Current through Register Vol. 35, No. 18, September 24, 2024
MAD pays for services provided by a day treatment provider
as part of the EPSDT program for eligible recipients under 21 years of age
(42 CFR section
441.57) . The need for day treatment services
(DTS) must be identified through an EPSDT tot to teen health check or other
diagnostic evaluation. Day treatment services include eligible recipient and
parent education, skill and socialization training that focus on the
amelioration of functional and behavioral deficits. Intensive coordination and
linkage with the eligible recipient's school or other child serving agencies is
included. The goals of the service must be clearly documented utilizing a
clinical model for service delivery and support.
A.
Eligible providers: An
agency must be certified by CYFD to provide day treatment services in addition
to meeting the general provider enrollment requirements in Subsections A and B
of
8.321.2.9
NMAC.
B.
Coverage
criteria:
(1) Day treatment services
must be provided in a school setting or other community setting; however, there
must be a distinct separation between these services in staffing, program
description and physical space from other behavioral health services
offered.
(2) A family who is unable
to attend the regularly scheduled sessions at the day treatment facility due to
transportation difficulties or other reasons may receive individual family
sessions scheduled in the family's home by the day treatment agency.
(3) Services must be based upon the eligible
recipient's individualized treatment plan goals and should include
interventions with a significant member of the family which are designed to
enhance the eligible recipients' adaptive functioning in their home and
community.
(4) The certified DTS
provider delivers adequate care and continuous supervision of the client at all
times during the course of the client's DTS program participation.
(5) 24-hour availability of appropriate staff
or implementation of crisis plan (which may include referral) to respond to the
eligible recipient's crisis situation.
(6) Only those activities of daily living and
basic life skills that are assessed as a clinical problem should be addressed
in the treatment plans and deemed appropriate to be included in the eligible
recipient's individualized program.
(7) Day treatment services are provided at a
minimum of four hours of structured programming per day, two to five days per
week based on acuity and clinical needs of the eligible recipient and his or
her family as identified in the treatment plan.
C.
Identified population: MAD
covers day treatment services for an eligible recipient under age 21 who:
(1) is diagnosed with an emotional,
behavioral, and neurobiological or substance abuse problem;
(2) may be at high risk of out-of-home
placement;
(3) requires structured
therapeutic services in order to attain or maintain functioning in major life
domains of home, work or school; and
(4) through an assessment process, has been
determined to meet the criteria established by MAD or its designee for
admission to day treatment services.
D.
Covered services:
(1) Day treatment services are
non-residential specialized services and training provided during or after
school, weekends or when school is not in session. Services include parent and
eligible recipient education, and skills and socialization training that focus
on the amelioration of functional and behavioral deficits. Intensive
coordination and linkage with the eligible recipient's school or other child
serving agencies are included. Other behavioral health services (e.g.
outpatient counseling, ABA) may be provided in addition to the day treatment
services when the goals of the service are clearly documented, utilizing a
clinical model for service delivery and support.
(2) The goal of day treatment is to maintain
the eligible recipient in his or her home or community environment.
(3) The service is designed to complement and
coordinate with the eligible recipient's educational system.
(4) Services must be identified in the
treatment plan, including crisis planning, which is formulated on an ongoing
basis by the treatment team. The treatment plan guides and records for each
client: individualized therapeutic goals and objectives; individualized
therapeutic services provided; and individualized discharge and aftercare
plans. Treatment plan requirements are detailed in the BH policy and billing
manual.
(5) The following services
must be furnished by a day treatment service agency to receive reimbursement
from MAD:
(a) the assessment and diagnosis of
the social, emotional, physical and psychological needs of the eligible
recipient and his or her family for treatment planning ensuring that
evaluations already performed are not unnecessarily repeated;
(b) development of individualized treatment
and discharge plans and ongoing reevaluation of these plans;
(c) regularly scheduled individual, family,
multifamily, group or specialized group sessions focusing on the attainment of
skills, such as managing anger, communicating and problem-solving, impulse
control, coping and mood management, chemical dependency and relapse
prevention, as defined in the DTS treatment plan;
(d) family training and family outreach to
assist the eligible recipient in gaining functional and behavioral
skills;
(e) supervision of
self-administered medication, as clinically indicated;
(f) therapeutic recreational activities that
are supportive of the clinical objectives and identified in each eligible
recipient's individualized treatment plan;
(g) 24-hour availability of appropriate staff
or implementation of crisis plan, which may include referral, to respond to the
eligible recipient's crisis situations;
(h) advance schedules are posted for
structured and supervised activities which include individual, group and family
therapy, and other planned activities appropriate to the age, behavioral and
emotional needs of the client pursuant to the treatment plan.
E.
Non-covered
services: Day treatment services are subject to the limitations and
coverage restrictions which exist for other MAD services. See Subsection G of
8.321.2.9
NMAC for non-covered MAD behavioral health services or activities. MAD does not
cover the following specific services billed in conjunction with day treatment
services:
(1) educational programs;
(2) pre-vocational training;
(3) vocational training which is related to
specific employment opportunities, work skills or work settings;
(4) any service not identified in the
treatment plan;
(5) recreation
activities not related to the treatment plan;
(6) leisure time activities such as watching
television, movies or playing computer or video games;
(7) transportation reimbursement for the
therapist who delivers services in the family's home; or
(8) a partial hospitalization program and
residential programs cannot be offered at the same time as day treatment
services.
F.
Prior
authorization: See Subsection J of
8.321.2.9
NMAC for general behavioral health services prior authorization requirements.
This service does not require prior authorization.
G.
Reimbursement:
(1) All services described in Subsection D of
8.321.2.21 NMAC are covered in the bundled day treatment rate;
(2) Day treatment providers must submit
claims for reimbursement on the CMS-1500 claim form or its successor. See
Subsection H of
8.321.2.9
NMAC for MAD general reimbursement requirements, see 8.302.2 NMAC. Once
enrolled, a provider receives instructions on how to access documentation,
billing and claims processing information.
