TITLE 8 SOCIAL
SERVICES
CHAPTER 320 EARLY
AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES
PART 6
SCHOOL-BASED SERVICES
FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE
8.320.6.1 ISSUING
AGENCY: New Mexico Human Services Department (HSD).
[8.320.6.1 NMAC - Rp,
8.320.6.1 NMAC, 7/1/2015]
8.320.6.2 SCOPE: The rule applies to the general public.
[8.320.6.2 NMAC -
Rp, 8.320.6.2 NMAC, 7/1/2015]
8.320.6.3 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.
[8.320.6.3 NMAC -
Rp, 8.320.6.3 NMAC, 7/1/2015]
8.320.6.4 DURATION:
Permanent.
[8.320.6.4 NMAC -
Rp, 8.320.6.4 NMAC, 7/1/2015]
8.320.6.5 EFFECTIVE
DATE: July 1, 2015, unless a later date is cited at
the end of a section.
[8.320.6.5 NMAC -
Rp, 8.320.6.5 NMAC, 7/1/2015]
8.320.6.6 OBJECTIVE: The
objective of these rules is to provide instruction for the service portion of
the New Mexico medical assistance division’s (MAD) medical assistance programs
(MAP).
[8.320.6.6 NMAC -
Rp, 8.320.6.6 NMAC, 7/1/2015]
8.320.6.7 DEFINITIONS:
[RESERVED]
8.320.6.8 MISSION
STATEMENT: 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.
[8.320.6.8 NMAC -
Rp, 8.320.6.8 NMAC, 7/1/2015; Repealed, 2/1/2020; A, 7/1/2022]
8.320.6.9 SCHOOL-BASED
SERVICES FOR RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE: MAD pays for medically necessary services for a MAP eligible recipient
under twenty-one years of age when the services are part of the MAP eligible
recipient’s (eligible recipient’s) individualized education program (IEP) or an
individualized family service plan (IFSP), a section 504 accommodation plan
pursuant to 34 CFR 104 Subpart D (504 plan), an individual health care plan
(IHCP), or are otherwise medically necessary as appropriate for each covered
service for treatment (correction, amelioration, or prevention of
deterioration) of an identified medical condition.
[8.320.6.9 NMAC -
Rp, 8.320.6.9 NMAC, 7/1/2015; A, 7/1/2022]
8.320.6.10 GENERAL PROVIDER INSTRUCTIONS:
Health care to New Mexico MAP eligible recipients is furnished by a
variety of providers and provider groups.
The reimbursement for these services is administered by MAD. Upon approval of a provider participation
agreement (PPA) by MAD or its designee, licensed practitioners, facilities and other providers of services that meet
applicable requirements are eligible to be reimbursed for furnishing MAD
covered services to MAP eligible recipients.
A provider must be approved before submitting a claim for payment to the
MAD claims processing contractors. MAD
makes available on the HSD website, on other program-specific websites, or in
hard copy format, information necessary to participate in health care programs
administered by HSD/MAD or its authorized agents, including program rules,
billing instructions, utilization review (UR) instructions, and other pertinent
materials. When approved, a provider
receives instruction on how to access these documents, it is the provider’s
responsibility to access these instructions, to understand the information
provided and to comply with the requirements.
The provider must contact HSD or its authorized agents to obtain answers
to questions related to the material or not covered by the material. To be eligible for reimbursement, a provider
must adhere to the provisions of the MAD PPA and all applicable statutes,
regulations, rules, and executive orders.
MAD or its selected claims processing contractor issues payment to a
provider using the electronic funds transfer (EFT) only. Providers must supply necessary information in order for payment to be made. Services must be provided within the scope of
the practice and licensure for each agency, each rendering provider within that
agency and each individual provider.
Services must be in compliance with the
statutes, rules and regulations of his or her practitioner’s applicable
practice board and act. Providers must be eligible for reimbursement as
described in 8.310.3 NMAC.
[8.320.6.10 NMAC - Rp,
8.320.6.10 NMAC, 7/1/2015]
8.320.6.11 ELIGIBLE
PROVIDERS:
A. Upon approval of
a New Mexico MAD PPA by MAD or its designee, local education agencies (LEAs),
regional educational cooperatives (RECs), and other state-funded educational
agencies (SFEAs) that meet specified requirements are eligible to be reimbursed
for furnishing services to an eligible recipient. The LEA, REC, or other SFEA must enter into a
governmental services agreement (GSA) with HSD and abide by the terms and
conditions of it.
B. The following individual
service providers must be employed by, or under contract to, the LEA, REC, or
other SFEA when furnishing treatment and meet other specified qualification
criteria:
(1) physical
therapists (PT);
(2) physical
therapy assistants working under the supervision of a MAD enrolled PT;
(3) occupational
therapists (OT);
(4) occupational
therapy assistants working under the supervision of a MAD enrolled licensed
occupational therapist;
(5) speech
and language pathologists (SLP) and clinical fellows;
(6) apprentices
in speech-language (ASL) working under the supervision of a MAD enrolled
licensed speech therapist; supervision for those providers listed in Paragraphs
(1) - (6) above must adhere to the requirements of the practitioner’s
applicable licensing board;
(7) audiologists;
(8) licensed
nutritionists or registered dieticians;
(9) case
managers meeting one of the following requirements:
(a) bachelor’s
degree in social work, counseling, psychology, nursing or a related health or social
services field from an accredited institution;
(b) one
year experience serving medically-at-risk children or adolescents; or
(c) a
licensed registered (RN).
(10) psychologists
meeting one of the following requirements:
(a) psychologists
(Ph.D., Psy.D., or Ed.D.); or
(b) master's
level practitioners licensed by the New Mexico psychologist examiners board as
psychologist associates or licensed by PED as school psychologists and working
under the supervision of a MAD enrolled licensed psychiatrist or a licensed
psychologist (Ph.D., Psy.D., or Ed.D.) or a PED level 3 independent school
psychologist, as applicable;
(c) supervision
of psychologist associates and school psychologists must adhere to the
requirements of the practitioner’s applicable licensing board.
(11) social
work practitioners meeting one of the following requirements:
(a) licensed
independent social worker (LISW); or
(b) licensed
master social worker (LMSW) or licensed baccalaureate social worker (LBSW) and working
under the supervision of a MAD enrolled licensed independent social worker
(LISW) or licensed psychologist (Ph.D., Psy.D., Ed.D.) or other supervisor
approved by the New Mexico board of social work examiners;
(i) services provided by licensed master
social workers (LMSW) and licensed baccalaureate social workers (LBSW) must be
within the scope of their practice respectively and supervised and periodically
evaluated;
(ii) an
eligible recipient receiving services from an LMSW or LBSW must be diagnosed by
the practitioner’s supervisor; the diagnosis must be documented in the MAP
eligible recipient’s record with the signature of the supervisor.
(12) licensed
counselors or therapists meeting one of the following requirements:
(a) licensed
professional clinical mental health counselor (LPCC); or
(b) licensed
marriage and family therapist (LMFT); or
(c) licensed
mental health counselor (LMHC) or licensed professional mental health counselor
(LPC) and working under the supervision of a MAD enrolled licensed
psychiatrist, a licensed psychologist (Ph.D., Psy.D., or Ed.D.), licensed
professional clinical mental health counselor (LPCC), licensed marriage and
family therapist (LMFT), or licensed independent social worker (LISW);
(i) supervision of licensed mental
health counselors (LMHC) and licensed professional mental health counselors
(LPC) must adhere to the requirements of the practitioner’s applicable
licensing board;
(ii) an
eligible recipient receiving services from a LMHC or LPC must be diagnosed by the
practitioner’s supervisor; the diagnosis must be documented in the eligible
recipient’s record with the signature of the supervisor.
(d) licensed
associate marriage and family therapist (LAMFT); supervision of LAMFTs must
adhere to the requirements of the practitioner’s applicable licensing board;
(13) licensed
psychiatric clinical nurse specialist (CNS);
(14) physicians
and psychiatrists licensed by the board of medical examiners; or
(15) registered nurse (RN), licensed
practical nurse (LPN) or unlicensed school personnel providing delegated
nursing services in accordance with the New Mexico board of nursing under the
supervision of a RN. Delegated nursing
services must be delivered in accordance with Subsection B of 16.12.2.12 NMAC.
C. For a LEA, REC, or
other SFEA that employs a RN or a licensed practical nurse (LPN) not as a case
worker, each is under the oversight of the department of health’s (DOH)
district health officer, as provided by state statue (Section 24-1-4 NMSA 1978). A LPN must work
under the supervision of a RN who is a PED licensed school nurse.
D. As applicable, each
provider must be licensed by the public education department (PED) when such
licensure exists.
E. As applicable,
each provider must be licensed by its specific regulation and licensing
division (RLD)’s board of practice or by PED.
[8.320.6.11 NMAC -
Rp, 8.320.6.11 NMAC, 7/1/2015; A, 2/1/2020; A, 7/1/2022]
8.320.6.12 PROVIDER
RESPONSIBILITIES:
A. General responsibilities:
(1) A
provider who furnishes services to an eligible recipient must comply with all terms
and conditions of his or her MAD PPA and the MAD New Mexico administrative code
(NMAC) rules.
(2) A
provider must verify that an individual is an eligible recipient at the time
services are billed.
(3) A
provider must appoint a program liaison and backup alternate for each LEA, REC
or other SFEA, who will be responsible for receiving and disbursing all
communication, information and guidelines from HSD
regarding the MAD school-based services program, including information on, but
not limited to, direct services and administrative claiming.
B. Documentation requirements:
(1) A
provider must maintain all records necessary to fully disclose the nature,
quality, amount and medical necessity of services billed
to a MAP eligible recipient who is currently receiving MAD services or has
received MAD school-based services in the past that are or were part of the
eligible recipient’s IEP, IFSP, 504 plan, IHCP or other care plan. Payment for services billed to MAD that are
not substantiated in the eligible recipient’s records are subject to
recoupment. Documentation must be
retained for at least six years from the date of payment or until ongoing audit
issues are resolved, whichever is longer; see 8.302.2 NMAC.
(2) For
services covered under this rule, complete copies of the eligible recipient’s IEP,
IFSP, 504 plan, IHCP or other care plan with the individualized treatment plan
(ITP) portions of the IEP, IFSP, 504 plan, IHCP or other care plan must be
maintained as part of the required records.
Those records must clearly indicate that the MAD school-based service is
a part of the eligible recipient’s IEP, IFSP, 504 plan, IHCP or other care plan.
(3) Documents
in the MAP eligible recipient’s file must include:
(a) the
IEP, IFSP, 504 plan, IHCP or other care plan with the ITP;
(b) evaluation
performed by the provider or the annual and current present level of
performance or other determination of medical necessity;
(c) annual
PCP notification or documentation of a good faith effort for services provided
through an IEP/IFSP;
(d) treatment
notes that relate directly to the IEP, IFSP, 504 plan, IHCP or other care plan
goals and objectives specific to each MAP eligible recipient; and
(e) billing
information recorded in units of time; see 8.302.2 NMAC.
C. Record availability: The provider must upon request promptly
furnish to HSD, the secretary of the federal department of health and human
services, or the state medicaid fraud control unit
any information required in this rule, including the eligible recipient and
employee records, and any information regarding payments claimed by the
provider furnishing services. Failure to
provide records on request may result in a denial of claims.
[8.320.6.12 NMAC -
Rp, 8.320.6.12 NMAC, 7/1/2015; A, 7/1/2022]
8.320.6.13 COVERED
SERVICES: MAD covers the following services when
medically necessary and rendered as part of an eligible recipient’s IEP, IFSP,
504 plan, IHCP or other care plan by specified providers in school settings.
A. For services in
Subsections A - E of 8.320.6.13 NMAC, a provider must first develop and then
update the eligible recipient’s present level of performance for each of his or
her IEP or IFSP cycles. 504 plans, IHCPs
or other care plans should be reviewed annually to establish ongoing medical
necessity for services. MAD requires the
following elements be included in the provider’s treatment notes:
(1) the
specific activity provided to the MAP eligible recipient for each date of
service billed;
(2) a
description of the level of engagement and the ability of the eligible
recipient for each date of service billed; and
(3) the
outcomes of session on the impact on the eligible recipient’s exceptionality
for each date of service billed.
B. To be reimbursed
for a MAD school-based service, all of the
requirements in this subsection must be met.
(1) Services
must be medically necessary and must meet the needs specified in his or her IEP,
IFSP, 504 plan, IHCP or other care plan.
The services must be necessary for the treatment of the eligible recipient’s
specific identified condition.
(2) The
ITP portion of the IEP, IFSP, 504 plan, IHCP or other care plan must be
developed in conjunction with the appropriate qualified PT, OT, SLP,
audiologist, RN, or behavioral health provider listed in 8.320.6.11 NMAC.
(3) The
LEA, REC or other SFEA must complete a MAD specified good faith effort to
notify the eligible recipient’s PCP of the services to be provided under an IEP
or IFSP.
(4) Frequency
and duration of services billed may not exceed those specified in the eligible
recipient’s IEP, IFSP, 504 plan, IHCP or other care plan.
(5) Reimbursement
is made directly to the LEA, REC, or other SFEA when therapy, licensed
nutritionists or registered dieticians, transportation, case manager, or nurse providers
furnish services under contract to the LEA, REC, or other SFEA.
C. Therapy services: MAD covers physical, occupational,
audiological and speech evaluations, and therapy required for treatment of an
identified medical condition that is part of an eligible recipient’s ITP.
D. Nutritional assessment and counseling: MAD covers nutritional assessment and
counseling when rendered by a licensed nutritionist or dietician for an eligible
recipient who has been referred for a nutritional need when part of his or her
ITP. A nutritional assessment consists
of an evaluation of the nutritional needs of the eligible recipient based upon
appropriate biochemical, anthropometric, physical, and dietary data, including
a recommendation for appropriate nutritional intake.
E. Transportation services: MAD covers transportation services for an eligible
recipient who must travel from his or her school to receive a covered service
from a MAD provider when the service is unavailable in the school setting and
when the service is medically necessary and are part of the eligible recipient’s
IEP or IFSP; see 8.324.7 NMAC. MAD
covers transportation to and from the school on the date a medically necessary MAD
school-based service is rendered in the school setting for an eligible
recipient who has a disability.
(1) MAD
school-based services are billed on the specific day on which transportation is
rendered and are part of the ITP portion of his or her IEP or IFSP.
(2) The
eligible recipient requires transportation in a vehicle adapted to serve his or
her needs that are part of the ITP portion of his or her IEP or IFSP.
(3) Transportation
occurs in a modified school bus for disabled students.
F. Case management: MAD covers school-based case management
services rendered in school settings to an eligible recipient who is medically
at risk when these services are part of the eligible recipient’s ITP. Medically at risk refers to an eligible
recipient who has a diagnosed physical condition which has high probability of
impairing cognitive, emotional, neurological, social, or physical development.
(1) The service is developed in
conjunction with a qualified case manager.
(2) MAD
covers the following school-based case management services.
(a) The
assessment of the eligible recipient’s medical, social
and functional abilities at least every six months, unless more frequent
reassessment is indicated by the eligible recipient’s condition.
(b) The
development and implementation of a comprehensive case management plan of care
that helps the eligible recipient retain or achieve the maximum degree of
independence.
(c) The
mobilization of the use of natural helping networks, such as family members,
church members, community organizations, support groups, friends, and the
school, if the eligible recipient is able to attend.
(d) Coordination
and monitoring of the delivery of services, evaluation of the effectiveness and
quality of the services, and revision of the case management plan of care as
necessary.
(e) All
services must be delivered to be eligible for MAD reimbursement.
(3) An
eligible recipient has the freedom to choose a case management service
provider. MAD will pay for only one case management provider to furnish
services to an eligible recipient at any given time period. If an eligible recipient has a case manager
or chooses to use a case manager who is not employed or under contract to the
LEA, REC or other SFEA, the LEA, REC or other SFEA must coordinate with the
case manager in the development of the eligible recipient’s ITP.
G. Nursing: MAD covers certain nursing services required
for treatment of a diagnosed medical condition that qualifies an eligible
recipient for an IEP , IFSP or IHCP when provided by a licensed RN or LPN. Nursing services require professional nursing
expertise and are provided by a licensed RN or a LPN and
must be provided in accordance with the New Mexico Nursing Practice Act and
must be a covered MAD service. Delegated
nursing services which are tasks in accordance with the New Mexico board of
nursing that may be delegated by the RN to unlicensed school personnel. Delegated staff may include, but is not
limited to, school or contracted staff, such as health assistants, teachers,
teacher assistants, therapists, school administrators, administrative staff,
cafeteria staff, or personal care aides.
(1) The IHCP should be written by the RN
in accordance with the NM DOH school health manual.
(2) Delegated nursing services must be
delivered in accordance with Subsection B of 16.12.2.12 NMAC.
H. Behavioral health services: MAD covers counseling, evaluation and therapy
required for treatment of an identified behavioral health condition that is
part of an eligible recipient’s ITP.
I. Telemedicine
services: MAD covers school-based services provided via telemedicine; see
8.310.2 NMAC.
J. Administrative activities: MAD
covers the cost of certain administrative activities that directly support
efforts to provide health-related services to a MAP eligible recipient with
special education or health care needs.
These administrative activities include, but are not limited to,
providing information about MAD services and how to access them; facilitating
the eligibility determination process; assisting in obtaining transportation
and translation services when necessary to receive health care services; making
referrals for MAD reimbursable services; and coordinating and monitoring MAD
covered medical services.
(1) Payment
for an allowable administrative activity is contingent upon the following:
(a) the
LEA, REC or other SFEA must complete a MAD PPA to become an approved school-based
health services provider;
(b) the
LEA, REC or other SFEA must enter into a GSA with HSD and agree to abide by the
terms and conditions of the GSA;
(c) the
LEA, REC or other SFEA must submit claims for allowable administrative
activities in accordance with federal and state regulations, rules
and guidelines.
(2) A
provider or contractor coordination with the school or contractor or in consultation
with principals, school counselors, or teachers are not billable as a service by
the provider. The provider must consult
with the school to determine if the school will include such activities in its
contract with the provider or contractor.
The school may not bill MAD separately for these services but can
include the costs as administrative costs.
(3) Administrative
claiming is subject to compliance reviews and audits conducted by HSD, the
state medicaid fraud control unit and the Centers for
Medicare and Medicaid Services (CMS). By
signing the MAD PPA, the LEA, REC or other SFEA agrees to cooperate fully with
HSD, the state medicaid fraud control unit and CMS in
the performance of all reviews and audits and further agrees to comply with all
review and audit requirements.
[8.320.6.13 NMAC - Rp,
8.320.6.13 NMAC, 7/1/2015; A, 2/1/2020; A, 7/1/2022]
8.320.6.14 INDIVIDUALIZED
TREATMENT PLAN:
A. The ITP must
specify:
(1) the
eligible recipient’s objectives and goals; and
(2) the
duration, the frequency of the service for the eligible recipient.
B. The plan is
developed by the LEA, REC or other SFEA in conjunction with the eligible
recipient, his or her family, and applicable service providers.
C. The
ITP is a plan of care agreed upon by the eligible recipient, his or her parents
or legal guardians, the evaluating therapists, the IEP or IFSP committee, and the
eligible recipient’s teacher, all of whom are included in the IEP or IFSP. The ITP utilizes the eligible recipient’s
health history, medical and educational evaluations and recommendations by the
PCP and other medical providers, as applicable.
If medical needs are identified in the IEP or IFSP, the medical portion
of the IEP or IFSP is the eligible recipient’s ITP. The ITP must be incorporated into the IEP or
IFSP.
D. For purposes of non-IEP/IFSP school-based services, the
ITP may also be listed in a section 504 accommodation plan pursuant to 34 CFR
104 Subpart D, an individual health care plan, or other plan of care services
that are otherwise determined to be medically necessary as appropriate for each
covered service.
[8.320.6.14 NMAC - Rp,
8.320.6.14 NMAC, 7/1/2015; A, 7/1/2022]
8.320.6.15 NON-COVERED
SERVICES: MAD school-based services billed in school
settings are subject to the limitations and coverage restrictions that exist
for other MAD services; see 8.301.3 NMAC.
MAD does not cover the following services.
A. Services
classified as educational.
B. Services to non-MAP
eligible individuals.
C. Services billed
by a practitioner outside his or her area of expertise.
D. Vocational
training that is related solely to specific employment opportunities, work
skills or work settings.
E. Services that
duplicate services billed outside the school setting unless determined to be
medically necessary and MAD or its designee gave prior authorization for the
service.
F. Services not identified in the eligible recipient’s IEP, IFSP, 504 plan, IHCP or other care plan.
G. Transportation
services listed below:
(1) transportation
that a MAP eligible recipient would otherwise receive in the course of attending
school;
(2) transportation
for the eligible recipient with special education needs under the Individuals
with Disabilities Education Act (IDEA) who rides the regular school bus to and
from school with non-disabled children; and
(3) transportation
of a minor aged child, such as a sibling of the eligible recipient who is
simply accompanying the eligible recipient to a MAD service.
[8.320.6.15 NMAC - Rp,
8.320.6.16 NMAC, 7/1/2015; A, 7/1/2022]
8.320.6.16 PRIOR
AUTHORIZATION AND UTILIZATION REVIEW: Certain procedures or services
identified in the UR instructions may require prior authorization from MAD or its designee. Services for which prior authorization was obtained remain
subject to UR at any point in the payment process. All services are subject to UR for medical
necessity and program compliance.
Reviews can be performed before services are furnished, after services
are furnished and before payment is made, or after payment is made. When services are billed to and paid by a
coordinated services contractor authorized by HSD, the provider must follow
that contractor’s instructions for authorization of services. A specific service may have additional prior
authorization requirements listed in the service’s prior authorization
section. The prior authorization of a
service does not guarantee that an individual is eligible for a MAD service. A provider must verify that an individual is
eligible for a specific MAD service at the time the service is furnished and
must determine if the eligible recipient has other health insurance. A provider who disagrees with the denial of a
prior authorization request or
other review decision can request a reconsideration.
[8.320.6.16 NMAC - Rp,
8.320.6.17 NMAC, 7/1/2015]
8.320.6.17 REIMBURSEMENT: Reimbursement
to the LEA, REC, or SFEA is not contingent upon billing a third
party payer first when the eligible recipient has other insurance. MAD is generally the payer of last
resort. However, if medical services are
included in the eligible recipient’s IEP, IFSP, 504 plan, IHCP or other care
plan, and an exception is created under 42 USE 1396b(c), 20 USC 1412(a)(12) and
34 CFR 300.142., and the services are otherwise covered by MAD, then MAD is authorized
to pay for such services. The LEA, REC,
or other SFEA must submit claims for reimbursement on the 837P electronic
format or its successor unless it received written permission from MAD to bill
on paper.
A. Interim
payment to the LEA, REC or other SFEA for covered services are made at the MAD
fee schedule for the specific service.
B. The LEA, REC or
other SFEA will complete an annual cost report utilized to reconcile interim
payments with actual costs in accordance with CMS approved methodology. The LEA, REC or other SFEA must participate
in the CMS approved quarterly random moment time study (RMTS).
C. A MAD school-based
service that is in the eligible recipient’s IEP, IFSP, 504 plan, IHCP or other
care plan must only be billed by the school.
When the school utilizes a contractor to render the service, the school
must submit the claim, not the contractor.
It is the responsibility of the school to reimburse the contractor.
[8.320.6.17 NMAC - Rp,
8.320.6.18 NMAC, 7/1/2015; A, 7/1/2022]
HISTORY OF 8.320.6 NMAC:
Pre NMAC History: The
material in this part was derived from that previously filed with the State
Records Center:
MAD-747, School
Based Services for Recipients Under Twenty-one Years of Age, filed 12/16/1994.
History of Repealed Material:
8.320.6 NMAC, School
Based Services for Recipients Under Twenty-One Years of Age, filed 10/16/2002 -
Repealed 1-1-2014.
8.320.6 NMAC, School
Based Services for Recipients Under Twenty-One Years of Age, filed 12/17/2013 -
Repealed 7/1/2015.