New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 325 - SPECIALTY SERVICES
Part 8 - REHABILITATION SERVICE PROVIDERS
Section 8.325.8.12 - COVERED SERVICES AND SERVICE LIMITATIONS

Universal Citation: 8 NM Admin Code 8.325.8.12

Current through Register Vol. 35, No. 18, September 24, 2024

Medicaid covers physical therapy, occupational therapy, and speech therapy services which are reasonable and necessary for the treatment of the recipient's specific condition.

A. For all services, there must be an expectation that the recipient's condition will improve significantly in a reasonable and generally predictable period of time based on an assessment by physicians of the recipient's restoration potential.

(1) If the recipient's expected restoration potential is insignificant in relation to the extent and duration of therapy required to achieve the potential, the therapy is not considered reasonable and necessary.

(2) If a determination that the expectations for restoration will not materialize is made at any point in the treatment, the services are no longer covered by medicaid.

B. Recipients who require low nursing facility level of care and reside in nursing facilities (NFs) can receive services furnished by home health agencies, certified outpatient rehabilitation centers, certified independent physical therapists, and certified independent occupational therapists. Therapy providers can bill directly for these services. Reimbursement for rehabilitation services for recipients who require high NF level of care is included in the NF's per diem rate and cannot be billed separately by the therapy provider.

C. Physical, occupational and speech therapy services must be ordered by physicians and specifically related to active written treatment plans developed by physicians in consultation with qualified physical, occupational or speech therapists.

D. Medicaid covers speech therapy services furnished by hospitals, home health agencies, outpatient hospitals, rehabilitation hospitals and rehabilitation centers licensed and certified by the department of health.

(1) Speech therapy services can be furnished by employees of the previously described providers or by an outside source such as an agency or clinic, under arrangements with the provider facility. Reimbursement for services is made to the facility.

(2) Speech therapy services must be furnished by individuals who are licensed as speech pathologists by the New Mexico regulation and licensing department.

E. Services furnished in PPS-exempt psychiatric units of general acute care hospitals, PPS-exempt rehabilitation units of general acute care hospitals and free-standing psychiatric hospitals are included in the hospital reimbursement rate and cannot be billed separately by independent providers.

Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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