New Mexico Register / Volume XXX,
Issue 17 / September 10, 2019
NOTICE
OF RULEMAKING
The
Human Services Department (the Department), Medical Assistance Division (MAD), is
amending the following rule that is part of the New Mexico Administrative Code (NMAC):
8.321.2 NMAC - Specialized Behavioral
Health Services.
Section 9-8-6 NMSA 1978, authorizes the Department Secretary to promulgate
rules and regulations that may be necessary to carry out the duties of the
Department and its divisions.
Notice Date: September 10, 2019
Hearing Date: October 16, 2019
Adoption Date: Proposed as January 1, 2020
Technical
Citations: 42 CFR 400-1099
MAD is proposing some new services, as
well as changes to some existing services.
The rule was also reviewed for currency and clarity with changes being
made as necessary. Language was also added throughout the rule to direct
individuals to the Behavioral Health (BH) Policy and Billing Manual for
additional information.
The
financial impact for the new services described in this proposed rule, is
estimated to be $34,000,000, annually, in combined federal and state funds. The primary fiscal impact is related to new
services that are being added as part of the Department’s 1115 waiver renewal
for the Centennial Care program.
The
Department proposes to amend the rule as follows:
Section
8: Mission Statement - Language in this section was removed
and will be reserved for promulgation at a later date.
Section
9: General Provider Instruction
Subsection C: The
Department proposes to allow licensed alcohol and drug abuse counselors
(LADACs) and certified alcohol and drug abuse counselors (CADCs) to provide
therapeutic services for alcohol and drug abuse diagnoses only, including
treatment of co-occurring mental health conditions when supervised by an
independently licensed counselor or therapist.
This addition will provide increased access to services for Medicaid
recipients with a substance use disorder (SUD).
Subsection D: The Department
proposes to add new types of agencies to the list of agencies that may utilize
non-independent practitioners under supervision for rendering behavioral health
services: 1) a CareLink
NM Health Home (CLNM HH); 2) a crisis triage center licensed by the Department
of Health (DOH); 3) a Behavioral Health Agency (BHA) with a Behavioral Health
Services Division (BHSD) supervisory certificate; 4) an opioid treatment
program in a methadone clinic with a BHSD supervisory certificate; 5) a
political subdivision of the state of New Mexico as a BHA with a BHSD
supervisory certificate; and 6) a crisis services community provider as a BHA
with a BHSD supervisory certificate.
Each agency type will increase access to behavioral health services
through the use of mid-level practitioners.
Subsection E: The Department
proposes to add new non-independent practitioners to the list of those that can
render services within one of the agencies listed in Subsection D. These are:
1) a registered nurse with existing New Mexico licensure when supervised
by a behavioral health certified nurse practitioner, clinical nurse specialist,
or physician; 2) a physician assistant; or 3) certain individuals in
educational programs including a master’s level behavioral health intern, a
psychology intern (including psychology practicum students and pre doctoral
internship), a pre-licensure psychology post doctorate student, a certified
peer support worker, or a certified family peer support worker. All of the practitioners must be enrolled as
a MAD provider. The addition of these
non-licensed practitioners will extend access to behavioral health services for
eligible recipients; provides needed experience for behavioral health interns;
add to the workforce within agencies; and support the premise that interns,
once assimilated into the New Mexico behavioral health workforce, are more
likely to stay in New Mexico once they are licensed. All supervisory requirements must be met. In
compliance with 2019 Senate Bill 207 the rule provides for licensed substance
abuse associates to be reimbursed for the services provided to medical assistance
recipients within the licensed substance abuse associate's scope of practice.
Subsection I: Added clarity that all pre-authorizations must
comply with federal parity laws.
Subsection J: Changes
are proposed to requirements for a practitioner to render therapeutic services
to an eligible recipient. Detailed
requirements for assessments and service or treatment plans have been moved to
the BH Policy and Billing Manual. The rule requiring that the diagnostic evaluation
and treatment plan must precede the rendering of behavioral health services is
proposed to be waived when a recipient only requires up to four behavioral
health encounters. Under this condition,
a provisional diagnosis based on screening results can be utilized as in the
“treat first” clinical model. When a
recipient only requires up to four behavioral health encounters, a treatment
plan is not required.
Subsection K: The
Department proposes to add a requirement for the lead provider to complete a
comprehensive assessment and service plan for all recipients with a serious
mental illness (SMI) or severe emotional disturbance (SED), as determined
through a diagnostic evaluation.
Conditions for this requirement include:
1) only the agencies designated in Subsection D of 8.321.2.9 NMAC may
bill for a comprehensive assessment.
Other agency types and practitioners may bill for an assessment that
does not require the accumulation of collateral information from multiple
provider types; 2) all practitioner types within such agencies may develop the
assessment and plan if they are under the supervision of an independently
licensed practitioner and are HIPAA trained; and 3) a comprehensive assessment
and service plan cannot be billed if care coordination is being billed through
bundled service packages such as case rate, high fidelity wrap around, or CLNM
Health Homes.
Subsection L:
The Department proposes to add provisions to allow for interdisciplinary
teaming to update treatment plans (referred to as “service plans” when
developed by an interdisciplinary team).
The team consists of a lead agency, which must be one of the agencies
listed in Subsection D of 8.321.2.9 NMAC, and at least two other providers or
agencies.
Section
10: Accredited Residential Treatment
Center (ARTC) for Adults with Substance Use Disorders - The Department proposes to add this
benefit for both fee-for-service and managed care eligible recipients subject
to approval by the federal Centers for Medicare and Medicaid Services (CMS) as
part of the 1115 waiver renewal for Centennial Care and for inclusion in the
Medicaid State Plan. This section
outlines level-three services as defined by the American Society of Addiction
Medicine (ASAM) and requires the ARTC to be accredited by the Joint Commission
(JC), the Commission on Accreditation of Rehabilitation Facilities (CARF), or
the Council on Accreditation (COA). The
effective date will be January 1, 2019, or as otherwise approved by CMS.
Section
11: Accredited Residential Treatment
Center (ARTC) for Youth - This section was updated to align with
Children, Youth and Families Department (CYFD) regulations. Specifically, the Council on Accreditation
(COA) was added as one of the national accrediting agencies. Individuals are directed to the Behavioral
Health Policy and Billing Manual for details related to findings and
recommendations for an Indian Health Service (IHS) or federally recognized
tribal government’s ARTC.
Section
12: Applied Behavior Analysis (ABA)
Subsection A:
The Department proposes to add a section on coverage criteria, outlining
three items that must be in place for ABA services to be covered, unless
otherwise allowed under Subsection B: 1)
confirmation of the presence or risk of Autism Spectrum Disorder (ASD) by an
approved autism evaluation provider (AEP) through a comprehensive diagnostic
evaluation (CDE), targeted evaluation,
or targeted risk evaluation; 2) an integrated service plan (ISP), which must be
developed by the AEP together with a referral to an approved ABA provider
agency; or 3) completion of a behavioral or functional analytic assessment to
determine if a focused or comprehensive model shall be selected, together with
completion of a treatment plan. All services must be rendered in accordance
with the treatment plan. In compliance with 2019 House Bill 322 the rule
provides that autism spectrum disorder will not be subject to age restrictions
or dollar limits.
Subsection B: To comply with
new requirements, the Department proposes to update eligible providers based on
the three stages of service. Specialty
care providers or practitioners who are enrolled as approved behavior analysts
(BAs) have been added but must provide additional documentation that
demonstrates that 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. The Department also proposes to add
additional provider types that may refer a recipient for ABA services, including: psychologists licensed by the New Mexico
Regulation and Licensing Division (RLD); psychiatric clinical nurse specialists
or certified nurse practitioners with a specialty of pediatrics or psychiatry
licensed by the New Mexico Board of Nursing; medical doctor (MD) or doctor of
osteopathic medicine (DO) board licensed psychiatrists who are board certified
in child and adolescents; or licensed pediatricians.
Subsection C:
The Department proposes to update the identified population. The reader
is directed to the BH Policy and Billing Manual for details.
Subsection D:
The Department proposes to reorganize covered services in the structure
of the rule. The reader is directed to the BH Policy and Billing Manual for
details.
Subsection E:
Language has been proposed to reflect that prior authorization is no
longer required for stage-two ABA services. Stage-three ABA services still
require prior authorization.
Section
13: Assertive Community Treatment
Services (ACT)
Subsection A:
The Department proposes to add three additional provider types as the
lead to address the shortage of psychiatrists in New Mexico: 1) a certified psychiatric nurse
practitioner; 2) a psychiatric clinical nurse specialist; and 3) a prescribing
psychologist under the supervision/consultation of a MD, which may be provided
via telehealth. Adds
to the two nurse requirement to allow for other allied medical professionals to
be used in place of one nurse. Previously,
the team leader was required to be a psychiatrist. Added clarity that 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.
Subsection B:
Language is proposed to specify four levels of interaction to assure
that services are based on evidence-based practice: 1) face-to-face encounters; 2) collateral
encounters with the recipient’s family or significant others; 3) assertive
outreach with the recipient; and 4) group encounters including basic living
skills development, psychosocial skills training, peer groups, and wellness and
recovery groups.
Subsection C: Language is
proposed to include ACT service eligibility for individuals 15 to 30 years of
age who are within the first two years of their first episode of psychosis or
meet the criteria of serious mental illness (SMI) with a special emphasis on
psychiatric disorders.
Subsection D:
Language is proposed to clarify that 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.
Subsection E:
The Department is proposing to allow reimbursement for a six-month
period while reimbursing another Medicaid covered service for transitioning
levels of care with the condition that the need is identified as a component of
the treatment plan. Concurrent therapy
modalities may assure a smooth transition with the potential outcome being that
there will be no further need for the high level of support provided with ACT
services.
Section
14: Behavioral Health Professional
Services for Screenings, Evaluations, Assessments and Therapy - The Department is proposing to allow
validated screenings and brief interventions for high risk conditions in order
to provide prevention or early intervention, based on New Mexico’s “treat
first” clinical model.
Subsection B: The Department
proposes to remove the requirement for an assessment to be conducted at least
annually. However, the rule also states
that if a non-independent practitioner is conducting the assessment, it must be
done under the supervision of an independent practitioner and must be
counter-signed by the independent practitioner along with the diagnosis
indicating the need for the assessment.
Subsection C: The Department
proposes to add language that outpatient therapy services now include
consultation with the recipient’s family and other professional staff when the
service is on behalf of the recipient.
Section
15: Behavioral Health Respite Care (MCO
only) - Proposed language has been incorporated
to specify that behavioral health respite care is available to MCO
members. BH Respite Care was previously
outlined in a separate section of NMAC.
Section
16: Behavioral Management Skills (BMS)
Development Services - Proposed language has been added to
align services with CYFD regulations.
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.
Subsection B: Coverage
criteria for BMS has been updated to clarify that a treatment plan must include
crisis planning based on an assessment that includes the identification of
skills deficits that will benefit from the integrated program of therapeutic
services; and 24 hour availability of appropriate staff or implementation of
the crisis plan, which may include referral to respond to the recipient’s
crisis situation. The previous version
of the rule did not have the option of referral to an outside source for 24
hour availability of crisis services.
Based on the New Mexico Crisis and Access Line (NMCAL) 24 hour crisis
service and its referral network, the Department believes this option should be
available based on potentially limited resources in the BMS workforce. The rule expands the primary responsibilities
of independently licensed supervisors and directs the reader to the BH Policy
and Billing Manual for specifics. The
rule also expands the team of professionals to include the recipient and his or
her family, which must review the treatment plan every 30 days. If the team assesses a lack of progress over
the last 30 days, the treatment plan will be amended and approved by the BMS
supervisor.
Section 17: Cognitive Enhancement Therapy (CET) - CET services were previously
covered through individual and group therapy reimbursement, but the Department
now proposes to classify CET as a “special service.”
Proposed language is added to require an application to BHSD to assure
that required training has occurred, and that the use of the evidence-based
practice is in place. A letter of
approval from BHSD will be required to add this service to one of these
approved agencies: a community mental health center (CMHC); a
federally-qualified health center (FQHC); an IHS facility; a PL 93-638 tribal
facility; a core service agency (CSA); a CLNM Health Home; or a BHA with a BHSD
supervisory certificate. The effective
date will be January 1, 2019, or as otherwise approved by CMS.
Section
18: Comprehensive Community Support
Services (CCSS)
Subsection A:
The Department proposes to add BHAs with a supervisory certificate,
CMHCs, and CLNM Health Homes to the list of providers that can deliver
CCSS. Training is available through the
University of New Mexico (UNM). An attestation that this training has taken
place is required for CCSS to be added to the provider’s list of specialty
services. If providing this service to
children and adolescents, CYFD will provide required background checks.
Subsection B: The Department
proposes to waive the requirement, up to the first four encounters, for which a
diagnostic evaluation must occur prior to treatment; however, a provisional
diagnosis must be included for billing.
After four encounters, the diagnostic evaluation with a resultant
diagnosis is required. This is
consistent with the “treat first” clinical model.
Subsection D: The Department
proposes to add eligible recipients with substance use disorders to the other
two qualifying categories of behavioral health disorders, which are serious
mental illness and severe emotional disturbance.
Section
19: Crisis Intervention Services - In this section, the Department proposes
to expand the three current crisis intervention services to include a fourth
type: crisis stabilization services in a community-based center. Crisis stabilization services are defined as
outpatient services for up to 24 hours of stabilization of crisis conditions
that may, but do not necessarily, include American Society of Addiction Medicine
(ASAM) level-two withdrawal management, and can also serve as an alternative to
the emergency department or police department.
The eligible population is age 14 years and older.
Subsection B: This section
lists the proposed types of provider agencies eligible to deliver crisis
stabilization services and specifies proposed staffing requirements. Eligible providers include: CSAs; CMHCs; crisis triage centers; IHS or
tribal 638 clinics; hospital outpatient clinics; BHAs with a supervisory
certificate; political subdivisions of the state of NM with a supervisory
certificate; and opioid treatment programs within a methadone clinic with a
supervisory certificate. Staffing must include at least: during all hours of operation, one registered
nurse with experience or training in crisis triage and managing intoxication
and withdrawal management, if this service is provided; one master’s level
licensed mental health professional on-site during all hours of operation; a
certified peer support worker on-site during all hours of operation; a
physician or certified nurse practitioner either on-site or on call during all
hours of operation; and at least one staff trained in basic cardiac life
support and use of the automated external defibrillator equipment and first aid
during all hours of operation.
Subsection C: Proposes to
add clarification of covered services, including details of ambulatory
withdrawal management, crisis stabilization, and navigational services for
individuals transitioning to the community.
Section
20: Crisis Triage Center (CTC) - This new section proposes to add
information clarifying that CTC covers both outpatient crisis stabilization and
residential services for up to eight days with a limit of 12 beds. The effective date of residential CTC
services will be January 1, 2019, or as otherwise approved by the Centers for
Medicare and Medicaid Services (CMS).
Section
21: Day Treatment (DT)
Subsection B: The
Department proposes to add information clarifying the conditions under which DT
services can be provided and changing covered services to be in alignment with
CYFD regulations. Specifically, coverage
criteria includes the following provisions:
1) a family who is unable to attend the regularly scheduled sessions at
the DT facility due to transportation difficulties or other reasons may receive
individual family sessions scheduled in the family’s home by the DT agency; 2)
the certified DT services provider delivers adequate care and continuous
supervision of the client at all times during the course of the client’s DT
program participation; and 3) 24-hour availability of appropriate staff or
implementation of a crisis plan, which may include referral, to respond to the
eligible recipient’s crisis situation.
Subsection C: To align with
CYFD requirements, the Department proposes to add language clarifying covered
services. DT 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 the following 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. Advance schedules are posted for structured
and supervised activities that include individual, group and family therapy,
and other planned activities appropriate to the age, behavioral and emotional needs
of the client subject to the treatment plan.
Section
22: Family Support Services (FSS) (MCO
only) - Proposed language has been added to
specify that Family Support Services are available to MCO members.
Section
23: Inpatient Psychiatric Care in
Freestanding Psychiatric Hospitals or Psychiatric Units of Acute Care Hospitals - The Department proposes language
clarifying that there is no age limit for treatment in psychiatric units of
acute care hospitals.
Subsection B: The Department
proposes to add language that a treatment plan and all supporting documentation
must be available for review in the eligible recipient’s file.
Section
24: Institutions for Mental Disease
(IMDs) - This new proposed section increases IMD
coverage from 15 to 30 days for eligible recipients ages 22 through 64 for
substance abuse disorders. The effective
date of this benefit will be January 1, 2019, or as otherwise approved by CMS.
Section
25: Intensive Outpatient Program (IOP)
for Substance Use Disorders
Subsection A:
The Department proposes to add three new provider agency types that can
deliver IOP services: a CLNM Health
Home; a BHA with a BHSD supervisory certificate; or an opioid treatment program
in a methadone clinic with a BHSD supervisory certificate. Non-independent
practitioners that can provide IOP services under the supervision of the IOP
supervisor include a LMSW, LMHC, LADAC, CADC, LSAA, or a master’s level
psychologist associate. The approval
letter author was changed from a MAD IOP approval letter to an IOP
Interdepartmental Council approval letter.
BHSD, MAD, and CYFD work together in the approval and audit process for
IOP services. The concept of a
transitional age program for which the provider must specify the age range was
added.
Subsection B: The Department
proposes to eliminate the list of approved evidence-based programs (EBPs) from
the rule and directs individuals instead to the IOP Interdepartmental Council
or the BH Policy and Billing Manual.
Also contained within those two sources are the directions for having
another EBP approved. New wording was
added to reemphasize that IOP must address co-occurring mental health
disorders, as well as substance use disorders, when indicated.
Subsection C: Proposed
language was added to clarify the addition of therapy or counseling services
outside of the bundled IOP services. For
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 that 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 is required
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: a current
assessment, a co-occurring diagnosis, and the inclusion in the service plan for
outpatient therapy services. An IOP
agency may 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 may 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 in coordination with
the new provider.
Subsection D: The Department
proposes to lower the age range of adolescents from 13 years to 11 years. This
section also includes provision of services that have been mandated by the
local judicial system; adds the transitional age group for a separate service;
adds the judicial system mandate; and adds the judicial mandate for the adult
population program.
Subsection
F: Proposes to clarify that medication assisted
treatment (MAT) and other mental health therapies are billed and reimbursed
separately from the bundled rate and to allow for inclusion of contract
employees within the IOP team.
Section
26: Intensive Outpatient Program for
Mental Health Conditions (IOP for MH) - This proposed new section of the rule
was added to comply with IOP regulations.
IOP for mental health conditions currently have no approved
evidence-based practices (EBP); therefore, any agency requesting coverage must
submit the EBP being proposed to the Interdepartmental IOP Council for approval
as indicated in the BH Policy and Billing Manual. The effective date will be January 1, 2019,
or as otherwise approved by CMS.
Section
27: Medication Assisted Treatment
(MAT): Buprenorphine Treatment for
Opioid Use Disorder - The Department proposes to restructure
the rule by adding this new section. MAT is already a covered Medicaid benefit.
Section
29: Non-Accredited Residential Treatment
Centers (RTCs) and Group Homes (GHs) - Proposed changes were made to align with
CYFD regulations.
Subsection A: Proposed
language in the rule directs the reader to the BH Policy and Billing Manual for
details on CYFD findings and recommendations for RTCs operated by IHS or a
federally recognized tribal government.
Subsection B: In this
section, the Department proposes the following: 1) to add the statement that
RTC services are provided through a treatment team approach and the roles,
responsibilities and leadership of the team are clearly defined; 2) to
delineate the 24 hour therapeutic group living environment as one that meets
the recipient’s developmental, psychological, and emotional needs; 3) to update
the provision of appropriate on-site staff based on the acuity of recipient
needs on a 24 hour basis to ensure adequate supervision of recipients and
response in a proactive and timely manner; 4) to direct the reader to the BH
Policy and Billing Manual for details on development of the interdisciplinary
treatment plan. If the recipient is solely receiving RTC services, a treatment
plan is not required; it is only required if the recipient is also receiving
other behavioral health services; 5) to assure appropriate discharge timing and
planning by requiring regular assessments outlining clinically appropriate
after-care services. Discharge planning
begins when the recipient is admitted to residential treatment and is updated
and documented in the recipient record at every treatment plan review, or more
frequently as needed; and 6) to add the requirement that services, care and
supervision are provided at all times, including the provision of, or access
to, medical services on a 24 hour basis, and the maintenance of a
staff-to-recipient ratio appropriate to the level of care and needs of the
recipient.
Section
30: Opioid Treatment Program (OTP) - This new proposed section incorporates
the previously named Medication Assisted Treatment (MAT) in a methadone clinic
with new federal regulations for more comprehensive services when a recipient
is receiving methadone treatment. In
compliance with 2019 Senate Bill 221 requires prescribers of opioid analgesics
shall provide the patient information on the risks of overdose and inform the
patient of the availability of an opioid antagonist.
Section
31: Partial Hospitalization (PH)
Services in an Acute Care or Freestanding Psychiatric Hospital - The Department proposes to expand the
definition of PH and to update requirements.
Subsection A: This section
lists the required practitioners for PH:
a registered nurse; a clinical supervisor that is an independently
licensed behavioral health practitioner or psychiatric nurse practitioner or
psychiatric nurse clinician; or a licensed behavioral health practitioner. This section also lists other practitioners
that may, but are not required, to be part of the PH team: physician assistants; certified peer support
workers; certified family peer support workers; licensed practical nurses; and
mental health technicians.
Subsection B: This section
lists eight new proposed criteria that must be adhered to for this
service: 1) all services must be ordered
by a psychiatrist or licensed Ph.D.; 2) PH 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; 3) a history and
physical must be conducted within 24 hours of admission; 4) an
interdisciplinary biopsychosocial assessment must be conducted within seven
days of admission including alcohol and drug screening; 5) services are
furnished under an individualized written treatment plan established within
seven days of initiation of service, which must be reviewed and updated every
15 days; 6) documentation must be sufficient to demonstrate that coverage criteria
are met; 7) treatment must be reasonably
expected to improve the recipient’s condition or designed to reduce or control
psychiatric symptoms to prevent relapse or hospitalization, and to improve or
maintain the recipient’s level of function; and 8) for recipients in elementary
or secondary school, educational services must be coordinated with the
recipient’s school system.
Subsection
C: The Department proposes language that
specifies the conditions for which eligible recipients may receive PH
including: the recipient is under the
care of a psychiatrist for SMI, SED, or moderate to severe SUD, the recipient
must have an adequate support system to sustain/maintain him or herself outside
the PH program; recipients 19 and over must have a serious mental illness
including substance use and be safely managed in the community with high
intensity therapeutic intervention, and would be at risk of requiring inpatient
care without this treatment; and recipients age 5 to 18 must have severe
emotional disturbances which may include substance use disorders, are able to
be safely managed in the community with high intensity therapeutic
intervention, and would be at risk of requiring inpatient care without this
treatment.
Subsection E: The Department
proposes to clarify that 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 service that makes up active
treatment in a PH program and, therefore, is a non-covered service.
Subsection F: The Department
proposes to eliminate prior authorization (PA) unless the length of stay
exceeds 45 days, at which time prior authorization is required. The proposed rule stipulates the conditions
that must be documented when requesting PA.
Subsection G: The Department
lists the services that may be billed separately from PH, which include:
performance of necessary evaluations and psychological testing for development
of the treatment plan; physical examinations and any resultant medical
treatment; any medically necessary occupational or physical therapy; and other
professional services not rendered as part of the program.
Section
32: Psychosocial Rehabilitation Services
(PSR) - The Department proposes to update the
definition of PSR. PSR is to be a transitional
level of care based on the recipient’s recovery and resiliency goals.
Subsection A: Proposes to
add PSR staffing requirements. PSR services must meet a staff ratio guideline
of 1:2 minimum and 1:10 maximum. In both the clubhouse and classroom settings,
the entire staff works as a team and the team must have a clinical
supervisor/team lead that can include:
certified peer support workers; certified family support workers;
community support workers; and other HIPAA trained individuals working under
the direct supervision of the clinical supervisor. Minimum qualifications for the clinical
supervisor/team lead include: an
independently licensed behavioral health professional; one year of demonstrated
supervisory experience; demonstrated knowledge and competence in the field of
PSR; and an attestation of training related to providing clinical supervision
of non-clinical staff.
Subsection D:
The Department proposes to revise the PSR services rendered to include
four major components: 1) basic living
skills development; 2) psychosocial skills training; 3) therapeutic
socialization; and 4) individual empowerment.
Components of each of the four major services are also listed.
Subsection
F: The Department proposes to clarify that
although there is no PA requirement for PSR, the factors for determining
medical necessity are: recipient
assessment; recipient diagnostic formation; recipient service and treatment
plans; and compliance with 8.321.2 NMAC.
Section
33: Recovery Services (MCO only) - This section is currently in rule;
however, the Department proposes to move it under this section.
Section
34: Screening, Brief Intervention &
Referral to Treatment (SBIRT) - This proposed new section adds the SBIRT
service to the Medicaid benefit package. The effective date of this change will be
January 1, 2019, or as approved by CMS. Expanded
the list of eligible providers to provide this important service to capture the
range of psychical health settings where this service can be provided.
Section
36: Supportive Housing Pre-Tenancy and
Tenancy Services (PSH-TSS) - This proposed new section adds PSH-TSS
to the Medicaid benefit package for recipients enrolled in Centennial Care. The effective date will be July 1, 2019, or as
otherwise approved by CMS.
Section
37: Treatment Foster Care I and II (TFC) - The Department proposes to update this
section to align with CYFD regulations.
TFC I and II have been combined, rather than listed separately, as
requirements are similar. When there is
a difference, it is cited in the rule.
The definition was modified to reinforce the use of a treatment plan
directed to the development of skills and re-integration into family and
community.
Subsection A: The Department
proposes to update TFC eligibility criteria to include a CYFD certified TFC
agency that must be licensed as a child placement agency by CYFD Protective
Services.
Subsection B: The Department
proposes to add a section clarifying the conditions of coverage for both the
agency and TFC families. The conditions
are: 1) the TFC 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; 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 be able to be physically present to meet the
eligible recipient’s emotional and behavioral needs; 7) in the event that 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; and 8) a recipient eligible for TFC I or II may change
treatment foster homes only under the following circumstances: an effort is being made to reunite siblings;
or a change of treatment foster home is clinically indicated, as documented in
the client’s record by the treatment team.
Subsection C: This section
emphasizes the rights of recipients, describes the transition between levels of
care, and differentiates between TFC I and TFC
II. TFC I services are for an eligible
recipient who meets the following criteria:
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 has
complex and difficult psychiatric, psychological, neurobiological, behavioral,
psychosocial problems; and requires and would optimally benefit from the
behavioral health services and supervision provided in a treatment foster home
setting. 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: has successfully completed treatment
foster care services level I (TFC I), as indicated by the treatment team; or
requires the initiation or continuity of the treatment and support of the treatment
foster family to secure or maintain therapeutic gains; or requires this
treatment modality as an appropriate entry level service from which the client
will optimally benefit. An
eligible recipient has the right to receive services from any MAD TFC enrolled
agency of his or her choice.
Subsection
D: The Department proposes to add new
requirements and clarify processes. The
TFC parental responsibilities include but are not limited to: 1) meeting the recipient’s base needs and
providing daily care and supervision; 2) 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; and 3) 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. 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 or II agencies unless specified for either I or II: a) 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; b) family
therapy is required when client reunification with their family is the goal; c)
providing crisis intervention on call to treatment foster parents, recipient’s
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;
d) 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; e)
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; f) 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; g) 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; h) 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; i) 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 j) conducting at a minimum, one phone contact with
the TFC II parents weekly by the treatment coordinator; phone contact is not
necessary in the same week as the face-to-face contact.
Subsection
E: Proposes to update the dual reimbursement for
TFC and CCSS to allow CCSS to be reimbursed while transitional planning from
one level to the next, or to family or community is
occurring: CCSS as part of the discharge
planning from either the eligible recipient’s TFC I or II placement.
The
register for these proposed amendments to this rule will be available September
10, 2019 on the HSD website at http://www.hsd.state.nm.us/LookingForInformation/registers.aspx or at http://www.hsd.state.nm.us/2017-comment-period-open.aspx. If you do not have Internet access, a copy of
the proposed rules may be requested by contacting MAD in Santa Fe at 505-827-1337.
The
Department proposes to implement this rule effective January 1, 2020. A public
hearing to receive testimony on this rule will be held in the Rio Grande Room,
Toney Anaya Building, 2550 Cerrillos Road, Santa Fe, New Mexico, 87505 on Wednesday,
October 16, 2019 at 9:00 a.m. Mountain Time (MT).
Interested
parties may submit written comments directly to: Human Services Department, Office of the
Secretary, ATTN: Medical Assistance Division Public Comments, P.O. Box 2348, Santa
Fe, New Mexico 87504-2348.
If
you are a person with a disability and you require this information in an
alternative format or require a special accommodation to participate in the
public hearing, please contact MAD in Santa Fe at 505-827-1337. The Department requests at least ten (10)
days advance notice to provide requested alternative formats and special
accommodations.
Copies
of all comments will be made available by the MAD upon request by providing
copies directly to a requestor or by making them available on the MAD website
or at a location within the county of the requestor.