N.M. Admin. Code § 8.321.2.11

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.321.2.11 - ADULT ACCREDITED RESIDENTIAL TREATMENT CENTER (AARTC) FOR ADULTS WITH SERIOUS MENTAL HEALTH CONDITIONS

To help an eligible recipient 18 years of age and older, who has been diagnosed as having a serious mental health condition, and the need for AARTC has been identified in the eligible recipient's diagnostic evaluation as meeting criteria of the level of care utilization system (LOCUS) for psychiatric and SUD services level of care five for whom a less restrictive setting is not appropriate. MAD pays for services furnished to them by an AARTC accredited by the joint commission (JC), the commission on accreditation of rehabilitation facilities (CARF) or the council on accreditation (COA).

A.Eligible facilities:

(1) To be eligible to receive reimbursement for providing AARTC services to an eligible recipient, an AARTC facility:

(a) must be accredited by JC, COA, or CARF as an adult (18 and older) residential treatment facility;

(b) must be certified through an application process with BHSD which includes site visits. Site visit requirements are outlined in the BH policy and billing manual;

(c) must have written policies and procedures specifying utilization of the LOCUS evaluation parameters for assessment of service needs and ensuring that based on the dimensional rating scale, clients meet LOCUS level 5 criteria as the basis for accepting eligible recipients into the treatment program;

(d) must meet LOCUS level five service definitions for the care environment, clinical services, support services, and crisis stabilization and prevention services;

(e) must assess for and treat co-occurring SUDs;

(f) must provide or refer eligible recipients for MAT for SUD, if appropriate; to include access to buprenorphine and methadone, if appropriate and desired by the recipient. Programs may not exclude recipients from receiving AARTC services on the basis of receiving or desiring to receive MAT services.

(g) must train all clinicians or practitioners in the LOCUS for psychiatric and SUD services. The LOCUS training must be conducted by a LOCUS approved trainer and must be comprehensive in covering the evaluation parameters for assessment of service needs and level of care definitions for LOCUS level 5 services;

(h) prior to the initial hire and every three years thereafter employees must pass a nationwide caregiver criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and 7.1.9 NMAC and an abuse registry screen pursuant to section 27-7a-1 et seq. NMSA 1978 and 8.11.6 NMAC; additionally employees must pass the employee abuse registry (EAR) pursuant to 7.1.12 NMAC, certified nurse aide registry pursuant to 16- 12.20 NMAC, office of inspector exclusion list pursuant to section 1128B(f) of the Social Security Act; and the national sex offender registry pursuant to 6201 as federal authority for active programs;

(i) must maintain appropriate drug permit required, issued by the state board of pharmacy, as applicable;

(j) must maintain appropriate food service permit required, issued by the NMED, as applicable; and

(k) must allow individuals the opportunity to notify their family that they have been admitted to the facility and shall not admit an individual for residential treatment without obtaining or providing evidence that the facility has attempted to obtain contact information for a family member of the patient.

(2) An out-of-state or MAD enrolled border AARTC must have JC, CARF or COA accreditation, use LOCUS level five criteria for accepting recipients, and be licensed in its own state as an AARTC residential treatment facility.

B.Coverage criteria:

(1) Treatment must be provided under the direction of an independently licensed clinician/practitioner and the program must have sufficient staffing to meet the LOCUS level five clinical capabilities description.

(2) Treatment shall be based on the eligible recipient's individualized treatment plan rendered by the AARTC facility's practitioners, within the scope and practice of their professions as defined by state law, rule or regulation. See Subsection B of 8.321.2.9 NMAC for general behavioral health professional requirements.

(3) The following services shall be performed by the AARTC agency to receive reimbursement from MAD:

(a) diagnostic evaluation, necessary psychological testing, and development of the eligible recipient's treatment plan, while ensuring that evaluations already performed are not repeated;

(b) provision of regularly scheduled counseling and therapy sessions in an individual, family or group setting following the eligible recipient's treatment plan, and according to LOCUS level five service descriptions the care environment, clinical services, support services, and crisis stabilization and prevention services;

(c) facilitation of age-appropriate life skills development;

(d) assistance to the eligible recipient in their self-administration of medication in compliance with state statute, regulation and rules;

(e) maintain appropriate staff available on a 24-hour basis to respond to crisis situations, determine the severity of the situation, stabilize the eligible recipient, make referrals as necessary, and provide follow-up to the eligible recipient; and

(f) consultation with other professionals or allied caregivers regarding the needs of the eligible recipient, as applicable.

(4) Admission and treatment criteria based on the LOCUS level five criteria based on the dimensional evaluation of service needs. Length of stay duration is determined by medical necessity and ongoing LOCUS level five criteria and symptomology. The LOCUS levels of care are based on the intensity of clinical services, particularly as demonstrated by the degree of involvement of psychiatric, medical, and nursing professionals. The defining characteristic of LOCUS level five is that it serves recipients who need a medically monitored residential setting for stabilization and treatment. Recipients are transferred to lower levels of care when they have established sufficient skills to safely continue treatment at a lower level of care.

(5)Sub-levels of level five level of care:

(a) moderate intensity long term residential treatment services as specified in LOCUS level of care 5c are covered for recipients whose condition meets the criteria for LOCUS Level 5c and who are experiencing long term and persistent disabilities that require extended rehabilitation and skill building to develop capacity for community living:

(b) moderate intensity intermediate stay residential treatment programs as specified in LOCUS levels of care 5b are covered for recipients whose condition meets the criteria of LOCUS level 5c and who need rehabilitation and skill building following stabilization of a crisis or to prevent precipitous deterioration in functioning.

(c) intensive short term residential services as specified in LOCUS level of care 5a are covered for recipients whose condition meets the criteria for LOCUS level 5a and who are stepping down from acute inpatient care or people who are in crisis but who do not require the security of a locked facility.

C.Covered services: AARTCs treating all recipients meeting LOCUS level five criteria. MAD covers residential treatment services which are medically necessary for the diagnosis and treatment of an eligible recipient's condition. A LOCUS level five AARTC facility must provide 24-hour care with trained staff.

D.Non-covered services: AARTC services are subject to the limitations and coverage restrictions that exist for other MAD covered services. See Subsection G of 8.321.2.9 NMAC for general MAD behavioral health non-covered services or activities. MAD does not cover the following specific services billed in conjunction with AARTC services to an eligible recipient:

(1) Comprehensive community support services (CCSS), except when provided by a CCSS agency in discharge planning for the eligible recipient from the facility;

(2) Services for which prior approval was not requested and approved;

(3) Services furnished to ineligible individuals;

(4) Formal educational and vocational services which relate to traditional academic subjects or vocational training; and

(5) Activity therapy, group activities, and other services primarily recreational or diversional in nature.

E.Treatment plan: The treatment plan must be developed by a team of professionals in consultation with the eligible recipient and in accordance with LOCUS and accreditation standards. The interdisciplinary team must review the treatment plan at least every 15 days.

F.Prior authorization: Prior authorization is not required for up to five days for eligible recipients meeting LOCUS level 5 criteria to facilitate immediate admission and treatment to the appropriate level of care. Within that five day period, the provider must furnish notification of the admission and if the provider believes that continued care beyond the initial five days is medically necessary, prior authorization must be obtained from MAD or its designee. For out-of-state AARTCs prior authorization is required prior to admission. Services for which prior authorization was obtained remain subject to utilization review at any point in the payment process. All MAD services are subject to utilization review for medical necessity, inspection of care, and program compliance. Follow-up auditing is done by the accrediting agency per their standards.

G.Reimbursement: An AARTC agency must submit claims for reimbursement on the UB-04 form or its successor. See Subsection H of 8.321.2.9 NMAC for MAD general reimbursement requirements and see 8.302.2 NMAC. Once enrolled, the agency receives instructions on how to access documentation, billing, and claims processing information.

(1) MAD reimbursement covers services considered routine in the residential setting. Routine services include, but are not limited to, counseling, therapy, activities of daily living, medical management, crisis intervention, professional consultation, transportation, rehabilitative services and administration.

(2) Services which are not covered in routine services include other MAD services that an eligible recipient might require that are not furnished by the facility, such as pharmacy services, primary care visits, laboratory or radiology services. These services are billed directly by the applicable providers and are governed by the applicable sections of NMAC rules.

(3) MAD does not cover room and board.

(4) Detailed billing instructions can be accessed in the BH policy and billing manual.

N.M. Admin. Code § 8.321.2.11

Adopted by New Mexico Register, Volume XXX, Issue 23, December 17, 2019, eff. 1/1/2020, Adopted by New Mexico Register, Volume XXXII, Issue 15, August 10, 2021, eff. 8/10/2021, Adopted by New Mexico Register, Volume XXXV, Issue 23, December 10, 2024, eff. 12/10/2024