Current through Register Vol. 35, No. 18, September 24, 2024
To assist the eligible recipient in receiving necessary
mental health services, MAD pays for inpatient psychiatric care furnished in
freestanding psychiatric hospitals as part of the EPSDT program (42 CFR
441.57) . A freestanding psychiatric hospital
(an inpatient facility that is not a unit in a general acute care hospital),
with more than 16 beds is an institution for mental disease (IMD) subject to
the federal medicaid IMD exclusion that prohibits medicaid payment for
inpatient stays for eligible recipients aged 22 through 64 years. Coverage of
stays in a freestanding psychiatric hospital that is considered an IMD are
covered only for eligible recipients up to age 21 and over age 64. A managed
care organization making payment to an IMD as an in lieu of service may pay for
stays that do not exceed 15 days. For stays in an IMD that include a substance
use disorder (SUD) refer to
8.321.2.24
NMAC, Institution for Mental Diseases (IMD). However, for
freestanding psychiatric hospitals, if the eligible recipient who is receiving
inpatient services reaches the age of 21 years, services may continue until one
of the following conditions is reached: until the date the eligible recipient
no longer requires the services, or until the date the eligible recipient
reaches the age of 22 years, whichever occurs first. The need for inpatient
psychiatric care in a freestanding psychiatric hospital must be identified in
the eligible recipient's tot to teen health check screen or another diagnostic
evaluation furnished through a health check referral. Inpatient stays for
eligible recipients in an inpatient psychiatric unit of a general acute care
hospital are also covered. As these institutions are not considered to be IMDs,
there are no age exclusions for their services.
A.
Eligible providers: A MAD
eligible provider must be licensed and certified by the New Mexico DOH (or the
comparable agency if in another state), comply with
42 CFR
456.201 through
456.245;
and be accredited by at least one of the following:
(1) the joint commission (JC);
(2) the council on accreditation of services
for families and children (COA);
(3) the commission on accreditation of
rehabilitation facilities (CARF); or
(4) another accrediting organization
recognized by MAD as having comparable standards; and
(5) be an approved MAD provider before it
furnishes services, see
42 CFR
Sections 456.201 through
456.245.
B.
Covered services:
MAD covers inpatient psychiatric hospital services which are medically
necessary for the diagnosis or treatment of mental illness as required by the
condition of the eligible recipient.
(1) These
services must be furnished by eligible providers within the scope and practice
of his or her profession (see
8.321.2.9
NMAC) and in accordance with federal regulations; see (42 CFR
441.156);
(2) Services must be furnished under the
direction of a physician;
(3) In
the case of an eligible recipient under 21 years of age these services:
(a) must be furnished under the direction of
a board prepared, board eligible, board certified psychiatrist or a licensed
psychologist working in collaboration with a similarly qualified psychiatrist;
and
(b) the psychiatrist must
conduct an evaluation of the eligible recipient, in person within 24 hours of
admission.
(4) In the
case of an eligible recipient under 12 years of age, the psychiatrist must be
board prepared, board eligible, or board certified in child or adolescent
psychiatry. The requirement for the specified psychiatrist for an eligible
recipient under age 12 and an eligible recipient under 21 years of age can be
waived when all of the following conditions are met:
(a) the need for admission is urgent or
emergent and transfer or referral to another provider poses an unacceptable
risk for adverse patient outcomes;
(b) at the time of admission, a psychiatrist
who is board prepared, board eligible, or board certified in child or
adolescent psychiatry, is not accessible in the community in which the facility
is located;
(c) there is another
facility which has a psychiatrist who is board prepared, board eligible, board
certified in child or adolescent psychiatry, but the facility, is not available
or is inaccessible to the community in which the facility is located;
and
(d) the admission is for
stabilization only and a transfer arrangement to the care of a psychiatrist who
is board prepared, board eligible, board certified in child or adolescent
psychiatry, is made as soon as possible with the understanding that if the
eligible recipient needs transfer to another facility, the actual transfer will
occur as soon as the eligible recipient is stable for transfer in accordance
with professional standards.
(5) A freestanding hospital must provide the
following components to an eligible recipient to receive reimbursement:
(a) performance of necessary evaluations and
psychological testing for the development of the treatment plan, while ensuring
that evaluations already performed are not repeated;
(b) a treatment plan and all supporting
documentation must be available for review in the eligible recipient's
file;
(c) regularly scheduled
structured behavioral health therapy sessions for the eligible recipient,
group, family, or a multifamily group based on individualized needs, as
specified in the eligible recipient's treatment plan;
(d) 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;
(e) assistance to an eligible recipient in
his or her self administration of medication in compliance with state
regulations, policies and procedures;
(f) appropriate staff available on a 24-hour
basis to respond to crisis situations; determine the severity of the situation;
stabilize the eligible recipient by providing support; make referrals, as
necessary; and provide follow-up;
(g) a consultation with other professionals
or allied caregivers regarding a specific eligible recipient;
(h) non-medical transportation services
needed to accomplish treatment objectives;
(i) therapeutic services to meet the
physical, social, cultural, recreational, health maintenance, and
rehabilitation needs of the eligible recipient; and
(j) plans for discharge must begin upon
admittance to the facility and be included in the eligible recipient's
treatment plan. If the eligible recipient will receive services in the
community or in the custody of CYFD, the discharge must be coordinated with
those individuals or agencies responsible for post-hospital placement and
services. The discharge plan must consider related community services to ensure
continuity of care with the eligible recipient, his or her family, and school
and community.
(6) MAD
covers "awaiting placement days" when the MAD UR contractor determines that an
eligible recipient under 21 years of age no longer meets this acute care
criteria and determines that the eligible recipient requires a residential
placement which cannot be immediately located. Those days during which the
eligible recipient is awaiting placement to the step-down placement are termed
awaiting placement days. Payment to the hospital for awaiting placement days is
made at the average payment for accredited residential treatment centers plus
five percent. A separate claim form must be submitted for awaiting placement
days.
(7) A treatment plan must be
developed by a team of professionals in consultation with an eligible
recipient, his or her parent, legal guardian or others in whose care the
eligible recipient will be released after discharge. The plan must be developed
within 72 hours of admission of the eligible recipient's admission to
freestanding psychiatric hospitals. The interdisciplinary team must review the
treatment plan at least every five calendar days. See the BH policy and billing
manual for a description of the treatment team and plan.
C.
Non-covered services:
Services furnished in a freestanding psychiatric hospital are subject to the
limitations and coverage restrictions which exist for other MAD services; see
Subsection G of
8.321.2.9
NMAC for MAD general non-covered services. MAD does not cover the following
specific services for an eligible recipient in a freestanding psychiatric
hospital in the following situations:
(1)
conditions defined only by Z codes in the current version of the international
classification of diseases (ICD) or the current version of DSM;
(2) services in freestanding psychiatric
hospital for an eligible recipient 22 years of age through 64, except as
allowed in 8.321.2 NMAC;
(3)
services furnished after the determination by MAD or its designee has been made
that the eligible recipient no longer needs hospital care;
(4) formal educational or vocational
services, other than those covered in Subsection B of
8.321.2.9
NMAC, related to traditional academic subjects or vocational training; MAD only
covers non-formal education services if they are part of an active treatment
plan for an eligible recipient under the age of 21 receiving inpatient
psychiatric services; see
42 CFR Section
441.13(b); or
(5) drugs classified as "ineffective" by the
food and drug administration (FDA) drug evaluation.
D.
Prior authorization and utilization
review: All MAD services are subject to utilization review for medical
necessity, inspection of care, and program compliance. Reviews can be performed
before services are furnished, after services are furnished and before payment
is made, or after payment is made; see 8.310.2 and 8.310.3 NMAC.
(1) All inpatient services for an eligible
recipient under 21 years of age in a freestanding psychiatric hospital require
prior authorization from MAD or its designee. Services for which prior
authorization was obtained remain subject to utilization review at any point in
the payment process.
(2) Prior
authorization of services does not guarantee that individuals are eligible for
MAD services. Providers must verify that an individual is eligible for MAD
services at the time services are furnished and through his or her inpatient
stay and determine if the eligible recipient has other health
insurance.
(3) A provider who
disagrees with prior authorization request denials or other review decisions
can request a re-review and a reconsideration; see 8.350.2 NMAC.
E.
Reimbursement: A
freestanding psychiatric hospital service provider must submit claims for
reimbursement on the UB-04 claim form or its successor; see 8.302.2 NMAC. Once
enrolled, providers receive instructions on how to access documentation,
billing, and claims processing information.
(1) Reimbursement rates for New Mexico
freestanding psychiatric hospital are based on the Tax Equity and Fiscal
Responsibility Act (TEFRA) provisions and principles of reimbursement; see
8.311.3 NMAC. Covered inpatient services provided in a freestanding psychiatric
hospital will be reimbursed at an interim rate established by HSD to equal or
closely approximate the final payment rates that apply under the cost
settlement TEFRA principles.
(2) If
a provider is not cost settled, the reimbursement rate will be at the
provider's cost-to-charge ratio reported in the provider's most recently filed
cost report prior to February 1, 2012. Otherwise, rates are established after
considering available cost-to-charge ratios, payment levels made by other
payers, and MAD payment levels for services of similar cost, complexity and
duration.
(3) Reimbursement rates
for services furnished by a psychiatrist and licensed Ph.D. psychologist in a
freestanding psychiatric hospital are contained in 8.311.3 NMAC. Services
furnished by a psychiatrist and psychologist in a freestanding psychiatric
hospital cannot be included as inpatient psychiatric hospital
charges.
(4) When services are
billed to and paid by a MAD coordinated services contractor, the provider must
also enroll as a provider with the MAD coordinated services contractor and
follow that contractor's instructions for billing and for authorization of
services.
(5) The provider agrees
to be paid by a MCO at any amount mutually-agreed upon between the provider and
MCO when the provider enters into contracts with MCO contracting with HSD for
the provision of managed care services to an eligible recipient.
(a) If the provider and the HSD contracted
MCO are unable to agree to terms or fail to execute an agreement for any
reason, the MCO shall be obligated to pay, and the provider shall accept, one
hundred percent of the "applicable reimbursement rate" based on the provider
type for services rendered under both emergency and non-emergency
situations.
(b) The "applicable
reimbursement rate" is defined as the rate paid by HSD to the provider
participating in the medical assistance programs administered by MAD and
excludes disproportionate share hospital and medical education
payments.
