Current through Register Vol. 35, No. 18, September 24, 2024
MAD pays for IOP services which provide a time-limited,
multi-faceted approach to treatment for an eligible recipient with a SMI or SED
including an eating disorder or borderline personality disorder who requires
structure and support to achieve and sustain recovery. IOP must utilize a
research and evidence-based model approved by the IOP interdepartmental
council, and target specific behaviors with individualized behavioral
interventions. The effective date will be January 1, 2019, or as otherwise
approved by the centers for medicare and medicaid services (CMS).
A.
Eligible providers: Services
may only be delivered through an agency approved by HSD and CYFD after
demonstrating that the agency meets all the requirements of IOP program
services and supervision. See Subsections A and B of
8.321.2.9
NMAC for MAD general provider requirements.
(1) IOP services are provided through an
integrated interdisciplinary approach by staff with expertise in the mental
health condition being addressed. This team may have services rendered by
non-independent practitioners under the direction of the IOP supervisor
including LMSW, LMHC, a master's level psych associates, RNs or registered
dieticians.
(2) Each IOP program
must have a clinical supervisor. Both clinical services and supervision by
licensed practitioners must be conducted in accordance with respective
licensing board regulations. An IOP clinical supervisor must meet all of the
following requirements:
(a) be licensed as a
MAD approved independent practitioner; see Subsection C of
8.321.2.9
NMAC;
(b) have two years relevant
experience in providing the evidence-based model to be delivered; and
(c) have one year demonstrated supervisory
experience.
(3) The IOP
agency is required to develop and implement a program outcome evaluation
system.
(4) The agency must
maintain the appropriate state facility licensure if offering medication
treatment.
(5) The agency must hold
an IOP approval letter and be enrolled by MAD to render IOP services to an
eligible recipient. In the application process each IOP must identify if it is
a youth program, an adult program, a transitional age program, or multiple
programs. Transitional age programs must specify the age range of the target
population. A MAD IOP agency will be provisionally approved for a specified
timeframe to render IOP services to an eligible recipient. During this
provisionally approved time, MAD or its designee will determine if the IOP
meets MAD IOP requirements and if so, the agency will receive an approval
letter for IOP full enrollment.
B.
Coverage criteria:
(1) An IOP is based on research and
evidence-based practice (EBP) models that target specific behaviors with
individualized behavioral interventions. All EBP services must be culturally
sensitive and incorporate recovery and resiliency values into all service
interventions. EBPs must be approved by the IOP interdepartmental council. A
list of pre-approved EBPs is available through the council, as are the criteria
for having another model approved. They are also listed in the BH policy and
billing manual.
(2) Treatment
services must address co-occurring disorders when indicated.
C.
Covered services:
(1) IOP core services include:
(a) individual therapy;
(b) group therapy (group membership may not
exceed 15 in number); and
(c)
psycho-education for the eligible recipient and his or her family.
(2) Medication management services
are available either in the IOP agency or by referral to oversee the use of
psychotropic medications and medication assisted treatment of substance use
disorders.
(3) The amount of weekly
services per eligible recipient is directly related to the goals specified in
his or her IOP treatment plan and the IOP EBP in use.
(4) Treatment services must address
co-occurring disorders when indicated.
D.
Identified population:
(1) IOP services are provided to an eligible
recipient, 11 through 17 years of age diagnosed with a SED.
(2) IOP services are provided to an eligible
adult recipient 18 years of age and older diagnosed with a SMI.
(3) Prior to engaging in a MAD IOP program,
the eligible recipient must have a treatment file containing:
(a) one diagnostic evaluation with a
diagnosis of serious mental illness or severe emotional disturbance; or
diagnosis for which the IOP is approved; and
(b) one individualized service plan that
includes IOP as an intervention.
E.
Non-covered services: IOP
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 general non-covered MAD behavioral health services and 8.310.2 NMAC
for MAD general non-covered services. MAD does not cover the following specific
services billed in conjunction with IOP services:
(1) acute inpatient;
(2) residential treatment services (i.e.,
ARTC, RTC, group home, and transitional living services);
(3) ACT;
(4) partial hospitalization;
(5) outpatient therapies which do not meet
Subsection C of
8.321.2.9
NMAC;
(6) multi-systemic therapy
(MST);
(7) activity therapy;
or
(8) psychosocial rehabilitation
(PSR) group services.
F.
Reimbursement: See Subsection H of
8.321.2.9
NMAC for MAD behavioral health general reimbursement.
(1) For IOP services, the agency must submit
claims for reimbursement on the CMS-1500 claim form or its successor.
(2) Core IOP services are reimbursed through
a bundled rate. Medications and other mental health therapies are billed and
reimbursed separately from the bundled rate.
(3) IOP services furnished by an IOP team
member are billed by and reimbursed to a MAD IOP agency whether the team member
is under contract with or employed by the IOP agency.
(4) IOP services not provided in accordance
with the conditions for coverage as specified in the rule are not a MAD covered
service and are subject to recoupment.
