New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 321 - SPECIALIZED BEHAVIORAL HEALTH SERVICES
Part 2 - SPECIALIZED BEHAVIORAL HEALTH PROVIDER ENROLLMENT AND REIMBURSEMENT
Section 8.321.2.13 - ASSERTIVE COMMUNITY TREATMENT SERVICES
Universal Citation: 8 NM Admin Code 8.321.2.13
Current through Register Vol. 35, No. 18, September 24, 2024
To help an eligible recipient with medically necessary services MAD pays for covered assertive community treatment services (ACT). See Subsections A and B of 8.321.2.9 NMAC for MAD general provider requirements.
A. Eligible providers:
(1) An ACT agency must demonstrate compliance
with administrative, financial, clinical, quality improvement and information
services infrastructure standards established by MAD or its designee, including
compliance and outcomes consistent with the ACT fidelity model. See Subsections
A and B of
8.321.2.9
NMAC for MAD general provider requirements.
(2) An ACT agency providing coordinated
specialty care for an individual with first episode psychosis must provide
services consistent with the coordinated specialty care (CSC) model.
(3) ACT services must be provided by an
agency designated team of 10 to 12 members; see Paragraph (5) of Subsection A
of 8.321.2.13 NMAC for the required composition. Lower number of team member
compositions may be considered by BHSD for a waiver request dependent on the
nature of the clinical severity and rural vs. urban environment pending BHSD
approval. Each team must have a designated team leader. Practitioners on this
team shall have sufficient individual competence, professional qualifications
and experience to provide service coordination; crisis assessment and
intervention; symptom assessment and management; individual counseling and
psychotherapy; prescription, administration, monitoring and documentation of
medications; substance abuse treatment; work-related services; activities of
daily living services; support services or direct assistance to ensure that the
eligible recipient obtains the basic necessities of daily life; and
coordination, support and consultation to the eligible recipient's family and
other major supports. The agency must coordinate its ACT services with local
hospitals, local crisis units, local law enforcement agencies, local behavioral
health agencies, and consider referrals from social service agencies.
(4) Each ACT team staff member must be
successfully and currently certified or trained according to ACT fidelity model
standards. The training standards focus on developing staff competencies for
delivering ACT services according to the most recent ACT evidenced-based
practices and ACT fidelity model. Each ACT team shall have sufficient numbers
of qualified staff to provide treatment, rehabilitation, crisis and support
services 24-hours a day, seven days a week.
(5) Each ACT team shall have a staff-to
eligible recipient ratio dependent on the nature of the team based on clinical
severity and rural vs. urban environment pending BHSD approval to ensure
fidelity with current model.
(6)
Each ACT team must comply with
8.321.2.9
NMAC for specific licensing requirements for ACT staff team members as
appropriate, and must include:
(a) one team
leader who is an independently licensed behavioral health practitioner (LPCC,
LMFT, LISW, LCSW, LPAT, psychologist);
(b) medical director/prescriber:
(i) board certified or board eligible
psychiatrist; or
(ii) NM licensed
psychiatric certified nurse practitioner; or
(iii) NM licensed psychiatric clinical nurse
specialist; or
(iv) prescribing
psychologist under the supervision or consultation of an MD; or
(c) two licensed nurses, one of
whom shall be a RN, or other allied medical professionals may be used in place
of one nurse;
(d) at least one
other MAD recognized licensed behavioral health professional;
(e) at least one MAD recognized licensed
behavioral health practitioner with expertise in substance use
disorders;
(f) at least one
employment specialist;
(g) at least
one New Mexico certified peer support worker (CPSW) through the approved state
of New Mexico certification program; or certified family peer support worker
(CFPSW);
(h) one administrative
staff person; and
(i) the eligible
recipient shall be considered a part of the team for decisions impacting his or
her ACT services.
(7)
The agency must have a HSD ACT approval letter to render ACT services to an
eligible recipient. The approval letter will authorize an agency also
delivering CSC services.
(8) Any
adaptations to the model require an approved variance from BHSD.
B. Coverage criteria:
(1) MAD covers medically necessary ACT
services required by the condition of the eligible recipient.
(2) The ACT program provides four levels of
interaction with the participating individuals:
(a) Face-to-face encounters.
(b) Collateral encounters designated as
members of the recipient's family or household, or significant others who
regularly interact with the recipient and are directly affected by or have the
capability of affecting his or her condition, and are identified in the service
plan as having a role in treatment.
(c) Assertive outreach defined as the ACT
team having knowledge of what is happening with an individual. This occurs in
either locating the individual or acting quickly and decisively when action is
called for, while increasing client independence. This is done on behalf of the
client, and can comprise only five percent per individual of total service time
per month.
(d) Group encounters
defined by the following types:
(i) Basic
living skills development;
(ii)
Psychosocial skills training;
(iii)
Peer groups; or
(iv) Wellness and
recovery groups.
(3) The ACT therapy model is based on
empirical data and evidence-based interventions that target specific behaviors
with an individualized treatment plan for the eligible recipient. Specialized
therapeutic and rehabilitative interventions falling within the fidelity of the
ACT model are used to address specific areas of need, such as experiences of
repeated hospitalization or incarcerations, severe problems completing
activities of daily living and individuals who have a significant history of
involvement in behavioral health services.
C. Identified population:
(1) ACT services are provided to an eligible
recipient aged 18 and older whose diagnosis or diagnoses meet the criteria of
serious mental illness (SMI) with a special emphasis on psychiatric disorders,
including schizophrenia, schizoaffective disorder, bipolar disorder or
psychotic depression for individuals who have severe problems completing
activities of daily living, who have a significant history of involvement in
behavioral health services and who have experienced repeated hospitalizations
or incarcerations due to mental illness.
(2) ACT services can also be provided to
eligible individuals 15 to 30 years of age who are within the first two years
of their first episode of psychosis.
(3) A co-occurring diagnosis of substance
abuse shall not exclude an eligible recipient from ACT services.
D. Covered services: ACT is a voluntary medical, comprehensive case management and psychosocial intervention program provided on the basis of principles covered in the BH policy and billing manual.
E. Non-covered services: ACT 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 MAD general non-covered behavioral health services. MAD does not cover other psychiatric, mental health nursing, therapeutic, non-intensive outpatient substance abuse or crisis services when billed in conjunction with ACT services to an eligible recipient, except for medically necessary medications and hospitalizations. Psychosocial rehabilitation services can be billed for a six-month period for transitioning levels of care, but must be identified as a component of the treatment plan.
F. Reimbursement: ACT agencies must submit claims for reimbursement on the CMS-1500 claim form or its successor. See Subsection H of 8.321.2.9 for MAD general reimbursement requirements.
Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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