New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 372 - INTERAGENCY BEHAVIORAL HEALTH PURCHASING COLLABORATIVE
Part 1 - GENERAL PROVISIONS
Section 8.372.1.7 - DEFINITIONS
Universal Citation: 8 NM Admin Code 8.372.1.7
Current through Register Vol. 35, No. 18, September 24, 2024
This section contains the glossary for the New Mexico behavioral health system. The following definitions apply to terms used in this chapter and shall guide any rules promulgated by collaborative members regarding behavioral health.
A. Definitions beginning with letter "A":
(1)
Abuse, individual: Any
intentional, knowing or reckless act or failure to act that produces or is
likely to produce physical or great mental or emotional harm, unreasonable
confinement, sexual abuse or sexual assault consistent with 30-47-1 NMSA
1978.
(2)
Abuse,
provider: Provider practices that are inconsistent with sound fiscal,
business, medical or service related practices and result in an unnecessary
cost to the program, or in reimbursement for services that are not medically,
clinically, or psychosocially necessary or in services that fail to meet
professionally recognized standards for behavioral health care.
(3)
Adult behavioral health procedures
manual: The procedures manual that includes the psychiatric
rehabilitation program requirements and comprehensive community support
services requirements.
(4)
Advance directive: Written instructions such as a mental
healthcare advance directive, psychiatric advance directive, living will,
durable health care power of attorney, durable mental health care power of
attorney, or advance health directive, relating to the provision of health care
when an adult is incapacitated. (See generally, Sections 27-7A-1 - 27-7A-18
NMSA, 1978, and Section 24-7B-1 - 24-7B-16 NMSA 1978.)
(5)
Adverse determination: A
determination by the BHE that the behavioral health services furnished, or
proposed to be furnished to a consumer, are not medically, clinically or
psychosocially necessary or not appropriate.
(6)
American society of addiction
medicine (ASAM): An organization of professionals in addiction services
that developed, in the early 1990s, a set of criteria and tools to identify the
level of care best suited to an individual in need of addiction
services.
B. Definitions beginning with letter "B":
(1)
Behavioral health (BH): The
umbrella term for mental health and substance abuse. It includes both mental
health (MH), including psychiatric illnesses and emotional disorders, and
substance abuse (SA), including addictive and chemical dependency disorders,
and includes co-occurring MH and SA disorders and the prevention of those
disorders.
(2)
Behavioral
health entity (BHE): One or more managed care organizations selected by
HSD and the collaborative to provide all defined behavioral health service
responsibilities, including medicaid behavioral health.
(3)
Behavioral health planning council
(BHPC): The body created to meet federal and state advisory council
requirements and to provide consistent, coordinated input to the behavioral
health service delivery system in New Mexico, and with which the BHE will be
expected to interact with as an advisory council. (See Section 24-1-28 NMSA,
1978)
C. Definitions beginning with letter "C":
(1)
Chair or co-chairs: The
secretary of the health care authority shall serve as the chair of the
collaborative. The secretary of health and the secretary of children youth and
families shall alternate each state fiscal year as the co-chair of the
collaborative.
(2)
Clinical
necessity: The determination made by a behavioral health professional
exercising prudent clinical judgment as to whether a behavioral health service
would promote growth and development, prevent, diagnose, detect, treat,
ameliorate, or palliate the effects of a behavioral health condition, injury,
or disability for the consumer.
(3)
Collaborative: The interagency behavioral health purchasing
collaborative, responsible for planning, designing and directing a statewide
behavioral health system. The collaborative, established under Section 9-7-6.4
NMSA 1978, by its statutory member agencies collectively, operates under
by-laws adopted by the collaborative.
(4)
Collaborative members or member
agencies: The statutory and ex officio agency
representatives who sit on the collaborative or their agency
designees.
(5)
Comprehensive
community support services (CCSS): CCSS is a recovery and resiliency
oriented service which is provided in the community, primarily face-to-face,
using natural supports to the maximum extent possible to build on client and
family strengths. These services are goal-directed mental health rehabilitation
services and supports for children, adolescents, and adults necessary to assist
individuals in achieving recovery and resiliency goals. These services assist
in the development and coordination of a consumer or member's service plan and
include therapeutic interventions which address barriers that impede the
development of skills necessary for independent functioning in the community.
(See, 8.315.6 NMAC, 8.305.1 NMAC and collaborative adult behavioral health
procedural manual.)
(6)
Consumer: For purposes of these rules, a person with a mental
health or substance use disorder receiving or eligible to receive behavioral
health services through collaborative or collaborative member contracts, or a
past recipient of such services.
(7)
Consumer empowerment:
Activities that address the following areas:
(a) consumer choice
(b) consumer voice
(c) self-management
(d) community integration
(8)
Continuous quality
improvement (CQI): CQI is a process for improving quality that assumes
opportunities for improvement are unlimited; is customer-oriented, data driven,
and results in implementation of improvements; and requires continual
measurement of implemented improvements and modification of improvements, as
indicated.
(9)
Core service
agencies (CSAs): Multiservice agencies that help to bridge treatment
gaps in the child and adult treatment systems, promote the appropriate level of
service intensity for consumers with complex behavioral health service needs,
ensure that community support services are integrated into treatment, and
develop the capacity for consumers to have a single point of accountability for
identifying and coordinating their behavioral health, health and other social
services.
(10)
Credentialing: A systematic process whereby the BHE or provider
verifies and warrants that an employed, contracted or affiliated behavioral
health professional or agency meets specified practice standards including
education, experience, licensure and certification.
(11)
Cultural competence: A set
of congruent behaviors, attitudes, and policies that come together in a system,
agency, or among professionals that enables them to work effectively in
cross-cultural situations, including situations of diverse culture, race,
ethnicity, national origin or disability. Cultural competency involves the
integration and transformation of knowledge, information and data about
individuals and groups of people into specific clinical standards, service
approaches, techniques and marketing programs that match an individual's
culture to increase the quality and appropriateness of behavioral health care
and outcomes. See, 8.305.1.7 NMAC.
D. Definitions beginning with letter "D":
(1)
Delegation: A
formal process by which a BHE gives another entity the authority to perform
certain functions on its behalf but for which the BHE retains full
accountability for the delegated functions.
(2)
Designated representative: A
person designated under a valid mental health care treatment advance directive
as an individual's authorized agent according to the provisions of the Mental
Health Care Treatment Decisions Act (Subsection B of Section 24-7 NMSA 1978)
and who has personal knowledge of the respondent and the facts as required in
Subsection B of the act.
E. Definitions beginning with letter "E":
(1)
EPSDT: Early and
periodic screening, diagnostic and treatment.
(2)
Ex-officio members:
Non-voting members of the collaborative, who otherwise serve as full members
(e.g. the secretary of higher education department, secretary of veteran's
services department, New Mexico public defender, and the children's cabinet
coordinator).
(3)
Executive
committee: A committee of the collaborative comprised of the secretaries
of the health care authority, health, and children youth and families. The
executive committee is authorized to negotiate, approve and execute contracts
and amendments on behalf of the collaborative.
F. Definitions beginning with letter "F":
(1)
Family-centered
care: When a child is the consumer, the system of care reflects the
importance of the family or legal guardian in the way services are planned and
delivered. Family-centered care facilitates collaboration between family
members and behavioral health professionals, builds on individual and family
strengths and respects diversity of families.
(2)
Family specialist: An
approved provider who is certified as a family specialist through an approved
state certification program. (See Subsection U of
7.20.11.7 NMAC)
G. Definitions beginning with letter "G":
(1)
Grievance
(consumer): Oral or written statement by a member expressing
dissatisfaction with any aspect of the BHE or its operations that is not a BHE
action.
(2)
Grievance
(provider): Oral or written statement by a provider to the BHE
expressing dissatisfaction with any aspect of the BHE or its operations that is
not a BHE action.
H. Definitions beginning with letter "H": HIPAA: Health Insurance Portability and Accountability Act of 1996.
I. Definitions beginning with letter "I": Indicated prevention: Interventions that identify individuals who are experiencing early signs of substance abuse, mental illness and other related problem behavior and target them with special programs.
J. Definitions beginning with letter "J": [RESERVED]
K. Definitions beginning with letter "K": [RESERVED]
L. Definitions beginning with letter "L":
(1)
Letter of direction
(LD): Written instructions, detailed action steps, and guidelines to
clarify the implementation of programs funded by new funding sources or changes
to programs funded by funding sources identified in the BHE contract.
(2)
Local collaborative (LC): An
advisory body, delineated by either judicial district or tribal grouping and
recognized by the collaborative, that provides input on local and regional
behavioral health issues to the collaborative, the BHPC and the BHE.
(3)
Logic model, prevention
services: A logical conceptual framework used to connect the prevention
effort with its intended results and the goal of reducing substance abuse. The
framework is based upon existing knowledge that is refined or revised with new
research. The logic model specifically describes the changes expected within
the target population(s), why it is likely that these changes would result from
the proposed prevention services and activities, and how this logically relates
to the needs assessment.
M. Definitions beginning with letter "M":
(1)
Managed care
organization (MCO): An organization that contracts with the state of New
Mexico to provide a variety of health care services to individuals who are
enrolled.
(2)
Management
letter: A document signed by the co-chairs of the collaborative and a
representative of the BHE authorized to bind the BHE that describes a certain
task or activity to be pursued or conducted by the BHE, the specific approach
to that task or activity, the expected result and the schedule to be followed
to implement the task or activity. Such letters are not intended to be
amendments to the BHE contract, but more specific directions for completing
contract requirements.
(3)
Medicaid: The medical assistance program authorized under Title
XIX and Title XXI of the Social Security Act or its successors, furnished to
New Mexico residents who meet specific eligibility requirements.
(4)
Medically necessary
services: Clinical and rehabilitative physical, mental or behavioral
health services that:
(a) are essential to
prevent, diagnose or treat medical or behavioral health conditions or are
essential to enable the consumer to attain, maintain or regain the consumer's
optimal functional capacity;
(b)
are delivered in the amount, duration, scope and setting that is both
sufficient and effective to reasonably achieve their purposes and clinically
appropriate to the specific physical, mental and behavioral health care needs
of the consumer;
(c) are provided
within professionally accepted standards of practice and national guidelines;
and
(d) are required to meet the
physical, mental and behavioral health needs of the consumer and are not
primarily for the convenience of the consumer, the provider or the BHE.
(Subparagraphs (a) and (b) of Paragraph (7) of Subsection M of 8.305.1.7
NMAC)
N. Definitions beginning with letter "N":
(1)
Network provider: An
individual provider, clinic, group, association or facility employed by or
contracted with a BHE to furnish covered behavioral health services to
consumers under the provisions of the BHE contract.
(2)
Non-network provider: An
individual provider, clinic, group, association or facility that provides
covered services and does not have a contract with the BHE.
O. Definitions beginning with letter "O": [RESERVED]
P. Definitions beginning with letter "P":
(1)
Peer specialist:
An approved provider who is certified as a peer specialist through a state
approved certification program. (Paragraph (4) of Subsection A of 8.315.6.10
NMAC)
(2)
Performance
measures: A system of operational and tracking indicators specified by
state or federal requirements or the collaborative, including but not limited
to the federal national outcome measures (NOMS).
(3)
Prevention services:
Services that follow current national standards for prevention including both
physical and behavioral health.
(4)
Prevention provider: A provider under contract for the exclusive
or primary purpose of providing services designed to prevent or reduce the
prevalence of substance abuse, mental illness, or other specified behavioral
health disorders.
(5)
Psychosocial necessity: Services or products provided to a
consumer with the goal of helping that individual develop to their fullest
capacities through learning and environmental supports and reduce the risk of
the consumer developing a behavioral health disorder or an increase in the
severity of behavioral health symptoms. The consumer need not have a behavioral
health diagnosis but rather have a need to improve psychosocial
functioning.
Q. Definitions beginning with letter "Q": [RESERVED]
R. Definitions beginning with letter "R":
(1)
Recovery:
Behavioral health recovery is an individual's personal journey of healing and
transformation enabling a person with a behavioral health problem to live a
meaningful life in a community of their choice while striving to achieve their
full potential.
(2)
Recredentialing: A systematic process whereby the BHE verifies and
warrants that an employed or affiliated behavioral health professional who is
currently credentialed, continues to meet specified practice standards,
including education, experience, licensure and certification.
(3)
Resiliency: A global term
describing a dynamic process, whereby people overcome adversity and go on with
their lives in a productive and self-satisfying manner.
(4)
Responsible offeror: An
offeror who submits a response proposal and who has furnished, when required,
information and data to prove that the offeror's financial resources,
production or service facilities, personnel, service reputation and experience
are adequate to make satisfactory delivery of the services or items of tangible
personal property described in the proposal.
S. Definitions beginning with letter "S":
(1)
Selective
prevention: Prevention interventions targeted at a subgroup of the
general population that is determined to be at risk for sexual assault,
substance abuse or mental illness.
(2)
State: The state of New
Mexico, including any entity or agency of the state and including but not
limited to the collaborative and member agencies.
(3)
Subcontract: A written
agreement between the BHE and a third party, or between a subcontractor and
another subcontractor, to provide services, and where appropriate approved by
the collaborative.
(4)
Subcontractor: A third party who contracts with the BHE or a BHE
subcontractor for the provision of services.
(5)
Supported employment:
Integrated work for not less than the federal minimum wage in a setting with
ongoing support services for individuals with severe disabilities for whom
competitive employment:
(a) has not
traditionally occurred;
(b) has
been interrupted or intermittent as a result of severe disability, and
who,
(c) because of the nature and
severity of their disabilities need intensive physical, educational, social or
psychological support to perform work.
(6)
Supportive housing:
Permanent housing that is affordable to individuals with low or no incomes, is
chosen by the individual, which a person retains even if their service needs
change, and which is an essential ingredient to foster and support a person's
journey towards recovery and resiliency.
T. Definitions beginning with letter "T": [RESERVED]
U. Definitions beginning with letter "U": Universal prevention: Prevention interventions intended to reach the entire population or a large share of it, without regard to individual risk factors.
V. Definitions beginning with letter "V": [RESERVED]
W. Definitions beginning with letter "W": [RESERVED]
X. Definitions beginning with letter "X": [RESERVED]
Y. Definitions beginning with letter "Y": [RESERVED]
Z. Definitions beginning with letter "Z": [RESERVED]
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