TITLE 8 SOCIAL
SERVICES
CHAPTER 308 MANAGED CARE PROGRAM
PART 11 TRANSITION
OF CARE
8.308.11.1 ISSUING
AGENCY: New Mexico Human Services Department (HSD).
[8.308.11.1
NMAC - Rp, 8.308.11.1 NMAC, 5/1/2018]
8.308.11.2 SCOPE: This rule applies to the general public.
[8.308.11.2
NMAC - Rp, 8.308.11.2 NMAC, 5/1/2018]
8.308.11.3 STATUTORY
AUTHORITY: The New Mexico medicaid program and other
health care programs are administered pursuant to regulations promulgated by
the federal department of health and human services under Title XIX of the
Social Security Act as amended or by state statute. See Section 27-1-12 et seq., NMSA 1978.
[8.308.11.3
NMAC - Rp, 8.308.11.3 NMAC, 5/1/2018]
8.308.11.4 DURATION: Permanent.
[8.308.11.4
NMAC - Rp, 8.308.11.4 NMAC, 5/1/2018]
8.308.11.5 EFFECTIVE
DATE: May 1, 2018, unless a later date is cited at
the end of a section.
[8.308.11.5
NMAC - Rp, 8.308.11.5 NMAC, 5/1/2018]
8.308.11.6 OBJECTIVE: The objective of this rule is to provide
instructions for the service portion of the New Mexico medical assistance
programs (MAP).
[8.308.11.6
NMAC - Rp, 8.308.11.6 NMAC, 5/1/2018]
8.308.11.7 DEFINITIONS: [RESERVED]
8.308.11.8 MISSION: To transform lives. Working with our partners, we design and
deliver innovative, high quality health and human services that improve the
security and promote independence for New Mexicans in their communities.
[8.308.11.8
NMAC - Rp, 8.308.11.8 NMAC, 5/1/2018; A, 4/5/2022]
8.308.11.9 TRANSITION
OF CARE: Transition of care refers to movement of an
eligible recipient or a manage care organization (MCO) member from one health
care practitioner or setting to another as their condition and health care
needs change. The MCO shall have the
resources, the policies and the procedures in place to actively assist the
member with their transition of care.
A. Care
coordination will be offered to members who are:
(1) transitioning
from a nursing facility or out-of-home placement to the community;
(2) moving
from a higher level of care to a lower level of care (LOC);
(3) turning
21 years of age;
(4) changing
MCOs while hospitalized;
(5) changing
MCOs during major organ and tissue transplantation services; and
(6) changing
MCOs while receiving outpatient treatments for significant medical
conditions. A member shall continue to
receive medically necessary services in an uninterrupted manner during
transitions of care.
B. The following is
a list of HSD’s general MCO requirements for transition of care.
(1) The
MCO shall establish policies and procedures to ensure that each member is
contacted in a timely manner and is appropriately assessed by its MCO, using
the HSD prescribed timeframes, processes and tools to identify their needs.
(2) The
MCO shall have policies and procedures covering the transition of an eligible
recipient into a MCO, which shall include:
(a) member
and provider educational information about the MCO;
(b) self-care
and the optimization of treatment; and
(c) the
review and update of existing courses of the member’s treatment.
(3) The
MCO shall not transition a member to another provider for continuing services,
unless the current provider is not a contracted provider.
(4) The
MCO shall facilitate a seamless transition into a new service, a new provider,
or both, in a care plan developed by the MCO without disruption in the member’s
services.
(5) When
a member of a MCO is transitioning to another MCO, the receiving MCO shall
immediately contact the member’s relinquishing MCO and request the transfer of
“transition of care data” as specified by HSD.
If a MCO is contacted by another MCO requesting the transfer of
“transition of care data” for a transitioning member, then upon verification of
such a transition, the relinquishing MCO shall provide such data in the
timeframe and format specified by HSD to the receiving MCO, and both MCOs shall
facilitate a seamless transition for the member.
(6) The
receiving MCO will ensure that its newly transitioning member is held harmless
by their provider for the costs of medically necessary covered services, except
for applicable cost sharing.
(7) For
a medical assistance division (MAD) medically necessary covered service
provided by a contracted provider, the MCO shall provide continuation of such
services from that provider, but may require prior authorization for the
continuation of such services from that provider beyond 30 calendar days. The receiving MCO may initiate a provider
change only as specified in the MCO agreement with HSD.
(8) The
receiving MCO shall continue providing services previously authorized by HSD,
its contractor or designee, in the member’s approved community benefit care
plan, behavioral health treatment plan or service plan without regard to
whether such a service is provided by contracted or non-contracted
provider. The receiving MCO shall not
reduce approved services until the member’s care coordinator conducts a
comprehensive needs assessment (CNA).
C. Transplant
services, durable medical equipment and prescription drugs:
(1) If
an eligible recipient has received HSD approval, either through fee-for-service
(FFS) or any other HSD contractor, the receiving MCO shall reimburse the HSD
approved providers if a donor organ becomes available during the first 30
calendar days of the member’s MCO enrollment.
(2) If
a member was approved by a MCO for transplant services, HSD shall reimburse the
MCO approved providers if a donor organ becomes available during the first 30
calendar days of the eligible recipient’s FFS enrollment. The MCO provider who delivers these services
will be eligible for FFS enrollment if the provider is willing.
(3) If
a member received approval from their MCO for durable medical equipment (DME)
costing $2,000 or more, and prior to the delivery of the DME item, was
disenrolled from the MCO, the relinquishing MCO shall pay for the item.
(4) If
an eligible recipient received FFS approval for a DME costing $2,000 or more,
and prior to the delivery of the DME item, they are enrolled in a MCO, HSD
shall pay for the item. The DME provider
will be eligible for FFS provider enrollment if the provider is willing.
(5) If
a FFS eligible recipient enrolls in a MCO, the receiving MCO shall pay for
prescribed drug refills for the first 30 calendar days or until the MCO makes
other arrangements.
(6) If
a MCO member is later determined to be exempt from MCO enrollment, HSD will pay
for prescription drug refills for the first 30 calendar days of their FFS
enrollment. The pharmacy provider will
be eligible for FFS enrollment if the provider is willing;
(7) If
a FFS eligible recipient is later enrolled in a MCO, the receiving MCO will
honor all prior authorizations granted by HSD or its contractors for the first
30 calendar days or until it makes other arrangements for the transition of
services. A provider who delivered
services approved by HSD or through its contractors shall be reimbursed by the
receiving MCO.
(8) If
a MCO member is later determined to be exempt from MCO enrollment, HSD will honor
the relinquishing MCO’s prior authorizations for the first 30 calendar days or
until other arrangements for the transition of services have been made. The provider will be eligible for FFS
enrollment if the provider is willing.
D. Transition of care
requirements for pregnant individuals:
(1) When
a member is in their second or third trimester of pregnancy and is receiving
medically necessary covered prenatal care services prior to their enrollment in
the MCO, the receiving MCO will be responsible for providing continued access
to her prenatal care provider (whether a contracted or non-contracted provider)
through the 12-month postpartum period without any form of prior approval.
(2) When
a newly enrolled member is in their first trimester of pregnancy and is
receiving medically necessary covered prenatal care services prior to their
enrollment, the receiving MCO shall be responsible for the costs of
continuation of such medically necessary prenatal care services, including
prenatal care and delivery, without any form of prior approval from the
receiving MCO and without regard to whether such services are being provided by
a contracted or non-contracted provider for up to 60 calendar days from her MCO
enrollment or until they may be reasonably transferred to a MCO contracted
provider without disruption in care, whichever is less.
(3) When
a member is receiving services from a contracted provider, their MCO shall be
responsible for the costs of continuation of medically necessary covered
prenatal services from that provider, without any form of prior approval,
through the 12-month postpartum period.
(4) When
a member is receiving services from a non-contracted provider, their MCO will be
responsible for the costs of continuation of medically necessary covered
prenatal services, delivery, through the 12-month postpartum period, without
any form of prior approval, until such time when their MCO determines it can
reasonably transfer them to a contracted provider without impeding service
delivery that might be harmful to their health.
E. Transition from
institutional facility to community:
(1) The
MCO shall develop and implement methods for identifying members who may have
the ability, the desire, or both, to transition from institutional care to
their community, such methods include, at a minimum:
(a) the
utilization of a CNA;
(b) the
utilization of the preadmission screening and annual resident review (PASRR);
(c) minimum
data set (MDS);
(d) a
provider referral including hospitals, and residential treatment centers;
(e) an
ombudsman referral;
(f) a
family member referral;
(g) a
change in medical status;
(h) the
member’s self-referral;
(i) community
reintegration allocation received;
(j) state
agency referral; and
(k) incarceration
or detention facility referral.
(2) When
a member’s transition assessment indicates that they are a candidate for
transition to the community, their MCO care coordinator shall facilitate the
development and completion of a transition plan, which shall remain in place
for a minimum of 60 calendar days from the decision to pursue transition or
until the transition has occurred and a new care plan is in place. The transition plan shall address the
member’s transition needs including but not limited to:
(a) their
physical and behavioral health needs;
(b) the
selection of providers in their community;
(c) continuation
of MAP eligibility;
(d) their
housing needs;
(e) their
financial needs;
(f) their
interpersonal skills; and
(g) their
safety.
(3) The
MCO shall conduct an additional assessment within 75 calendar days of the
member’s transition to their community to determine if the transition was
successful and identify any remaining needs of the member.
F. Transition from
the New Mexico health insurance exchange:
(1) The
receiving MCO must minimize the disruption of the newly enrolled member’s care and
ensure they have uninterrupted access to medically necessary services when
transitioning between a MCO and their New Mexico health insurance exchange
qualified health plan coverage.
(2) At
a minimum, the receiving MCO shall establish transition guidelines for the
following populations:
(a) pregnant
members, including the 12-month postpartum period;
(b) members
with complex medical conditions;
(c) members
receiving ongoing services or who are hospitalized at the time of transition;
and
(d) members
who received prior authorization for services from their qualified health plan.
(3) The
receiving MCO is expected to coordinate services and provide phase-in and
phase-out time periods for each of these populations, and to maintain written
policies and procedures to address these coverage transitions.
[8.308.11.9
NMAC - Rp, 8.308.11.9 NMAC, 5/1/2018; A, 4/5/2022]
HISTORY OF 8.308.11 NMAC: [RESERVED]
History
of Repealed Material:
8.308.11 NMAC - Managed Care
Program, Transition of Care, filed 12/17/2013 Repealed effective 5/1/2018.