Current through Register Vol. 35, No. 18, September 24, 2024
To help an eligible recipient under 21 years of age when the
need for ARTC has been identified in the eligible recipient's tot to teen
health check screen (EPSDT) program (42 CFR section
441.57) or other diagnostic evaluation, and
for whom a less restrictive setting is not appropriate, MAD pays for services
furnished to him or her by an ARTC accredited by the joint commission (JC), the
commission on accreditation of rehabilitation facilities (CARF) or the council
on accreditation (COA). A determination must be made that the eligible
recipient needs the level of care (LOC) for services furnished in an ARTC. This
determination must have considered all environments which are least
restrictive, meaning a supervised community placement, preferably a placement
with the juvenile's parent, guardian or relative. A facility or conditions of
treatment that is a residential or institutional placement should only be
utilized as a last resort based on the best interest of the juvenile or for
reasons of public safety.
A.
Eligible facilities:
(1) In addition
to the requirements of Subsections A and B of
8.321.2.9
NMAC, in order to be eligible to be reimbursed for providing ARTC services to
an eligible recipient, an ARTC facility:
(a)
must provide a copy of its JC, COA, or CARF accreditation as a children's
residential treatment facility;
(b)
must provide a copy of its CYFD ARTC facility license and certification;
and
(c) must have written
utilization review (UR) plans in effect which provide for review of the
eligible recipient's need for the ARTC that meet federal requirements; see
42 CFR
Section 456.201 through
456.245;
(2) If the ARTC is operated by IHS
or by a federally recognized tribal government, the youth based facility must
meet CYFD ARTC licensing requirements, but is not required to be licensed or
certified by CYFD. In lieu of receiving a license and certification, CYFD will
provide MAD copies of its facility findings and recommendations. MAD will work
with the facility to address recommendations. Details related to findings and
recommendations for an IHS or federally recognized tribal government's ARTC are
detailed in the BH policy and billing manual; and
(3) In lieu of New Mexico CYFD licensure, an
out-of-state or MAD border ARTC facility must have JC, COA or CARF
accreditation and be licensed in its own state as an ARTC residential treatment
facility.
B.
Covered services: MAD covers accommodation and residential treatment
services which are medically necessary for the diagnosis and treatment of an
eligible recipient's condition. An ARTC facility must provide an
interdisciplinary psychotherapeutic treatment program on a 24-hour basis to the
eligible recipient. The ARTC will coordinate with the educational program of
the recipient, if applicable.
(1) Treatment
must be furnished under the direction of a MAD board eligible or certified
psychiatrist.
(2) Treatment must be
based on the eligible recipient's individualized treatment plans rendered by
the ARTC facility's practitioners, within the scope and practice of their
professions as defined by state law, rule or regulation. See Subsection B of
8.321.2.9
NMAC for general behavioral health professional requirements.
(3) Treatment must be reasonably expected to
improve the eligible recipient's condition. The treatment must be designed to
reduce or control symptoms or maintain levels of functioning and avoid
hospitalization or further deterioration is acceptable expectations of
improvement.
(4) The following
services must be performed by the ARTC agency to receive reimbursement from
MAD:
(a) performance of necessary evaluations,
psychological testing and development of the eligible recipient's treatment
plans, while ensuring that evaluations already performed are not
repeated;
(b) provide regularly
scheduled counseling and therapy sessions in an individual, family or group
setting following the eligible recipient's treatment plan;
(c) facilitation of age-appropriate skills
development in the areas of household management, nutrition, personal care,
physical and emotional health, basic life skills, time management, school
attendance and money management to the eligible recipient;
(d) assistance to the eligible recipient in
his or her self-administration of medication in compliance with state statute,
regulation and rules;
(e) maintain
appropriate staff available on a 24-hour basis to respond to crisis situations,
determine the severity of the situation, stabilize the eligible recipient, make
referrals, as necessary, and provide follow-up to the eligible
recipient;
(f) consultation with
other professionals or allied caregivers regarding the needs of the eligible
recipient, as applicable;
(g)
non-medical transportation services needed to accomplish the eligible
recipient's treatment objective; and
(h) therapeutic services to meet the
physical, social, cultural, recreational, health maintenance and rehabilitation
needs of the eligible recipients.
C.
Non-covered services: ARTC
services are subject to the limitations and coverage restrictions that exist
for other MAD services. See Subsection G of
8.321.2.9
NMAC for general MAD behavioral health non-covered services or activities. MAD
does not cover the following specific services billed in conjunction with ARTC
services to an eligible recipient:
(1) CCSS,
except when provided by a CCSS agency in discharge planning for the eligible
recipient from the facility;
(2)
services for which prior approval was not requested and approved;
(3) services furnished to ineligible
individuals; ARTC and group services are covered only for eligible recipients
under 21 years of age;
(4) formal
educational and vocational services which relate to traditional academic
subjects or vocation training; and
(5) activity therapy, group activities, and
other services primarily recreational or diversional in nature.
D.
Treatment plan:
The treatment plan must be developed by a team of professionals in
consultation with the eligible recipient, his or her parent, legal guardian and
others in whose care he or she will be released after discharge. The plan must
be developed within 14 calendar days of the eligible recipient's admission to
an ARTC facility. The interdisciplinary team must review the treatment plan at
least every 30 calendar days. In addition to the requirements of Subsection K
of
8.321.2.9
NMAC, all supporting documentation must be available for review in the eligible
recipient's file. The treatment plan must also include a statement of the
eligible recipient's cultural needs and provision for access to cultural
practices.
E.
Prior
authorization: Before any ARTC services are furnished to an eligible
recipient, prior authorization is required from MAD or its designee. Services
for which prior authorization was obtained remain subject to utilization review
at any point in the payment process.
F.
Reimbursement: An ARTC
agency must submit claims for reimbursement on the UB-04 form or its successor.
See Subsection H of
8.321.2.9
NMAC for MAD general reimbursement requirements and see 8.302.2 NMAC. Once
enrolled, the agency receives instructions on how to access documentation,
billing, and claims processing information.
(1) The MAD fee schedule is based on actual
cost data submitted by the ARTC agency. Cost data is grouped into various cost
categories for purposes of analysis and rate setting. These include direct
service, direct service supervision, therapy, admission and discharge planning,
clinical support, non-personnel operating, administration and consultation.
(a) The MAD fee schedule reimbursement covers
those services considered routine in the residential setting. Routine services
include, but are not limited to: counseling, therapy, activities of daily
living, medical management, crisis intervention, professional consultation,
transportation, rehabilitative services and administration.
(b) Services which are not covered in routine
services include other MAD services that an eligible recipient might require
that are not furnished by the facility, such as pharmacy services, primary care
visits, laboratory or radiology services, are billed directly by the applicable
providers and are governed by applicable sections of NMAC rules.
(c) Services which are not covered in the
routine rate and are not a MAD covered service include services not related to
medical necessity, clinical treatment, and patient care.
(2) A vacancy factor of 24 days annually for
each eligible recipient is built in for therapeutic leave and trial community
placement. Since the vacancy factor is built into the rate, an ARTC agency
cannot bill nor be reimbursed for days when the eligible recipient is absent
from the facility.
(3) An ARTC
agency must submit annual cost reports in a form prescribed by MAD. Cost
reports are due 90 calendar days after the close of the agency's fiscal year
end.
(a) If an agency cannot meet this due
date, it can request a 30 calendar day extension for submission. This request
must be made in writing and received by MAD prior to the original due
date.
(b) Failure to submit a cost
report by the due date or the extended due date, when applicable, will result
in suspension of all MAD payments until the cost report is received.
(4) Reimbursement rates for an
ARTC out-of-state provider located more than 100 miles from the New Mexico
border (Mexico excluded) are at the fee schedule unless a separate rate is
negotiated.
