Current through Register Vol. 35, No. 18, September 24, 2024
MAD and the member's MCO cover certain procedures, services,
and miscellaneous items. For those services that are the same in ABCB and SDCB,
detailed descriptions are found in
8.308.12.13
NMAC. Other services may be available to a member in the SDCB approach and
detailed descriptions are included in each subsection of this section.
A. Behavior support consultation is the
provision of assessment, treatment, evaluation and follow-up services to assist
the member, his or her parents, family, and primary caregivers with coping
skills which promote maintaining the member in a home environment. See
Subsection C of Section
8.308.12.13
NMAC for a detailed description of this service.
B. Customized community supports include
participation in community congregate day programs and centers that offer
functional meaningful activities that assist with acquisition, retention or
improvement in self-help, socialization and adaptive skills. Customized
community supports may include day support models. Customized community
supports are provided in community day program facilities and centers and can
take place in non-institutional and non-residential settings. These services
are provided at least four or more hours per day one or more days per week as
specified in the member's care plan. Customized community supports settings
must be integrated and support full access of individuals receiving medicaid
HCBS to the greater community, engage in community life, control personal
resources, and receive services in the community, to the same degree of access
as individuals not receiving medicaid HCBS.
C. Emergency response services provide an
electronic device that enables a member to secure help in an emergency at his
or her home, avoiding institutionalization. The member may also wear a portable
"help" button to allow for mobility. The system is connected to the member's
phone and programmed to signal a response center when the "help" button is
activated. The response center is staffed by trained professionals. See
Subsection E of Section
8.308.12.13
NMAC for a detailed description of this service.
D. Employment supports include job
development, job seeking and job coaching supports after available vocational
rehabilitation supports have been exhausted. Employment supports settings must
be integrated and support full access of individuals receiving medicaid HCBS to
the greater community, engage in community life, control personal resources,
and receive services in the community, to the same degree of access as
individuals not receiving medicaid HCBS. See Subsection F of Section
8.308.12.13
NMAC for a detailed description of this service.
E. Environmental modification services
include: the purchase of, the installation of equipment for the physical
adaptations to a member's residence that are necessary to ensure the health,
welfare, and safety of the member or enhance the member's level of
independence. See Subsection G of Section
8.308.12.13
NMAC for a detailed description of this service.
F. Home health aide services provide total
care or assist the member in all ADLs. See Subsection H of Section
8.308.12.13
NMAC for a detailed description of this service.
G. Self-directed personal care services (SD
PCS) are provided on an episodic or continuing basis to assist the member with
ADLs, performance of general household tasks, provide companionship to acquire,
maintain, or improve social interaction skills in the community, and enable the
member to accomplish tasks he or she would normally do for him or herself if he
or she did not have a disability.
(1)
Self-directed PCS are provided in the member's home and in the community,
depending on the member's needs. The member identifies the caregiver's training
needs, and, if the member is unable to do the training himself or herself, the
member arranges for the needed training.
(2) Self-directed PCS are not intended to
replace supports available from a primary caregiver. Self-directed PCS are not
duplicative of home health aide services.
(3) Home health aides may provide basic
non-invasive nursing assistant skills within the scope of their practice.
Self-directed PCS caregivers do not have this ability to perform such
tasks.
(4) Use of the Electronic
Visit Verification (EVV) system is required for payment of Self-directed
PCS.
H. Non-medical
transportation services are offered to enable a member to gain access to
services, activities, and resources, as specified by his or her care plan.
Payment for non-medical transportation is limited to the costs of
transportation needed to access community benefit services, activities, and
resources identified in the member's care plan. Payment for SDCB non-medical
transportation services is made to the member's individual transportation
employee or to a public or private transportation service vendor. Payment
cannot be made to the member. Non-medical transportation services for minors is
not a covered service. Non-medical transportation for members entering the SDCB
on or after January 1, 2019 is limited to a maximum of one thousand dollars
($1,000) annually per care plan year.
I. Nutritional counseling services include
assessment of the member's nutritional needs, development and revision of the
member's nutritional plan, counseling and nutritional intervention, and
observation and technical assistance related to implementation of the
nutritional plan.
J. Private duty
nursing services include activities, procedures, and treatment for a physical
condition, physical illness, or chronic disability for a member who is 21 years
of age and older with intermittent or extended direct nursing care in his or
her home. See Subsection K of Section
8.308.12.13
NMAC for a detailed description of this service.
K. Related goods are equipment, supplies or
fees and memberships, not otherwise provided through the member's MCO general
benefits.
(1) Related goods must address a
need identified in the member's CNA including improving and maintaining the
member's opportunities for full membership in the community, and meet all the
following requirements:
(a) be responsive to
the member's qualifying condition or disability;
(b) accommodate the member in managing his or
her household;
(c) facilitate the
member's ADL;
(d) promote the
member's personal safety and health;
(e) afford the member an accommodation for
greater independence;
(f) advance
the desired outcomes in the member's care plan; and
(g) decrease the need for other medicaid
services.
(2) Related
goods will be carefully monitored by the member's MCO to avoid abuses or
inappropriate use of this benefit.
(3) Services and goods that are recreational
or diversional in nature are excluded. Recreational and diversional in nature
is defined as inherently and characteristically related to activities done for
enjoyment.
(4) Related goods for
members entering the SDCB on or after January 1, 2019 are limited to a maximum
of two thousand dollars ($2,000) annually per care plan year.
L. Respite services are provided
to a member unable to care for him or herself and are furnished on a short-term
basis to allow the member's primary caregiver a limited leave of absence in
order to reduce stress, accommodate a caregiver illness, or meet a sudden
family crisis or emergency. See Subsection L of Section
8.308.12.13
NMAC for a detailed description of this service.
M. Skilled maintenance therapy services for a
member 21 years and older are provided when his or her MCO's general physical
health benefit skilled therapy services are exhausted or not a covered MCO
benefit. The community benefit skilled maintenance therapy services include
physical therapy, occupational therapy or speech language therapy. Therapy
services focus on improving functional independence, health maintenance,
community integration, socialization, and exercise, and enhance the support and
normalization of the member's family relationships. See Subsection M of
8.308.12.13
NMAC for a detailed description of this service.
N. Specialized therapies are non-experimental
therapies or techniques that have been proven effective for certain conditions.
A member may include specialized therapies in his or her care plan when the
services enhance opportunities to achieve inclusion in community activities and
avoid institutionalization. Services must be related to the member's disability
or condition, ensure the member's health and welfare in the community,
supplement rather than replace the member's natural supports and other
community services for which the member may be eligible, and prevent the
member's admission to institutional services.
(1) Acupuncture is a distinct system of
primary health care with the goal of prevention, cure, or correction of any
disease, illness, injury, pain or other physical or behavioral health condition
by controlling and regulating the flow and balance of energy, form, and
function to restore and maintain physical health and increased mental clarity
to a member. Acupuncture may provide effective pain control, decreased symptoms
of stress, improved circulation and a stronger immune system, as well as other
benefits to the member.
(2)
Biofeedback uses visual, auditory or other monitors to feed back physiological
information of which the member is normally unaware. This technique enables a
member to learn how to change physiological, psychological and behavioral
responses for the purposes of improving emotional, behavioral, and cognitive
health and performance. The use of biofeedback may assist in strengthening or
gaining conscious control over the above processes in order for the member to
self-regulate. Biofeedback therapy is also useful for muscle re-education of
specific muscle groups or for treating the member's pathological muscle
abnormalities of spasticity, incapacitating muscle spasm, or
weakness.
(3) Chiropractic care for
a member is designed to locate and remove interference with the transmissions
or expression of nerve forces in the human body by the correction of
misalignments or subluxations of the vertebral column and pelvis for the
purpose of restoring and maintaining health for treatment of human disease
primarily by, but not limited to, the adjustment and manipulation of the human
structure. Chiropractic therapy may positively affect neurological function,
improve certain reflexes and sensations, increase range of motion, and lead to
improved general health of the member.
(4) Cognitive rehabilitation therapy services
for a member are designed to improve cognitive functioning by reinforcing,
strengthening, or reestablishing previously learned patterns of behavior, or
establishing new patterns of cognitive activity or compensatory mechanisms for
impaired neurological systems. Treatments may be focused on improving a
particular cognitive domain such as attention, memory, language, or executive
functions. Alternatively, treatments may be skill-based, aimed at improving
performance of ADL. The overall goal is to restore the member's function in a
cognitive domain or set of domains, or to teach compensatory strategies to
overcome specific cognitive problems.
(5) Hippotherapy is a physical, occupational,
and speech-language therapy treatment strategy that utilizes equine movement as
part of an integrated intervention program to achieve functional outcomes.
Hippotherapy applies multidimensional movement of a horse for a member with
movement dysfunction and may increase mobility and range of motion, decrease
contractures and aid in normalizing muscle tone. Hippotherapy requires that the
member use cognitive functioning, especially for sequencing and memory. A
member with attention deficits and maladaptive behaviors is redirecting
attention and behaviors by focusing on the activity. Hippotherapy involves
therapeutic exercise, neuromuscular education, kinetic activities, therapeutic
activities, sensory integration activities, and for individual speech therapy.
The activities may also help improve respiratory function and assist with
improved breathing and speech production of the member.
(6) Massage therapy for a member is the
assessment and treatment of soft tissues and their dysfunctions for therapeutic
purposes primarily for comfort and relief of pain. It includes gliding,
kneading, percussion, compression, vibration, friction, nerve strokes,
stretching the tissue and exercising the range of motion, and may include the
use of oils, salt glows, hot or cold packs or hydrotherapy. Massage increases
the circulation, helps loosen contracted, shortened muscles and can stimulate
weak muscles to improve posture and movement, improves range of motion and
reduces spasticity. Massage therapy may increase, or help sustain, a member's
ability to be more independent in the performance of ADL; thereby, decreasing
dependency upon others to perform or assist with basic daily
activities.
(7) Naprapathy focuses
on the evaluation and treatment of neuro-musculoskeletal conditions, and is a
system for restoring functionality and reducing pain in muscles and joints. The
therapy uses manipulation and mobilization of the spine and other joints, and
muscle treatments such as stretching and massage. Based on the concept that
constricted connective tissue (ligaments, muscles and tendons) interfere with
nerve, blood and lymph flow, naprapathy uses manipulation of connective tissue
to open these channels of body function for a member.
(8) A native American healer is an individual
who is recognized as a healer within his or her respective native American
community. A native American member may be from one of the 22 sovereign tribes,
nations and pueblos in New Mexico or may be from other tribal backgrounds. A
native American healer delivers a wide variety of culturally-appropriate
therapies that support the member by addressing the member's physical,
emotional and spiritual health. Treatments delivered by a native American
healer may include prayer, dance, ceremony and song, plant medicines and foods;
participation in sweat lodges, and the use of meaningful symbols of healing,
such as the medicine wheel or other sacred objects. A native American healer
provides opportunities for the member to remain connected with his or her
tribal community. The communal and spiritual support provided by this type of
healing can reduce pain and stress and improve quality of life. It is also
important to note that some tribes, nations and pueblos prefer to keep these
healing therapies and practices safeguarded due to the significance of their
religious ties.
(9) Specialized
therapies for members entering the SDCB on or after January 1, 2019 are limited
to a maximum of two thousand dollars ($2,000) annually per care plan
year.
O. Start-up goods
are used when a member is transitioning from the ABCB model to the SDCB model.
Start-up goods enable a member to begin to self-direct his/her services.
Start-up goods include, but are not limited to, computers, printers and fax
machines. Start-up goods are provided one-time during the member's first full
or prorated care plan year and are limited to two thousand dollars
($2,000).
