. Since the vacancy factor is built into the
rate, an ARTC agency cannot bill nor be reimbursed for days when the eligible
recipient is absent from the facility.
(3) An
ARTC agency must submit annual cost reports in a form prescribed by MAD. Cost reports are due 90 calendar days after
the close of the agency’s fiscal year end.
(a) If
an agency cannot meet this due date, it can request a 30 calendar day extension
for submission. This request must be
made in writing and received by MAD prior to the original due date.
(b) Failure
to submit a cost report by the due date or the extended due date, when
applicable, will result in suspension of all MAD payments until the cost report
is received.
(4) Reimbursement
rates for an ARTC out-of-state provider located more than 100 miles from the New
Mexico border (Mexico excluded) are at the fee schedule unless a separate rate
is negotiated.
[8.321.2.11
NMAC - Rp, 8.321.2.11 NMAC, 8/10/2021]
8.321.2.12 APPLIED
BEHAVIOR ANALYSIS (ABA): MAD pays for
medically necessary, empirically supported, applied behavior analysis (ABA)
services for eligible recipients who have a well-documented medical diagnosis
of autism spectrum disorder (ASD), and for eligible recipients who have
well-documented risk for the development of ASD. As part of a three-stage comprehensive
approach consisting of evaluation, assessment, and treatment, ABA services may
be provided in coordination with other medically necessary services (e.g.,
family infant toddler program (FIT) services, occupational therapy, speech language
therapy, medication management, developmentally disabled waiver services,
etc.). ABA services are part of the
early periodic screening, diagnosis and treatment (EPSDT) program (CFR 42
section 441.57). There is no age
requirement to receive ABA services and ABA is a covered benefit for medicaid-enrolled adults.
A. Coverage Criteria:
(1) Confirmation
of the presence or risk of ASD must occur through an approved autism evaluation
provider (AEP) through a comprehensive diagnostic evaluation (CDE) used to
determine the presence of and a diagnosis of ASD. A targeted evaluation is used when the
eligible recipient who has a full diagnosis of ASD presents with behaviors that
are changed from the last CDE. An ASD
risk evaluation is used when an eligible recipient meets the at-risk criteria
found in Subsection C of 8.321.2.12 NMAC.
(2) An
integrated service plan (ISP) must be developed by the AEP together with a
referral to an approved ABA provider (AP) agency (stage one).
(3) The
AP agency completes a behavior or functional analytic assessment. The assessment results determine if a focused
or comprehensive model is selected and a treatment
plan is completed (stage two).
(4) ABA
stage two and three services are then rendered by a behavior analyst
certification board (BACB) approved behavior analyst (BA), a board certified
assistant behavior analyst (BCaBA) or a behavior
technician (BT), in accordance with the treatment plan (stage three). A BCaBA is referred
to 8.321.2 NMAC as a behavior analyst assistant (BAA).
B. Eligible providers: ABA services are
rendered by a number of providers and
practitioners: an AEP; a behavior
analyst (BA) and a behavior technician (BT) through an ABA provider (AP); and
an ABA specialty care provider. Each ABA
provider and practitioner has corresponding enrollment requirements and renders
unique services according to his or her provider type and specialty. All providers must successfully complete a
criminal background registry check. See
Subsections A and B of 8.321.2.9 NMAC for MAD general provider requirements.
(1) Stage 1: Autism Evaluation Provider
(AEP):
Completes the CDE, ASD risk evaluation or targeted evaluation and
develops the ISP for an eligible recipient.
(2) Behavior Analyst (BA): a BA who is a board
certified behavior analyst (BCBA® or BCBA-D®) by the behavior analyst
certification board (BACB®) or a psychologist who is certified by the American
board of professional psychology in behavior and cognitive psychology and who
was tested in the ABA part of his or her certification, may render ABA stage
two-behavior analytic assessment, service model determination and treatment
plan development and stage three services-implementation of an ABA treatment
plan. MAD refers to this practitioner in
rule and on the fee schedule as a BA.
(3) Stage
two and three BAA: A BAA who is a
board certified assistant behavior analyst (BCaBA®)
by the BACB® may assist his or her supervising BA in rendering a ABA stage
two-behavior or functional analytic assessment, service model determination and
ABA treatment plans development and stage three services implementation of the
ABA treatment plans, when the BAA’s supervising BA determines he or she has the
skills and knowledge to render such services.
This is determined in the contract the BAA has agreed to with his or her
supervising BA.
(4) Stage
three Behavioral Technician (BT): A
BT, under supervision of a BA, may assist stage two and implement stage three
ABA treatment plan interventions and services.
(5) Stage
three ABA specialty care provider eligibility requirements: practitioners who are enrolled as BAs must
provide additional documentation that demonstrates the practitioner has the
skills, training and clinical experience to oversee and render ABA services to
highly complex eligible recipients who require specialized ABA services.
(6) Additional provider types: To avoid a delay in receiving stage two
services, a recipient may be referred for ABA services with a diagnosis of ASD
by other medical provider types. While
the practitioners listed below may not meet the requirements to be approved as
AEPs and therefore are not considered AEPs, until further notice, MAD is
recognizing the diagnosis of ASD of a recipient by the following provider types
to expedite a recipient’s access to ABA stage two services:
(a) A
New Mexico regulation and licensing department (RLD) licensed psychologist.
(b) A
New Mexico board of nursing licensed:
(i) psychiatric clinical nurse
specialist; or
(ii) certified
nurse practitioner with a specialty of pediatrics or psychiatry.
(c) A
New Mexico MD or DO board licensed:
(i) psychiatrist who is board certified
in child and adolescent; or
(ii) pediatrician.
(d) A New Mexico behavioral health
credentialing board credentialed certified family peer support worker under the
supervision of an approved ABA supervisor.
C. Identified
population: The admission criteria
are separated into two types: at-risk
for ASD and diagnosed with ASD.
(1) At-risk for ASD: an eligible
recipient may be considered ‘at-risk’ for ASD and therefore eligible for
time-limited ABA services, if he or she does not meet full criteria for ASD per
the latest version of the diagnostic statistical manual (DSM) or international
classification of diseases (ICD). To be
qualified for the ABA criteria of at-risk, the eligible recipient must meet all
the following requirements:
(a) is
between 12 and 36 months of age;
(b) presents
with developmental differences and delays as measured by standardized
assessments;
(c) demonstrates
some characteristics of the disorder (e.g., impairment in social communication
and early indicators for the development of restricted and repetitive
behavior); and
(d) presents
with at least one genetic risk factor (e.g., genetic risk due to having an
older sibling with a well-documented ASD diagnosis; eligible recipient has a
diagnosis of Fragile X syndrome).
(2) Diagnosed with ASD: an eligible
recipient who has a documented medical diagnosis of ASD according to the latest
version of the DSM or the ICD is eligible for ABA services if he or she
presents with a CDE or targeted evaluation.
D. Covered services:
(1) Stage
one: An eligible recipient is
referred to an AEP after screening positive for ASD. The AEP conducts a diagnostic evaluation (CDE
or targeted evaluation), develops the ISP, and recommends ABA stage 2
services. For an eligible recipient who
has an existing ASD diagnosis, diagnostic re-evaluation is not necessary, but
the development of an ISP and the determination of the medical necessity for
ABA services are required.
(2) Stage
two BA: For all eligible recipients,
stage two services include a behavior or functional analytic assessment, ABA
service model determination, and treatment plan development. The family, eligible recipient (as
appropriate for age and developmental level), and the AP’s supervising BA work
collaboratively to make a final determination regarding the clinically
appropriate ABA service model, with consultative input from the AEP as
needed. A behavior or functional
analytic assessment addressing needs associated with both skill acquisition and
behavior reduction is conducted, and an individualized ABA treatment plan, as
appropriate for the ABA service model, is developed by the supervising BA. The BA is responsible for completing all of the following services:
(a) the
recipient’s assessment;
(b) selection
and measurement of goals; and
(c) treatment
plan formulation and documentation.
(3) Stage
three - treatment: Most ABA stage
three services require prior authorization and may vary in terms of intensity,
frequency and duration, the complexity and range of treatment goals, and the
extent of direct treatment provided.
(4) Stage
three - clinical management and case supervision: All stage three services require clinical
management. If a BAA or a BT is
implementing the treatment plan, the BAA or BT requires frequent, ongoing case supervision
from his or her BA or supervising BAA.
The BH policy and billing manual provides a detailed description of the
requirements for rendering clinical management and case supervision.
(5) Stage
three - ABA specialty care services:
Specialty care services require prior authorization. In cases where the needs of the eligible
recipient exceed the expertise of the AP and the logistical or practical
ability of the AP to fully support the eligible recipient MAD covers the
eligible recipient for a referral to a MAD enrolled ABA specialty care
practitioner (SCP).
(6) If
the eligible recipient is in a residential facility or institutional setting
that either specializes in or has as part of its treatment modalities MAD ABA
services, and the residential facility is not an AP for ABA stage two and three
services, and the eligible recipient has a MAD recognized CDE or targeted
evaluation which recommends ABA stage two services, the residential facility is
responsible to locate a MAD enrolled ABA stage two and three AP and develop an
agreement allowing the AP to render stage two and three services at the
residential facility. Reimbursement for
ABA stage two and three services is made to the MAD enrolled AP, not the residential
facility.
(7) For
an eligible recipient who meets the criteria for ABA services and who is in a
treatment foster care (TFC) placement, he or she is not considered to be in a
residential facility and may receive ABA services outside of the TFC
agency. An eligible recipient who meets the
criteria for ABA services who is in a residential treatment center, accredited
residential treatment center, or a group home may receive ABA services to the
extent that the residential provider is able to provide the services.
(8) See
the BH policy and billing manual for specific instructions concerning stages
one through three services.
E. Prior authorization - general
information stage three services:
(1) Prior
authorization to continue ABA stage three services must be secured every six
months. At each six month authorization
point, a UR contractor will assess, with input from the family and AP’s BA, whether or not changes are needed in the eligible
recipient’s ISP or treatment plan.
Additionally, the family or AP may request ISP modifications prior to
the UR contractor’s six-month authorization point if immediate changes are
warranted to preserve the health and wellbeing of the eligible recipient.
(2) To
secure the initial and ongoing prior authorization for stage three services,
the AP must submit the prior authorization request, specifically noting:
(a) the
CDE or targeted evaluation and the ISP from the AEP (developed in stage one)
along with the ABA treatment plan (developed in stage two);
(b) the
requested treatment model (focused or comprehensive), maximum hours of service
requested per week;
(c) the
number of hours of case supervision requested per week, if more than two hours
of supervision per 10 hours of intervention is requested; the BH policy and
billing manual provides detailed requirements for case supervision;
(d) the
number of hours of clinical management requested per week, if more than two
hours of clinical management per 10 hours of intervention is requested; and
(e) the
need for collaboration with an ABA specialty care provider, if such a need has
been identified through initial assessment and treatment planning; after
services have begun, the AP agency may refer the eligible recipient to a SCP
for a focused behavior or functional analytic assessment focusing on the
specific care needs of the eligible recipient.
The SCP will then request a prior authorization for specialty care
services to the eligible recipient’s UR contractor.
(3) The
request must document hours allocated to other services (e.g., early intervention
through FIT, physical therapy, speech and language therapy) that are in the
eligible recipient’s ISP in order for the eligible
recipient’s UR to determine if the requested intensity (i.e., hours per week)
is feasible and appropriate.
(4) When
an eligible recipient’s behavior exceeds the expertise of the AP and logistical
or practical ability of the AP to fully support him or her, MAD allows the AP
to refer the eligible recipient to his or her UR contractor for prior
authorization to allow an ABA specialty care provider to intervene. The UR contractor will approve a prior
authorization to the ABA specialty care provider to complete a targeted
assessment including a functional assessment and provide the primary AP with,
or to implement his or herself, individualized interventions to address the
behavioral concerns for which the referral is based on medical documentation.
(5) Services
may continue until the eligible recipient no longer meets service criteria for
ABA services as described in the BH policy and billing manual.
(6) See
the BH policy and billing manual for specific instructions on prior
authorizations.
F. Non-covered services:
(1) The
eligible recipient’s comprehensive or targeted diagnostic evaluation or the ISP
and treatment plan updates recommend placement in a higher, more intensive, or
more restrictive level of care (LOC) and no longer recommends ABA services.
(2) Activities
that are not designed to accomplish the objectives delineated in covered
services and that are not included in the ABA treatment plan.
(3) Activities
that are not based on the principles and application of applied behavior
analysis.
(4) Activities
that take place in school settings and have the potential to supplant
educational services.
(5) Activities
that are better described as another therapeutic service (e.g., speech language
therapy, occupational therapy, physical therapy, counseling, etc.), even if the
practitioner has expertise in the provision of ABA.
(6) Activities
which are better characterized as staff training certification or licensure or
certification supervision requirements, rather than ABA case supervision.
G. Reimbursement: Billing instructions for ABA services are
detailed in the BH policy and billing manual.
[8.321.2.12
NMAC - Rp, 8.321.2.12 NMAC, 8/10/2021]
8.321.2.13 ASSERTIVE COMMUNITY TREATMENT SERVICES: To help an eligible recipient with medically
necessary services MAD pays for covered assertive community treatment services
(ACT). See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
A. Eligible providers:
(1) An
ACT agency must demonstrate compliance with administrative, financial,
clinical, quality improvement and information services infrastructure standards
established by MAD or its designee, including compliance and outcomes
consistent with the ACT fidelity model.
See Subsections A and B of 8.321.2.9 NMAC for MAD general provider
requirements.
(2) An
ACT agency providing coordinated specialty care for an individual with first episode
psychosis must provide services consistent with the coordinated specialty care
(CSC) model.
(3) ACT
services must be provided by an agency designated team of 10 to 12 members; see
Paragraph (5) of Subsection A of 8.321.2.13 NMAC for the required composition. Lower number of team member compositions may
be considered by BHSD for a waiver request dependent on the nature of the
clinical severity and rural vs. urban environment pending BHSD approval. Each
team must have a designated team leader.
Practitioners on this team shall have sufficient individual competence,
professional qualifications and experience to provide service coordination;
crisis assessment and intervention; symptom assessment and management;
individual counseling and psychotherapy; prescription, administration,
monitoring and documentation of medications; substance abuse treatment;
work-related services; activities of daily living services; support services or
direct assistance to ensure that the eligible recipient obtains the basic
necessities of daily life; and coordination, support and consultation to the
eligible recipient’s family and other major supports. The agency must coordinate its ACT services
with local hospitals, local crisis units, local law enforcement agencies, local
behavioral health agencies, and consider referrals from social service
agencies.
(4) Each
ACT team staff member must be successfully and currently certified or trained
according to ACT fidelity model standards.
The training standards focus on developing staff competencies for
delivering ACT services according to the most recent ACT evidenced-based
practices and ACT fidelity model. Each
ACT team shall have sufficient numbers of qualified
staff to provide treatment, rehabilitation, crisis and support services
24-hours a day, seven days a week.
(5) Each ACT
team shall have a staff-to eligible recipient ratio dependent on the nature of
the team based on clinical severity and rural vs. urban environment pending
BHSD approval to ensure fidelity with current model.
(6) Each
ACT team must comply with 8.321.2.9 NMAC for specific licensing requirements
for ACT staff team members as appropriate, and must include:
(a) one
team leader who is an independently licensed behavioral health practitioner
(LPCC, LMFT, LISW, LCSW, LPAT, psychologist);
(b) medical
director/prescriber:
(i) board certified or board eligible
psychiatrist; or
(ii) NM
licensed psychiatric certified nurse practitioner; or
(iii) NM
licensed psychiatric clinical nurse specialist; or
(iv) prescribing
psychologist under the supervision or consultation of an MD; or
(c) two
licensed nurses, one of whom shall be a RN, or other allied medical
professionals may be used in place of one nurse;
(d) at
least one other MAD recognized licensed behavioral health professional;
(e) at
least one MAD recognized licensed behavioral health practitioner with expertise
in substance use disorders;
(f) at
least one employment specialist;
(g) at
least one New Mexico certified peer support worker (CPSW) through the approved
state of New Mexico certification program; or certified family peer support
worker (CFPSW);
(h) one
administrative staff person; and
(i) the eligible recipient shall be
considered a part of the team for decisions impacting his or her ACT services.
(7) The
agency must have a HSD ACT approval letter to render
ACT services to an eligible recipient.
The approval letter will authorize an agency also delivering CSC
services.
(8) Any adaptations to the model require
an approved variance from BHSD.
B. Coverage criteria:
(1) MAD
covers medically necessary ACT services required by the condition of the
eligible recipient.
(2) The
ACT program provides four levels of interaction with the participating
individuals:
(a) Face-to-face
encounters.
(b) Collateral
encounters designated as members of the recipient’s family or household, or
significant others who regularly interact with the recipient and are directly
affected by or have the capability of affecting his or her condition, and are
identified in the service plan as having a role in treatment.
(c) Assertive
outreach defined as the ACT team having knowledge of what is happening with an
individual. This occurs in either
locating the individual or acting quickly and decisively when action is called
for, while increasing client independence.
This is done on behalf of the client, and can comprise only five percent
per individual of total service time per month.
(d) Group
encounters defined by the following types:
(i) Basic living skills development;
(ii) Psychosocial
skills training;
(iii) Peer
groups; or
(iv) Wellness
and recovery groups.
(3) The
ACT therapy model is based on empirical data and evidence-based interventions
that target specific behaviors with an individualized treatment plan for the
eligible recipient. Specialized
therapeutic and rehabilitative interventions falling within the fidelity of the
ACT model are used to address specific areas of need, such as experiences of
repeated hospitalization or incarcerations, severe problems completing
activities of daily living and individuals who have a significant history of
involvement in behavioral health services.
C. Identified population:
(1) ACT
services are provided to an eligible recipient aged 18 and older whose
diagnosis or diagnoses meet the criteria of serious mental illness (SMI) with a
special emphasis on psychiatric disorders, including schizophrenia,
schizoaffective disorder, bipolar disorder or psychotic depression for
individuals who have severe problems completing activities of daily living, who
have a significant history of involvement in behavioral health services and who
have experienced repeated hospitalizations or incarcerations due to mental
illness.
(2) ACT services
can also be provided to eligible individuals 15 to 30 years of age who are
within the first two years of their first episode of psychosis.
(3) A
co-occurring diagnosis of substance abuse shall not exclude an eligible recipient
from ACT services.
D. Covered services: ACT is a voluntary medical, comprehensive
case management and psychosocial intervention program provided on the basis of principles covered in the BH policy and
billing manual. E. Non-covered services: ACT services are subject to the limitations
and coverage restrictions that exist for other MAD services. See Subsection G of 8.321.2.9 NMAC for MAD
general non-covered behavioral health services.
MAD does not cover other psychiatric, mental health nursing, therapeutic,
non-intensive outpatient substance abuse or crisis services when billed in
conjunction with ACT services to an eligible recipient, except for medically
necessary medications and hospitalizations.
Psychosocial rehabilitation services can be billed for a six-month
period for transitioning levels of care, but must be identified as a component
of the treatment plan.
F. Reimbursement: ACT agencies must submit claims for
reimbursement on the CMS-1500 claim form or its successor. See Subsection H of 8.321.2.9 for MAD general
reimbursement requirements.
[8.321.2.13
NMAC - Rp 8.321.2.13 NMAC, 8/10/2021]
8.321.2.14 BEHAVIORAL HEALTH PROFESSIONAL SERVICES FOR SCREENINGS,
EVALUATIONS, ASSESSMENTS AND THERAPY: MAD covers validated screenings for high risk conditions in order to provide prevention or early intervention. Brief interventions or the use of the treat
first clinical model may be billed with a provisional diagnosis for up to four
encounters. After four encounters, if
continuing treatment is required, a diagnostic evaluation must be performed,
and subsequent reimbursement is based on the diagnosis and resulting service
and treatment plan. See the BH policy
and billing manual for a description of the treat first clinical model.
A. Psychological,
counseling and social work: These
services are diagnostic or active treatments with the intent to reasonably
improve an eligible recipient’s physical, social, emotional and behavioral
health or substance abuse condition.
Services are provided to an eligible recipient whose condition or
functioning can be expected to improve with these interventions. Psychological, counseling and social work
services are performed by licensed psychological, counseling and social work
practitioners acting within their scope of practice and licensure (see
Subsections B through E of 8.321.2.9 NMAC).
These services include, but are not limited to assessments that appraise
cognitive, emotional and social functioning and self-concept. Therapy includes planning, managing and
providing a program of psychological services to the eligible recipient meeting
a current DSM, ICD, or DC:0-5 behavioral health diagnosis and may include
therapy with her or his family or parent/caretaker, and consultation with his
or her family and other professional staff.
B. An assessment as
described in the BH policy and billing manual, must be signed by the
practitioner operating within his or her scope of licensure (see Subsection B
of 8.321.2.9 NMAC). A non-independently
licensed behavioral health practitioner must have an independently licensed
behavioral health practitioner review and sign the assessment with a
diagnosis. Based on the eligible
recipient’s current assessment, his or her treatment file must document the
extent to which his or her treatment goals are being met and whether changes in
direction or emphasis of the treatment are needed. See Subsection K of 8.321.2.9 NMAC for
detailed description of the required eligible recipient file documentation.
C. Outpatient
therapy services (individual, family and group) includes planning, managing,
and providing a program of psychological services to the eligible recipient
with a diagnosed behavioral health disorder, and may include consultation with
his or her family and other professional staff with or without the eligible
recipient present when the service is on behalf of the recipient. See the BH policy and billing manual for detailed
requirements of service plans and treatment plans.
[8.321.2.14
NMAC - Rp, 8.321.2.14 NMAC, 8/10/2021]
8.321.2.15 BEHAVIORAL HEALTH RESPITE CARE (Managed Care Organization (MCO)): As part of
centennial care’s comprehensive service system, behavioral health (BH) respite
service is for short-term direct care and supervision of the eligible recipient
in order to afford the parent(s) or caregiver a
respite for their care of the recipient and takes place in the recipient’s home
or another setting. See Subsections A
and B of 8.321.2.9 NMAC for MAD general provider requirements.
A. Eligible practitioners:
(1) Supervisor:
(a) bachelor’s
degree and three years’ experience working with the target population;
(b) supervision
activities include a minimum of two hours per month individual supervision
covering administrative and case specific issues, and two additional hours per
month of continuing education in behavioral health respite care issues, or
annualized respite provider training;
(c) access to on call crisis support
available 24-hours a day; and
(d) supervision by licensed
practitioners must be in accordance with their respective licensing board
regulations.
(2) Respite
care staff:
(a) minimum
three years’ experience working with the target population;
(b) pass
all criminal records and background checks for all persons residing in the home
over 18;
(c) possess
a valid driver’s license, vehicle registration and insurance, if transporting
member;
(d) CPR and first aid; and
(e) documentation
of behavioral health orientation, training and supervision as defined in the BH
policy and billing manual.
B. Coverage criteria: The provider agency will assess the situation
and, with the caregiver, recommend the appropriate setting for respite. BH respite services may include a range of
activities to meet the social, emotional and physical needs identified through
the service or treatment plan, and documented in the treatment record. These services may be provided for a few
hours during the day or for longer periods of time involving overnight
stays. BH respite, while usually
planned, can also be provided in an emergency or unplanned basis.
C. Identified
population:
(1) Members up
to 21 years of age diagnosed with a severe emotional disturbance (SED), as
defined by the state of New Mexico who reside with the same primary caregivers on a daily basis; or
(2) Youth
in protective services custody whose placement may be at risk whether or not they are diagnosed with SED.
D. Non-covered
services:
(1) 30 days or
720 hours per year at which time prior authorization must be acquired for
additional respite care;
(2) May
not be billed in conjunction with the following medicaid
services:
(a) treatment
foster care;
(b) group
home;
(c) residential
services;
(d) inpatient
treatment.
(3) Non-enrolled
siblings of a child receiving BH respite services are not eligible for BH
respite benefits; and
(4) Cost
of room and board are not included as part of respite care.
[8.321.2.15
NMAC - Rp, 8.321.2.15 NMAC, 8/10/2021]
8.321.2.16 BEHAVIOR MANAGEMENT SKILLS DEVELOPMENT SERVICES: To help an eligible
recipient under 21 years of age who is in need of
behavior management intervention receive services, MAD pays for behavior
management services (BMS) as part of the EPSDT program and when the need for
BMS is identified in a tot to teen health check screen or other diagnostic
evaluation (see 42 CFR Section 441.57).
BMS services are designed to provide highly supportive and structured
therapeutic behavioral interventions to maintain the eligible recipient in his
or her home or community. BMS assists in
reducing or preventing inpatient hospitalizations or out-of-home residential
placement of the eligible recipient through use of teaching, training and
coaching activities designed to assist him or her in acquiring, enhancing and
maintaining the life, social and behavioral skills needed to function
successfully within his or her home and community settings. BMS is provided as part of a comprehensive
approach to treatment and in conjunction with other services as indicated in
the eligible recipient’s comprehensive behavioral health treatment or service
plan. BMS is not provided as a
stand-alone service, but delivered as part of an integrated plan of services to
maintain eligible recipients in their communities as an alternative to
out-of-home services.
A. Eligible providers: An agency must be certified by CYFD to provide
BMS services. See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
B. Coverage criteria: MAD reimburses for behavior management
services specified in the eligible recipient’s individualized treatment plan
which are designed to improve his or her performance in targeted behaviors,
reduce emotional and behavioral episodic events, increase social skills and
enhance behavioral skills through a regimen of positive intervention and
reinforcement.
(1) Implementation
of the eligible recipient’s BMS treatment plan, which includes crisis planning,
must be based on a clinical assessment that includes identification of skills
deficits that will benefit from an integrated program of therapeutic
services. A detailed description of
required elements of the assessment and treatment plan are found in the BH
policy and billing manual.
(2) 24-hour
availability of appropriate staff or implementation of crisis plan, which may
include referral, to respond to the eligible recipient’s crisis situations.
(3) Supervision
of behavioral management staff by an independent level practitioner is required
for this service (8.321.2.9 NMAC).
Policies governing supervisory responsibilities are detailed in the BH
policy and billing manual. The
supervisor must ensure that:
(a) a
clinical assessment of the eligible recipient is completed upon admission into
BMS. The clinical assessment identifies
the need for BMS as medically necessary to prevent inpatient hospitalizations
or out-of-home residential placement of the eligible recipient;
(b) the
assessment is signed by the recipient or his or her parent or legal guardian;
and
(c) the
BMS worker receives documented supervision for a minimum of two hours per month
dependent on the complexity of the needs presented by recipients and the
supervisory needs of the BMS worker.
(4) An
eligible recipient’s treatment plan must be reviewed at least every 30 calendar
days after implementation of the comprehensive service plan. The BMS, in partnership with the client and
family as well as all other relevant treatment team members such as school
personnel, juvenile probation officer (JPO), and guardian ad litem (GAL), shall
discuss progress made over time relating to the BMS service goals. If the BMS treatment team assesses the
recipient’s lack of progress over the last 30 days, the treatment plan will be
amended as agreed upon during the treatment team meeting. Revised BMS treatment plans will be reviewed
and approved by the BMS supervisor, which must be documented in the recipient’s
file.
C. Identified population: In order to receive BMS services, an eligible
recipient must be under the age of 21 years, be diagnosed with a behavioral
health condition and:
(1) be
at-risk for out-of-home residential placement due to unmanageable behavior at
home or within the community;
(2) need
behavior management intervention to avoid inpatient hospitalizations or
residential treatment; or
(3) require
behavior management support following an institutional or other out-of-home
placement as a transition to maintain the eligible recipient in his or her home
and community.
(4) either
the need for BMS is NOT listed on an individualized education plan (IEP), or it
is listed in the supplementary aid & service section of the IEP.
D. Non-covered services: BMS 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 or activities. MAD does not cover the following specific
services billed in conjunction with BMS services:
(1) activities
which are not designed to accomplish the objectives in the BMS treatment plan;
(2) services
provided in residential treatment facilities; and
(3) services
provided in lieu of services that should be provided as part of the eligible
recipient’s individual educational plan (IEP) or individual family service plan
(IFSP).
(4) BMS
is not a reimbursable service through the medicaid
school based service program.
E. Reimbursement: A BMS agency must submit claims for
reimbursement on the CMS-1500 claim form or its successor. See Subsection H of 8.321.2.9 NMAC for MAD
general reimbursement requirements and 8.302.2 NMAC.
[8.321.2.16
NMAC - Rp 8.321.2.16 NMAC, 8/10/2021]
8.321.2.17 COGNITIVE ENHANCEMENT THERAPY (CET): CET
services provide treatment service for an eligible recipient 18 years of age or
older with cognitive impairment associated with the following serious mental
illnesses: schizophrenia, bipolar
disorder, major depression, recurrent schizoaffective disorder, or autism
spectrum disorder. CET uses an
evidence-based model to help eligible recipients with these conditions improve
their processing speed, cognition, and social cognition. Any CET program must be approved by the
behavioral health services division (BHSD) and ensure that treatment is
delivered with fidelity to the evidence-based model.
A. Eligible providers: Services may only be delivered
through a MAD approved agency after demonstrating that the agency meets all the
requirements of CET program services and supervision. See Subsections A and B
of 8.321.2.9 NMAC for MAD general provider requirements.
(1) CET services
are provided through an integrated interdisciplinary approach by staff with
expertise in the mental health condition being addressed and have received
training from a state approved trainer.
Staff can include independently licensed behavioral health
practitioners, non-independently licensed behavioral health practitioners, RNs,
or CSWs. For every CET cohort of
eligible recipients, there must be two practitioners who have been certified in
the evidence-based practice by a state approved trainer or training
center. The agency shall retain
documentation of the staff that has been trained. The size of each cohort who receives CET must
conform to the evidence-based practice (EBP) model in use.
(2) The agency must hold an approval
letter issued by BHSD certifying that the staff have participated in an
approved training or have arranged to participate in training and have
supervision by an approved trainer prior to commencing services.
(3) Weekly
required participation in hourly fidelity monitoring sessions with a certified
CET trainer for all providers delivering CET who have not yet received
certification.
B. Covered services:
(1) CET
services include:
(a) weekly
social cognition groups with enrollment according to model fidelity;
(b) weekly
computer skills groups with enrollment according to model fidelity;
(c) weekly
individual face-to-face coaching sessions to clarify questions and to work on
homework assignments;
(d) initial
and final standardized assessments to quantify social-cognitive impairment,
processing speed, cognitive style; and
(e) individual
treatment planning.
(2) The
duration of an eligible recipient’s CET intervention is based on model
fidelity. Each individual participating
in CET receives up to three hours of group treatment and up to one hour of
individual face-to-face coaching.
C. Identified population: CET services are provided to an eligible
adult recipient 18 years of age and older with cognitive impairment associated
with the following serious mental illnesses:
(1) schizophrenia;
(2) bipolar
disorder;
(3) major
depression, recurrent;
(4) schizoaffective
disorder; or
(5) autism
spectrum disorder.
D. Non-covered
services:
(1) CET
services are subject to the limitation 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.
(2) MAD
does not cover the CET during an acute inpatient stay.
E. Reimbursement: See subsection H of 8.321.2.9 NMAC for MAD
behavioral health general reimbursement.
(1) For
CET services, the agency must submit claims for reimbursement on the CMS-1500
claim form or its successor.
(2) Core
CET services are reimbursed through a bundled rate. Medications and other mental health therapies
are billed and reimbursed separately from the bundled rate.
(3) CET
services furnished by a CET team member are billed by and reimbursed to a MAD
CET agency whether the team member is under contract with or employed by the
CET agency.
(4) CET
services not provided in accordance with the conditions for coverage as
specified in 8.321.2.9 NMAC are not a MAD covered service and are subject to
recoupments.
(5) Billing
instructions for CET services are detailed in the BH policy and billing manual.
[8.321.2.17
NMAC - Rp, 8.321.2.17 NMAC, 8/10/2021]
8.321.2.18 COMPREHENSIVE COMMUNITY SUPPORT SERVICES (CCSS): To help a New Mexico
eligible recipient receive medically necessary services, MAD pays for covered
CCSS. This culturally sensitive service
coordinates and provides services and resources to an eligible recipient and
his or her family necessary to promote recovery, rehabilitation and resiliency. CCSS identifies and addresses the barriers
that impede the development of skills necessary for independent functioning in
the eligible recipient’s community, as well as strengths that may aid the
eligible recipient and family in the recovery or resiliency process.
A. Eligible providers and practitioners:
(1) See Subsections A and B of 8.321.2.9
NMAC for MAD general provider requirements.
To provide CCSS services, a provider must receive CCSS training through
the state or state approved trainer and attest that they have received this
training when contacting the state’s fiscal agent to add the specialty service
107, CCSS to their existing enrollment in medicaid. The children, youth and families
department (CYFD) will provide background checks for CCSS direct service and
clinical staff for child/youth CCSS programs.
(2) Clinical services and supervision by
licensed behavioral health practitioners must be in accord with their
respective licensing board regulations:
(a) Minimum
staff qualifications for the community support worker (CSW):
(i) must be at least 18 years of age;
and
(ii) hold
a bachelor’s degree in a human services field from an accredited university and
have one year of relevant experience with the target population; or
(iii) hold
an associate’s degree and a minimum of two years of
experience working with the target population; or
(iv) hold
an associate’s degree in approved curriculum in
behavioral health coaching; no experience necessary; or
(v) have
a high school diploma or equivalent and a minimum of three years of experience
working with the target population; or
(vi) hold
a certification from the New Mexico credentialing board for behavioral health
professionals as a certified peer support worker (CPSW) or as a certified peer
family specialist (CPFS).
(b) Minimum
staff qualifications for certified peer support workers (CPSW):
(i) must be 18 years of age or older;
and
(ii) have
a high school diploma or equivalent; and
(iii) be
self-identified as a current or former consumer of mental health or substance
abuse services, and have at least two years of mental health or substance abuse
recovery; and
(iv) have
received certification as a CPSW.
(c) Minimum staff qualifications for
certified family peer support workers (CFPSW):
(i) must be 18 years of age or older;
and
(ii) have
a high school diploma or equivalent; and
(iii) must have lived-experience
of being actively involved in raising a child who experienced emotional,
behavioral, mental health, or mental health with co-occurring substance use or
developmental disability challenges prior to the age of 18 years.
(iv) must have
personal experience navigating child serving systems on behalf of their own
child. Must also have an understanding of how these
systems operate in New Mexico; and
(v) have received certification as a
CFPSW.
(d) Minimum staff qualifications for
certified youth peer support workers (CYPSW):
(i) must
be 18 years of age or older; and
(ii) have a high school diploma or
equivalent; and
(iii) have personal experience navigating any
of the child/family-serving systems prior to the age of 18 years. Must also have an
understanding of how these systems operate in New Mexico; and
(iv) have received certification as a
CYPSW.
(e) Minimum staff qualifications for the
CCSS program supervisor:
(i) must hold a bachelor’s degree in a
human services field from an accredited university; and
(ii) have
four years relevant experience in the delivery of case management or CCSS with
the target population; and
(iii) have
one year demonstrated supervisory experience.
(f) Minimum staff qualifications for the
clinical supervisor:
(i) must be a licensed independent
practitioner (i.e. psychiatrist, psychologist, LISW, LPCC, LMFT),
psychiatrically certified clinical nurse specialist or clinical nurse
practitioner practicing under the scope of their NM licensure; and
(ii) have
one year demonstrated supervisory experience; and
(iii) provide
documented clinical supervision on a regular basis to the CSW, CPS and CFS.
(3) Staff training requirements:
(a) Minimum
staff training requirements for a community support worker includes:
(i) an initial training comprised of 20
hours of documented education within the first 90 days of employment drawn from
an array of areas documented in the BH policy and billing manual;
(ii) documentation
of ongoing training comprised of 20 hours is required of a CSW every year,
after the first year of hire, with content of the education based upon agency
assessment of staff need.
(b) Minimum
staff training requirements for supervisors:
(i) the same 20 hours of documented
training or continuing education as required for the CCSS community support
worker;
(ii) an
attestation of training related to providing clinical supervision of
non-clinical staff.
(4) The
clinical supervisor and the CCSS program supervisor may be the same individual.
(5) Documentation
requirements: In addition to the
standard client record documentation requirements for all services, the
following is required for CCSS:
(a) case
notes identifying all activities and location of services;
(b) duration
of service span (e.g., 1:00 p.m.-2:00 p.m.); and
(c) description
of the service provided with reference to the CCSS treatment plan and related
goals.
B. Coverage criteria:
(1) CCSS must be identified in the
service plan for an individual. When
identifying a need for this service, if the provider agency is utilizing the
“Treat First” clinical model, they may be placed in this service for up to four
encounters without having had a psychiatric diagnostic evaluation with the
utilization of a provisional diagnosis for billing purposes. After four encounters, an individual must
have a comprehensive needs assessment, a diagnostic evaluation, and a CCSS
treatment plan. Further details related
to the CCSS treatment plan can be accessed in the BH policy and billing manual.
(2) A
maximum of 16 units per each admission or discharge may be billed concurrently
with:
(a) accredited
residential treatment center (ARTC);
(b) adult accredited residential treatment center (AARTC);
(c) residential
treatment center (RTC);
(d) group home service;
(e) inpatient hospitalization; or
(f) treatment foster care (TFC).
C. Covered services: The
purpose of CCSS is to provide an eligible recipient and his or her family with
the services and resources necessary to promote recovery, rehabilitation and
resiliency. Community support services
address goals specifically in the following areas of the eligible recipient’s
activities: independent living; learning; working; socializing and recreation. CCSS consists of a variety of interventions,
based on coaching and addressing barriers that impeded the development of
skills necessary for independent functioning in the community. Community support services also include
assistance with identifying and coordinating services and supports identified
in an individual’s service plan; supporting an individual and family in crisis
situations; and providing individual interventions to develop or enhance an
individual’s ability to make informed and independent choices.
D. Identified population:
(1) CCSS
is provided to an eligible recipient under 21 years who meets the NM state
criteria for severe emotional disturbance (SED)/neurobiological/behavioral
disorders; and
(2) CCSS
is provided to an eligible recipient 21 years and older whose diagnosis or
diagnoses meet the NM state criteria of serious mental illness (SMI) and for an
eligible recipient with a diagnosis that does not meet the criteria for SMI,
but for whom time-limited CCSS would support his or
her recovery and resiliency process; and
(3) Recipients
with a moderate to severe substance use disorder (SUD) according to the current
DSM V or its successor; and
(4) Recipients
with a co-occurring disorder (mental illness/substance use) or dually diagnosed
with a primary diagnosis of mental illness.
E. Non-covered services: CCSS is subject to the limitations and
coverage restrictions which exist for other MAD services. See 8.310.2 NMAC for a detailed description
of MAD general non-covered services and Subsection G of 8.321.2.9 NMAC for all
non-covered MAD behavioral health services or activities. Specifically, CCSS may not be billed in
conjunction with multi-systemic therapy (MST) or ACT services, or resource
development by New Mexico corrections department (NMCD).
F. Reimbursement: CCSS agencies must submit claims for
reimbursement on the CMS-1500 claim form or its successor; see 8.302.2
NMAC. Once enrolled, a provider receives
instructions on how to access documentation, billing, and claims processing
information. General reimbursement
instructions are found in this rule under Subsection H of 8.321.2.9 NMAC. Billing instructions for CCSS are found in
the BH policy and billing manual.
[8.321.2.18
NMAC - Rp, 8.321.2.18 NMAC, 8/10/2021]
8.321.2.19 CRISIS INTERVENTION SERVICES: MAD pays for
community-based crisis intervention services which are immediate, crisis
oriented services designed to ameliorate or minimize an acute crisis episode or
to prevent inpatient psychiatric hospitalization or medical detoxification. Services are provided to eligible recipients
who have suffered a breakdown of their normal strategies or resources and who
exhibit acute problems or disturbed thoughts, behaviors, or moods which could
threaten the safety of self or others.
MAD covers four types of crisis services: telephone crisis services; face-to-face
crisis intervention in a clinic setting; mobile crisis services; and outpatient
crisis stabilization services.
A. Coverage criteria:
(1) Telephone crisis services:
(a) Must
provide 24-hour, seven day-a-week telephone services to eligible recipients
that are in crisis and to callers who represent or seek assistance for persons
in a mental health crisis;
(b) The
establishment of a toll-free number dedicated to crisis calls for the
identified service area;
(c) Assurance
that a backup crisis telephone system is available if the toll-free number is
not accessible;
(d) Assurance
that calls are answered by a person trained in crisis response as described in
the BH policy and billing manual;
(e) Processes
to screen calls, evaluate crisis situation, and
provide counseling and consultation to crisis callers are documented and
implemented;
(f) Assurance
that face-to-face intervention services are available immediately if clinically
indicated either by the telephone service or through memorandums of
understanding with referral sources;
(g) Provision
of a toll-free number to active clients and their support; and
(h) A
crisis log documenting each phone call must be maintained and include:
(i) date, time and duration of call;
(ii) name
of individual calling;
(iii) responder
handling call;
(iv) description
of crisis; and
(v) intervention
provided, (e.g. counseling, consultation, referral, etc.).
(2) Face-to-face clinic crisis services:
(a) The provider
shall make an immediate assessment for purposes of developing a system of
triage to determine urgent or emergent needs of the person in crisis. (Note:
The immediate assessment may have already been completed as part of a
telephone crisis response.)
(b) Within
the first two hours of the crisis event, the provider will initiate the
following activities:
(i) immediately conduct the crisis
assessment;
(ii) protect
the individual (possibly others) and de-escalate the situation;
(iii) determine
if a higher level of service or other supports are required and arrange, if
applicable.
(c) Follow-up. Initiate telephone call or face-to-face
follow up contact with individual within 24 hours of initial crisis.
(3) Mobile
crisis intervention services: When
mobile crisis is provided, the response will include a two member team capable
of complying with the initial crisis requirements described in 8.321.2.19 NMAC.
(4) Crisis
stabilization services: Outpatient
services for up to 24 hour stabilization of crisis conditions which may, but do
not necessarily, include ASAM level two withdrawal management, and can also
serve as an alternative to the emergency department or police department. Eligible population is 14 years and older.
B. Eligible practitioners:
(1) Telephone crisis services
(Independently licensed BH practitioner):
(a) Individual
crisis workers who are covering the crisis telephone must meet the following
criteria:
(i) CPSW with one year work experience
with individuals with behavioral health condition;
(ii) Bachelor
level community support worker employed by the agency with one year work
experience with individuals with a behavioral health condition;
(iii) RN
with one year work experience with individuals with behavioral health
condition;
(iv) LMHC
with one year work experience with individuals with behavioral health
condition;
(v) LMSW
with one year work experience with individuals with behavioral health condition;
or
(vi) Psychiatric
physician assistant.
(b) Supervision
by a:
(i) licensed independent behavioral
health practitioner; or
(ii) behavioral
health clinical nurse specialist; or
(iii) psychiatric
certified nurse practitioner; or
(iv) psychiatrist.
(c) Training:
(i) 20 hours of crisis intervention
training that addresses the developmental needs of the full age span of the
target population by a licensed independent mental health professional with two
years crisis work experience; and
(ii) 10
hours of crisis related continuing education annually.
(2) Mobile crisis intervention services:
(a) Services
must be delivered by licensed behavioral health practitioners employed by a
mental health or substance abuse provider organization as described above.
(b) One
of the team members may be a certified peer support or family peer support
worker.
(3) Crisis stabilization services staffing must
include all of the below positions and must be
adequate to serve the expected population, but not less than:
(a) one registered nurse (RN) licensed by the NM board of
nursing with experience or training in crisis triage and managing intoxication
and withdrawal management, if this service is provided during all hours of operation;
(b) one regulation and licensing
department (RLD) master’s level licensed mental health professional on-site
during all hours of operation;
(c) certified peer support worker
on-site or available for on-call response during all hours of operation;
(d) board certified physician or
certified nurse practitioner licensed by the NM board of nursing either on-site
or on call; and
(e) at least one staff trained in basic
cardiac life support (BCLS), the use of the automated external defibrillator
(AED) equipment, and first aid shall be on duty at all times.
C. Covered services:
(1) Telephone crisis services:
(a) The
screening of calls, evaluation of the crisis situation
and provision of counseling and consultation to the crisis callers.
(b) Referrals
to appropriate mental health professions, where applicable.
(c) Maintenance
of telephone crisis communication until a face-to-face response occurs, as
applicable.
(2) Face-to-face
clinic crisis services:
(a) crisis
assessment;
(b) other
screening, as indicated by assessment;
(c) brief
intervention or counseling; and
(d) referral
to needed resource.
(3) Mobile crisis intervention services:
(a) crisis
assessment;
(b) other
screening, as indicated by assessment;
(c) brief
intervention or counseling; and
(d) referral
to needed resource.
(4) Crisis stabilization services:
(a) Ambulatory
withdrawal management includes:
(i) evaluation, withdrawal
management and referral services under a defined set of physician
approved policies and clinical protocols.
The physician does not have to be on-site, but available during all
hours of operation;
(ii) clinical
consultation and supervision for bio-medical, emotional, behavioral, and
cognitive problems;
(iii) comprehensive
medical history and physical examination of recipient at admission;
(iv) psychological
and psychiatric consultation;
(v) conducting
or arranging for appropriate laboratory and toxicology test;
(vi) assistance
in accessing transportation services for recipients who lack safe
transportation.
(b) Crisis
stabilization includes but is not limited to:
(i) crisis triage that involves making
crucial determinations within several minutes about an individual’s course of
treatment;
(ii) screening
and assessment;
(iii) de-escalation
and stabilization;
(iv) brief
intervention or psychological counseling;
(v) peer
support; and
(vi) prescribing
and administering medication, if applicable.
(c) Navigational
services for individuals transitioning to the community include:
(i) prescription and medication
assistance;
(ii) arranging
for temporary or permanent housing;
(iii) family
and natural support group planning;
(iv) outpatient
behavioral health referrals and appointments; and
(v) other
services determined through the assessment process.
D. Reimbursement: See
Subsection H of 8.321.9 NMAC for MAD behavioral health general reimbursement
requirements. See the BH policy and
billing manual for reimbursement specific to crisis intervention services.
[8.321.2.19 NMAC - Rp 8.321.2.19 NMAC,
8/10/2021]
8.321.2.20 CRISIS TRIAGE CENTER: MAD pays for a set of services, either
outpatient only or including residential, to eligible adults and youth 14 years
of age and older, to provide voluntary stabilization of behavioral health
crises including emergency mental health evaluation and care. Crisis triage centers (CTC) shall provide
emergency screening and evaluation services 24 hours a day, seven days a week.
A. Coverage criteria for CTCs which
include residential care:
(1) The CTC
shall provide emergency screening, and evaluation services 24-hours a day,
seven days a week and shall admit 24-hours a day seven days a week and
discharge seven days a week;
(2) Readiness
for discharge shall be reviewed in collaboration with the recipient every day;
(3) An
independently licensed mental health practitioner or non-independent mental
health practitioner under supervision must assess each
individual with the assessment focusing on the stabilization needs of
the client;
(4) The
assessment must include medical and mental health history and status, the onset
of the illness, the presenting circumstances, risk assessment, cognitive
abilities, communication abilities, social history and history of trauma;
(5) A
licensed mental health professional must document a crisis stabilization plan
to address needs identified in the assessment which must also include criteria
describing evidence of stabilization and either transfer or discharge criteria;
(6) The
CTC identifies recipients at high risk of suicide or intentional self-harm, and
subsequently engages these recipients through solution-focused and
harm-reducing methods;
(7) Education
and program offerings are designed to meet the stabilization and transfer of
recipients to a different level of care;
(8) The
charge nurse, in collaboration with a behavioral health practitioner, shall
make the determination as to the time and manner of transfer to ensure no
further deterioration of the recipient during the transfer between facilities,
and shall specify the benefits expected from the transfer in the recipient’s
record;
(9) The
facility shall develop policies and procedures addressing risk assessment and
mitigation including, but not limited to: assessments, crisis intervention plans,
treatment, approaches to supporting, engaging and problem solving, staffing,
levels of observation and documentation.
The policies and procedures must prohibit seclusion and address physical
restraint, if used, and the facility’s response to clients that present with
imminent risk to self or others, assaultive and other high-risk behaviors;
(10) Use
of seclusion is prohibited;
(11) The
use of physical restraint must be consistent with federal and state laws and
regulation;
(12) Physical
restraint, as defined in the BH policy and billing manual, shall be used only as
an emergency safety intervention of last resort to ensure the physical safety
of the client and others, and shall be used only after less intrusive or
restrictive interventions have been determined to be ineffective;
(13) If
serving both youth and adult populations, the service areas must be separate;
and
(14) If
an on-site laboratory is part of services, the appropriate clinical laboratory
improvement amendments (CLIA) license must be obtained.
B. Coverage criteria for CTCs which are
outpatient only: Paragraph (3) through (14) of Subsection A of 8.321.2.20
NMAC are conditions of coverage for outpatient only services.
C. Eligible providers and
practitioners:
(1) A provider agency licensed through the department of
health as a crisis triage center
offering one of the following types of service:
(a) a CTC structured for less than
24-hour stays providing only outpatient withdrawal management or other
stabilization services;
(b) a CTC providing outpatient and
residential crisis stabilization services; or
(c) a CTC providing residential crisis
stabilization services.
(2) Practitioners
must be contracted or employed by the provider agency as part of its crisis
triage center service delivery.
(3) All
providers must be licensed in New Mexico for services performed in New
Mexico. For services performed by
providers licensed outside of New Mexico, a provider’s out-of-state license may
be accepted in lieu of licensure in New Mexico if the out-of-state licensure
requirements are similar to those of the state of New
Mexico.
(4) For
services provided under the public health service including IHS, providers must
meet the requirements of the public health service corps.
(5) The
facility shall maintain sufficient staff including supervision and direct care
and mental health professionals to provide for the care of residential and
non-residential clients served by the facility, based on the acuity of client
needs.
(6) The
following individuals and practitioners must be contracted or employed by the
provider agency as part of its crisis triage center service delivery:
(a) An
on-site administrator which can be the same person as the clinical
director. The administrator is
specifically assigned to crisis triage center service oversight and
administrative responsibilities and:
(i) is experienced in acute mental
health; and
(ii) is
at least 21 years of age; and
(iii) holds
a minimum of a bachelor’s degree in the human services field; or
(iv) is
a registered nurse (RN) licensed by the NM board of nursing with
experience
or training in acute mental health treatment.
(b) A
full time clinical director that is:
(i) at least 21 years of age; and
(ii) is
a licensed independent mental health practitioner or certified nurse
practitioner or clinical nurse specialist with experience and training in acute
mental health treatment and withdrawal management services,
if withdrawal management services are provided.
(c) A charge nurse on duty during all
hours of operation under whom all services are directed, with
the exception of services provided by the physician and the licensed
independent mental health practitioner, and who is:
(i) at least 18 years of age; and
(ii) a
RN licensed by the NM board of nursing with experience in acute mental health
treatment and withdrawal management services, if withdrawal management services
are provided.
(d) A
regulation and licensing department (RLD) master's level licensed mental health
practitioner.
(e) Certified
peer support workers (CPSW) holding a certification by the New Mexico
credentialing board for behavioral health professionals as a certified peer
support worker staffed appropriate to meet the client needs 24 hours a day 7
days a week.
(f) An
on call physician during all hours of operation who is a physician licensed to
practice medicine (MD) or osteopathy (DO), or a licensed certified nurse
practitioner (CNP), or a licensed clinical nurse specialist (CNS) with
behavioral health experience as described in 8.310.3 NMAC.
(g) A
part time psychiatric consultant or prescribing psychologist, hours determined
by size of center, who is a physician (MD or DO) licensed by the board of
medical examiners or board of osteopathy and is board eligible or board
certified in psychiatry as described in 8.321.2 NMAC, or a prescribing
psychologist licensed by the board of psychologist examiners or psychiatric
certified nurse practitioner as licensed by the board of nursing. These services may be provided through
telehealth.
(h) At
least one staff trained in basic cardiac life support (BCLS), the use of the
automated external defibrillator (AED) equipment, and first aid shall be on duty at all times.
(7) Additional staff may include an
emergency medical technician (EMT) with documentation of three hours of annual
training in suicide risk assessment.
D. Identified population:
(1) An
eligible recipient is 18 years of age and older who meets the crisis triage
center admission criteria if the CTC is an adults only
agency.
(2) If
serving youth, an eligible recipient is 14 years through 17 years.
(3) Recipients
may also have other co-occurring diagnoses.
(4) The
CTC shall not refuse service to any recipient who meets the agency’s criteria
for services, or solely based on the recipient being on a law enforcement hold
or living in the community on a court ordered conditional release.
E. Covered services:
(1) Comprehensive
medical history and physical examination of recipient at admission;
(2) Development
and update of the assessment and plan as described in the BH policy and billing
manual;
(3) Crisis
stabilization including, but not limited to:
(a) crisis
triage that involves making crucial determinations within several minutes about
an individual’s course of treatment;
(b) screening
and assessment as described in the BH policy and billing manual;
(c) de-escalation
and stabilization;
(d) brief
intervention and psychological counseling;
(e) peer
support.
(4) Ambulatory
withdrawal management (non-residential) based on American society of addiction
medicine (ASAM) 2.1 level of care includes:
(a) evaluation,
withdrawal management and referral services under a defined set of physician approved policies and clinical protocols;
(b) clinical
consultation and supervision for bio-medical, emotional, behavioral, and
cognitive problems;
(c) psychological
and psychiatric consultation; and
(d) other
services determined through the assessment process.
(5) Clinically
or medically monitored withdrawal management in residential setting, if
included, not to exceed services described in level 3.7 of the current ASAM
patient placement criteria.
(6) Prescribing
and administering medication, if applicable.
(7) Conducting
or arranging for appropriate laboratory and toxicology testing.
(8) Navigational
services for individuals transitioning to the community when available include:
(a) prescription
and medication assistance;
(b) arranging
for temporary or permanent housing;
(c) family
and natural support group planning;
(d) outpatient
behavioral health referrals and appointments; and
(e) other
services determined through the assessment process.
(9) Assistance
in accessing transportation services for recipients who lack safe transportation.
F. Non-covered services: are subject to the
limitations and coverage restrictions that exist for other MAD services. See 8.310.2 and 8.321.2 NMAC for general
non-covered services. Specific to crisis
triage services, the following apply:
(1) Acute
medical alcohol detoxification that requires hospitalization as diagnosed by
the agency physician or certified nurse practitioner.
(2) Medical
care not related to crisis triage intervention services beyond basic medical
care of first aid and CPR.
G. Prior authorization and utilization
review:
All MAD services are subject to utilization review (UR) for medical
necessity and program compliance. The
provider agency must contact HSD or its authorized agents to request UR
instructions. It is the provider
agency’s responsibility to access these instructions or ask for hard copies to
be provided, to understand the information provided, to comply with the
requirements, and to obtain answers to questions not covered by these
materials.
(1) Prior
authorization: Crisis triage
services do not require prior authorization, but are provided as approved by
the crisis triage center provider agency.
However, other procedures or services may require prior authorization
from MAD or its designee when such services require prior authorization for
other MAD eligible recipients, such as inpatient admission. Services for which prior authorization was
obtained remain subject to utilization review at any point in the payment
process, including after payment has been made. It is the provider agency’s responsibility to
contact MAD or its designee and review documents and instructions available
from MAD or its designee to determine when prior authorization is necessary.
(2) Timing
of UR: A UR may be performed at any
time during the service, payment, or post payment processes. In signing the MAD PPA, a provider agency
agrees to cooperate fully with MAD or its designee in their performance of any
review and agree to comply with all review requirements.
H. Reimbursement: Crisis triage center
services are reimbursed through an agency specific cost based bundled rate
relative to type of services rendered.
Billing details are provided in the BH policy and billing manual.
[8.321.2.20
NMAC - Rp, 8.321.2.20 NMAC, 8/10/2021]
8.321.2.21 DAY TREATMENT: MAD pays for services provided by a day
treatment provider as part of the EPSDT program for eligible recipients under
21 years of age (42 CFR section 441.57).
The need for day treatment services (DTS) must be identified through an
EPSDT tot to teen health check or other diagnostic evaluation. Day treatment services include eligible
recipient and parent education, skill and socialization training that focus on
the amelioration of functional and behavioral deficits. Intensive coordination and linkage with the
eligible recipient’s school or other child serving agencies is included. The goals of the service must be clearly
documented utilizing a clinical model for service delivery and support.
A. Eligible providers: An agency must be
certified by CYFD to provide day treatment services in addition to meeting the
general provider enrollment requirements in Subsections A and B of 8.321.2.9
NMAC.
B. Coverage criteria:
(1) Day
treatment services must be provided in a school setting or other community
setting; however, there must be a distinct separation between these services in
staffing, program description and physical space from other behavioral health
services offered.
(2) A
family who is unable to attend the regularly scheduled sessions at the day
treatment facility due to transportation difficulties or other reasons may
receive individual family sessions scheduled in the family’s home by the day
treatment agency.
(3) Services
must be based upon the eligible recipient’s individualized treatment plan goals
and should include interventions with a significant member of the family which
are designed to enhance the eligible recipients’ adaptive functioning in their
home and community.
(4) The
certified DTS provider delivers adequate care and continuous
supervision of the client at all times during the course of the client’s
DTS program participation.
(5) 24-hour
availability of appropriate staff or implementation of crisis plan (which may
include referral) to respond to the eligible recipient’s crisis
situation.
(6) Only
those activities of daily living and basic life skills that are assessed as a
clinical problem should be addressed in the treatment plans and deemed
appropriate to be included in the eligible recipient’s individualized program.
(7) Day
treatment services are provided at a minimum of four hours of structured
programming per day, two to five days per week based on acuity and clinical
needs of the eligible recipient and his or her family as identified in the
treatment plan.
C. Identified
population: MAD covers day treatment
services for an eligible recipient under age 21 who:
(1) is
diagnosed with an emotional, behavioral, and neurobiological or substance abuse
problem;
(2) may
be at high risk of out-of-home placement;
(3) requires
structured therapeutic services in order to attain or
maintain functioning in major life domains of home, work or school; and
(4) through
an assessment process, has been determined to meet the criteria established by
MAD or its designee for admission to day treatment services.
D. Covered services:
(1) Day
treatment services are non-residential specialized services and training
provided during or after school, weekends or when school is not in session. Services include parent and eligible
recipient education, and skills and socialization training that focus on the
amelioration of functional and behavioral deficits. Intensive coordination and linkage with the
eligible recipient’s school or other child serving agencies are included. Other behavioral health services (e.g.
outpatient counseling, ABA) may be provided in addition to the day treatment
services when the goals of the service are clearly documented, utilizing a
clinical model for service delivery and support.
(2) The
goal of day treatment is to maintain the eligible recipient in his or her home
or community environment.
(3) The
service is designed to complement and coordinate with the eligible recipient’s
educational system.
(4) Services
must be identified in the treatment plan, including crisis planning, which is
formulated on an ongoing basis by the treatment team. The treatment plan guides and records for
each client: individualized therapeutic
goals and objectives; individualized therapeutic services provided; and
individualized discharge and aftercare plans.
Treatment plan requirements are detailed in the BH policy and billing
manual.
(5) The
following services must be furnished by a day treatment service agency to
receive reimbursement from MAD:
(a) the
assessment and diagnosis of the social, emotional, physical and psychological
needs of the eligible recipient and his or her family for treatment planning
ensuring that evaluations already performed are not unnecessarily repeated;
(b) development
of individualized treatment and discharge plans and ongoing reevaluation of
these plans;
(c) regularly
scheduled individual, family, multifamily, group or specialized group sessions
focusing on the attainment of skills, such as managing anger, communicating and
problem-solving, impulse control, coping and mood management, chemical
dependency and relapse prevention, as defined in the DTS treatment plan;
(d) family
training and family outreach to assist the eligible recipient in gaining
functional and behavioral skills;
(e) supervision
of self-administered medication, as clinically indicated;
(f) therapeutic
recreational activities that are supportive of the clinical objectives and
identified in each eligible recipient’s individualized treatment plan;
(g) 24-hour
availability of appropriate staff or implementation of crisis plan, which may
include referral, to respond to the eligible recipient’s crisis situations;
(h) advance
schedules are posted for structured and supervised activities which include
individual, group and family therapy, and other planned activities appropriate
to the age, behavioral and emotional needs of the client pursuant to the
treatment plan.
E. Non-covered services: Day treatment 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
non-covered MAD behavioral health services or activities. MAD does not cover the following specific
services billed in conjunction with day treatment services:
(1) educational
programs;
(2) pre-vocational
training;
(3) vocational
training which is related to specific employment opportunities, work skills or
work settings;
(4) any
service not identified in the treatment plan;
(5) recreation
activities not related to the treatment plan;
(6) leisure
time activities such as watching television, movies or playing computer or
video games;
(7) transportation
reimbursement for the therapist who delivers services in the family’s home; or
(8) a
partial hospitalization program and residential programs cannot be offered at
the same time as day treatment services.
F. Prior authorization: See Subsection J of 8.321.2.9 NMAC for
general behavioral health services prior authorization requirements. This service does not require prior
authorization.
G. Reimbursement:
(1) All
services described in Subsection D of 8.321.2.21 NMAC are covered in the
bundled day treatment rate;
(2) Day
treatment providers must submit claims for reimbursement on the CMS-1500 claim
form or its successor. See Subsection H
of 8.321.2.9 NMAC for MAD general reimbursement requirements, see 8.302.2
NMAC. Once enrolled, a provider receives
instructions on how to access documentation, billing and claims processing
information.
[8.321.2.21 NMAC - Rp, 8.321.2.21
NMAC, 8/10/2021]
8.321.2.22 FAMILY SUPPORT SERVICES (FSS) (MCO reimbursed
only): Family support services are community-based, face-to-face
interactions with children, youth or adults and their family, available to
managed care members only. Family
support services enhance the member family’s strengths, capacities, and
resources to promote the member’s ability to reach the recovery and resiliency behavioral
health goals they consider most important.
See Subsections A and B of 8.321.2.9 NMAC for MAD general provider
requirements.
A. Eligible providers:
(1) Family support service providers and staff shall meet
standards established by the state of NM and documented in the New Mexico BH
policy and billing manual.
(2) Family support service staff and
supervision by licensed behavioral health practitioners must be in accordance
with their respective licensing board regulations or credentialing standards
for peer support workers or family peer support workers.
(3) Minimum staff qualifications for peer
support workers or family peer support workers includes maintenance of
credentials as a peer support worker or family peer support worker in New
Mexico.
(4) Minimum staff qualifications for the
clinical supervisor:
(a) Must
be a licensed independent practitioner (i.e., psychiatrist, psychologist, LISW,
LPCC, LMFT, or psychiatrically certified nurse practitioner) practicing under
the scope of their NM licensure;
(b) Have
four years’ relevant experience in the delivery of case management or
comprehensive community support services or family support services with the
target population;
(c) Have
one year demonstrated supervisory experience; and
(d) Have
completed both basic and supervisory training regarding family support
services.
B. Identified population:
(1) Members
with parents, family members, legal guardians, and other primary caregivers who
are living with or closely linked to the member and engaged in the plan of care
for the member.
(2) Members
are young persons diagnosed with a severe emotional disturbance or adults
diagnosed with serious mental illness as defined by the state of New Mexico.
C. Covered services:
(1) Minimum
required family support services activities:
(a) review
of the existing social history and other relevant information with the member
and family;
(b) review
of the existing service and treatment plans;
(c) identification
of the member and family functional strengths and any barriers to recovery;
(d) participation
in service planning and delivery with the member and family; and
(e) adherence
to the applicable code of ethics.
(2) The
specific services provided are tailored to the individual needs of the member
and family according to the individual’s treatment or service plan and include
but are not limited to support needed to:
(a) prevent
members from being placed into more restrictive setting; or
(b) quickly
reintegrate the member to their home and local community; or
(c) direct
the member and family towards recovery, resiliency, restoration, enhancement
and maintenance of the member’s functioning; or
(d) increase
the family’s ability to effectively interact with the member.
(3) Family
support services focus on psycho-education, problem
solving, and skills building for the family to support the member and may
involve support activities such as:
(a) working
with teams engaged with the member;
(b) engaging
in service planning and service delivery for the member;
(c) identifying
family strengths and resiliencies in order to
effectively articulate those strengths and prioritize their needs;
(d) navigating
the community-based systems and services that impact the member’s life;
(e) identifying
natural and community supports;
(f) assisting
the member and family to understand, adjust to, and manage behavioral health
crises and other challenges;
(g) facilitating
an understanding of the options for treatment of behavioral health issues;
(h) facilitating
an understanding of the principles and practices of recovery and resiliency;
and
(i) facilitating effective access and
use of the behavioral health service system to achieve recovery and resiliency.
(4) Documentation
requirements:
(a) notes
related to all family support service interventions to include how and to what
extent the activity promoted family support in relationship to the member’s
recovery and resilience goals and outcomes;
(b) any
supporting collateral documentation.
D. Non-covered
services: This service may be billed
only during the transition phases from these services:
(a) accredited residential treatment
center (ARTC);
(b) adult accredited residential
treatment center (AARTC);
(c) residential treatment center
services;
(d) group home services;
(e) inpatient hospitalization;
(f) partial hospitalization;
(g) treatment foster care; or
(h) crisis
triage centers.
E. Reimbursement: To
help an eligible MCO member receive medically necessary services, the
centennial care MCOs pay for family support services.
[8.321.2.22
NMAC - Rp, 8.321.2.22 NMAC, 8/10/2021]
8.321.2.23 INPATIENT PSYCHIATRIC CARE IN
FREESTANDING PSYCHIATRIC HOSPITALS AND PSYCHIATRIC UNITS OF ACUTE CARE
HOSPITALS:
To assist the eligible recipient in receiving necessary mental health
services, MAD pays for inpatient psychiatric care furnished in freestanding
psychiatric hospitals as part of the EPSDT program (42 CFR 441.57). A freestanding psychiatric hospital (an inpatient
facility that is not a unit in a general acute care hospital), with more than
16 beds is an institution for mental disease (IMD) subject to the federal medicaid IMD exclusion that prohibits medicaid
payment for inpatient stays for eligible recipients aged 22 through 64
years. Coverage of stays in a
freestanding psychiatric hospital that is considered an IMD are covered only
for eligible recipients up to age 21 and over age 64. A managed care organization making payment to
an IMD as an in lieu of service may pay for stays that do not exceed 15
days. For stays in an IMD that include a
substance use disorder (SUD) refer to 8.321.2.24 NMAC, Institution for
Mental Diseases (IMD). However, for
freestanding psychiatric hospitals, if the eligible recipient who is receiving
inpatient services reaches the age of 21 years, services may continue until one
of the following conditions is reached: until the date the
eligible recipient no longer requires the services, or until the date the
eligible recipient reaches the age of 22 years, whichever occurs first. The need for inpatient psychiatric care in a
freestanding psychiatric hospital must be identified in the eligible
recipient’s tot to teen health check screen or another diagnostic evaluation
furnished through a health check
referral. Inpatient stays for eligible
recipients in an inpatient psychiatric unit of a general acute care hospital
are also covered. As these institutions
are not considered to be IMDs, there are no age exclusions for their services.
A. Eligible providers: A MAD eligible provider must be licensed and
certified by the New Mexico DOH (or the comparable agency if in another state),
comply with 42 CFR 456.201 through 456.245; and be accredited by at least one
of the following:
(1) the
joint commission (JC);
(2) the
council on accreditation of services for families and children (COA);
(3) the
commission on accreditation of rehabilitation facilities (CARF); or
(4) another
accrediting organization recognized by MAD as having comparable standards; and
(5) be
an approved MAD provider before it furnishes services, see 42 CFR Sections
456.201 through 456.245.
B. Covered services:
MAD covers inpatient psychiatric
hospital services which are medically necessary for the diagnosis or treatment
of mental illness as required by the condition of the eligible recipient.
(1) These
services must be furnished by eligible providers within the scope and practice
of his or her profession (see 8.321.2.9 NMAC) and in accordance with federal
regulations; see (42 CFR 441.156);
(2) Services
must be furnished under the direction of a physician;
(3) In
the case of an eligible recipient under 21 years of age these services:
(a) must
be furnished under the direction of a board prepared, board eligible, board
certified psychiatrist or a licensed psychologist working in collaboration with
a similarly qualified psychiatrist; and
(b) the
psychiatrist must conduct an evaluation of the eligible recipient, in person
within 24 hours of admission.
(4) In
the case of an eligible recipient under 12 years of age, the psychiatrist must
be board prepared, board eligible, or board certified
in child or adolescent psychiatry. The
requirement for the specified psychiatrist for an eligible recipient under age
12 and an eligible recipient under 21 years of age can be waived when all of the following conditions are met:
(a) the
need for admission is urgent or emergent and transfer or referral to another
provider poses an unacceptable risk for adverse patient outcomes;
(b) at
the time of admission, a psychiatrist who is board prepared, board eligible, or
board certified in child or adolescent psychiatry, is not accessible in the
community in which the facility is located;
(c) there
is another facility which has a psychiatrist who is board prepared, board
eligible, board certified in child or adolescent psychiatry, but the facility,
is not available or is inaccessible to the community in which the facility is
located; and
(d) the
admission is for stabilization only and a transfer arrangement to the care of a
psychiatrist who is board prepared, board eligible, board certified in child or
adolescent psychiatry, is made as soon as possible with the understanding that
if the eligible recipient needs transfer to another facility, the actual
transfer will occur as soon as the eligible recipient is stable for transfer in
accordance with professional standards.
(5) A
freestanding hospital must provide the following components to an eligible
recipient to receive reimbursement:
(a) performance
of necessary evaluations and psychological testing for the development of the
treatment plan, while ensuring that evaluations already performed are not
repeated;
(b) a
treatment plan and all supporting documentation must be available for review in
the eligible recipient’s file;
(c) regularly
scheduled structured behavioral health therapy sessions for the eligible
recipient, group, family, or a multifamily group based on individualized needs,
as specified in the eligible recipient’s treatment plan;
(d) facilitation
of age-appropriate skills development in the areas of household management,
nutrition, personal care, physical and emotional health, basic life skills,
time management, school, attendance and money management;
(e) assistance
to an eligible recipient in his or her self administration of medication in compliance with state
regulations, policies and procedures;
(f) appropriate
staff available on a 24-hour basis to respond to crisis situations; determine
the severity of the situation; stabilize the eligible recipient by providing
support; make referrals, as necessary; and provide follow-up;
(g) a
consultation with other professionals or allied caregivers regarding a specific
eligible recipient;
(h) non-medical
transportation services needed to accomplish treatment objectives; (i) therapeutic
services to meet the physical, social, cultural, recreational, health
maintenance, and rehabilitation needs of the eligible recipient; and
(j) plans
for discharge must begin upon admittance to the facility and be included in the
eligible recipient’s treatment plan. If
the eligible recipient will receive services in the community or in the custody
of CYFD, the discharge must be coordinated with those individuals or agencies
responsible for post-hospital placement and services. The discharge plan must consider related
community services to ensure continuity of care with the eligible recipient,
his or her family, and school and community.
(6) MAD
covers “awaiting placement days” when the MAD UR contractor determines that an
eligible recipient under 21 years of age no longer meets this acute care
criteria and determines that the eligible recipient requires a residential
placement which cannot be immediately located.
Those days during which the eligible recipient is awaiting placement to
the step-down placement are termed awaiting placement days. Payment to the hospital for awaiting
placement days is made at the average payment for accredited residential
treatment centers plus five percent. A
separate claim form must be submitted for awaiting placement days.
(7) A
treatment plan must be developed by a team of professionals in consultation
with an eligible recipient, his or her parent, legal guardian or others in
whose care the eligible recipient will be released after discharge. The plan must be developed within 72 hours of
admission of the eligible recipient’s admission to freestanding psychiatric
hospitals. The interdisciplinary team
must review the treatment plan at least every five calendar days. See the BH policy and billing manual for a
description of the treatment team and plan.
C. Non-covered services: Services furnished in
a freestanding psychiatric hospital are subject to the limitations and coverage
restrictions which exist for other MAD services; see Subsection G of 8.321.2.9
NMAC for MAD general non-covered services.
MAD does not cover the following specific services for an eligible
recipient in a freestanding psychiatric hospital in the following situations:
(1) conditions
defined only by Z codes in the current version of the international
classification of diseases (ICD) or the current version of DSM;
(2) services
in freestanding psychiatric hospital for an eligible recipient 22 years of age
through 64, except as allowed in 8.321.2 NMAC;
(3) services
furnished after the determination by MAD or its
designee has been made that the eligible recipient no longer needs hospital
care;
(4) formal
educational or vocational services, other than those covered in Subsection B of
8.321.2.9 NMAC, related to traditional academic subjects or vocational
training; MAD only covers non-formal education services if they are part of an
active treatment plan for an eligible recipient under the age of 21 receiving
inpatient psychiatric services; see 42 CFR Section 441.13(b); or
(5) drugs
classified as "ineffective" by the food and drug administration (FDA)
drug evaluation.
D. Prior authorization and utilization
review: All MAD services are subject to utilization
review for medical necessity, inspection of care, and program compliance. Reviews can be performed before services are
furnished, after services are furnished and before payment is made, or after payment
is made; see 8.310.2 and 8.310.3 NMAC.
(1) All
inpatient services for an eligible recipient under 21 years of age in a
freestanding psychiatric hospital require prior authorization from MAD or its
designee. Services for which prior authorization was obtained remain subject to
utilization review at any point in the payment process.
(2) Prior
authorization of services does not guarantee that individuals are eligible for
MAD services. Providers must verify that
an individual is eligible for MAD services at the time services are furnished
and through his or her inpatient stay and determine if the eligible recipient
has other health insurance.
(3) A
provider who disagrees with prior authorization request denials or other review
decisions can request a re-review and a reconsideration; see 8.350.2 NMAC.
E. Reimbursement: A freestanding
psychiatric hospital service provider must submit claims for reimbursement on
the UB-04 claim form or its successor; see 8.302.2 NMAC. Once enrolled, providers receive instructions
on how to access documentation, billing, and claims processing information.
(1) Reimbursement
rates for New Mexico freestanding psychiatric hospital are based on the Tax
Equity and Fiscal Responsibility Act (TEFRA) provisions and principles of
reimbursement; see 8.311.3 NMAC. Covered
inpatient services provided in a freestanding psychiatric hospital will be
reimbursed at an interim rate established by HSD to equal or closely
approximate the final payment rates that apply under the cost settlement TEFRA
principles.
(2) If
a provider is not cost settled, the reimbursement rate will be at the
provider’s cost-to-charge ratio reported in the provider’s most recently filed
cost report prior to February 1, 2012.
Otherwise, rates are established after considering available cost-to-charge
ratios, payment levels made by other payers, and MAD payment levels for
services of similar cost, complexity and duration.
(3) Reimbursement
rates for services furnished by a psychiatrist and licensed Ph.D. psychologist
in a freestanding psychiatric hospital are contained in 8.311.3 NMAC. Services furnished by a psychiatrist and
psychologist in a freestanding psychiatric hospital cannot be included as
inpatient psychiatric hospital charges.
(4) When
services are billed to and paid by a MAD coordinated services contractor, the
provider must also enroll as a provider with the MAD coordinated services
contractor and follow that contractor’s instructions for billing and for
authorization of services.
(5) The
provider agrees to be paid by a MCO at any amount mutually-agreed upon between the provider and MCO when the
provider enters into contracts with MCO contracting with HSD for the provision
of managed care services to an eligible recipient.
(a) If
the provider and the HSD contracted MCO are unable to agree to terms or fail to
execute an agreement for any reason, the MCO shall be obligated to pay, and the
provider shall accept, one hundred percent of the “applicable reimbursement
rate” based on the provider type for services rendered under both emergency and
non-emergency situations.
(b) The
“applicable reimbursement rate” is defined as the rate paid by HSD to the
provider participating in the medical assistance programs administered by MAD
and excludes disproportionate share hospital and medical education payments.
[8.321.2.23 NMAC - Rp, 8.321.2.23
NMAC, 8/10/2021]
8.321.2.24 INSTITUTION FOR MENTAL DISEASES (IMD) FOR SUBSTANCE ABUSE: IMD
is defined as any facility with more than 16 beds that is primarily engaged in
the delivery of psychiatric care or treating substance use disorders (SUD) that
is not part of a certified general acute care hospital. The federal medicaid
IMD exclusion generally prohibits payment to these providers for recipients
aged 22 through 64. Based upon a New
Mexico state plan amendment and 1115 waiver MAD covers inpatient
hospitalization in an IMD for SUD diagnoses only with criteria for medical
necessity and based on ASAM admission criteria.
The coverage may also include co-occurring behavioral health disorders
with the primary SUD. For other approved
IMD stays for eligible recipients under age 21 or over age 64, the number of
days is determined by medical necessity as the age restriction for IMDs does
not apply to ages under 21 or over 65.
Also refer to 8.321.2.23 NMAC, Inpatient Psychiatric Care in
Freestanding Psychiatric Hospitals and Psychiatric Units of Acute Care
Hospitals.
A. Eligible
recipients: Adolescents and adults
with a mental health or substance use disorder or co-occurring mental health
and SUD.
B. Covered services: Withdrawal management (detoxification) and
rehabilitation.
C. Prior authorization is
required. Utilize the substance abuse
and mental health services administration (SAMHSA) admission criteria for
medical necessity.
D. Reimbursement: An
IMD is reimbursed according to the provisions in Subsection E of 8.321.2.23
NMAC.
[8.321.2.24
NMAC - Rp, 8.321.2.24 NMAC, 8/10/2021]
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.
[8.321.2.25
NMAC - Rp, 8.321.2.25 NMAC, 8/10/2021]
8.321.2.26 INTENSIVE OUTPATIENT PROGRAM FOR MENTAL HEALTH
CONDITIONS (IOP):
MAD
pays for IOP services which provide a time-limited, multi-faceted approach to
treatment for an eligible recipient with a SMI or SED including an eating
disorder or borderline personality disorder 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. The effective
date will be January 1, 2019, or as otherwise approved by the centers for medicare and medicaid services
(CMS).
A. Eligible providers: Services
may only be delivered through an agency approved by HSD and CYFD 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 by staff
with expertise in the mental health condition being addressed. This team may have services rendered by
non-independent practitioners under the direction of the IOP supervisor
including LMSW, LMHC, a master’s level psych associates, RNs or registered
dieticians.
(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 of 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 in providing the evidence-based model to be
delivered; and
(c) have
one year demonstrated supervisory experience.
(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.
(5) The agency must hold an IOP 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 (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 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 disorders when indicated.
C. Covered services:
(1) IOP
core services include:
(a) individual
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) 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.
(3) 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.
(4) Treatment
services must address co-occurring disorders when indicated.
D. Identified population:
(1) IOP
services are provided to an eligible recipient, 11 through 17 years of age
diagnosed with a SED.
(2) IOP
services are provided to an eligible adult recipient 18 years of age and older
diagnosed with a SMI.
(3) 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 serious mental illness or severe
emotional disturbance; or diagnosis for which the IOP is approved; and
(b) one
individualized 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.
(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. Medications 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 the rule are not a MAD covered service and are subject to
recoupment.
[8.321.2.26
NMAC - Rp, 8.321.2.26 NMAC, 8/10/2021]
8.321.2.27 MEDICATION ASSISTED TREATMENT (MAT): BUPRENORPHINE TREATMENT FOR OPIOID
USE DISORDER: MAD pays for coverage for medication assisted treatment
(MAT) for opioid use disorder to an eligible recipient as defined in the Drug
Addiction Treatment Act of 2000 (DATA 2000), the Comprehensive Addiction and
Recovery Act of 2016 (CARA), and the Substance Use Disorder Prevention that
Promotes Opioid Recovery and Treatment for Patients and Communities Act of 2018
(SUPPORT Act). Services include, but are
not limited to, the administration of opioid replacement medication (excluding
methadone) to an eligible recipient for detoxification from opioids or
maintenance treatment. See Subsections A
and B of 8.321.2.9 NMAC for MAD general provider requirements.
A. Eligible providers
and practitioners:
(1) Any
clinic, office, or hospital staffed by required practitioners.
(2) Practitioners
for diagnosing, assessment, and prescribing include:
(a) a
physician or DO licensed in the state of New Mexico
that has board certification in addiction medicine or addiction psychiatry or
has completed special training and has the federal waiver to prescribe
buprenorphine;
(b) a
certified nurse practitioner that has completed 24 hours of required training
and has a DATA 2000 waiver; or
(c) a
physician assistant licensed in the state of New Mexico and has the federal
DATA 2000 waiver to prescribe buprenorphine.
(3) Practitioners
for administration and education:
(a) a
registered nurse licensed in the state of New Mexico; or
(b) a
physician assistant licensed in the state of New Mexico.
(4) Practitioners
for counseling and education may include behavioral health practitioners
licensed for counseling or therapy.
(5) Practitioners
for skills and education include certified peer support workers or certified
family peer support workers to provide skill-building, recovery and resiliency
support.
B. Coverage criteria:
(1) an
assessment and diagnosis by the prescribing practitioner as to whether the
recipient has an opioid abuse diagnosis and their readiness for change must be
conducted prior to starting treatment;
(2) an
assessment for concurrent medical or behavioral health illnesses;
(3) an
assessment for co-occurring substance abuse disorders;
(4) educating
the recipient as to differing treatment options prior to starting treatment;
and
(5) a
service plan that prescribes either in house counseling or therapy, or referral
to outside services, as indicated.
C. Eligible recipients: Individuals with an opioid use disorder
diagnosis defined by DSM 5 or ICD 10.
D. Covered services:
(1) history
and physical;
(2) comprehensive
assessment and treatment plan;
(3) induction
phase of opioid treatment;
(4) administration
of medication and concurrent education;
(5) subsequent
evaluation and management visits;
(6) development
and maintenance of medical record log of opioid replacement medication
prescriptions;
(7) development
and maintenance of required records regarding inventory, storage and
destruction of controlled medications if dispensing from office;
(8) initiation
and tracking of controlled substance agreements with eligible recipients;
(9) regular
monitoring and documentation of NM prescription monitoring program results;
(10) urine
drug screens;
(11) recovery
services (MCO members only);
(12) family
support services (MCO members only).
E. Reimbursement: See Subsection H of 8.321.9 NMAC for MAD
behavioral health general reimbursement requirements. See the BH policy and billing manual for
reimbursement specific to MAT.
[8.321.2.27
NMAC - Rp, 8.321.2.27 NMAC, 8/10/2021]
8.321.2.28 MULTI-SYSTEMIC THERAPY (MST): To help an eligible
recipient 10 up to 18 years of age receive behavioral health services to either
remain in or re-enter his or her home and community, MAD pays for MST services
as part of EPSDT program (42 CFR 441.57).
MAD covers medically necessary MST services required by the condition of
the eligible recipient. MST provides
intensive home, family and community-based treatment for an eligible recipient
10 to 18 years of age who is at risk of out-of-home placement or is returning
home from an out-of-home placement. The
need for MST services must be identified in the eligible recipient’s tot to
teen health check screen or another diagnostic evaluation.
A. Eligible providers: In addition to the requirements of
Subsections A and B of 8.321.2.9 NMAC, in order to be
eligible to be reimbursed for providing MST services, an agency must hold a
copy of MST Inc licensure, or any of its approved subsidiaries. MST Inc is a national organization located in
Mt. Pleasant, South Carolina, and is deemed by MAD to be the primary authority
on licensure of New Mexico MST programs.
(1) The
MST program includes an assigned MST team for each eligible recipient. The MST team must include at minimum:
(a) master’s
level independently licensed behavioral health professional clinical
supervision; see Subsection H of 8.321.2.9 NMAC;
(b) licensed
master’s and bachelor’s level behavioral health staff able to provide 24-hour
coverage, seven days a week; see Subsection E of 8.321.2.9 NMAC;
(c) a
licensed master’s level behavioral health practitioner that is required to
perform all MST interventions; a bachelor’s level behavioral health
practitioner is limited to performing functions defined within the scope of his
or her RLD practice board licensure or practice (see Subsection E of 8.321.2.9
NMAC;
(d) bachelor’s
level staff that has a degree in social work, counseling, psychology or a
related human services field and must have at least three years’ experience
working with the identified population of children, adolescents and their
families; and
(e) staffing
for MST services is comprised of no more than one-third bachelor’s level staff
and, at minimum, two-thirds licensed master’s level staff.
(2) Clinical
supervision must include at a minimum:
(a) weekly
supervision provided by an independently licensed master’s level behavioral
health practitioner (see Subsection C of 8.321.2.9 NMAC) who is MST trained;
this supervision, following the MST supervisory protocol, is provided to team
members on topics directly related to the needs of the eligible recipient and
his or her family on an ongoing basis; and
(b) one
hour of local group supervision per week and one hour of telephone consultation
per week with the MST systems supervisor, provided to team members on topics
directly related to the needs of the eligible recipient and his or her family
on an ongoing basis.
(3) All
clinical staff is required to participate in and complete a prescribed five-day
MST introductory training and subsequent quarterly trainings.
B. Identified population:
(1) MST
is provided to an eligible recipient 10 to 18 years of age who meets the
criteria of SED, involved in or at serious risk of involvement with the
juvenile justice system; has antisocial, aggressive, violent, and
substance-abusing behaviors; is at risk for an out-of-home placement; or is
returning from an out-of-home placement where the above behaviors were the
focus of his or her treatment and his or her family’s involvement.
(2) A
co-occurring diagnosis of substance abuse shall not exclude an eligible
recipient from the program.
C. Covered services and service limitations: MST is a culturally sensitive service,
rendered by a MST team, to provide intensive home, family and community-based
treatment for the family of an eligible recipient who is at risk of an
out-of-home placement or is returning home from an out-of-home placement. MST services are primarily provided in the
eligible recipient’s home, but a MST worker may also
intervene at the eligible recipient’s school and other community settings. Specialized therapeutic and rehabilitative
interventions are used to address specific areas of need, such as substance
abuse, delinquency and violent behavior.
(1) The
following services must be furnished as part of the MST service to be eligible
for reimbursement:
(a) an
initial assessment to identify the focus of the MST intervention;
(b) therapeutic
interventions with the eligible recipient and his or her family;
(c) case
management; and
(d) crisis
stabilization.
(2) MST
services are conducted by practitioners using the MST team approach. The MST team must have the ability to deliver
services in various environments, such as homes, schools, homeless shelters, or
street locations. MST services:
(a) promote
the recipient’s family’s capacity to monitor and manage his or her behavior;
(b) involve
the eligible recipient’s family and other systems, such as the school,
probation officers, extended families and community connections;
(c) provide
access to a variety of interventions 24-hours a day, seven days a week, by
staff that maintain contact and intervene as one organizational unit; and
(d) include
structured face-to-face therapeutic interventions to provide support and
guidance in all areas of the recipient’s functional domains, such as adaptive,
communication, psychosocial, problem solving, and behavior management.
(3) The
duration of MST intervention is typically three to six months. Weekly interventions may range from three to
20 hours a week; less as an eligible recipient nears discharge.
D. Non-covered services: MST services are subject to the limitations
and coverage restrictions that exist for other MAD services. See Subsection G of 8.321.2.9 NMAC for
general non-covered specialized behavioral health services.
E. Reimbursement: MST agencies must submit claims for
reimbursement on the CMS-1500 claim form or its successor. See Subsection E of 8.321.2.9 NMAC for MAD
general reimbursement requirements and 8.302.2 NMAC. Once enrolled, the MST agency receives
instructions on how to access documentation, billing, and claims processing
information.
[8.321.2.28 NMAC - Rp, 8.321.2.28
NMAC, 8/10/2021]
8.321.2.29 NON-ACCREDITED RESIDENTIAL TREATMENT CENTERS (RTC) AND GROUP HOMES: MAD pays for
medically necessary services for an eligible recipient under 21 years of age
which are designed to develop skills necessary for successful reintegration
into his or her family or transition into his or her community. A determination must be made that the
eligible recipient needs the level of care (LOC) for services furnished in a
RTC or group home. This determination
must have considered all environments which are least restrictive, meaning a
supervised community placement, preferably a placement with the juvenile’s
parent, guardian or relative. A facility
or conditions of treatment that is a residential or institutional placement
should only be utilized as a last resort based on the best interest of the juvenile
or for reasons of public safety.
Residential services must be rehabilitative and provide access to
necessary treatment services in a therapeutic environment. MAD pays for services furnished in a RTC or
group home as part of EPSDT program (42 CFR 441.57). The need for RTC and group home services must
be identified in the eligible recipient’s tot to teen health check screen or
other diagnostic evaluation furnished through a health check referral.
A. Eligible providers: In addition to the requirements of
Subsections A and B of 8.321.2.9 NMAC, in order to be
eligible to be reimbursed for providing RTC or group home services to an
eligible recipient, an agency must meet the following requirements:
(1) a
RTC must be certified by the children, youth and families
department (CYFD) see 7.20.12 NMAC;
(2) a
group home must be certified and licensed by CYFD;
(3) if
the RTC is operated by IHS or by a federally recognized tribal government, the
facility must meet CYFD RTC licensing and certification requirements but is not
required to be licensed or certified by CYFD.
In lieu of receiving a license and certification, CYFD provides MAD
copies of its facility findings and recommendations. MAD will work with the facility to address
recommendations. The BH policy and
billing manual provides guidance for addressing the facility findings and
recommendations.
B. Covered services: Residential treatment services are provided
through a treatment team approach and the roles, responsibilities and
leadership of the team are clearly defined.
MAD covers accommodation and residential treatment services which are
medically necessary for the diagnosis and treatment of an eligible recipient’s
condition. A RTC or group home must
provide an interdisciplinary psychotherapeutic treatment program on a 24-hour
basis to the eligible recipient through the provision of a 24-hour therapeutic
group living environment to meet their developmental, psychological, social,
and emotional needs. The following are
covered services:
(1) performance
of necessary evaluations, assessments and psychological testing of the eligible
recipient for the development of his or her treatment plan for each service,
while ensuring that assessments already performed are not repeated;
(2) provide
regularly scheduled counseling and therapy sessions in an individual, family or
group setting following the eligible recipient’s individualized treatment plan;
(3) facilitation
of age-appropriate skills development in the areas of household management,
nutrition, personal care, physical and emotional health, basic life skills,
time management, school attendance and money management to the eligible
recipient;
(4) assistance
to the eligible recipient in his or her self-administration of medication in
compliance with state statute, regulation and rules;
(5) provision
of appropriate on-site staff based upon the acuity of recipient needs on a
24-hour basis to ensure adequate supervision of the recipients, and response in
a proactive and timely manner. Response
to crisis situations, determining the severity of the situation, stabilizing
the eligible recipient by providing individualized treatment plan/safety plan
interventions and support, and making referrals for emergency services or to
other non-agency services, as necessary, and providing follow-up;
(6) development
of an interdisciplinary service plan; see the BH policy and billing manual;
(7) non-medical
transportation services needed to accomplish the treatment objective;
(8) therapeutic
services to meet the physical, social, cultural, recreational, health
maintenance and rehabilitation needs of the eligible recipient;
(9) for
planning of discharge and aftercare services to facilitate timely and
appropriate post discharge care regular assessments are conducted. These assessments support discharge planning
and effect successful discharge with clinically appropriate after care
services. This discharge planning begins
when the recipient is admitted to residential treatment services and is updated
and documented in the recipient record at every treatment plan review, or more
frequently as needed; and
(10) the
RTC and group homes provide services, care and supervision at
all times, including:
(a) the
provision of, or access to, medical services on a 24-hour basis; and
(b) maintenance
of a staff-to-recipient ratio appropriate to the level of care and needs of the
recipients.
C. Non-covered services: RTC and group home services are subject to
the limitations and coverage restrictions that exist for other MAD
services. See Subsection G of 8.321.2.9
NMAC for general MAD behavioral health non-covered services or activities. MAD does not cover the following specific
services billed in conjunction with RTC and group home services to an eligible
recipient:
(1) Comprehensive
community support services (CCSS) except by a CCSS agency when discharge
planning with the eligible recipient from the RTC or group home facility;
(2) services
not considered medically necessary for the condition of the eligible recipient,
as determined by MAD or its UR contractor;
(3) room
and board;
(4) services
for which prior approval was not obtained; or
(5) services
furnished after a MAD or UR contractor determination that the recipient no
longer meets the LOC for RTC or group home care.
D. Treatment plan: If the eligible recipient is solely receiving
RTC or group home services, a service plan is not required. If the eligible recipient is receiving other
behavioral health services, then a service plan is required, see Subsection K
of 8.321.2.9 NMAC and the BH policy and billing manual.
E. Prior authorization: Before a RTC or group home service is
furnished to an eligible recipient, prior authorization is required from MAD or
its UR contractor or the respective centennial care MCO. Services for which prior authorization was
obtained remain subject to utilization review at any point in the payment
process.
F. Reimbursement:
A RTC or group home agency must submit claims for reimbursement on the
UB-04 form or its successor. See
Subsection H of 8.321.2.9 NMAC for MAD general reimbursement requirements and
see 8.302.2 NMAC. Once enrolled, the
agency receives instructions on how to access documentation, billing, and
claims processing information. For IHS
and a tribal 638 facility and any other “Indian Health Care Provider (IHCP)”
defined in 42 Code of Federal Regulations §438.14(a),
MAD considers RTC services to be outside the IHS all
inclusive rate and RTC is therefore reimbursed at the MAD fee schedule
utilizing the appropriate claim form designated by MAD.
(1) The
fee schedule is established after considering cost data submitted by the RTC or
group home agency. Cost data is grouped
into various cost categories for purposes of analysis and rate setting. These include direct service, direct service
supervision, therapy, admission and discharge planning, clinical support,
non-personnel operating, administration and consultation.
(a) The
MAD fee schedule reimbursement covers those services considered routine in the
residential setting. Routine services
include, but are not limited to: counseling, therapy, activities of daily
living, medical management, crisis intervention, professional consultation,
transportation, rehabilitative services and administration.
(b) Services
which are not included in the RTC or group home rate include:
(i) direct services furnished by a
psychiatrist or licensed Ph.D. psychologist; these services can be billed
directly by the provider; see 8.310.3 NMAC; and
(ii) other
MAD services that an eligible recipient might require that are not furnished by
the facility, such as pharmacy services, primary care visits, laboratory or
radiology services, are billed directly by the applicable providers and are
governed by the applicable sections of NMAC rules.
(c) Services
which are not covered in the routine rate and are not a MAD covered service
include:
(i) room and board; and
(ii) services
not related to medical necessity, clinical treatment, and patient care.
(2) A
vacancy factor of 24 days annually for each eligible recipient is built into
the rate to allow for therapeutic leave and trial community placement. Since the vacancy factor is built into the
rate, a RTC and group home agency cannot bill or be reimbursed for days when
the eligible recipient is absent from the facility.
[8.321.2.29 NMAC - Rp, 8.321.2.29
NMAC, 8/10/2021]
8.321.2.30 OPIOID TREATMENT PROGRAM (OTP): MAD pays for coverage for medication assisted treatment for
opioid addiction to an eligible recipient through an opioid treatment center as
defined in (42 CFR Part 8), certification of opioid treatment programs
(OTP). Services include, but are not
limited to, the administration of methadone (opioid replacement medication) to
an individual for detoxification from opioids and maintenance treatment. The administration/supervision must be
delivered in conjunction with the overall treatment based upon a treatment
plan, which must include counseling/therapy, case review, drug testing, and medication
monitoring. See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
A. Eligible providers and
practitioners:
(1) Provider
requirements:
(a) Accreditation
with a substance abuse and mental health services administration (SAMHSA)/CSAT
approved nationally recognized accreditation body, (e.g., commission on
accreditation of rehabilitation facilities (CARF), joint commission (JC) or
council on accreditation of services for families and children (COA).
(b) Behavioral
health services division (BHSD) approval.
As a condition of approval to operate an OTP, the OTP must maintain
above accreditation. In
the event that such accreditation lapses, or approval of an application
for accreditation becomes doubtful, or continued accreditation is subject to
any formal or alleged finding of need for improvement, the OTP program will
notify the BHSD within two business days of such event. The OTP program will furnish the BHSD with
all information related to its accreditation status, or the status of its
application for accreditation, upon request.
(c) The
BHSD shall grant approval or provisional approval to operate pending
accreditation, provided that all other requirements of these regulations are
met.
(2) Staffing
requirements:
(a) Both
clinical services and supervision by licensed practitioners must be in accord
with their respective licensing board regulations. Provider staff members must be culturally
competent;
(b) Programs
must be staffed by:
(i) medical director (MD licensed to
practice in the state of New Mexico or a DO licensed to practice in the State
of New Mexico);
(ii) clinical
supervisor (must be one of the following:
licensed psychologist, or licensed independent social worker; or
certified nurse practitioner in psychiatric nursing; or licensed professional
clinical mental health counselor; or licensed marriage and family therapist;
(iii) licensed
behavioral health practitioner; registered nurse; or licensed practical nurse;
and
(iv) full
time or part time pharmacist.
(c) Programs may also be staffed by:
(i) licensed
substance abuse associate (LSAA);
(ii) certified peer support worker (CPSW);
and
(iii) emergency medical technicians (EMT)
with documentation of three hours of annual training in substance use disorder.
B. Coverage criteria:
(1) A
physician licensed to practice in New Mexico is designated to serve as medical
director and to have authority over all medical aspects of opioid treatment.
(2) The
OTP shall formally designate a program sponsor who shall agree on behalf of the
OTP to adhere to all federal and state requirements and regulations regarding
the use of opioid agonist treatment medications in the treatment of opioid
addiction which may be promulgated in the future.
(3) The
OTP shall be open for patients every day of the week with an option for closure
for federal and state holidays, and Sundays, and be closed only as allowed in
advance in writing by CSAT and the state opioid treatment authority. Clinic hours should be conducive to the
number of patients served and the comprehensive range of services needed.
(4) Written
policies and procedures outlined in the BH policy and billing manual are
developed, implemented, compiled, and maintained at the OTP.
(5) OTP
programs will not deny a reasonable request for transfer.
(6) The
OTP will maintain criteria for determining the amount and frequency of
counseling that is provided to a patient.
(7) Referral
or transfer of recipients to a suitable alternative treatment program. Because of the risks of relapse following
detoxification, patients must be offered a relapse prevention program that
includes counseling, naloxone and opioid replacement therapy.
(8) Provision
of unscheduled treatment or counseling to patients.
(9) Established
substance abuse counselor caseloads based on the intensity and duration of
counseling required by each patient.
Counseling can be provided in person or via telehealth. Counselor to patient ratios should be
sufficient to ensure that patients have reasonable and prompt access to
counselors and receive counseling services at the required levels of frequency
and intensity.
(10) Preparedness
planning: the program has a list of all
patients and the patients’ dosage requirements available and accessible to
program on call staff members.
(11) Patient
records: The OTP program shall establish
and maintain a recordkeeping system that is adequate to document and monitor
patient care. The system shall comply
with all federal and state requirements relevant to OTPs and to confidentiality
of patient records.
(12) Diversion
control: a written plan is developed,
implemented, and complied with to prevent diversion of opioid treatment
medication from its intended purpose to illicit purposes. This plan shall assign specific
responsibility to licensed and administrative staff for carrying out the
diversion control measures and functions described in the plan. The program shall develop and implement a
policy and procedure providing for the reporting of theft or division of
medication to the relevant regulatory agencies, and law enforcement
authorities.
(13) Prescription [drug] monitoring
program (PMP): a written plan is
developed, implemented, and complied with to ensure that all OTP physicians and
other health care providers, as permitted, are registered to use the New Mexico
(PMP). The (PMP) should be checked
quarterly through the course of each patient’s treatment.
(14) HIV/AIDS
and hepatitis testing and education are available to patients either at the
provider or through referral, including treatment, peer group or support group
and to social services either at the provider or through referral to a
community group.
(15) Requirements
for health care providers who prescribe, distribute or dispense opioid
analgesics:
(a) A health
care provider who prescribes, distributes or dispenses an opioid analgesic for
the first time to a patient shall advise the patient on the risks of overdose
and inform the patient of the availability of an opioid antagonist.
(b) For a
patient to whom an opioid analgesic has previously been prescribed, distributed
or dispensed by the health care provider, the health care provider shall advise
the patient on the risks of overdose and inform the patient of the availability
of an opioid antagonist on the first occasion that the health care provider
prescribes, distributes or dispenses an opioid analgesic each calendar year.
(c) A health
care provider who prescribes an opioid analgesic for a patient shall
co-prescribe an opioid antagonist if the amount of opioid analgesic being
prescribed is at least a five-day supply.
The prescription for the opioid antagonist shall be accompanied by
written information regarding the temporary effects of the opioid antagonist
and techniques for administering the opioid antagonist. That written information shall contain a
warning that a person administering the opioid antagonist should call 911
immediately after administering the opioid antagonist.
C. Identified population:
(1) An
eligible recipient is treated for opioid dependency only after the agency’s
physician determines and documents that:
(a) the
recipient meets the definition of opioid use disorder using generally accepted
medical criteria, such as those contained in the current version of the DSM;
(b) the
recipient has received an initial medical examination as required by 7.32.8.19
NMAC, Opioid Treatment Program Admissions;
(c) if
the recipient is requesting maintenance treatment, he or she must have been
addicted for at least 12 months prior to starting OTP services unless the
recipient receives a waiver of this requirement from the agency’s physician
because the recipient:
(i) was released from a penal
institution within the last six months;
(ii) is
pregnant, as confirmed by the agency’s physician;
(iii) was
treated for opioid use disorder within the last 24 months;
(iv) is
under the age of 18; has had two documented unsuccessful attempts at short-term
opioid treatment withdrawal procedures of drug-free treatment within a 12 month
period, and has informed consent for treatment provided by a parent, guardian,
custodian or responsible adult designated by the relevant state authority; or
(v) meets
any other requirements specified in 7.32.8 NMAC, Opioid Treatment Program regarding waivers, consent, and waiting
periods.
D. Covered services:
(1) Withdrawal
treatment and medically supervised dose reduction.
(2) A
biopsychosocial assessment will be conducted by a licensed behavioral health
professional or a LADAC under the supervision of an independently licensed
clinician, as defined by the NM RLD within 14 days of admission.
(3) A
comprehensive, patient centered, individualized treatment plan shall be
conducted within 30 days of admission and be documented in the patient record.
(4) Each
OTP will ensure that adequate medical, psychosocial counseling, mental health,
vocational, educational and other services identified in the initial and
ongoing treatment plans are fully and reasonably available to patients, either
by the program directly, or through formal, documented referral agreements with
other providers.
(5) Drug
screening: A recipient in comprehensive
maintenance treatment receives one random urine drug detection test per month;
short-term opioid treatment withdrawal procedure patients receive at least one
initial drug abuse test; long-term opioid treatment withdrawal procedure
patients receive an initial and monthly random tests;
and other toxicological tests are performed according to written orders from
the program medical director or medical practitioner designee. Samples that are sent out for confirmatory
testing (by internal or external laboratories) are billed separately by the
laboratory.
E. Non-covered services: Blood
samples collected and sent to an outside laboratory.
F. Reimbursement:
(1) The
bundled reimbursement rate for administration and dispensing includes the cost
of methadone, administering and dispensing methadone, and urine dipstick testing conducted within the agency.
(2) Other
services performed by the agency as listed below are reimbursed separately and
are required by (42 CFR Part 8.12 (f)), or its successor.
(a) A
narcotic replacement or agonist drug item other than methadone that is
administered or dispensed;
(b) Behavioral health prevention and
education services to affect knowledge, attitude, or behavior can be rendered
by a licensed substance abuse associate or certified peer support worker in
addition to independently licensed practitioners;
(c) Outpatient therapy other than the
substance abuse and HIV counseling required by (42 CFR Part 8.12 (f)) is
reimbursable when rendered by a MAD approved independently licensed provider
that meets Subsection H of 8.321.2.9 NMAC;
(d) An eligible recipient’s initial
medical examination when rendered by a MAD approved medical provider who meets
8.310.2 and 8.310.3 NMAC requirements;
(e) Full medical examination, prenatal
care and gender specific services for a pregnant recipient; if she is referred
to a provider outside the agency, payment is made to the provider of the
service;
(f) Medically necessary services
provided beyond those required by (42 CFR Part 8.12 (f)), to address the
medical issues of the eligible recipient; see 8.310.2 and 8.310.3 NMAC;
(g) The quantity of service billed in a
single day can include, in addition to the drug items administered that day,
the number of take-home medications dispensed that day; and
(h) Guest dosing can be reimbursed at medicaid-enrolled agencies per 7.32.8 NMAC. Arrangements must be confirmed prior to
sending the patient to the receiving clinic.
(3) For an IHS, [or] tribal 638 facility or any other
“Indian Health Care Provider (IHCP)” defined in 42 Code of Federal Regulations
§438.14(a), MAD considers the bundled OTP services to be outside the IHS
all-inclusive rate and is therefore reimbursed at the MAD fee schedule
utilizing the appropriate claim form designated by MAD; see 8.310.12 NMAC. Non-bundled services may be billed at the
office of management and budget (OMB) rate.
(4) For
a FQHC, MAD considers the bundled OTP services to be outside the FQHC
all-inclusive rate and is therefore reimbursed at the MAD fee schedule
utilizing the appropriate claim form designated by MAD; see 8.310.12 NMAC. Non-bundled services may be billed at the
FQHC rate.
[8.321.2.30
NMAC - Rp, 8.321.2.30 NMAC, 8/10/2021]
8.321.2.31 PARTIAL HOSPITALIZATION SERVICES: To help an eligible
recipient receive the level of services needed, MAD pays for partial
hospitalization services furnished by an acute care or freestanding psychiatric
hospital. Partial Hospitalization
Programs (PHP) are structured to provide intensive psychiatric care through
active treatment that utilizes a combination of clinical services. They are designed to stabilize deteriorating
conditions or avert inpatient admissions, or can be a step-down strategy for individuals
with SMI, SUD or SED who have required inpatient admission. The environment is highly structured, is
time-limited and outcome oriented for recipients experiencing acute symptoms or
exacerbating clinical conditions that impede their ability to function on a
day-to-day basis. Program objectives
focus on ensuring important community tdies and
closely resemble the real-life experiences of the recipients served.
A. Eligible providers and practitioners: In addition to the requirements found in Subsections A and B of 8.321.2.9 NMAC,
an eligible provider includes a facility joint commission accredited, and
licensed and certified by DOH or the comparable agency in another state.
(1) The
program team must include:
(a) registered
nurse;
(b) a
clinical supervisor that is an independently licensed behavioral health
practitioner or psychiatric nurse practitioner or psychiatric nurse clinician;
and
(c) licensed
behavioral health practitioners.
(2) The
team may also include:
(a) physician
assistants;
(b) certified
peer support workers;
(c) certified
family peer support workers;
(d) licensed
practical nurses;
(e) mental
health technicians.
B. Coverage criteria: MAD covers only those services which meet the
following criteria:
(1) Services
that are ordered by a psychiatrist or licensed Ph.D.
(2) Partial
hospitalization is a voluntary, intensive, structured and medically staffed,
psychiatrically supervised treatment program with an interdisciplinary team
intended for stabilization of acute psychiatric or substance use symptoms and
adjustment to community settings. The
services are essentially of the same nature and intensity, including medical
and nursing services, as would be provided in an inpatient setting, except that
the recipient is in the program less than 24-hours a day, and it is a
time-limited program.
(3) A
history and physical (H&P) must be conducted within 24 hours of
admission. If the eligible recipient is
a direct admission from an acute or psychiatric hospital setting, the program
may elect to obtain the H&P in lieu of completing a new H&P. In this instance, the program physician’s
signature indicates the review and acceptance of the document. The H&P may be conducted by a clinical
nurse specialist, a clinical nurse practitioner, a physician assistant or a
physician.
(4) An
interdisciplinary biopsychosocial assessment within seven days of admission
including alcohol and drug screening. A
full substance abuse evaluation is required if alcohol and drug screening indicates the need.
If the individual is a direct admission from an acute psychiatric
hospital setting, the program may elect to obtain and review this assessment in
lieu of completing a new assessment.
(5) Services
are furnished under an individualized written treatment plan established within
seven days of initiation of service by the psychiatrist, together with the
program’s team of professionals, and in consultation with recipients, parents,
legal guardian(s) or others who participate in the recipient’s care. The plan must state the type, amount,
frequency and projected duration of the services to be furnished, and indicate
the diagnosis and anticipated goals. The
treatment plan must be reviewed and updated by the interdisciplinary team every
15 days.
(6) Documentation
must be sufficient to demonstrate that coverage criteria are met, including:
(a) Daily
documentation of treatment interventions which are outcome focused and based on
the comprehensive assessment, treatment goals, culture, expectations, and needs
as identified by the recipient, family or other caregivers.
(b) Supervision
and periodic evaluation of the recipient, either individually or in a group, by
the psychiatrist or psychologist to assess the course of treatment. At a minimum, this periodic evaluation of services
at intervals indicated by the condition of the recipient must be documented in
the recipient’s record.
(c) Medical
justification for any activity therapies, recipient education programs and
psychosocial programs.
(7) Treatment
must be reasonably expected to improve the eligible recipient’s condition or
designed to reduce or control the eligible recipient’s psychiatric symptoms to
prevent relapse or hospitalization and to improve or maintain the eligible
recipient’s level of functions. Control
of symptoms and maintenance of a functional level to avoid further
deterioration or hospitalization are acceptable expectations of improvement.
(8) For
recipients in elementary and secondary school, educational services must be
coordinated with the recipient’s school system.
C. Identified
population:
(1) Recipients
admitted to a PHP shall be under the care of a psychiatrist who certifies the
need for partial hospitalization. The
recipient requires comprehensive, structured, multimodal treatment requiring
medical supervision and coordination, provided under an individualized plan of
care, because of a SMI, SED or moderate to severe SUD which severely interferes
with multiple areas of daily life, including social, vocational or educational
functioning. Such dysfunction generally
is of an acute nature;
(2) Recipients
must have an adequate support system to sustain/maintain his or herself outside
the PHP;
(3) Recipients
19 and over with a serious mental illness including substance use who can be
safely managed in the community with high intensity therapeutic intervention
more intensive than outpatient services but are at risk of inpatient care
without this treatment; or
(4) Recipients
five to 18 with severe emotional disturbances including substance use disorders
who can be safely managed in the community with high intensity therapeutic
intervention more intensive than outpatient services but are at risk of
inpatient care without this treatment.
D. Covered services and service limitations: A program of services must be furnished by a
MAD enrolled provider delivering partial hospitalization to receive
reimbursement from MAD. Payment for
performance of these services is included in the facility’s reimbursement rate:
(1) regularly
scheduled structured counseling and therapy sessions for an eligible recipient,
his or her family, group or multifamily group based on individualized needs
furnished by licensed behavioral health professionals, and,
as specified in the treatment plan;
(2) educational
and skills building groups furnished by the program team to promote recovery;
(3) age-appropriate
skills development in the areas of household management, nutrition, personal
care, physical and emotional health, basic life skills, time management, school
attendance and money management;
(4) drugs
and biologicals that cannot be self-administered and are furnished for
therapeutic management;
(5) assistance
to the recipient in self-administration of medication in compliance with state
policies and procedures;
(6) appropriate
staff available on a 24-hour basis to respond to crisis situations, evaluate
the severity of the situation, stabilize the recipient make referrals as
necessary, and provide follow-up;
(7) consultation
with other professionals or allied caregivers regarding a specific recipient;
(8) coordination
of all non-medical services, including transportation needed to accomplish a
treatment objective;
(9) therapeutic
services to meet the physical, social, cultural, recreational, health
maintenance, and rehabilitation needs of recipients; and
(10) discharge
planning and referrals as necessary to community resources, supports, and
providers in order to promote a recipient’s return to
a higher level of functioning in the least restrictive environment.
E. Non-covered services: Partial hospitalization 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 all general non-covered MAD behavioral health services or
activities. MAD does not cover the
following specific services with partial hospitalization:
(1) meals;
(2) transportation
by the partial hospitalization provider;
(3) group
activities or other services which are primarily recreational or diversional in
nature;
(4) a
program that only monitors the management of medication for recipients whose
psychiatric condition is otherwise stable, is not the combination, structure,
and intensity of services which make up active treatment in a partial
hospitalization program;
(5) actively
homicidal or suicidal ideation that would not be safely managed in a PHP;
(7) services
to treat social maladjustments without manifest psychiatric disorders,
including occupational maladjustment, marital maladjustment, and sexual
dysfunction.
F. Prior authorization: Prior authorization is not required for this
service unless the length of stay exceeds 45 days, at which time continued stay
must be prior authorized (PA) from MAD or its UR contractor; or applicable
centennial care MCO. Request for
authorization for continued stay must state evidence of the need for the acute,
intense, structured combination of services provided by a PHP, and must address
the continuing serious nature of the recipient’s psychiatric condition
requiring active treatment in a PHP and include expectations for imminent
improvement. Control of symptoms and
maintenance of a functional level to avoid further deterioration or
hospitalization are acceptable expectations of improvement. The request for authorization must also
specify that a lower level of outpatient services would not be advised, and
why, and that the recipient may otherwise require inpatient psychiatric care in
the absence of continued stay in the PHP.
The request describes:
(1) the
recipient’s response to the therapeutic interventions provided by the PHP;
(2) the
recipient’s psychiatric symptoms that continue to place the recipient at risk
of hospitalization; and
(3) treatment
goals for coordination of services to facilitate discharge from the PHP. See Subsection F of 8.321.2.9 NMAC for MAD
general prior authorization requirements.
G. Reimbursement: A provider of partial hospitalization
services must submit claims for reimbursement on the UB claim form or its
successor. See 8.302.2 NMAC and
Subsection H of 8.321.2.9 NMAC for MAD general reimbursement requirements. Specific to partial hospitalization services:
(1) Freestanding
psychiatric hospitals are reimbursed at an interim percentage rate established
by HSD to equal or closely approximate the final payment rates that apply under
the cost settlement TEFRA principles using the Title XVIII (medicare)
principles cost methodology, MAD reduces the medicare
allowable costs by three percent. For
partial hospitalization services that are not cost settled, such as general
acute care hospitals, payments are made at the outpatient hospital prospective
levels, when applicable, on the procedure codes (see Subsection E of 8.311.2.15
NMAC).
(2) The
payment rate is at a per diem representing 8 hours, which is billed fractions
of .25, .5, or .75 units to represent 2, 4, or 6 hours when applicable.
(3) Any
professional services are billed and reimbursed to the provider under a
separate professional component number, all costs for these services must be
removed from the hospital cost report prior to cost settlement or rebasing.
(4) Services
performed by a physician or Ph.D. psychologist are billed separately as a
professional service. Other services
performed by employees or contractors to the facility are included in the per
diem rate which may be billed separately are:
(a) performance
of necessary evaluations and psychological testing for the development of the
treatment plan, while ensuring that evaluations already performed are not
repeated;
(b) physical
examination and any resultant medical treatments, while ensuring that a
physical examination already performed is not repeated;
(c) any
medically necessary occupational or physical therapy; and
(d) other
professional services not rendered as part of the program.
[8.321.2.31 NMAC - Rp & Rn,
8.321.2.31 NMAC, 8/10/2021]
8.321.2.32 PSYCHOSOCIAL REHABILITATION SERVICES: To help an adult
eligible recipient (18 years and older) who met the criteria of SMI, MAD pays
for psychosocial rehabilitation services (PSR).
PSR is an array of services offered in a group setting through a
clubhouse or a classroom and is designed to help an individual to capitalize on
personal strengths, to develop coping strategies and skills to deal with
deficits, and to develop a supportive environment in which to function as
independently as possible. Psychosocial
rehabilitation intervention is intended to be a transitional level of care
based on the individual’s recovery and resiliency goals. See Subsections A and B of 8.321.2.9 NMAC for
MAD general provider requirements.
A. Eligible providers and practitioners:
(1) Agency staff must possess the
education, skills, abilities, and experience to perform the activities that
comprise the full spectrum of PSR services.
See Subsection A of 8.321.2.9 NMAC for MAD general provider
requirements.
(2) Staffing requirements:
(a) Both
clinical services and supervision by licensed practitioners must be in accord
with their respective licensing board regulations.
(b) PSR
services must meet a staff ratio sufficient to ensure that patients have
reasonable and prompt access to services.
(c) In
both clubhouse and classroom settings, the entire staff works as a team.
(d) The
team must include a clinical supervisor/team lead and can include the
following:
(i) certified peer support workers;
(ii) certified
family support workers;
(iii) community
support workers; and
(iv) other
HIPAA trained individuals working under the direct supervision of the clinical
supervisor.
(e) Minimum
qualifications for the clinical supervisor/team lead:
(i) independently licensed behavioral health
professional (i.e. psychiatrist, psychologist, LISW, LPCC, LMFT,
psychiatrically certified (CNS) practicing under the scope of their NM license;
(ii) have
one year of demonstrated supervisory experience;
(iii) demonstrated
knowledge and competence in the field of psychosocial; rehabilitation; and
(iv) an
attestation of training related to providing clinical supervision of
non-clinical staff.
B. Coverage criteria:
(1) MAD
covers only those PSR services which comply with DOH licensing standards and
are medically necessary to meet the individual needs of the eligible recipient,
as delineated in his or her service plan and treatment plan. Medical necessity is based upon the eligible
recipient’s level of functioning as affected by his or her SMI. The PSR services are limited to goals which
are individually designed to accommodate the level of the eligible recipient’s functioning and which reduce the disability and restore the
recipient to his or her best possible level of functioning.
(2) These
services must be provided in a facility-based setting, either in a clubhouse
model or a structured classroom.
(3) PSR
services must be identified and justified in the individual’s treatment or
service plan. Recipients shall
participate in PSR services for those activities that are identified in the
treatment or service plan and are tied directly to the recipient’s recovery and
resiliency plan/goals.
(4) Specific
service needs (e.g., household management, nutrition, hygiene, money
management, parenting skills, etc.) must be identified in the individual’s
treatment or service plan.
C. Identified
population:
(1) An
eligible recipient 18 years or older meeting the criteria for SMI and for whom
the medical necessity for PSR services was determined.
(2) Adults
diagnosed with co-occurring SMI and substance use disorders and for whom the
medical necessity for PSR services was determined.
(3) A
resident in an institution for mental illness is not eligible for this service.
D. Covered services: The psychosocial intervention (PSI) program
must include the following major components:
basic living skills development; psychosocial skills training;
therapeutic socialization; and individual empowerment.
(1) Basic
living skills development activities address the following areas, including but
not limited to:
(a) basic
household management;
(b) basic
nutrition, health, and personal care including hygiene;
(c) personal
safety;
(d) time
management skills;
(e) money
management skills;
(f) how
to access and utilize transportation;
(g) awareness
of community resources and support in their use;
(h) child care/parenting skills;
(i) work or employment skill-building;
and
(j) how
to access housing resources.
(2) Psychosocial
skills training activities address the following areas:
(a) self-management;
(b) cognitive
functioning;
(c) social/communication;
and
(d) problem-solving
skills.
(3) Therapeutic
socialization activities address the following areas:
(a) understanding
the importance of healthy leisure time;
(b) accessing
community recreational facilities and resources;
(c) physical
health and fitness needs;
(d) social
and recreational skills and opportunities; and
(e) harm
reduction and relapse prevention strategies (for individuals with co-occurring
disorders).
(4) Individual
empowerment activities address the following areas:
(a) choice;
(b) self-advocacy;
(c) self-management;
and
(d) community
integration.
E. Non-covered services: PSR 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 all
general non-covered MAD behavioral health services or activities. Specifically, PSR cannot be billed
concurrently when the recipient is a resident of an institution for the
mentally ill.
F. Prior authorization: No prior authorization is required. To determine retrospectively if the medical
necessity for the service has been met, the following factors are considered:
(1) recipient
assessment;
(2) recipient
diagnostic formation;
(3) recipient
service and treatment plans; and
(4) compliance
with 8.321.2 NMAC.
G. Reimbursement: Claims for reimbursement are submitted on the
CMS-1500 claim form or its successor.
See Subsection H of 8.321.2.9 NMAC for MAD general reimbursement
requirements and see 8.302.2 NMAC.
[8.321.2.32 NMAC - Rp, 8.321.2.32
NMAC, 8/10/2021]
8.321.2.33 RECOVERY SERVICES (MCOs only): Recovery services are peer-to-peer support
for centennial care members to develop and enhance wellness and health care
practices. Recovery services promote
self-responsibility through recipients learning new health care practices from
a peer who has had similar life challenges and who has developed self-efficacy
in using needed skills. See Subsections
A and B of 8.321.2.9 NMAC for MAD general provider requirements.
A. Staffing requirements:
(1) all staff must possess a current and valid NM driver’s
license;
(2) clinical supervisor:
(a) licensed as an independent
practitioner (i.e., psychiatrist, psychologist, LISW, LPCC, LMFT, CNP, CNS);
and
(b) two years relevant experience with
the target population; and
(c) one year demonstrated supervisory
experience; and
(d) expertise in both mental health and
addiction treatment services; and
(e) supervision must be conducted in
accord with respective licensing board regulations.
(3) certified peer support workers; and
(4) certified family specialists.
(5) Group ratios should be sufficient to
ensure that patients have reasonable and prompt access to services at the
required levels of frequency and intensity within the practitioner’s scope of
practices.
B. Coverage criteria: Services
occur individually or with consumers who support each other to optimize
learning new skills. This skill
enhancement then augments the effectiveness of other treatment and recovery
support initiatives.
(1) Admissions
criteria: Consumer has been unable to
achieve functional use of natural and community support systems to effectively
self-manage recovery and wellness.
(2) Continuation
of services criteria: Consumer has made
progress in achieving use of natural and community support systems to
effectively self-manage recovery and wellness, but continues to need support in
developing those competencies.
(3) Discharge
criteria: Consumer has achieved maximum
use of natural and community support systems to effectively self-manage
recovery and wellness.
C. Identified population:
(1) Children
experiencing serious emotional/neurobiological/behavioral disorders;
(2) Adults
with serious mental illness (SMI); and
(3) Individuals
with chronic substance abuse; or individuals with a co-occurring disorder
(mental illness/substance abuse) or dually diagnosed with a primary diagnosis
of mental illness.
D. Covered services:
(1) This
service will particularly focus on the individual’s wellness, ongoing recovery
and resiliency, relapse prevention, and chronic disease management.
(2) Recovery
services support specific recovery goals through:
(a) use
of strategies for maintaining the eight dimensions of wellness;
(b) creation
of relapse prevention plans;
(c) learning
chronic disease management methods; and
(d) identification
of linkages to ongoing community supports.
(3) Activities
must support the individual’s recovery goals.
There must be documented evidence of the individual identifying desired
recovery goals and outcomes and incorporating them into a recovery services
treatment plan.
(4) Recovery
services activities include, but are not limited to:
(a) screening,
engaging, coaching, and educating.
(b) emotional
support that demonstrates empathy, caring, or concern to bolster the person’s
self-esteem and confidence.
(c) sharing
knowledge and information or providing life skills training.
(d) provision
of concrete assistance to help others accomplish tasks.
(e) facilitation
of contacts with other people to promote learning of social and recreational
skills, create community and acquire a sense of belonging.
(5) Recovery
services can be delivered in an individual or group setting.
E. Non-covered services: This
service may not be billed in conjunction with:
(1) multi-systemic
therapy (MST);
(2) assertive
community treatment (ACT);
(3) partial
hospitalization;
(4) transitional
living services (TLS); or
(5) treatment foster care (TFC).
[8.321.2.33
NMAC - Rp, 8.321.2.33 NMAC, 8/10/2021]
8.321.2.34 SCREENING, BRIEF INTERVENTION & REFERRAL TO
TREATMENT (SBIRT) TO BE EFFECTIVE FOLLOWING CMS WAIVER APPROVAL. SBIRT
is a community-based practice designed to identify, reduce and prevent
problematic substance use or misuse and co-occurring mental health disorders as
an early intervention. Through early
identification in a medical setting, SBIRT services expand and enhance the
continuum of care and reduce costly health care utilization. The primary objective is the integration of
behavioral health with medical care.
SBIRT is delivered through a process consisting of universal screening,
scoring the screening tool and a warm hand-off to a SBIRT trained professional
who conducts a face-to-face brief intervention for positive screening
results. If the need is identified for
additional treatment, the staff member will refer to behavioral health
services. See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
A. Eligible providers
and practitioners:
(1) Providers
may include:
(a) primary care offices including FQHCs,
IHS 638 tribal facilities and any other “Indian Health Care Provider (IHCP)” defined
in 42 Code of Federal Regulations §438.14(a);
(b) patient
centered medical homes;
(c) urgent
care centers;
(d) hospital
outpatient facilities;
(e) emergency
departments;
(f) rural
health clinics;
(g) specialty
physical health clinics; [and]
(h) school
based health centers; and
(i) nursing facilities.
(2) Practitioners
may include:
(a) licensed
nurse trained in SBIRT;
(b) licensed
nurse practitioner or licensed nurse clinician trained in SBIRT;
(c) behavioral
health practitioner trained in SBIRT;
(d) certified
peer support worker trained in SBIRT;
(e) certified
community health worker trained in SBIRT;
(f) licensed
physician assistant trained in SBIRT;
(g) physician
trained in SBIRT;
(h) home
health agency trained in SBIRT
(i) nurse home visit EPSDT;
(j) medical
assistant trained in SBIRT; and
(k) community
health representative in tribal clinics trained in SBIRT.
B. Coverage Criteria:
(1) screening
shall be universal for recipients being seen in a medical setting;
(2) referral
relationships with mental health agencies and practices are in place;
(3) utilization
of approved screening tool specific to age described in the BH policy and
billing manual;
(4) all
participating providers and practitioners are trained in SBIRT through state
approved SBIRT training entities. See
details in the BH policy and billing manual.
C. Identified population:
(1) MAD
recipient adolescents 11-13 years of age with parental consent;
(2) MAD
recipient adolescents 14-18 years of age;
(3) MAD
recipient adults 19 years and older.
D. Covered services:
(1) SBIRT
screening with negative results eligible for only screening component;
(2) SBIRT
screening with positive results for alcohol, or other drugs, and co-occurring
with depression, or anxiety, or trauma are eligible for:
(a) screening;
and
(b) brief
intervention and referral to behavioral health treatment, if needed.
E. Reimbursement:
(1) Screening
services do not require a diagnosis; brief interventions can be billed with a
provisional diagnosis.
(2) See
BH policy and billing manual for coding and billing instruction.
[8.321.2.34
NMAC - Rp, 8.321.2.34 NMAC, 8/10/2021]
8.321.2.35 SMOKING CESSATION COUNSELING: See 8.310.2 NMAC for
a detailed description of tobacco cessation services and approved behavioral
health providers.
[8.321.2.35 NMAC - Rp, 8.321.2.35
NMAC, 8/10/2021]
8.321.2.36 SUPPORTIVE HOUSING PRE-TENANCY AND TENANCY SERVICES
(PSH-TSS) (MCO only): MAD pays for coverage for permanent supportive housing
pre-tenancy and tenancy support services (PSH-TSS) to an eligible recipient
enrolled in a managed care organization to facilitate community integration and
contribute to a holistic focus on improved health outcomes, to reduce the
negative health impact of precarious housing and homelessness, and to reduce
costly inpatient health care utilization.
Services include, but are not limited to, pre-tenancy services including
individual housing support and crisis planning, tenancy orientation and
landlord relationship services as well as tenancy support services to identify
issues that undermine housing stability and coaching, education and assistance
in resolving tenancy issues for an eligible recipient who has a serious mental
illness and is enrolled in a medicaid managed care
organization on, or after, July 1, 2019.
The effective date will be July 1, 2019, or as otherwise approved by the
centers for medicare and medicaid
services (CMS).
A. Eligible providers and
practitioners:
(1) Any
clinic, office or agency providing permanent supportive housing under the human
services department’s linkages program administered by the behavioral health
services division.
(2) Behavioral
health practitioners employed or contracted with such facilities including:
(a) behavioral
health professional licensed in the state of New Mexico; and
(b) certified
peer support workers or certified family peer support workers.
B. Coverage criteria:
(1) Enrollment
in the linkages permanent supportive housing program.
(2) An
assessment documenting serious mental illness.
C. Eligible recipients: Individuals with serious mental illness.
D. Covered services:
(1) Pre-tenancy
services, including:
(a) screening
and identifying preferences and barriers related to successful tenancy;
(b) developing
an individual housing support plan and housing crisis plan;
(c) ensuring
that the living environment is safe and ready for move-in;
(d) tenancy
orientation and move-in assistance;
(e) assistance
in securing necessary household supplies; and
(f) landlord
relationship building and communication.
(2) Tenancy
support services, including:
(a) early
identification of issues undermining housing stability, including member
behaviors;
(b) coaching
the member about relationships with neighbors, landlords and tenancy
conditions;
(c) education
about tenant responsibilities and rights;
(d) assistance
and advocacy in resolving tenancy issues;
(e) regular
review and updates to housing support plan and housing crisis plan; and
(f) linkages
to other community resources for maintaining housing.
E. Duration: The PSH-TSS benefit is available to an
eligible member for the duration of the member’s enrollment in a linkages
program, ceasing when the client leaves the program.
F. Reimbursement: See Subsection H of 8.321.9 NMAC for MAD
behavioral health general reimbursement requirements. See the BH policy and billing manual for
reimbursement specific to PSH-TSS. These
services do not include tenancy assistance in the form of rent or subsidized
housing.
[8.321.2.36
NMAC - Rp, 8.321.2.36 NMAC, 8/10/2021]
8.321.2.37 TREATMENT FOSTER CARE I and II: MAD pays for
medically necessary services furnished to an eligible recipient under 21 years
of age who has an identified need for treatment foster care (TFC) and meets the
TFC I or TFC II level of care (LOC) as part of the EPSDT program. MAD covers those services included in the
eligible recipient’s individualized treatment plan which is designed to help
him or her develop skills necessary for successful reintegration into his or
her family or transition back into the community. TFC I agency provides therapeutic services to
an eligible recipient who is experiencing emotional or psychological trauma and
who would optimally benefit from the services and supervision provided in a TFC
I setting. The
TFC II agency provides therapeutic family living experiences as the core
treatment service to which other individualized services can be added. The need for TFC I and II services must be
identified in the tot to teen health check or other diagnostic evaluation
furnished through the eligible recipient’s health check referral.
A. Eligible agencies: In addition to the requirements of
Subsections A and B of 8.321.2.9 NMAC, in order to be
eligible to be reimbursed for providing TFC services to an eligible recipient,
the agency must be a CYFD certified TFC agency and be licensed as a child
placement agency by CYFD protective services.
In
lieu of New Mexico CYFD licensure and certification, an out-of-state TFC agency
must have equivalent accreditation and be licensed in its own state as a TFC
agency.
B. Coverage criteria:
(1) The
treatment foster care agency provides intensive support, technical assistance,
and supervision of all treatment foster parents.
(2) A
TFC I and II parent is either employed or contracted by the TFC agency and
receives appropriate training and supervision by the TFC agency.
(3) Placement
does not occur until after a comprehensive assessment of how the prospective
treatment foster family can meet the recipient’s needs and preferences, and a
documented determination by the agency that the prospective placement is a
reasonable match for the recipient.
(4) An
initial treatment plan must be developed within 72 hours of admission and a
comprehensive treatment plan must be developed within 14 calendar days of the
eligible recipient’s admission to a TFC I or II program. See the BH policy and billing manual for the
specific requirements of a TFC treatment plan.
(5) The
treatment team must review the treatment plan every 30 calendar days.
(6) TFC
families must have one parent readily accessible at all times,
cannot schedule work when the eligible recipient is normally at home, and is
able to be physically present to meet the eligible recipient’s emotional and
behavioral needs.
(7) In
the event the treatment foster parents request a
treatment foster recipient be removed from their home, a treatment team meeting
must be held and an agreement made that a move is in the best interest of the
involved recipient. Any treatment foster parent(s) who demands removal of a treatment foster
recipient from his or her home without first discussing with and obtaining
consensus of the treatment team, may have their license revoked.
(8) A
recipient eligible for treatment foster care services, level I or II, may
change treatment foster homes only under the following circumstances:
(a) an
effort is being made to reunite siblings; or
(b) a
change of treatment foster home is clinically indicated, as documented in the
client’s record by the treatment team.
C. Identified
population:
(1) TFC
I services are for an eligible recipient who meets the following criteria:
(a) is
at risk for placement in a higher level of care or is returning from a higher
level of care and is appropriate for a lower level of care; or
(b) has
complex and difficult psychiatric, psychological, neurobiological, behavioral,
psychosocial problems; and
(c) requires
and would optimally benefit from the behavioral health services and supervision
provided in a treatment foster home setting.
(2) TFC
II services are for an eligible recipient who meets the criteria listed in
Section 25 Subsection B of 8.321.2.9 NMAC and also
meet one of the following criteria:
(a) has
successfully completed treatment foster care services level I (TFC I), as
indicated by the treatment team; or
(b) requires
the initiation or continuity of treatment and support of the treatment foster
family to secure or maintain therapeutic gains; or
(c) requires
this treatment modality as an appropriate entry level service from which the
client will optimally benefit.
(3) An
eligible recipient has the right to receive services from any MAD TFC enrolled
agency of his or her choice.
D. Covered services: The family living experience is the core
treatment service to which other individualized services can be added, as
appropriate to meet the eligible recipient’s needs.
(1) The
TFC parental responsibilities include, but are not limited to:
(a) meeting
the recipient’s base needs, and providing daily care and supervision;
(b) participating
in the development of treatment plans for the eligible recipient by providing
input based on his or her observations;
(c) assuming
the primary responsibility for implementing the in-home treatment strategies
specified in the eligible recipient’s treatment plan;
(d) recording
the eligible recipient’s information and documentation of activities, as
required by the TFC agency and the standards under which it operates;
(e) assisting
the eligible recipient with maintaining contact with his or her family and
enhancing that relationship;
(f) supporting
efforts specified by the treatment plan to meet the eligible recipient’s
permanency planning goals;
(g) reunification
with the recipient’s family. The treatment
foster parents work in conjunction with the treatment
team toward the accomplishment of the reunification objectives outlined in the
treatment plan;
(h) assisting
the eligible recipient obtain medical, educational, vocational and other
services to reach goals identified in treatment plan;
(i) ensuring proper and adequate supervision is provided at all times.
Treatment teams determine that all out-of-home activities are
appropriate for the recipient’s level of need, including the need for supervision;
and
(j) working
with all appropriate and available community-based resources to secure services
for and to advocate for the eligible recipient.
(2) The
treatment foster care agency provides intensive support, technical assistance,
and supervision of all treatment foster parents. The following services must be furnished by
both TFC I and II agencies unless specified for either I or II. Payment for performance of these services is
included in the TFC agency’s reimbursement rate:
(a) facilitation,
monitoring and documenting of treatment of TFC parents initial and ongoing
training;
(b) providing
support, assistance and training to the TFC parents;
(c) providing
assessments for pre placement and placement to
determine the eligible recipient’s placement is therapeutically appropriate;
(d) ongoing
review of the eligible recipient’s progress in TFC and assessment of family
interactions and stress;
(e) ongoing
treatment planning as defined in Subsection G of 8.321.2.9 NMAC and treatment
team meetings;
(f) provision
of individual, family or group psychotherapy to recipients as described in the
treatment plan. The TFC therapist is an
active treatment team member and participates fully in the treatment planning
process;
(g) family
therapy is required when client reunification with their family is the goal;
(h) ensuring
facilitation of age-appropriate skill development in the areas of household
management, nutrition, physical and emotional health, basic life skills, time
management, school attendance, money management, independent living, relaxation
techniques and self-care techniques for the eligible recipient;
(i) providing crisis intervention on
call to treatment foster parents, recipients and their families on a 24-hour,
seven days a week basis including 24-hour availability of appropriate staff to
respond to the home in crisis situations;
(j) assessing
the family’s strengths, needs and developing a family service plan when an
eligible recipient’s return to his or her family is planned;
(k) conducting
a private face-to-face visit with the eligible recipient within the first two
weeks of TFC I placement and at least twice monthly thereafter by the treatment
coordinator;
(l) conducting
a face-to-face interview with the eligible recipient’s TFC parents within the
first two weeks of TFC I placement and at least twice monthly thereafter by the
treatment coordinator;
(m) conducting
at a minimum one phone contact with the TFC I parents weekly; phone contact is
not necessary in the same week as the face-to-face contact by the treatment
coordinator;
(n) conducting
a private face-to face interview with the eligible recipient’s TFC II parent
within the first two weeks of TFC II placement and at least once monthly
thereafter by the treatment coordinator;
(o) conducting
a face-to-face interview with the eligible recipient’s TFC II parent within the
first two weeks of TFC II placement and at least once monthly thereafter by the
treatment coordinator; and
(p) conducting
at a minimum one phone contact with the TFC II parents weekly; phone contact is
not necessary in the same week as the face-to-face contact by the treatment
coordinator.
E. Non-covered service: TFC I and II services are subject to the
limitations and coverage restrictions that exist for other MAD services. See Subsection G of 8.321.2.9 NMAC for all
non-covered MAD behavioral health services or activities. Specific to TFC I and II services MAD does
not cover:
(1) room
and board;
(2) formal
educational or vocational services related to traditional academic subjects or
vocational training;
(3) respite
care; and
(4) CCSS
except as part of the discharge planning from either the eligible recipient’s
TFC I or II placement.
F. Prior authorization: Before any TFC service is furnished to an
eligible recipient, prior authorization is required from MAD or its UR
contractor. Services for which prior
authorization was obtained remain subject to utilization review at any point in
the payment process.
G. A TFC agency
must submit claims for reimbursement on the CMS-1500 form or its
successor. See Subsection H of 8.321.2.9
NMAC for MAD general reimbursement requirements and see 8.302.2 NMAC.
[8.321.2.37 NMAC - Rp, 8.321.2.37
NMAC, 8/10/2021; A/E, 3/1/2023]
HISTORY OF 8.321.2 NAMC:
Pre-NMAC History: The material in this
part was derived from that previously filed with the State Records Center:
ISD
310.1700, EPSDT Services, filed 2/13/1980.
ISD
310.1700, EPSDT Services, filed 6/25/1980.
ISD
Rule 310.1700, EPSDT Services, filed 10/22/1984.
MAD
Rule 310.17, EPSDT Services, filed 5/1/1992.
MAD
Rule 310.17, EPSDT Services, filed 7/14/1993.
MAD
Rule 310.17, EPSDT Services, filed 11/12/1993.
MAD
Rule 310.17, EPSDT Services, filed 12/17/1993.
MAD
Rule 310.17, EPSDT Services, filed 3/14/1994.
MAD
Rule 310.17, EPSDT Services, filed 6/15/1994.
MAD
Rule 310.17, EPSDT Services, filed 11/30/1994.
History of Repealed Material:
MAC
Rule 310.17, EPSDT Services, filed 11/30/1994 - Repealed effective 2/1/1995.
8.321.2
NMAC, Inpatient Psychiatric Care in Freestanding Psychiatric Hospitals, filed
10/8/2010 - Repealed effective 1/1/2014.
8.321.3
NMAC, Accredited Residential Treatment Center Services, filed 2/17/2012 -
Repeal effective 1/1/2014.
8.321.4
NMAC, Non- Accredited Residential Treatment Center Services, filed 2/17/2012 -
Repeal effective 1/1/2014
8.321.5
NMAC, Outpatients and Partial Hospitalization Services in Freestanding
Psychiatric Hospitals, filed 1/5/2012 - Repealed effective 1/1/2014.
8.322.2
NMAC, Treatment Foster Care, filed 2/17/2012 - Repealed effective 1/1/2014.
8.322.3
NMAC, Behavioral Management Skills Development Services, filed 10/12/2005 -
Repealed effective 1/1/2014.
8.322.4
NMAC, Day Treatment, filed 10/12/2005 - Repealed effective 1/1/2014.
8.322.5
NMAC, Treatment Foster Care II, filed 2/17/2012 - Repealed effective 1/1/2014.
8.322.6
NMAC, Multi-Systemic Therapy, filed 11/16/2007 - Repealed effective 1/1/2014.
8.321.2
NMAC, Specialized Behavioral Health
Provider Enrollment and Reimbursement filed 12/17/2013, Repealed effective 8/10/2021.
8.321.2
NMAC, Specialized Behavioral Health
Provider Enrollment and Reimbursement filed 12/3/2019, Repealed effective 8/10/2021.
Other
History:
8.321.2
NMAC, Specialized Behavioral Health
Provider Enrollment and Reimbursement filed 12/17/2013 was replaced by 8.321.2
NMAC, Specialized Behavioral Health
Provider Enrollment and Reimbursement effective 8/10/2021.
8.321.2
NMAC, Specialized Behavioral Health
Provider Enrollment and Reimbursement filed 12/3/2019 was replaced by 8.321.2
NMAC, Specialized Behavioral Health
Provider Enrollment and Reimbursement effective 8/10/2021.