Current through Register Vol. 35, No. 6, March 26, 2024
MAD pays for case management services furnished to a
medically at risk MAP eligible recipient under 21 years of age as an EPSDT
service. The need for case management services must be identified in the tot to
teen healthcheck screen or through other diagnostic evaluations or
assessments.
A. EPSDT case management
eligible providers: A qualified MAD enrolled case management agency is eligible
to be reimbursed for furnishing services to a MAP eligible recipient. An agency
must demonstrate direct experience in successfully serving medically at risk
individuals under the age of 21 years and demonstrate knowledge of available
community services and methods for gaining access to those services.
(1) The following agencies can furnish case
management services:
(a) a governmental
agency;
(b) a native Indian tribal
government;
(c) the IHS;
(d) a FQHC; and
(e) a community case management
agency.
(2) Case manager
qualifications: A case manager employed by a MAD enrolled case management
agency must possess the education, skills, abilities, and experience to perform
case management services. Case managers must have at least one year of
experience serving medically at risk individuals under the age of 21 years.
Case managers must have the necessary skills to meet the needs of a particular
MAP eligible recipient. In some instances, it is important that the case
manager have language skills, cultural sensitivity and acquired knowledge
unique to a geographic area. In addition, a case manager must meet at least one
of the following requirements:
(a) hold a
bachelor's degree in social work, counseling, psychology, sociology, education,
special education, cultural anthropology or a related health or social service
field from an accredited institution; a case manager with a bachelor's degree
in another field can substitute two years of direct experience in serving the
medically at risk population for the required field of study; or
(b) be licensed as a RN or LPN;
(c) case management services for medically
fragile MAP eligible recipients must be provided by a licensed RN;
and
(d) if there are no suitable
case managers with the previously described qualifications, an agency can
employ a case manager with the following education and experience rendering
services under the direct supervision of an experienced case manager who meets
the qualifications specified above:
(i) hold
an associate's degree and has a minimum of three years of experience in
community health or social services; or
(ii) hold a high school diploma or a graduate
equivalence diploma (GED) and has a minimum of four years of experience in
community health or social services.
(3) Agency restrictions: MAD restricts the
type of agency that can provide case management services to a MAP eligible
recipient with developmental disabilities. See
42 U.S.C. Section
1396 n(g)(1)(2). A case management provider
for a MAP eligible recipient with developmental disability or severe emotional
disturbance must be certified by DOH or CYFD.
(4) MAP eligible recipients: When a MAD
enrolled recipient is determined to be medically at risk, he or she is eligible
for case management services. "Medically at risk" is defined as an individual
who has a diagnosed physical or social emotional condition which has a high
probability of impairing his or her cognitive, emotional, neurological, social
or physical development.
B. EPSDT case management treatment plan
(CMTP) or individualized service plan (ISP): The CMTP or ISP is developed by
the case manager in cooperation with the MAP eligible recipient, his or her
family or legal guardian, his or her PCP, as appropriate, and others involved
with the MAP eligible recipient's care. The CMTP is developed within 30
calendar days of the initiation of services. The MAP eligible recipient is
reassessed and the CMTP is updated annually, or more often as indicated. For a
MAP eligible recipient who is medically fragile, the ISP is written and
approved within 60 calendar days of the initiation of services which are to
start immediately. The ISP is reviewed regularly during the monthly visits;
however, the MAP eligible recipient is reassessed annually with a new ISP
developed with the MAP eligible recipient, his or her family and the
interdisciplinary team. A social worker may be involved in the development of
the treatment plan in the case of a MAP eligible recipient who is in the
custody of CYFD or another state agency.
(1)
The following, as appropriate, must be contained in the CMTP and ISP or
documents used in the development of each. The CMTP, the ISP, and all
supporting documentation must be available for review in the MAP eligible
recipient's file:
(a) statement of the nature
of the specific problem and the specific needs of the MAP eligible
recipient;
(b) description of the
functional level of the MAP eligible recipient, including the following:
(i) social emotional or behavioral health
status assessment;
(ii)
intellectual function assessment;
(iii) psychological assessment;
(iv) educational assessment;
(v) vocational assessment;
(vi) social assessment;
(vii) medical assessment; and
(viii) physical assessment;
(c) statement of the least
restrictive conditions necessary to achieve the purposes of
treatment;
(d) description of the
intermediate and long-range goals, with the projected timetable for their
attainment and duration and scope of services; and
(e) statement and rationale of the CMTP or
ISP for achieving these intermediate and long-range goals, including provisions
of review and modification of the plan and plans for discontinuation of
services, criteria for discontinuation of services and projected date service
will be discontinued for the MAP eligible recipient.
(2) Assessments must be performed
face-to-face with the MAP eligible recipient, his or her family or legal
guardian.
(3) The agency must have
a statement of the specific case management services needed to meet the MAP
eligible recipient's unique needs and to achieve the outcomes specified in the
CMTP or ISP, 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.
C. EPSDT case management covered services:
(1) MAD covers the following case management
services:
(a) face-to-face assessment of the
MAP eligible recipient's medical, behavioral health, social needs and
functional limitations; the MAP eligible recipient is reassessed and the CMTP
is updated annually, or more often as indicated;
(b) the development and implementation of
plans of care designed to help the MAP eligible recipient retain or achieve the
maximum degree of independence; certain EPSDT enhanced services can be
furnished only if included in the CMTP or ISP, including private duty
nursing;
(c) the mobilization of
the use of natural helping networks such as family members, church members,
community organizations, support groups and friends; and
(d) the coordination and monitoring of the
delivery of services, the evaluation of the effectiveness and quality of the
services, and the revision of the MAP eligible recipient's CMTP or ISP, when
appropriate.
(2) When a
MAP eligible recipient is in an out-of-home placement, MAD covers comprehensive
coordinated support services (CCSS) detailed in 8.321.2 NMAC during the last 30
calendar days of his or her placement.
D. EPSDT case management noncovered services:
Case management services are subject to the limitations and coverage
restrictions which exist for other MAD services. Case management services may
not be billed in conjunction with:
(1)
services to an individual who is not eligible or who does not meet the MAD
definition of medically at risk;
(2) services furnished by other practitioners
such as: therapists, transportation providers, homemakers or personal care
service providers;
(3) formal
educational or vocation services related to traditional academic subjects or
vocational training;
(4) client
outreach activities in which a provider attempts to contact potential
recipients;
(5) administrative
activities, such as MAD eligibility determinations and agency intake
processing;
(6) institutional
discharge planning which is a required condition for payment of hospital,
nursing home, treatment foster care or other residential treatment center
services; discharge planning must not be billed separately as a targeted case
management service;
(7) services
which are not documented by the case manager in the MAP eligible recipient's
agency file; or
(8) services to a
recipient who receives case management services through a home and
community-based services waiver program.
