Current through Register Vol. 35, No. 18, September 24, 2024
MAD pays for medically necessary services for an eligible
recipient under 21 years of age which are designed to develop skills necessary
for successful reintegration into his or her family or transition into his or
her community. A determination must be made that the eligible recipient needs
the level of care (LOC) for services furnished in a RTC or group home. 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. Residential services must be rehabilitative and
provide access to necessary treatment services in a therapeutic environment.
MAD pays for services furnished in a RTC or group home as part of EPSDT program
(42 CFR
441.57) . The need for RTC and group home
services must be identified in the eligible recipient's tot to teen health
check screen or other diagnostic evaluation furnished through a health check
referral.
A.
Eligible
providers: 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 RTC or group home
services to an eligible recipient, an agency must meet the following
requirements:
(1) a RTC must be certified by
the children, youth and families department (CYFD) see 7.20.12 NMAC;
(2) a group home must be certified and
licensed by CYFD;
(3) if the RTC is
operated by IHS or by a federally recognized tribal government, the facility
must meet CYFD RTC licensing and certification requirements but is not required
to be licensed or certified by CYFD. In lieu of receiving a license and
certification, CYFD provides MAD copies of its facility findings and
recommendations. MAD will work with the facility to address recommendations.
The BH policy and billing manual provides guidance for addressing the facility
findings and recommendations.
B.
Covered services: Residential
treatment services are provided through a treatment team approach and the
roles, responsibilities and leadership of the team are clearly defined. MAD
covers accommodation and residential treatment services which are medically
necessary for the diagnosis and treatment of an eligible recipient's condition.
A RTC or group home must provide an interdisciplinary psychotherapeutic
treatment program on a 24-hour basis to the eligible recipient through the
provision of a 24-hour therapeutic group living environment to meet their
developmental, psychological, social, and emotional needs. The following are
covered services:
(1) performance of necessary
evaluations, assessments and psychological testing of the eligible recipient
for the development of his or her treatment plan for each service, while
ensuring that assessments already performed are not repeated;
(2) provide regularly scheduled counseling
and therapy sessions in an individual, family or group setting following the
eligible recipient's individualized treatment plan;
(3) 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;
(4) assistance to the eligible recipient in
his or her self-administration of medication in compliance with state statute,
regulation and rules;
(5) provision
of appropriate on-site staff based upon the acuity of recipient needs on a
24-hour basis to ensure adequate supervision of the recipients, and response in
a proactive and timely manner. Response to crisis situations, determining the
severity of the situation, stabilizing the eligible recipient by providing
individualized treatment plan/safety plan interventions and support, and making
referrals for emergency services or to other non-agency services, as necessary,
and providing follow-up;
(6)
development of an interdisciplinary service plan; see the BH policy and billing
manual;
(7) non-medical
transportation services needed to accomplish the treatment objective;
(8) therapeutic services to meet the
physical, social, cultural, recreational, health maintenance and rehabilitation
needs of the eligible recipient;
(9) for planning of discharge and aftercare
services to facilitate timely and appropriate post discharge care regular
assessments are conducted. These assessments support discharge planning and
effect successful discharge with clinically appropriate after care services.
This discharge planning begins when the recipient is admitted to residential
treatment services and is updated and documented in the recipient record at
every treatment plan review, or more frequently as needed; and
(10) the RTC and group homes provide
services, care and supervision at all times, including:
(a) the provision of, or access to, medical
services on a 24-hour basis; and
(b) maintenance of a staff-to-recipient ratio
appropriate to the level of care and needs of the recipients.
C.
Non-covered
services: RTC and group home 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 RTC
and group home services to an eligible recipient:
(1) Comprehensive community support services
(CCSS) except by a CCSS agency when discharge planning with the eligible
recipient from the RTC or group home facility;
(2) services not considered medically
necessary for the condition of the eligible recipient, as determined by MAD or
its UR contractor;
(3) room and
board;
(4) services for which prior
approval was not obtained; or
(5)
services furnished after a MAD or UR contractor determination that the
recipient no longer meets the LOC for RTC or group home care.
D.
Treatment plan: If
the eligible recipient is solely receiving RTC or group home services, a
service plan is not required. If the eligible recipient is receiving other
behavioral health services, then a service plan is required, see Subsection K
of
8.321.2.9
NMAC and the BH policy and billing manual.
E.
Prior authorization: Before a
RTC or group home service is furnished to an eligible recipient, prior
authorization is required from MAD or its UR contractor or the respective
centennial care MCO. Services for which prior authorization was obtained remain
subject to utilization review at any point in the payment process.
F.
Reimbursement: A RTC or group
home 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. For IHS and a tribal 638 facility
and any other "Indian Health Care Provider (IHCP)" defined in 42 Code of
Federal Regulations §438.14(a), MAD considers RTC services to be outside
the IHS all inclusive rate and RTC is therefore reimbursed at the MAD fee
schedule utilizing the appropriate claim form designated by MAD.
(1) The fee schedule is established after
considering cost data submitted by the RTC or group home 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 included in the RTC or group home rate include:
(i) direct services furnished by a
psychiatrist or licensed Ph.D. psychologist; these services can be billed
directly by the provider; see 8.310.3 NMAC; and
(ii) 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 the applicable
sections of NMAC rules.
(c) Services which are not covered in the
routine rate and are not a MAD covered service include:
(i) room and board; and
(ii) 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 into the rate to allow for
therapeutic leave and trial community placement. Since the vacancy factor is
built into the rate, a RTC and group home agency cannot bill or be reimbursed
for days when the eligible recipient is absent from the facility.
