New Mexico Register / Volume XXIX, Issue 23 / December 11, 2018

 

 

This is an amendment to 8.308.9 NMAC, Sections 7, 17, and 23 through 26, effective 1/1/2019.

 

8.308.9.7               DEFINITIONS:

                A.            Alternative benefits plan services with limitations (ABP):  The medical assistance division (MAD) category of eligibility “other adults” has an alternative benefit plan (ABP).  The HSD contracted managed care organization (MCO) covers ABP specific services for an ABP member.  Services are made available through MAD under a benefit plan similar to services provided by commercial insurance plans.  ABP benefits include preventive services and treatment services.  An ABP member has limitations on specific benefits; and does not have all MCO medicaid benefits available.  All early and periodic screening, diagnosis and treatment (EPSDT) program services are available to an ABP member under 21 years.  ABP services for an ABP member under the age of 21 years are not subject to the duration, frequency, and annual or lifetime benefit limitations that are applied to an ABP eligible recipient 21 years of age and older.  A MCO ABP contracted provider and an ABP member have rights and responsibilities as described in Title 8 Chapter 308 NMAC, Social Services.

                B.            Alternative benefits plan general benefits for ABP exempt member (ABP exempt):  An ABP member who self-declares he or she has a qualifying condition is evaluated by the MCO’s utilization management for determination if he or she meets the qualifying condition.  An ABP exempt member utilizes his or her benefits described in 8.308.9 NMAC and in 8.308.12 NMAC.

                C.            Early childhood home visiting program:  A program that uses home visiting as a primary service delivery strategy and offers services on a voluntary basis to eligible pregnant women and their children from birth up to kindergarten entry, according to the program standard.

                D.            Evidence-based, early childhood home visiting program:  A home visiting program that is recognized by the U.S. department of health & human services maternal, infant, and early childhood home visiting (MIECHV) project and:

                                (1)           is grounded in relevant, empirically-based best practice and knowledge that:

                                                (a)           is linked to and measures the following outcomes:

                                                                (i)            babies that are born healthy;

                                                                (ii)           children that are nurtured by their parents and caregivers;

                                                                (iii)         children that are physically and mentally healthy;

                                                                (iv)          children that are ready for school;

                                                                (v)           children and families that are safe; and

                                                                (vi)          families that are connected to formal and informal supports in their communities;

                                                (b)           has comprehensive home visiting standards that ensure high-quality service delivery and continuous quality improvement; and

                                                (c)           has demonstrated significant, sustained positive outcomes;

                                (2)           follows program standards that specify the purpose, outcomes, duration and frequency of services that constitute the program;

                                (3)           follows the curriculum of an evidence-based home visiting model;

                                (4)           employs well-trained and competent staff and provides continual professional supervision and development relevant to the specific program and model being delivered;

                                (5)           demonstrates strong links to other community-based services;

                                (6)           operates within an organization that ensures compliance with home visiting standards;

                                (7)           continually evaluates performance to ensure fidelity to the program standards;

                                (8)           collects data on program activities and program outcomes; and

                                (9)           is culturally and linguistically appropriate.

[8.308.9.7 NMAC - Rp, 8.308.9.7 NMAC, 5/1/2018; A, 1/1/2019]

 

8.308.9.17             PREVENTIVE PHYSICAL HEALTH SERVICES:  The MCO shall follow current national standards for preventive health services, including behavioral health preventive services.  Standards are derived from several sources, including the U.S. preventive services task force, the centers for disease control and prevention; and the American college of obstetricians and gynecologists.  Any preventive health guidelines developed by the MCO under these standards shall be adopted and reviewed at least every two years, updated when appropriate and disseminated to its practitioners and members.  Unless a member refuses and the refusal is documented, the MCO shall provide the following preventive health services or screens or document that the services (with the results) were provided by other means.  The MCO shall document medical reasons not to perform these services for an individual member.  Member refusal is defined to include refusal to consent to and refusal to access care.

                A.            Initial assessment:  The MCO shall conduct a health risk assessment (HRA), per HSD guidelines and processes, for the purpose of obtaining basic health and demographic information about the member, assisting the MCO in determining the need for a comprehensive needs assessment (CNA) for care coordination level assignment.

                B.            Family planning:  The MCO must have a family planning policy.  This policy must ensure that a member of the appropriate age of both sexes who seeks family planning services is provided with counseling and treatment, if indicated, as it relates to the following:

                                (1)           methods of contraception; and

                                (2)           HIV and other sexually transmitted diseases and risk reduction practices.

                C.            Guidance:  The MCO shall adopt policies that shall ensure that an applicable asymptomatic member is provided guidance on the following topics unless the member’s refusal is documented:

                                (1)           prevention of tobacco use;

                                (2)           benefits of physical activity;

                                (3)           benefits of a healthy diet;

                                (4)           prevention of osteoporosis and heart disease in a menopausal member citing the advantages and disadvantages of calcium and hormonal supplementation;

                                (5)           prevention of motor vehicle injuries;

                                (6)           prevention of household and recreational injuries;

                                (7)           prevention of dental and periodontal disease;

                                (8)           prevention of HIV infection and other sexually transmitted diseases;

                                (9)           prevention of an unintended pregnancy; and

                                (10)         prevention or intervention for obesity or weight issues.

                D.            Immunizations:  The MCO shall adopt policies that to the extent possible, ensure that within six months of enrollment, a member is immunized according to the type and schedule provided by current recommendations of the state department of health (DOH).  The MCO shall encourage providers to verify and document all administered immunizations in the New Mexico statewide immunization information system (SIIS).

                E.            Nurse advice line:  The MCO shall provide a toll-free clinical telephone nurse advice line function that includes at least the following services and features:

                                (1)           clinical assessment and triage to evaluate the acuity and severity of the member’s symptoms and make the clinically appropriate referral; and

                                (2)           pre-diagnostic and post-treatment health care decision assistance based on the member’s symptoms.

                F.             Prenatal care:  The MCO shall operate a proactive prenatal care program to promote early initiation and appropriate frequency of prenatal care consistent with the standards of the American college of obstetrics and gynecology.  The program shall include at least the following:

                                (1)           educational outreach to a member of childbearing age;

                                (2)           prompt and easy access to obstetrical care, including an office visit with a practitioner within three weeks of having a positive pregnancy test (laboratory or home) unless earlier care is clinically indicated;

                                (3)           risk assessment of a pregnant member to identify high-risk cases for special management;

                                (4)           counseling which strongly advises voluntary testing for HIV;

                                (5)           case management services to address the special needs of a member who has a high risk pregnancy, especially if risk is due to psychosocial factors, such as substance abuse or teen pregnancy;

                                (6)           screening for determination of need for a post-partum home visit; [and]

                                (7)           coordination with other services in support of good prenatal care, including transportation, other community services and referral to an agency that dispenses baby car seats free or at a reduced price; and

                                (8)           referral to a home visiting pilot program for eligible pregnant women and children residing in the HSD-designated counties for services as outlined at 8.308.9.23 NMAC.

                G.            Screens: The MCO shall adopt policies which will ensure that, to the extent possible, within six months of enrollment or within six months of a change in screening standards, each asymptomatic member receives at least the following preventive screening services listed below.

                                (1)           Screening for breast cancer:  A female member between the ages of 40-69 years shall be screened every one to two years by mammography alone or by mammography and annual clinical breast examination.

                                (2)           Blood pressure measurement:  A member 18 years of age or older shall receive a blood pressure measurement at least every two years.

                                (3)           Screening for cervical cancer:  A female member with a cervix shall receive cytopathology testing starting at the onset of sexual activity, but at least by 21 years of age and every three years thereafter until reaching 65 years of age when prior testing has been consistently normal and the member has been confirmed not to be at high risk.  If the member is at high risk, the frequency shall be at least annual.

                                (4)           Screening for chlamydia:  All sexually active female members 25 years of age and younger shall be screened for chlamydia.  All female members over 25 years of age shall be screened for chlamydia if they inconsistently use barrier contraception, have more than one sex partner, or have had a sexually transmitted disease in the past.

                                (5)           Screening for colorectal cancer:  A member 50 years of age and older, who is at normal risk for colorectal cancer shall be screened with annual fecal occult blood testing or sigmoidoscopy or colonoscopy or double contrast barium at a periodicity determined by the MCO.

                                (6)           EPSDT screening for elevated blood lead levels:  A risk assessment for elevated blood lead levels shall be performed beginning at six months and repeated at nine months of age.  A member shall receive a blood lead measurement at 12 months and 24 months of age.  A member between the ages of three and six years, for whom no previous test exists, should also be tested, and screenings shall be done in accordance with the most current recommendations of the American academy of pediatrics.

                                (7)           EPSDT newborn screening:  A newborn member shall be screened for those disorders specified in the state of New Mexico metabolic screen and any screenings shall be done in accordance with the most current recommendations of the American academy of pediatrics.

                                (8)           Screening for obesity:  A member shall receive body weight, height and length measurements with each physical exam.  A member under 21 years of age shall receive a BMI percentile designation.

                                (9)           Prenatal screening: All pregnant members shall be screened for preeclampsia, Rh (D) incompatibility, down syndrome, neural tube defects, hemoglobinopathies, vaginal and rectal group B streptococcal infection and screened and counseled for HIV in accordance with the most current recommendations of the American college of obstetricians and gynecologists.

                                (10)         Screening for rubella: All female members of childbearing ages shall be screened for rubella susceptibility by history of vaccination or by serology.

                                (11)         Screening for tuberculosis:  Routine tuberculin skin testing shall not be required for all members.  The following high-risk members shall be screened or previous screenings noted:

                                                (a)           a member who has immigrated from countries in Asia, Africa, Latin America or the middle east in the preceding five years;

                                                (b)           a member who has substantial contact with immigrants from those areas; a member who is a migrant farm worker;

                                                (c)           a member who is an alcoholic, homeless or is an injecting drug user.  HIV-infected persons shall be screened annually; and

                                                (d)           a member whose screening tuberculin test is positive (>10 mm of induration) must be referred to the local DOH public health office in his or her community of residence for contact investigation.

                                (12)         Serum cholesterol measurement:  A male member 35 years and older and a female member 45 years and older who is at normal risk for coronary heart disease shall receive serum cholesterol and HDL cholesterol measurement every five years.  A member 20 years and older with risk factors for heart disease shall have serum cholesterol and HDL cholesterol measurements annually.

                                (13)         Tot-to-teen health checks:  The MCO shall operate the tot-to-teen mandated EPSDT program as outlined in 8.320.2 NMAC.  Within three months of enrollment lock-in, the MCO shall ensure that the member is current according to the screening schedule, unless more stringent requirements are specified in these standards.  The MCO shall encourage its PCPs to assess and document for age, height, gender appropriate weight, and body mass index (BMI) percentage during EPSDT screens to detect and treat evidence of weight or obesity issues in members under 21 years of age.

                                (14)         Screening for type 2 diabetes:  A member with one or more of the following risk factors for diabetes shall be screened.  Risk factors include:

                                                (a)           a family history of diabetes (parent or sibling with diabetes); obesity (>twenty percent over desired body weight or BMI >27kg/m2);

                                                (b)           race or ethnicity (e.g. hispanic, native American, African American, Asian-Pacific islander);

                                                (c)           previously identified impaired fasting glucose or impaired glucose tolerance; hypertension (>140/90 mmHg); HDL cholesterol level <35 mg/dl and triglyceride level >250 mg/dl; history of gestational diabetes mellitus (GDM); and

                                                (d)           a delivery of newborn over nine pounds.

                                (15)         A member 21 years of age and older must be screened to detect high risk for behavioral health conditions at his or her first encounter with a PCP after enrollment.

                                (16)         The MCO shall require its PCPs to refer a member, whenever clinically appropriate, to behavioral health provider, see 8.321.2 NMAC.  The MCO shall assist the member with an appropriate behavioral health referral.

                                (17)         Screens and preventative screens shall be updated as recommended by the United States preventative services task force.

[8.308.9.17 NMAC - Rp, 8.308.9.17 NMAC, 5/1/2018; A, 1/1/2019]

 

8.308.9.23             CENTENNIAL HOME VISITING (CHV) PILOT PROGRAM SERVICES:  Beginning January 1, 2019, the benefit is available to approximately 300 eligible pregnant medicaid managed care enrolled members and their children who reside in Bernalillo county (other HSD-designated counties may be included at a later time and with a distinct enrollment limit) in accordance with the program standard.  The MCO shall contract with agencies operating in the HSD-designated counties that provide services that are in alignment with one of the two following evidence-based early childhood home visiting delivery models:

                A.            Nurse family partnership (NFP):  The services to be delivered under the NFP national program standards are for first-time parents only.  In Bernalillo county, the program is anticipated to serve up to 132 families by the end of the first year of implementation using one NFP team and to approximately 240 eligible members (annual average at full implementation) thereafter using two NFP teams.  The number of families served will be determined based on the number of active NFP teams in any program year.  HSD may expand this program to other counties at HSD’s discretion dependent upon provider capacity.  The NFP services will be suspended once the child reaches two years of age.

                B.            Parents as teachers (PAT):  The PAT evidence-based program services will adhere to the national model and curriculum and serve approximately 60 families (annual average at full implementation) in Bernalillo county.  Services will begin during pregnancy and may continue until the child reaches five years of age or kindergarten entry.  HSD may expand this program to other counties at HSD’s discretion dependent upon provider capacity.  The number of families served in other counties will be determined based on the number of active PAT teams in the program year.  The MCO may propose other evidence-based early childhood home visiting delivery models with similar services in lieu of the PAT model if available in the HSD-designated service areas.

                C.            Description of services:  The services available under the CHV pilot program are described below:

                                (1)           Prenatal home visits:  the benefit package includes the following services for eligible pregnant women during their pregnancy:

                                                (a)           monitoring for high blood pressure or other complications of pregnancy (only covered under the NFP model);

                                                (b)           diet and nutritional education;

                                                (c)           stress management;

                                                (d)           sexually transmitted disease (STD) prevention education;

                                                (e)           tobacco use screening and cessation education;

                                                (f)            alcohol and other substance misuse screening and counseling;

                                                (g)           depression screening; and

                                                (h)           domestic and intimate partner violence screening and education.

                                (2)           Postpartum home visits:  the benefit package includes the following services that may be delivered as part of a postpartum home visit, when provided during the 60 day postpartum period to an eligible member:

                                                (a)           diet and nutritional education;

                                                (b)           stress management;

                                                (c)           sexually transmitted disease (STD) prevention education;

                                                (d)           tobacco use screening and cessation education;

                                                (e)           alcohol use and other substance misuse screening and counseling;

                                                (f)            depression screening;

                                                (g)           domestic and intimate partner violence screening and education;

                                                (h)           breastfeeding support and education.  Members may be referred to a lactation specialist, but lactation consultant services are not covered as a home visiting service;

                                                (i)            guidance and education regarding wellness visits to obtain recommended preventive services;

                                                (j)            medical assessment of the postpartum mother and infant (only covered under the NFP model);

                                                (k)           maternal-infant safety assessment and education, such as safe sleep education for sudden infant death syndrome (SIDS) prevention;

                                                (l)            counseling regarding postpartum recovery, family planning, and needs of a newborn;

                                                (m)          assistance to the family in establishing a primary source of care and a primary care provider, including help ensuring that the mother/infant has a postpartum/newborn visit scheduled; and

                                                (n)           parenting skills and confidence building.

                                (3)           Infant and children home visits:  the benefit package includes the following services that may be delivered to newborn infants born to CHV Pilot Project members until the child reaches two years of age for NFP and five years of age or kindergarten entry for PAT, as part of an infant home visit:

                                                (a)           breastfeeding support and education.  Members may be referred to a lactation specialist, but lactation consultant services are not covered as a home visiting service;

                                                (b)           child developmental screening at major developmental milestones from birth to age two for NFP according to the model standard practice, and age five or kindergarten entry for PAT; and

                                                (c)           parenting skills and confidence building.

[8.308.9.23 NMAC - N, 1/1/2019]

 

[8.308.9.23] 8.308.9.24      SERVICES EXCLUDED FROM THE MCO BENEFIT PACKAGE:  MAD does not cover some services.  For the following services that are covered in another MAP category of eligibility, reimbursement shall be made by MAD or its contractor.  However, the MCO is expected to coordinate these services, when applicable, and ensure continuity of care by overseeing PCP consultations, medical record updates and general coordination.

                A.            Medicaid in the schools:  Services are covered under 8.320.6 NMAC.  Reimbursement for services is made by MAD or its contractor.

                B.            Special rehabilitation services-family infant toddler (FIT):  Early intervention services provided for a member birth to three years of age who has or is at risk for a developmental delay.  Reimbursement for services is made by MAD or its contractor.

[8.308.9.23 NMAC - Rp, 8.308.9.23 NMAC, 5/1/2018; A and Rn, 1/1/2019]

 

[8.308.9.24] 8.308.9.25      EMERGENCY AND POST STABILIZATION SERVICES:

                A.            In this section, emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:

                                (1)           Placing the health of the individual (or, for a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.

                                (2)           Serious impairment to bodily functions.

                                (3)           Serious dysfunction of any bodily organ or part.

                B.            In this section, emergency services means covered inpatient and outpatient services as follows.

                                (1)           Furnished by a provider that is qualified to furnish these services under the federal rules.  See 42 CFR 438.114.

                                (2)           Needed to evaluate or stabilize an emergency medical condition.

                C.            Post-stabilization care services means covered services, related to an emergency medical condition that are provided after a member is stabilized to maintain the stabilized condition, or, under the circumstances described 42 CFR 438.114 (e), to improve or resolve the member’s condition.

                D.            The MCO is responsible for coverage and payment of emergency services and post-stabilization care services.  The MCO must cover and pay for emergency services regardless of whether the provider that furnishes the services has a contract with the MCO.  The MCO may not deny payment for treatment obtained under either of the following circumstances.

                                (1)           A member had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of emergency medical condition in Subsection A of 8.308.9.24 NMAC.

                                (2)           A representative of the MCO instructs the member to seek emergency services.

                E.            The MCO may not:

                                (1)           limit what constitutes an emergency medical condition with reference to Subsection A of 8.308.9.24 NMAC on the basis of lists of diagnoses or symptoms; or

                                (2)           refuse to cover emergency services based on the emergency room provider or hospital not notifying the member’s PCP or the MCO.

                F.             A member who has an emergency medical condition may not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the member.

                G.            The attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and that determination is binding on the MCO that is responsible for coverage and payment.

[8.308.9.24 NMAC - Rp, 8.308.9.24 NMAC, 5/1/2018; A and Rn, 1/1/2019]

 

[8.308.9.25] 8.308.9.26      ADDITIONAL COVERAGE REQUIREMENTS:

                A.            The MCO may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the member.

                B.            The services supporting members with ongoing or chronic conditions or who require long-term services and supports must be authorized in a manner that reflects the member's ongoing need for such services and supports.

                C.            Family planning services are provided in a manner that protects and enables the member's freedom to choose the method of family planning to be used consistent with 42 CFR 441.20, family planning services.

                D.            The MCO must specify what constitutes “medically necessary services” in a manner that:

                                (1)           is no more restrictive than that used in the New Mexico administrative code (NMAC) MAD rules, including quantitative and non-quantitative treatment limits, as indicated in state statutes and rules.  The state plan, and other state policy and procedures; and

                                (2)           addresses the extent to which the MCO is responsible for covering services that address:

                                                (a)           the prevention, diagnosis, and treatment of a member's disease, condition, or disorder that results in health impairments or disability;

                                                (b)           the ability for a member to achieve age-appropriate growth and development;

                                                (c)           the ability for a member to attain, maintain, or regain functional capacity; and

                                                (d)           The opportunity for a member receiving long-term services and supports to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of his or her choice.

                E.            Authorization of services:  For the processing of requests for initial and continuing authorizations of services, the MCO must:

                                (1)           have in place, and follow, written policies and procedures;

                                (2)           have in effect mechanisms to ensure consistent application of review criteria for authorization decisions;

                                (3)           consult with the requesting provider for medical services when appropriate;

                                (4)           authorize long term services and supports (LTSS) based on an enrollee's current needs assessment and consistent with the person-centered service plan;

                                (5)           assure that any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, be made by an individual who has appropriate expertise in addressing the member's medical, behavioral health, or LTSS needs;

                                (6)           notify the requesting provider, and give the member written notice of any decision by the MCO to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested and the notice must meet the requirements of 42 CFR 438.404, timely and adequate notice of adverse benefit determination; and

                                (7)           for drug items that require prior authorization and drug items that are not on the MCO preferred drug list:

                                                (a)           provide a response by telephone or other telecommunication device within 24 hours of a request for prior authorization;

                                                (b)           provide for the dispensing of at least a 72-hour supply of a covered outpatient prescription drug in an emergency situation;

                                                (c)           consider in the review process any medically accepted indications for the drug item consistent with the American hospital formulary service drug information; United States pharmacopeia-drug information (or its successor publications); the DRUGDEX information system; and peer-reviewed medical literature as described in section 1927(d)(5)(A) of the Social Security Act.

[8.308.9.25 NMAC - Rp, 8.308.9.25 NMAC, 5/1/2018; 8.308.9.26 NMAC - Rn, 8.308.9.25 NMAC, A and Rn, 1/1/2019]