New
Mexico Register / Volume XXIX, Issue 8 / April 24, 2018
TITLE 8 SOCIAL SERVICES
CHAPTER 308 MANAGED CARE PROGRAM
PART 11 TRANSITION OF CARE
8.308.11.1 ISSUING AGENCY: New Mexico Human Services Department (HSD).
[8.308.11.1
NMAC - Rp, 8.308.11.1 NMAC, 5/1/2018]
8.308.11.2 SCOPE: This rule applies to the general public.
[8.308.11.2
NMAC - Rp, 8.308.11.2 NMAC, 5/1/2018]
8.308.11.3 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 27-1-12 et seq., NMSA 1978.
[8.308.11.3
NMAC - Rp, 8.308.11.3 NMAC, 5/1/2018]
8.308.11.4 DURATION: Permanent.
[8.308.11.4
NMAC - Rp, 8.308.11.4 NMAC, 5/1/2018]
8.308.11.5 EFFECTIVE DATE: May 1, 2018, unless a later date is cited at
the end of a section.
[8.308.11.5
NMAC - Rp, 8.308.11.5 NMAC, 5/1/2018]
8.308.11.6 OBJECTIVE: The objective of this rule is to provide
instructions for the service portion of the New Mexico medical assistance
programs (MAP).
[8.308.11.6
NMAC - Rp, 8.308.11.6 NMAC, 5/1/2018]
8.308.11.7 DEFINITIONS: [RESERVED]
8.308.11.8 [RESERVED]
[8.308.11.8
NMAC - Rp, 8.308.11.8 NMAC, 5/1/2018]
8.308.11.9 TRANSITION OF CARE: Transition of care refers to movement of an
eligible recipient or a manage care organization (MCO) member from one health
care practitioner or setting to another as his or her condition and health care
needs change. The MCO shall have the
resources, the policies and the procedures in place to actively assist the
member with his or her transition of care.
A. Care
coordination will be offered to members who are:
(1) transitioning from a nursing facility or out-of-home
placement to the community;
(2) moving from a higher level of care to a lower level of care
(LOC);
(3) turning 21 years of age;
(4) changing MCOs while hospitalized;
(5) changing MCOs during major organ and tissue transplantation
services; and
(6) changing MCOs while receiving outpatient treatments for
significant medical conditions. A member
shall continue to receive medically necessary services in an uninterrupted
manner during transitions of care.
B. The following is
a list of HSD’s general MCO requirements for transition of care.
(1) The
MCO shall establish policies and procedures to ensure that each member is
contacted in a timely manner and is appropriately assessed by its MCO, using
the HSD prescribed timeframes, processes and tools to identify his or her
needs.
(2) The
MCO shall have policies and procedures covering the transition of an eligible
recipient into a MCO, which shall include:
(a) member and
provider educational information about the MCO;
(b) self-care
and the optimization of treatment; and
(c) the review
and update of existing courses of the member’s treatment.
(3) The
MCO shall not transition a member to another provider for continuing services,
unless the current provider is not a contracted provider.
(4) The
MCO shall facilitate a seamless transition into a new service, a new provider,
or both, in a care plan developed by the MCO without disruption in the member’s
services.
(5) When
a member of a MCO is transitioning to another MCO, the receiving MCO shall
immediately contact the member’s relinquishing MCO and request the transfer of
“transition of care data” as specified by HSD.
If a MCO is contacted by another MCO requesting the transfer of
“transition of care data” for a transitioning member, then upon verification of
such a transition, the relinquishing MCO shall provide such data in the
timeframe and format specified by HSD to the receiving MCO, and both MCOs shall
facilitate a seamless transition for the member.
(6) The
receiving MCO will ensure that its newly transitioning member is held harmless
by his or her provider for the costs of medically necessary covered services,
except for applicable cost sharing.
(7) For
a medical assistance division (MAD) medically necessary covered service
provided by a contracted provider, the MCO shall provide continuation of such
services from that provider, but may require prior authorization for the
continuation of such services from that provider beyond 30 calendar days. The receiving MCO may initiate a provider
change only as specified in the MCO agreement with HSD.
(8) The
receiving MCO shall continue providing services previously authorized by HSD,
its contractor or designee, in the member’s approved community benefit care
plan, behavioral health treatment plan or service plan without regard to
whether such a service is provided by contracted or non-contracted
provider. The receiving MCO shall not
reduce approved services until the member’s care coordinator conducts a
comprehensive needs assessment (CNA).
C. Transplant
services, durable medical equipment and prescription drugs:
(1) If
an eligible recipient has received HSD approval, either through fee-for-service
(FFS) or any other HSD contractor, the receiving MCO shall reimburse the HSD
approved providers if a donor organ becomes available during the first 30
calendar days of the member’s MCO enrollment.
(2) If
a member was approved by a MCO for transplant services, HSD shall reimburse the
MCO approved providers if a donor organ becomes available during the first 30
calendar days of the eligible recipient’s FFS enrollment. The MCO provider who delivers these services
will be eligible for FFS enrollment if the provider is willing.
(3) If
a member received approval from his or her MCO for durable medical equipment
(DME) costing two thousand dollars ($2,000) or more, and prior to the delivery
of the DME item, was disenrolled from the MCO, the
relinquishing MCO shall pay for the item.
(4) If
an eligible recipient received FFS approval for a DME costing two thousand
dollars ($2,000) or more, and prior to the delivery of the DME item, he or she
is enrolled in a MCO, HSD shall pay for the item. The DME provider will be eligible for FFS
provider enrollment if the provider is willing.
(5) If
a FFS eligible recipient enrolls in a MCO, the receiving MCO shall pay for
prescribed drug refills for the first 30 calendar days or until the MCO makes
other arrangements.
(6) If
a MCO member is later determined to be exempt from MCO enrollment, HSD will pay
for prescription drug refills for the first 30 calendar days of his or her FFS
enrollment. The pharmacy provider will
be eligible for FFS enrollment if the provider is willing;
(7) If
a FFS eligible recipient is later enrolled in a MCO, the receiving MCO will
honor all prior authorizations granted by HSD or its contractors for the first
30 calendar days or until it makes other arrangements for the transition of
services. A provider who delivered
services approved by HSD or through its contractors shall be reimbursed by the
receiving MCO.
(8) If
a MCO member is later determined to be exempt from MCO enrollment, HSD will
honor the relinquishing MCO’s prior authorizations for the first 30 calendar
days or until other arrangements for the transition of services have been
made. The provider will be eligible for
FFS enrollment if the provider is willing.
D. Transition of
care requirements for pregnant women:
(1) When
a member is in her second or third trimester of pregnancy and is receiving
medically necessary covered prenatal care services prior to her enrollment in
the MCO, the receiving MCO will be responsible for providing continued access
to her prenatal care provider (whether a contracted or non-contracted provider)
through the two month postpartum period without any form of prior approval.
(2) When
a newly enrolled member is in her first trimester of pregnancy and is receiving
medically necessary covered prenatal care services prior to her enrollment, the
receiving MCO shall be responsible for the costs of continuation of such
medically necessary prenatal care services, including prenatal care and
delivery, without any form of prior approval from the receiving MCO and without
regard to whether such services are being provided by a contracted or
non-contracted provider for up to 60 calendar days from her MCO enrollment or
until she may be reasonably transferred to a MCO contracted provider without
disruption in care, whichever is less.
(3) When
a member is receiving services from a contracted provider, her MCO shall be
responsible for the costs of continuation of medically necessary covered
prenatal services from that provider, without any form of prior approval,
through the two month postpartum period.
(4) When
a member is receiving services from a non-contracted provider, her MCO will be
responsible for the costs of continuation of medically necessary covered
prenatal services, delivery, through the two month postpartum period, without
any form of prior approval, until such time when her MCO determines it can
reasonably transfer her to a contracted provider without impeding service
delivery that might be harmful to her health.
E. Transition from
institutional facility to community:
(1) The
MCO shall develop and implement methods for identifying members who may have
the ability, the desire, or both, to transition from institutional care to his
or her community, such methods include, at a minimum:
(a) the utilization of a CNA;
(b) the utilization of the preadmission screening and annual
resident review (PASRR);
(c) minimum data set (MDS);
(d) a provider referral including hospitals, and residential
treatment centers;
(e) an ombudsman referral;
(f) a family member referral;
(g) a change in medical status;
(h) the member’s self-referral;
(i) community
reintegration allocation received;
(j) state agency referral; and
(k) incarceration or detention facility referral.
(2) When
a member’s transition assessment indicates that he or she is a candidate for
transition to the community, his or her MCO care coordinator shall facilitate
the development and completion of a transition plan, which shall remain in
place for a minimum of 60 calendar days from the decision to pursue transition
or until the transition has occurred and a new care plan is in place. The transition plan shall address the
member’s transition needs including but not limited to:
(a) his or her physical and behavioral health needs;
(b) the selection of providers in his or her community;
(c) continuation of MAP eligibility;
(d) his or her housing needs;
(e) his or her financial needs;
(f) his or her interpersonal skills; and
(g) his or her safety.
(3) The
MCO shall conduct an additional assessment within 75 calendar days of the
member’s transition to his or her community to determine if the transition was
successful and identify any remaining needs of the member.
F. Transition from
the New Mexico health insurance exchange:
(1) The
receiving MCO must minimize the disruption of the newly enrolled member’s care
and ensure he or she has uninterrupted access to medically necessary services
when transitioning between a MCO and his or her New Mexico health insurance
exchange qualified health plan coverage.
(2) At
a minimum, the receiving MCO shall establish transition guidelines for the
following populations:
(a) pregnant members, including the two month postpartum period;
(b) members with complex medical conditions;
(c) members receiving ongoing services or who are hospitalized
at the time of transition; and
(d) members who received prior authorization for services from
their qualified health plan.
(3) The
receiving MCO is expected to coordinate services and provide phase-in and
phase-out time periods for each of these populations, and to maintain written
policies and procedures to address these coverage transitions.
[8.308.11.9
NMAC - Rp, 8.308.11.9 NMAC, 5/1/2018]
HISTORY OF
8.308.11 NMAC: [RESERVED]
History of
Repealed Material:
8.308.11
NMAC - Managed Care Program, Transition of Care, filed 12/17/2013 Repealed
effective 5/1/2018.