Current through Register Vol. 35, No. 6, March 26, 2024
MAD covers the following services when medically necessary
and rendered as part of an eligible recipient's IEP, IFSP, 504 plan, IHCP or
other care plan by specified providers in school settings.
A. For services in Subsections A - E of
8.320.6.13 NMAC, a provider must first develop and then update the eligible
recipient's present level of performance for each of his or her IEP or IFSP
cycles. 504 plans, IHCPs or other care plans should be reviewed annually to
establish ongoing medical necessity for services. MAD requires the following
elements be included in the provider's treatment notes:
(1) the specific activity provided to the MAP
eligible recipient for each date of service billed;
(2) a description of the level of engagement
and the ability of the eligible recipient for each date of service billed;
and
(3) the outcomes of session on
the impact on the eligible recipient's exceptionality for each date of service
billed.
B. To be
reimbursed for a MAD school-based service, all of the requirements in this
subsection must be met.
(1) Services must be
medically necessary and must meet the needs specified in his or her IEP, IFSP,
504 plan, IHCP or other care plan. The services must be necessary for the
treatment of the eligible recipient's specific identified condition.
(2) The ITP portion of the IEP, IFSP, 504
plan, IHCP or other care plan must be developed in conjunction with the
appropriate qualified PT, OT, SLP, audiologist, RN, or behavioral health
provider listed in
8.320.6.11
NMAC.
(3) The LEA, REC or other
SFEA must complete a MAD specified good faith effort to notify the eligible
recipient's PCP of the services to be provided under an IEP or IFSP.
(4) Frequency and duration of services billed
may not exceed those specified in the eligible recipient's IEP, IFSP, 504 plan,
IHCP or other care plan.
(5)
Reimbursement is made directly to the LEA, REC, or other SFEA when therapy,
licensed nutritionists or registered dieticians, transportation, case manager,
or nurse providers furnish services under contract to the LEA, REC, or other
SFEA.
C.
Therapy
services: MAD covers physical, occupational, audiological and speech
evaluations, and therapy required for treatment of an identified medical
condition that is part of an eligible recipient's ITP.
D.
Nutritional assessment and
counseling: MAD covers nutritional assessment and counseling when
rendered by a licensed nutritionist or dietician for an eligible recipient who
has been referred for a nutritional need when part of his or her ITP. A
nutritional assessment consists of an evaluation of the nutritional needs of
the eligible recipient based upon appropriate biochemical, anthropometric,
physical, and dietary data, including a recommendation for appropriate
nutritional intake.
E.
Transportation services: MAD covers transportation services for an
eligible recipient who must travel from his or her school to receive a covered
service from a MAD provider when the service is unavailable in the school
setting and when the service is medically necessary and are part of the
eligible recipient's IEP or IFSP; see 8.324.7 NMAC. MAD covers transportation
to and from the school on the date a medically necessary MAD school-based
service is rendered in the school setting for an eligible recipient who has a
disability.
(1) MAD school-based services are
billed on the specific day on which transportation is rendered and are part of
the ITP portion of his or her IEP or IFSP.
(2) The eligible recipient requires
transportation in a vehicle adapted to serve his or her needs that are part of
the ITP portion of his or her IEP or IFSP.
(3) Transportation occurs in a modified
school bus for disabled students.
F.
Case management: MAD covers
school-based case management services rendered in school settings to an
eligible recipient who is medically at risk when these services are part of the
eligible recipient's ITP. Medically at risk refers to an eligible recipient who
has a diagnosed physical condition which has high probability of impairing
cognitive, emotional, neurological, social, or physical development.
(1) The service is developed in conjunction
with a qualified case manager.
(2)
MAD covers the following school-based case management services.
(a) The assessment of the eligible
recipient's medical, social and functional abilities at least every six months,
unless more frequent reassessment is indicated by the eligible recipient's
condition.
(b) The development and
implementation of a comprehensive case management plan of care that helps the
eligible recipient retain or achieve the maximum degree of
independence.
(c) The mobilization
of the use of natural helping networks, such as family members, church members,
community organizations, support groups, friends, and the school, if the
eligible recipient is able to attend.
(d) Coordination and monitoring of the
delivery of services, evaluation of the effectiveness and quality of the
services, and revision of the case management plan of care as
necessary.
(e) All services must be
delivered to be eligible for MAD reimbursement.
(3) An eligible recipient has the freedom to
choose a case management service provider. MAD will pay for only
one case management provider to furnish services to an
eligible recipient at any given time period. If an eligible recipient has a
case manager or chooses to use a case manager who is not employed or under
contract to the LEA, REC or other SFEA, the LEA, REC or other SFEA must
coordinate with the case manager in the development of the eligible recipient's
ITP.
G.
Nursing: MAD covers certain nursing services required for
treatment of a diagnosed medical condition that qualifies an eligible recipient
for an IEP, IFSP or IHCP when provided by a licensed RN or LPN. Nursing
services require professional nursing expertise and are provided by a licensed
RN or a LPN and must be provided in accordance with the New Mexico Nursing
Practice Act and must be a covered MAD service. Delegated nursing services
which are tasks in accordance with the New Mexico board of nursing that may be
delegated by the RN to unlicensed school personnel. Delegated staff may
include, but is not limited to, school or contracted staff, such as health
assistants, teachers, teacher assistants, therapists, school administrators,
administrative staff, cafeteria staff, or personal care aides.
(1) The IHCP should be written by the RN in
accordance with the NM DOH school health manual.
(2) Delegated nursing services must be
delivered in accordance with Subsection B of
16.12.2.12
NMAC.
H.
Behavioral health services: MAD covers counseling, evaluation and
therapy required for treatment of an identified behavioral health condition
that is part of an eligible recipient's ITP.
I.
Telemedicine services: MAD
covers school-based services provided via telemedicine; see 8.310.2
NMAC.
J.
Administrative
activities: MAD covers the cost of certain administrative activities
that directly support efforts to provide health-related services to a MAP
eligible recipient with special education or health care needs. These
administrative activities include, but are not limited to, providing
information about MAD services and how to access them; facilitating the
eligibility determination process; assisting in obtaining transportation and
translation services when necessary to receive health care services; making
referrals for MAD reimbursable services; and coordinating and monitoring MAD
covered medical services.
(1) Payment for an
allowable administrative activity is contingent upon the following:
(a) the LEA, REC or other SFEA must complete
a MAD PPA to become an approved school-based health services
provider;
(b) the LEA, REC or other
SFEA must enter into a GSA with HSD and agree to abide by the terms and
conditions of the GSA;
(c) the LEA,
REC or other SFEA must submit claims for allowable administrative activities in
accordance with federal and state regulations, rules and guidelines.
(2) A provider or contractor
coordination with the school or contractor or in consultation with principals,
school counselors, or teachers are not billable as a service by the provider.
The provider must consult with the school to determine if the school will
include such activities in its contract with the provider or contractor. The
school may not bill MAD separately for these services but can include the costs
as administrative costs.
(3)
Administrative claiming is subject to compliance reviews and audits conducted
by HSD, the state medicaid fraud control unit and the Centers for Medicare and
Medicaid Services (CMS). By signing the MAD PPA, the LEA, REC or other SFEA
agrees to cooperate fully with HSD, the state medicaid fraud control unit and
CMS in the performance of all reviews and audits and further agrees to comply
with all review and audit requirements.
