Current through Register Vol. 35, No. 18, September 24, 2024
To help an eligible recipient receive the level of services
needed, MAD pays for partial hospitalization services furnished by an acute
care or freestanding psychiatric hospital. Partial Hospitalization Programs
(PHP) are structured to provide intensive psychiatric care through active
treatment that utilizes a combination of clinical services. They are designed
to stabilize deteriorating conditions or avert inpatient admissions, or can be
a step-down strategy for individuals with SMI, SUD or SED who have required
inpatient admission. The environment is highly structured, is time-limited and
outcome oriented for recipients experiencing acute symptoms or exacerbating
clinical conditions that impede their ability to function on a day-to-day
basis. Program objectives focus on ensuring important community tdies and
closely resemble the real-life experiences of the recipients served.
A.
Eligible providers and
practitioners: In addition tothe requirements found in Subsections A and
B of
8.321.2.9
NMAC, an eligible provider includes a facility joint commission accredited, and
licensed and certified by DOH or the comparable agency in another state.
(1) The program team must include:
(a) registered nurse;
(b) a clinical supervisor that is an
independently licensed behavioral health practitioner or psychiatric nurse
practitioner or psychiatric nurse clinician; and
(c) licensed behavioral health
practitioners.
(2) The
team may also include:
(a) physician
assistants;
(b) certified peer
support workers;
(c) certified
family peer support workers;
(d)
licensed practical nurses;
(e)
mental health technicians.
B.
Coverage criteria: MAD covers
only those services which meet the following criteria:
(1) Services that are ordered by a
psychiatrist or licensed Ph.D.
(2)
Partial hospitalization is a voluntary, intensive, structured and medically
staffed, psychiatrically supervised treatment program with an interdisciplinary
team intended for stabilization of acute psychiatric or substance use symptoms
and adjustment to community settings. The services are essentially of the same
nature and intensity, including medical and nursing services, as would be
provided in an inpatient setting, except that the recipient is in the program
less than 24-hours a day, and it is a time-limited program.
(3) A history and physical (H&P) must be
conducted within 24 hours of admission. If the eligible recipient is a direct
admission from an acute or psychiatric hospital setting, the program may elect
to obtain the H&P in lieu of completing a new H&P. In this instance,
the program physician's signature indicates the review and acceptance of the
document. The H&P may be conducted by a clinical nurse specialist, a
clinical nurse practitioner, a physician assistant or a physician.
(4) An interdisciplinary biopsychosocial
assessment within seven days of admission including alcohol and drug screening.
A full substance abuse evaluation is required if alcohol and drug screening
indicates the need. If the individual is a direct admission from an acute
psychiatric hospital setting, the program may elect to obtain and review this
assessment in lieu of completing a new assessment.
(5) Services are furnished under an
individualized written treatment plan established within seven days of
initiation of service by the psychiatrist, together with the program's team of
professionals, and in consultation with recipients, parents, legal guardian(s)
or others who participate in the recipient's care. The plan must state the
type, amount, frequency and projected duration of the services to be furnished,
and indicate the diagnosis and anticipated goals. The treatment plan must be
reviewed and updated by the interdisciplinary team every 15 days.
(6) Documentation must be sufficient to
demonstrate that coverage criteria are met, including:
(a) Daily documentation of treatment
interventions which are outcome focused and based on the comprehensive
assessment, treatment goals, culture, expectations, and needs as identified by
the recipient, family or other caregivers.
(b) Supervision and periodic evaluation of
the recipient, either individually or in a group, by the psychiatrist or
psychologist to assess the course of treatment. At a minimum, this periodic
evaluation of services at intervals indicated by the condition of the recipient
must be documented in the recipient's record.
(c) Medical justification for any activity
therapies, recipient education programs and psychosocial programs.
(7) Treatment must be reasonably
expected to improve the eligible recipient's condition or designed to reduce or
control the eligible recipient's psychiatric symptoms to prevent relapse or
hospitalization and to improve or maintain the eligible recipient's level of
functions. Control of symptoms and maintenance of a functional level to avoid
further deterioration or hospitalization are acceptable expectations of
improvement.
(8) For recipients in
elementary and secondary school, educational services must be coordinated with
the recipient's school system.
C.
Identified population:
(1) Recipients admitted to a PHP shall be
under the care of a psychiatrist who certifies the need for partial
hospitalization. The recipient requires comprehensive, structured, multimodal
treatment requiring medical supervision and coordination, provided under an
individualized plan of care, because of a SMI, SED or moderate to severe SUD
which severely interferes with multiple areas of daily life, including social,
vocational or educational functioning. Such dysfunction generally is of an
acute nature;
(2) Recipients must
have an adequate support system to sustain/maintain his or herself outside the
PHP;
(3) Recipients 19 and over
with a serious mental illness including substance use who can be safely managed
in the community with high intensity therapeutic intervention more intensive
than outpatient services but are at risk of inpatient care without this
treatment; or
(4) Recipients five
to 18 with severe emotional disturbances including substance use disorders who
can be safely managed in the community with high intensity therapeutic
intervention more intensive than outpatient services but are at risk of
inpatient care without this treatment.
D.
Covered services and service
limitations: A program of services must be furnished by a MAD enrolled
provider delivering partial hospitalization to receive reimbursement from MAD.
Payment for performance of these services is included in the facility's
reimbursement rate:
(1) regularly scheduled
structured counseling and therapy sessions for an eligible recipient, his or
her family, group or multifamily group based on individualized needs furnished
by licensed behavioral health professionals, and, as specified in the treatment
plan;
(2) educational and skills
building groups furnished by the program team to promote recovery;
(3) 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;
(4) drugs and
biologicals that cannot be self-administered and are furnished for therapeutic
management;
(5) assistance to the
recipient in self-administration of medication in compliance with state
policies and procedures;
(6)
appropriate staff available on a 24-hour basis to respond to crisis situations,
evaluate the severity of the situation, stabilize the recipient make referrals
as necessary, and provide follow-up;
(7) consultation with other professionals or
allied caregivers regarding a specific recipient;
(8) coordination of all non-medical services,
including transportation needed to accomplish a treatment objective;
(9) therapeutic services to meet the
physical, social, cultural, recreational, health maintenance, and
rehabilitation needs of recipients; and
(10) discharge planning and referrals as
necessary to community resources, supports, and providers in order to promote a
recipient's return to a higher level of functioning in the least restrictive
environment.
E.
Non-covered services: Partial hospitalization 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 all general non-covered MAD behavioral health services or activities.
MAD does not cover the following specific services with partial
hospitalization:
(1) meals;
(2) transportation by the partial
hospitalization provider;
(3) group
activities or other services which are primarily recreational or diversional in
nature;
(4) a program that only
monitors the management of medication for recipients whose psychiatric
condition is otherwise stable, is not the combination, structure, and intensity
of services which make up active treatment in a partial hospitalization
program;
(5) actively homicidal or
suicidal ideation that would not be safely managed in a PHP;
(6) formal educational and vocational
services related to traditional academic subjects or vocational training;
non-formal education services can be covered if they are part of an active
treatment plan for the eligible recipient; see
42 CFR Section
441.13(b); or
(7) services to treat social maladjustments
without manifest psychiatric disorders, including occupational maladjustment,
marital maladjustment, and sexual dysfunction.
F.
Prior authorization: Prior
authorization is not required for this service unless the length of stay
exceeds 45 days, at which time continued stay must be prior authorized (PA)
from MAD or its UR contractor; or applicable centennial care MCO. Request for
authorization for continued stay must state evidence of the need for the acute,
intense, structured combination of services provided by a PHP, and must address
the continuing serious nature of the recipient's psychiatric condition
requiring active treatment in a PHP and include expectations for imminent
improvement. Control of symptoms and maintenance of a functional level to avoid
further deterioration or hospitalization are acceptable expectations of
improvement. The request for authorization must also specify that a lower level
of outpatient services would not be advised, and why, and that the recipient
may otherwise require inpatient psychiatric care in the absence of continued
stay in the PHP. The request describes:
(1)
the recipient's response to the therapeutic interventions provided by the
PHP;
(2) the recipient's
psychiatric symptoms that continue to place the recipient at risk of
hospitalization; and
(3) treatment
goals for coordination of services to facilitate discharge from the PHP. See
Subsection F of
8.321.2.9
NMAC for MAD general prior authorization requirements.
G.
Reimbursement: A provider of
partial hospitalization services must submit claims for reimbursement on the UB
claim form or its successor. See 8.302.2 NMAC and Subsection H of
8.321.2.9
NMAC for MAD general reimbursement requirements. Specific to partial
hospitalization services:
(1) Freestanding
psychiatric hospitals are reimbursed at an interim percentage rate established
by HSD to equal or closely approximate the final payment rates that apply under
the cost settlement TEFRA principles using the Title XVIII (medicare)
principles cost methodology, MAD reduces the medicare allowable costs by three
percent. For partial hospitalization services that are not cost settled, such
as general acute care hospitals, payments are made at the outpatient hospital
prospective levels, when applicable, on the procedure codes (see Subsection E
of
8.311.2.15
NMAC).
(2) The payment rate is at a
per diem representing 8 hours, which is billed fractions of.25,.5, or.75 units
to represent 2, 4, or 6 hours when applicable.
(3) Any professional services are billed and
reimbursed to the provider under a separate professional component number, all
costs for these services must be removed from the hospital cost report prior to
cost settlement or rebasing.
(4)
Services performed by a physician or Ph.D. psychologist are billed separately
as a professional service. Other services performed by employees or contractors
to the facility are included in the per diem rate which may be billed
separately are:
(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) physical examination
and any resultant medical treatments, while ensuring that a physical
examination already performed is not repeated;
(c) any medically necessary occupational or
physical therapy; and
(d) other
professional services not rendered as part of the program.
