Current through Register Vol. 35, No. 18, September 24, 2024
MAD special rehabilitation services are furnished through
the New Mexico early childhood education and care department (ECECD) family
infant toddler (FIT) program. FIT provides early intervention services for a
MAP eligible that has or is at risk of having a developmental delay from birth
to his or her third birth year. Developmental delay or at risk of is defined by
ECECD. A MAP eligible recipient with a developmental delay or who is at risk of
having a developmental delay is not considered to have a diagnosis of an
intellectual or developmental disability. FIT services include evaluation,
diagnostics and treatment necessary to correct or treat any defects or
conditions or to teach compensatory skills for deficits that directly result
from a medical or behavioral health condition. The appropriate information from
evaluation and diagnostics is interpreted and integrated in the individual
family service plan (IFSP). If the need for special rehabilitation is
identified outside of the tot to teen healthcheck process, the MAP eligible
recipient's PCP must be notified of the results and be included in the
treatment plan development, if the PCP so elects.
A. MAD EPSDT special rehabilitation eligible
providers: An enrolled MAD agency certified by ECECD as a special
rehabilitation services provider is eligible to be reimbursed for furnishing
special rehabilitation services to a MAP eligible recipient. Individual
providers rendering special rehabilitation services that are employed by or
contracted by a MAD special rehabilitation provider agency must meet applicable
ECECD standards. A provider shall:
(1) render
special rehabilitation services under the direction of a professional acting
within his or her scope of practice as defined by state law;
(2) render special rehabilitation services in
the most appropriate least restrictive environment;
(3) assure that claiming for special
rehabilitation services does not duplicate claiming for EPSDT administrative
outreach services or services funded under the state general fund ECECD
contract.
B. EPSDT
special rehabilitation MAP eligible recipients: An individual who has been
determined through a multidisciplinary developmental evaluation to have, or be
at risk for, a developmental delay and to be in need of special rehabilitative
services as defined by ECECD is eligible to receive special rehabilitation
services. Any individual that has been diagnosed with an intellectual or
developmental disability is not eligible for FIT services.
C. EPSDT special rehabilitation treatment
plan for a MAP eligible recipient: The need for special rehabilitation services
must be documented in the MAP eligible recipient's treatment plan or in his or
her IFSP. The treatment plan must be developed in accordance with applicable
ECECD policies and procedures and federal regulations governing Part C of the
Individuals with Disabilities Education Act. The treatment plan or IFSP must be
developed within 45 calendar days of the initiation of services and reviewed
every six months or more often as indicated. The following must be contained in
the treatment plan or IFSP documents and must be available for review in the
MAP eligible recipient's agency file:
(1) a
statement of the MAP eligible recipient's present levels of physical
development including vision, hearing, and health status;
(2) an assessment of his or her
communications development;
(3) an
assessment of his or her behavioral health status, to include his or her social
or emotional development;
(4) an
assessment of his or her cognitive development;
(5) an assessment of his or her adaptive
development;
(6) his or her family
history and other relevant family information;
(7) a description of his or her intermediate
and long-range goals, with a projected timetable for their attainment and
dates, and the duration and scope of services;
(8) the procedures and timelines to determine
the progress made toward achieving the outcomes and whether modifications to or
revisions of the outcomes or services are needed; and
(9) statement of the specific special
rehabilitation services needed to meet the MAP eligible recipient's unique
needs and also achieve the outcomes specified, including the frequency,
intensity and method of delivering each service, the environment in which each
service will be provided, and the location of each service.
D. EPSDT special rehabilitation
covered services:
(1) MAD only covers special
rehabilitation services necessary to enhance development in one or more of the
following developmental domains:
(a) physical
and motor;
(b)
communication;
(c)
adaptive;
(d) cognitive;
(e) behavioral health to include social or
emotional; or
(f)
sensory.
(2) Special
rehabilitation services generally involve the MAP eligible recipient's family
and are designed to support and enhance the MAP eligible recipient's
developmental services and are provided through FIT. The following are a list
of covered services:
(a) Developmental
evaluation and rehabilitation services are the assessments performed to
determine if motor, speech, language and psychological problems exist with the
MAP eligible recipient or to detect the presence of his or her developmental
lags. Services include diagnostic, evaluative and consultative services for the
purposes of identifying or determining the nature and extent of, and
rehabilitating a MAP eligible recipient's medical or other health-related
condition. Services also include consultation with the family and other
professional staff. These services are provided as a result of a referral from
the MAP eligible recipient's PCP.
(b) Nursing services are performed by a MAD
enrolled certified nurse practitioner (CNP), registered nurse (RN) or licensed
practical nurse (LPN) within the scope of his or her practice relevant to the
medical and rehabilitative needs of the MAP eligible recipient. These services
are provided as the result of a referral from the MAP eligible recipient's PCP.
Services include the administration and monitoring of medication,
catheterization, tube feeding, suctioning, and the screening and referral for
other health needs. Nursing services also include explanations to the MAP
eligible recipient's family or other professional staff concerning the
treatments, therapies, and physical or social emotional health
conditions.
(c) Physical therapy
services are provided by or under the direction of a qualified MAD enrolled
physical therapist (PT) as a result of a referral from the MAP eligible
recipient's PCP. Physical therapy services are the evaluations required to
determine the MAP eligible recipient's need for physical therapy and the
provision of therapies that are rehabilitative, active or restorative, and
designed to correct or compensate for a medical problem interfering with age
appropriate functional performance. Services also include consultation with the
family and other professional staff.
(d) Occupational therapy services are
provided by or under the direction of a qualified MAD enrolled occupational
therapist (OT) as the result of a referral from the MAP eligible recipient's
PCP. Occupational therapy services include the evaluation of the MAP eligible
recipient to determine if he or she is experiencing problems that interfere
with his or her functional performance and the provision of therapies that are
rehabilitative, active or restorative, and designed to correct or compensate
for a medical problem interfering with age appropriate functional performance.
Services also include consultation with the MAP eligible recipient's family and
other professional staff.
(e)
Behavioral health services are diagnostic or active treatments with the intent
to reasonably improve the MAP eligible recipient's condition; see 8.321.2 NMAC
for a detailed description of behavioral health services.
(f) Speech, language and hearing services
provided by or under the direction of a MAD enrolled SLP or audiologist, as the
result of a referral by the MAP eligible recipient's PCP. Speech, language and
hearing services are the evaluations required to determine the MAP eligible
recipient's need for these services and recommendations for a course of
treatment. Treatment is provided to a MAP eligible recipient with a diagnosed
speech, language or hearing disorder which adversely affects his or her
functioning. Services also include consultations with the MAP eligible
recipient's family and other professional staff.
E. EPSDT special rehabilitation
noncovered services: Special rehabilitation services are subject to the
limitations and coverage restrictions which exist for other MAD services. See
Section 14 of this rule for general non-covered MAD EPSDT services or
activities.
F. EPSDT special
rehabilitation prior approval and utilization: All MAD EPSDT 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. Specifically, for special
rehabilitation services, a maximum of 14 hours per month of services to a MAP
eligible recipient can be furnished by a provider before prior approval is
required from ECECD.
