New
Mexico Register / Volume XXXII, Issue 5 / March 9, 2021
NOTICE
OF RULEMAKING
The Human Services Department
(the Department), through the Medical Assistance Division (MAD), is proposing
to amend the following New Mexico Administrative Code (NMAC) rules: 8.308.6
NMAC, Managed Care Program, Eligibility, 8.308.7 NMAC, Managed Care
Program, Enrollment and Disenrollment, 8.310.2 NMAC, Health Care
Professional Services, General Benefit Description, and 8.321.2 NMAC, Specialized
Behavioral Health Services, Specialized Behavioral Health Provider Enrollment
and Reimbursement.
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: March 9, 2021
Hearing Date: April 8, 2021
Adoption Date: Proposed as July 1, 2021
Technical Citations: (42 CFR §438.12, 42 CFR §438.14, 42 CFR §438.214)
The Department is proposing to amend the rules
as follows:
8.308.6 NMAC
Section 8
Amended to include the Department’s current
mission statement.
Section 9, Subsection B
Amended to add an additional managed care
exclusion. Residents in an intermediate
care facility for individuals with intellectual disabilities (ICF/IID) are
excluded from managed care enrollment.
Section 10, Subsection C
A new Subsection C was added regarding
discharge from an ICF/IID. When an
ICF/IID resident is discharged, enrollment into managed care will begin 60 days
after discharge.
8.308.7 NMAC
Section 8
Amended to include the Department’s current
mission statement.
New language added to clarify that an individual must
be eligible for reenrollment into a previous MCO prior to auto assignment into
that MCO.
Section 9, Subsection
F
The notification period of the option to switch MCOs
has been changed from 60 days to two months.
Section 9, Subsection
I
Language revised to clarify where switch requests may
be submitted and to update name of the Human Services Department’s customer
service center.
New addition; language added to clarify Continuity of Care switch request criteria:
“Continuity of care (for example, a member's physician or specialist is no
longer in the MCO's provider network or a member lives in a rural area and the
closest physician that accepts their current MCO is too far away).
New
addition; language added to clarify Family Continuity switch request criteria:
“Family Continuity (for example, a switch that is requested so
that all family members are enrolled with the same MCO).”
New
addition; language added to clarify Administrative Error switch request
criteria: “Administrative error (for example, a member chooses an MCO at
initial enrollment or requests to change MCOs during an allowable switch
period, but the request was not honored).
8.310.2 NMAC
Section 8
Amended to include the Department’s current
mission statement.
Section
12, Subsection A
Removed
language “essentially normal”.
Language
added to provide gynecological or obstetrical ultrasounds without prior
authorization.
Language added to provide coverage of labor and
delivery services at a NMDOH licensed birth center. Does not cover the full
scope of midwifery services nor does it replace pediatric care that should
occur at a primary care clinic.
Section
12, Subsection B
Language
added to provide allowances for non-emergency transportation to pharmacy for
justice involved individuals.
Section
12, Subsection C
Language ‘an inpatient of nursing facilities or
hospitals’ replaced by ‘of an inpatient nursing facility or hospital’.
Section
12, Subsection D
Language ‘consent to sterilization’ replaced by
‘sterilization consent’, ‘hysterectomy acknowledgement’ replaced by
‘hysterectomy acknowledgement/consent’.
Language added that a Medical Assistance Program (MAP) eligible recipient’s informed consent to
the sterilization procedure must be attached to the claim.
Language added to provide coverage of labor and
delivery services at a New Mexico Department of Health (NMDOH) licensed birth
center. Does not cover the full scope of midwifery services nor replace pediatric
care that should occur at a primary care clinic.
Section
12, Subsection F
Consolidated Subsection N Transplantation Services.
Replaced with ‘MAD
covered transplantation services include hospital, a PCP, laboratory,
outpatient surgical, and other MAD covered services necessary to perform the
selected transplantation for the MAP eligible recipient and donor.’
Language added ‘Due
to special Medicare coverage available for individuals with end-stage renal
disease, Medicare eligibility must be pursued by the provider for coverage of a
kidney transplant before requesting MAD reimbursement.
Language
added to include MAD covers the MAP eligible recipient’s and donor’s related
medical, transportation, meals and lodging services for non-experimental transplantation.
Language
added to include that MAD does not cover any transplant procedures, treatments,
use of a drug, a biological product, a product or a device which are considered
unproven, experimental, investigational or not effective for the condition for
which they are intended or used.
Language
added to include that a written prior authorization must be obtained for any
transplant, with the exception of a cornea and a kidney. The prior authorization process must be
started by the MAP eligible recipient’s attending primary care physician (PCP)
contacting the MAD utilization review (UR) contractor. Services for which prior approval was
obtained remain subject to UR at any point in the payment.
Section
12, Subsection G
Language
added to provide one fluoride varnish treatment every six months for members
under the age of 21.
Section
12, Subsection L
Language
added to provide allowances and define benefits for justice involved individual
to receive non-emergency transportation to a pharmacy.
Section 12, Subsection M
Language
added to provide allowances and define Telehealth benefits services.
Section
12, Subsection N
Removed
and consolidated with Subsection F, Transplant Services.
Section
12, Subsection O
Language
added to include ‘Prior to performing
pregnancy termination services providers must complete and file in the MAP
eligible recipient medical record, a consent for pregnancy termination that
includes written certification of a provider that the procedure meets one of
the following conditions’.
Section
12, Subsection P
Opening sentence language removed, ‘Covered transplantation services include a
hospital, a PCP, a laboratory, an outpatient surgical and other MAD-covered
services necessary to perform the selected transplantation. Due to special medicare
coverage available for individuals with end-stage renal disease, medicare eligibility must be pursued by the provider for
coverage of a kidney transplant before requesting MAD reimbursement.
Section 12, Subsection Q
Title change from ‘Smoking Cessation’ to ‘Smoking/Tobacco
Cessation’.
Language ‘a pregnant MAP eligible recipient and for
a MAP eligible recipient under the age of 21 years of age’ replaced by ‘all MAP
eligible recipients.’
Updated language from singular to plural.
Language ‘a pregnant or postpartum’ replaced by
‘all’
Language ‘A cessation counseling attempt includes up to four
cessation counseling sessions (one attempt plus up to four sessions). Two cessation counseling attempts (or up to
eight cessation counseling sessions) are allowed in any 12-month period’
replaced by ‘The services do not have any limits on the length of treatment or
quit attempts per year. The program also allows participants to try multiple
treatments and does not impose any requirement to enroll into counseling’.
Section 12, Subsection R
New language added: Screening, Brief Intervention
and Referral to Treatment (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 physical health
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 behavioral health treatment, the certified
SBIRT staff, with the eligible recipient’s approval, assists in securing
behavioral health services. Only a
physical health office, clinic, or facility that has been certified by a HSD
approved SBIRT trainer and uses the approved healthy lifestyle questionnaire
(HLQ) can complete the screen. The
physical office, clinic or facility must be the billing provider, not the
individual practitioner. All
practitioners must be SBIRT certified and are employees or contractors of a
SBIRT physical health office, clinic, or facility. See the SBIRT policy and billing manual for
detailed description of the service and billing requirements.
Section
13, Subsection J
Language
changed to clarify that MAD only covers a routine physical examination for a
MAP eligible recipient residing in a NF or an ICF-IID facility or a MAP
eligible recipient under 21 years of age through the tot to teen healthcheck screen, New Mexico’s EPSDT screening
program. Included in the coverage is the
physical examinations, screenings and treatment.
Throughout 8.310.2 NMAC sections
have been renumbered.
8.321.2 NMAC:
Section
9
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) has been added to the
allowed independent providers.
A school-based health center with behavioral health
supervisory certification has been added to the list of agencies that are
eligible to be reimbursed for providing behavioral health professional services
when all conditions are met.
Language was added to clarify that 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 an independently licensed clinician.
Language was added clarifying that behavioral health
services should be delivered in the least restrictive setting.
Section
10
Throughout the section references were changed and
updated from Accredited Residential Treatment Center (ARTC) to Adult Accredited
Residential Treatment Center (AARTC).
Language added to clarify that the eligible facility
must be certified through an application process with behavioral health
services division which includes a supervisory certificate.
Language adding emergency medical technicians with
documentation of three (3) hours of annual training in substance abuse disorder
are able to assess and treat the recipient and obtain and interpret information
regarding the recipient’s needs.
Language added to clarify the length of stay is
typically 3-5 days, after which transfer to another level of care is indicated
for 3.2WM’s.
Section
11
Language added to clarify that 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.
Section
12
Language added to see Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements for eligible providers.
A New Mexico behavioral health credentialing board
credentialed Certified Family Peer Support Worker under the supervision of an
approved ABA supervisor has been added to additional provider types.
Section
13
Language added to See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
Language added that any adaptations to the model
require an approved variance from BHSD for Assertive Community Treatment
Services.
Section
14
Language added to clarify that therapy includes
planning, managing and providing a program of psychological services to the
eligible recipient meeting a current DSM, or ICD, 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.
Section
15
Language added to See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
Section
17
Language added to See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
Section
18
Language added to See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
Language clarifying minimum staff qualifications for
certified family peer support workers (CFPSW).
Language added to clarify that minimum staff
qualifications for the community support worker include: 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; must have personal experience
navigating child serving systems on behalf of their own child; must have an
understanding of how these systems operate in New Mexico; and, must have
received certification as a CFPSW.
Minimum staff qualifications for certified youth
peer support workers (CYPSW) include: must be 18 years of age or older; have a
high school diploma or equivalent; have personal experience navigating any of
the child/family-serving systems prior to the age of 18 years; have an
understanding of how these systems operate in New Mexico; and must have
received certification as a CYPSW.
Language added to clarify Comprehensive Community
Support Services (CCSS) must be identified in the service plan for an
individual.
Language added for adult accredited residential
treatment center (AARTC) in the coverage criteria.
Section
19
Language changed to clarify eligible practitioners.
Language changed to clarify crisis stabilization
services.
Section
20
Language added for clarification for eligible
provider agencies licensed through the Department of Health.
Language changed to clarify a provider agency
licensed through the Department of Health as a crisis triage center.
Language added to clarify the exception of services
provided by the physician and the licensed independent mental health
practitioner.
Language added that additional staff may include an
emergency medical technician (EMT) with documentation of three (3) hours of
annual training in suicide risk assessment.
Section
22
Language added to See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
Language added to clarify non-covered services.
Section
23
Language changed to clarify coverage of stays in a
freestanding psychiatric hospital that is considered an Institution of Mental
Disease (IMD) is covered only for eligible recipients up to age 21 and over age
64.
Section
24
Language changed to clarify based upon a New Mexico
state plan amendment and 1115 waiver MAD covers inpatient hospitalization in an
IMD for substance use disorder (SUD) diagnoses only with criteria for medical
necessity and based on American Society of Addiction Medicine (ASAM) admission
criteria and MCO covered stays.
Section
25
Language added to See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
Section
26
Language added to See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
Language changed to clarify services may only be
delivered through an agency approved by the Human Services Department (HSD) and
Children, Youth and Families Department (CYFD) after demonstrating that the
agency meets all the requirements of Intensive Outpatient Program (IOP) services and
supervision.
Section
27
Language changed to state that 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).
Language added to
See Subsections A and B of 8.321.2.9 NMAC for MAD general provider
requirements.
Section
29
Language added to Non-Accredited Residential
Treatment Center (RTC) and Group Homes to clarify that 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.
Section
30
Language added to
See Subsections A and B of 8.321.2.9 NMAC for MAD general provider
requirements.
Language added under staffing requirements that
programs may also be staffed by:
licensed substance abuse associate (LSAA); a certified peer support
worker (CPSW); and emergency medical technicians (EMT) with documentation of
three (3) hours of annual training in substance use disorder.
References to prescription drug monitoring program
(PDMP) were changed to prescription monitoring program (PMP).
Language added for other services performed by the
agency as listed are reimbursed separately and are required by (42 CFR Part
8.12 (f)), or its successor. 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.
Section 32
Language added to See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
Language changed to clarify that no prior
authorization is required. To determine
retrospectively if the medical necessity for the service has been met
additional factors listed are considered.
Section 33
Language added to See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
Reference to therapeutic foster care was corrected
to treatment foster care (TFC) under non-covered services.
Section 34
Language added to See Subsections A and B of
8.321.2.9 NMAC for MAD general provider requirements.
Added nursing facilities to eligible providers and
practitioners.
Sections
29, 30 and 34
Language
has been added to the sections to include IHS and a tribal 638 facility and any
other Indian Health Care Provider (IHCP) defined in 42 CFR §438.14(a).
Changes throughout the rules have also been
made for spelling corrections and clarity.
The
register for these proposed amendments to this rule will be available March 9,
2021 on the HSD web site 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
these rules effective July 1, 2021. A
public hearing to receive testimony on this proposed rule will be held via
conference call on April 8, 2021 at 10:00 a.m., Mountain Time
(MT). Conference phone
number: 1-800-747-5150. Access Code:
2284263.
Interested
parties may submit written comments directly to: Human Services Department, Office of the
Secretary, ATT: 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.