Current through Register Vol. 35, No. 18, September 24, 2024
To help an adult eligible recipient (18 years and older) who
met the criteria of SMI, MAD pays for psychosocial rehabilitation services
(PSR). PSR is an array of services offered in a group setting through a
clubhouse or a classroom and is designed to help an individual to capitalize on
personal strengths, to develop coping strategies and skills to deal with
deficits, and to develop a supportive environment in which to function as
independently as possible. Psychosocial rehabilitation intervention is intended
to be a transitional level of care based on the individual's recovery and
resiliency goals. See Subsections A and B of
8.321.2.9
NMAC for MAD general provider requirements.
A.
Eligible providers and
practitioners:
(1) Agency staff must
possess the education, skills, abilities, and experience to perform the
activities that comprise the full spectrum of PSR services. See Subsection A of
8.321.2.9
NMAC for MAD general provider requirements.
(2) Staffing requirements:
(a) Both clinical services and supervision by
licensed practitioners must be in accord with their respective licensing board
regulations.
(b) PSR services must
meet a staff ratio sufficient to ensure that patients have reasonable and
prompt access to services.
(c) In
both clubhouse and classroom settings, the entire staff works as a
team.
(d) The team must include a
clinical supervisor/team lead and can include the following:
(i) certified peer support workers;
(ii) certified family support
workers;
(iii) community support
workers; and
(iv) other HIPAA
trained individuals working under the direct supervision of the clinical
supervisor.
(e) Minimum
qualifications for the clinical supervisor/team lead:
(i) independently licensed behavioral health
professional (i.e. psychiatrist, psychologist, LISW, LPCC, LMFT,
psychiatrically certified (CNS) practicing under the scope of their NM
license;
(ii) have one year of
demonstrated supervisory experience;
(iii) demonstrated knowledge and competence
in the field of psychosocial; rehabilitation; and
(iv) an attestation of training related to
providing clinical supervision of non-clinical staff.
B.
Coverage
criteria:
(1) MAD covers only those PSR
services which comply with DOH licensing standards and are medically necessary
to meet the individual needs of the eligible recipient, as delineated in his or
her service plan and treatment plan. Medical necessity is based upon the
eligible recipient's level of functioning as affected by his or her SMI. The
PSR services are limited to goals which are individually designed to
accommodate the level of the eligible recipient's functioning and which reduce
the disability and restore the recipient to his or her best possible level of
functioning.
(2) These services
must be provided in a facility-based setting, either in a clubhouse model or a
structured classroom.
(3) PSR
services must be identified and justified in the individual's treatment or
service plan. Recipients shall participate in PSR services for those activities
that are identified in the treatment or service plan and are tied directly to
the recipient's recovery and resiliency plan/goals.
(4) Specific service needs (e.g., household
management, nutrition, hygiene, money management, parenting skills, etc.) must
be identified in the individual's treatment or service plan.
C.
Identified population:
(1) An eligible recipient 18 years or
older meeting the criteria for SMI and for whom the medical necessity for PSR
services was determined.
(2) Adults
diagnosed with co-occurring SMI and substance use disorders and for whom the
medical necessity for PSR services was determined.
(3) A resident in an institution for mental
illness is not eligible for this service.
D.
Covered services: The
psychosocial intervention (PSI) program must include the following major
components: basic living skills development; psychosocial skills training;
therapeutic socialization; and individual empowerment.
(1) Basic living skills development
activities address the following areas, including but not limited to:
(a) basic household management;
(b) basic nutrition, health, and personal
care including hygiene;
(c)
personal safety;
(d) time
management skills;
(e) money
management skills;
(f) how to
access and utilize transportation;
(g) awareness of community resources and
support in their use;
(h) child
care/parenting skills;
(i) work or
employment skill-building; and
(j)
how to access housing resources.
(2) Psychosocial skills training activities
address the following areas:
(a)
self-management;
(b) cognitive
functioning;
(c)
social/communication; and
(d)
problem-solving skills.
(3) Therapeutic socialization activities
address the following areas:
(a) understanding
the importance of healthy leisure time;
(b) accessing community recreational
facilities and resources;
(c)
physical health and fitness needs;
(d) social and recreational skills and
opportunities; and
(e) harm
reduction and relapse prevention strategies (for individuals with co-occurring
disorders).
(4)
Individual empowerment activities address the following areas:
(a) choice;
(b) self-advocacy;
(c) self-management; and
(d) community integration.
E.
Non-covered
services: PSR 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.
Specifically, PSR cannot be billed concurrently when the recipient is a
resident of an institution for the mentally ill.
F.
Prior authorization: No prior
authorization is required. To determine retrospectively if the medical
necessity for the service has been met, the following factors are considered:
(1) recipient assessment;
(2) recipient diagnostic formation;
(3) recipient service and treatment plans;
and
(4) compliance with 8.321.2
NMAC.
G.
Reimbursement: Claims for reimbursement are submitted on the
CMS-1500 claim form or its successor. See Subsection H of
8.321.2.9
NMAC for MAD general reimbursement requirements and see 8.302.2 NMAC.
