Current through Register Vol. 35, No. 18, September 24, 2024
A.
The MCO shall cover the following behavioral health services listed below. When
an additional behavioral health service is approved by MAD, the MCO shall cover
that service as well. See 8.321.2 NMAC for detailed descriptions of each
service. MAD makes available on its websiteits behavioral health service
definitions and crosswalk, along with other information.
(1)
Applied behavior analysis:
The benefit package includes applied behavior analysis (ABA) services for
eligible recipients who have a well-documented medical diagnosis of autism
spectrum disorder (ASD), and for eligible recipients who have well-documented
risk for the development of ASD. As part of a three-stage comprehensive
approach consisting of evaluation, assessment, and treatment, ABA services may
be provided in coordination with other medically necessary services (e.g.,
family infant toddler program (FIT) services, occupational therapy, speech
language therapy, medication management, developmentally disabled waiver
services, etc.). ABA services are part of the early periodic screening,
diagnosis and treatment (EPSDT) program (CFR 42 section 441.57). There is no
age requirement to receive ABA services and ABA is a covered benefit for
medicaid-enrolled adults.
(2)
Assertive community treatment services (ACT): The benefit package
includes assertive community treatment services for a member 18 years of age
and older.
(3)
Behavioral
health respite: Behavioral health respite care is provided to a member
under 21 years of age to support the member's family and strengthen their
resiliency during the respite while the member is in a supportive environment.
Respite care is provided to a member with a severe emotional disturbance who
resides with his or her family and displays challenging behaviors that may
periodically overwhelm the member's family's ability to provide ongoing
supportive care. See the New Mexico interagency behavioral health purchasing
collaborative service requirements and utilization guidelines-respite
services-for a detailed description. Behavioral health respite is not a benefit
for ABP eligible recipients.
(4)
Comprehensive community support services: The benefit package
includes comprehensive community support services for a member.
(5)
Crisis Services: The benefit
package includes three types of crisis services:
(a) 24-hour crisis telephone support;
and
(b) mobile crisis team;
and
(c) crisis triage
centers.
(6)
Family support services: The benefit package includes family
support services to a member whose focus is on the member and his or her family
and the interactive effect through a variety of informational and supportive
activities that assists the member and his or her family develop patterns of
interaction that promote wellness and recovery over time. The positive
interactive effect between the member and his or her family strengthens the
effectiveness of other treatment and recovery initiatives. See the New Mexico
interagency behavioral health purchasing collaborative service requirements and
utilization guidelines -family support services-for a detailed description.
Family support services are not a benefit for ABP eligible
recipients.
(7)
Hospital
outpatient services: The benefit package includes outpatient psychiatric
and partial hospitalization services provided in PPS-exempt unit of a general
hospital for a member.
(8)
Inpatient hospital services: The benefit package includes
inpatient hospital psychiatric services provided in general hospital units and
prospective payment system (PPS)-exempt units in a general hospital as detailed
in 8.311.2 NMAC.
(9)
Intensive outpatient (IOP) services: The benefit package includes
intensive outpatient services for a member 13 years of age.
(10)
Medication assisted treatment
(MAT) and Opioid Treatment Programs: The benefit package includes
opioid treatment services for opioid addiction to a member through an opioid
treatment center as defined in 42 CFR Part 8 , Certification of Opioid
Treatment; and buprenorphine and related pharmaceuticals. Medication assisted
treatments include use of buprenorphine and similarly acting
products.
(11)
Outpatient
therapy services: The benefit package includes outpatient therapy
services (individual, family, and group) for a member.
(12)
Psychological rehabilitation
services: The benefit package includes adult psychosocial rehabilitation
services for a member 18 years and older.
(13)
Recovery services: The MCO
benefit package includes recovery services for a member. Recovery services are
peer-to-peer support within a group setting to develop and enhance wellness and
healthcare practices. The service enables a member to identify additional needs
and goals and link him or herself to additional support as a result. See the
New Mexico interagency behavioral health purchasing collaborative service
requirements and utilization guidelines -recovery services-for a detailed
description. Recovery services are not a benefit for ABP eligible
recipients.
B.
Behavioral health EPSDT services: The benefit package includes the
delivery of the federally mandated EPSDT services (42 CFR Section
441.57) provided by a behavioral health
practitioner for a member under 21 years of age. See 8.321.2 NMAC for a
detailed description of each service. The MCO shall provide access to EPSDT for
a member identified in his or her EPSDT tot to teen health check screen or
another diagnostic evaluation as being at-risk for developing or having a
severe emotional, behavioral or neurobiological disorder.
(1)
Accredited residential treatment
center (ARTC): The benefit package includes services furnished in an
ARTC furnished as part of the EPSDT program. ARTC services are provided to a
member who needs the LOC furnished in an out-of-home residential setting. The
need for ARTC services must be identified in the member's tot to teen health
check screen or another diagnostic evaluation furnished through a health check
referral.
(2)
Behavior
management skills development services (BMS): The benefit package
includes BMS services furnished as part of the EPSDT program. BMS services are
provided to a member who has an identified need for such services and meets the
required LOC. The need for BMS services must be identified in the member's tot
to teen health check screen or another diagnostic evaluation furnished through
a health check referral.
(3)
Day treatment services: The benefit package includes day treatment
services furnished as part of the EPSDT program. Day treatment services are
provided to a member who has an identified need for such services and meets the
required LOC. The need for day treatment services must be identified in the
member's tot to teen health check screen or another diagnostic evaluation
furnished through a health check referral.
(4)
Inpatient hospitalization services
provided in freestanding psychiatric hospitals: The benefit package
includes inpatient psychiatric care furnished in a freestanding psychiatric
hospital furnished as part of the EPSDT program. Inpatient hospitalization
services are provided in a freestanding psychiatric hospital are provided to a
member who has an identified need for such services and meet the required LOC.
The need for such services must be identified in the member's tot to teen
health check screen or another diagnostic evaluation furnished through a health
check referral.
(5)
Multi-systemic therapy (MST): The benefit package includes MST
services furnished as part of the EPSDT program. MST services are provided to a
member who has an identified need for such services and meets the required LOC.
The need for MST services must be identified in the member's tot to teen health
check screen or another diagnostic evaluation furnished through a health check
referral.
(6)
Psychosocial
rehabilitation services (PSR): The benefit package includes PSR services
furnished as part of the EPSDT program. PSR is provided to a member who has an
identified need for such services and meets the required LOC. The need for PSR
services must be identified in the member's tot to teen health check screen or
another diagnostic evaluation furnished through a health check
referral.
(7)
Treatment
foster care I (TFC I): The benefit package includes TFC I furnished as
part of the EPSDT program. TFC I services are provided to a member who has an
identified need for such services and meets the required LOC. The need for TFC
I services must be identified in the member's tot to teen health check or
another diagnostic evaluation furnished through a health check
referral.
(8)
Treatment
foster care II (TFC II): The benefit package includes TFC II services
furnished as part of the EPSDT program. TFC II is provided to a member who has
an identified need for such services and meets the required LOC. The need for
TFC II services must be identified in the member's tot to teen health check or
another diagnostic evaluation furnished through a health check
referral.
(9)
Residential
non-accredited treatment center (RTC) and group home: The benefit
package includes services furnished in a RTC center or group home as part of
the EPSDT program. RTC or group home services are provided to a member who
needs the LOC furnished in an out-of-home residential setting. The need for RTC
and group home services must be identified in the member's tot to teen health
check screen or another diagnostic evaluation furnished through a health check
referral.