LEVEL OF CARE GUIDELINES

Transcription

1 LEVEL OF CARE GUIDELINES October 2012 Key Code: Throughout this document highlighting occurs to reflect direct language of either the State regulations or approved service definitions which were in effect as of July 22, 2011: Denotes verbatim language from NMAC/MAD Regulation (as of ) at Denotes verbatim language from approved Service Definition (as of ) at Statutes, regulations, service definitions and all related documents are revised from time to time and subject to change without notice. Although regulations and service definitions are set forth herein, this Level of Care Guidelines is subject to the current statues, regulations and State of NM/OHNM documents. It is the provider s responsibility to adhere to current statues, regulations and State of NM/OHNM documents relevant to the level of care regardless of what version is set forth herein. OHNM Level of Care Guidelines Page 1 of 82

2 Table of Contents Introduction... 3 Medical Necessity Definition Common Criteria... 6 Discharge Planning... 9 Level of Care Guidelines (LOC) Criteria Sets Acute Inpatient Hospitalization Inpatient Days Awaiting Placement (DAP) Rate Hour Observation Stay Partial Hospitalization Electroconvulsive Therapy Substance Abuse Inpatient Detoxification Sub- Acute Residential Treatment Residential Treatment Center Services Treatment Foster Care I and II Group Home Adolescent Transitional Living Services (TLS) Adult Transitional Living Services (TLS) Comprehensive Community Support Services (CCSS) Adult Substance Abuse Residential Treatment Center (RTC) Services Adaptive Skills Building (ABS) Behavior Management Services Psychosocial Rehabilitation (PSR) Services Inactive/ Retired Criteria Sets OHNM Level of Care Guidelines Page 2 of 82

3 Introduction This 2011 OptumHealth New Mexico (OHNM) Level of Care Guidelines document provides objective admission, continuing stay, discharge, and exclusionary criteria for behavioral health services offered by the OHNM provider network in support of a consumer s recovery. OptumHealth New Mexico may also use the American Society of Addiction Medicine Patient Placement Criteria, Second Edition-Revised (ASAM PPC-2R) to provide objective admission and continuing stay criteria for substance abuse services. The Level of Care Guidelines are intended to standardize utilization management decisions regarding the most appropriate and available level of care needed to support a consumer s path to recovery. Importantly, this year s revision is intended to serve as more than just a collection of criteria checklists. OHNM hopes that providers and other system stakeholders will see this document as a teaching document as it provides enhanced guidance for understanding the services subject to clinical care management and the utilization management process generally. Please note that statutes, regulations, service definitions and all related State and OHNM documents may be revised from time to time and subject to change without notice. Although regulations and service definitions are set forth herein, this Level of Care Guidelines is subject to the current statues, regulations and State/OHNM documents. It is the provider s responsibility to adhere to current statues, regulations and State/OHNM documents relevant to the level of care regardless of the fact that these Guidelines uses the documents and regulations in place as of July 22, OptumHealth New Mexico wishes to thank the members of the Clinical Advisory Committee for their invaluable assistance through the revision process. Medical Necessity Definition The following is the Medical Assistance Division current definition of medical necessity. This definition is used as part of the Level of Care Guidelines for consumers that are covered by Medicaid and/or OptumHealth New Mexico. This definition can be found at MAD-MR: NMAC. This medical necessity definition will be applied to all services funded, for all Collaborative agencies/funding streams A (7) NMAC citation/ MAD Citation 606 Medically necessary services: (a) Medically necessary services are clinical and rehabilitative physical or behavioral health services that: (i) are essential to prevent, diagnose or treat medical conditions or are essential to enable the individual to attain, maintain or regain functional capacity; OHNM Level of Care Guidelines Page 3 of 82

4 (ii) are delivered in the amount, duration, scope and setting that is clinically appropriate to the specific physical, mental and behavioral health care needs of the individual; (iii) are provided within professionally accepted standards of practice and national guidelines; and (iv) are required to meet the physical and behavioral health needs of the individual and are not primarily for the convenience of the individual, the provider or the payer. (b) Application of the definition: (i) a determination that a health care service is medically necessary does not mean that the health care service is a covered benefit or an amendment, modification or expansion of a covered benefit; (ii) the MCO/SE making the determination of the medical necessity of clinical, rehabilitative and supportive services consistent with the Medicaid benefit package applicable to an eligible individual shall do so by: 1) evaluating individual physical and behavioral health information provided by qualified professionals who have personally evaluated the individual within their scope of practice, who have taken into consideration the individual s clinical history including the impact of previous treatment and service interventions and who have consulted with other qualified health care professionals with applicable specialty training, as appropriate; 2) considering the views and choices of the individual or the individual s legal guardian, agent or surrogate decision maker regarding the proposed covered service as provided by the clinician or through independent verification of those views; and 3) considering the services being provided concurrently by other service delivery systems; (iii) physical and behavioral health services shall not be denied solely because the individual has a poor prognosis; required services may not be arbitrarily denied or reduced in amount, duration or scope to an otherwise eligible individual solely because of the diagnosis, type of illness or condition; and (iv) decisions regarding benefit coverage for children shall be governed by the EPSDT coverage rules The following are additional definitions that may guide clinical decision making by the OptumHealth New Mexico utilization management program, and come from OptumHealth New Mexico s contract with the New Mexico Interagency Behavioral Health Purchasing Collaborative: Clinical Necessity or Appropriateness OHNM Level of Care Guidelines Page 4 of 82

5 Clinical necessity is defined by the New Mexico Interagency Behavioral Health Purchasing Collaborative (Collaborative/ Statewide Entity Contract Contract - Article 2.1.K) as the determination made by a behavioral health professional exercising prudent clinical judgment as to whether a behavioral health service would promote normal growth and development and prevent, diagnose, detect, treat, ameliorate, or palliate the effects of a behavioral health condition, injury, or disability for the consumer. Psychosocial Necessity Psychosocially necessary services, as defined by the contract (Article 2.1.SS) are services or products provided to a consumer with the goal of helping that individual develop to his/her fullest capacities through learning and environmental supports and/or 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. *Note that these medical necessity, clinical appropriateness, and psychosocial necessity definitions apply for all services, and that authorization and payment are also contingent upon consumer eligibility and availability of funds, especially in the case of services supported by non-medicaid funds. OHNM Level of Care Guidelines Page 5 of 82

6 2011 Common Criteria The following criteria are common to all levels of care for behavioral health conditions and substance use disorders. These criteria will be used in conjunction with criteria for specific level of care. 1. The consumer is eligible for benefits. 2. The provider completes a thorough initial evaluation, including current assessment information. 3. The consumer s condition and proposed services are covered under the terms of the benefit plan. 4. The consumer s current condition can be most efficiently and effectively treated in the proposed level of care. 5. The consumer s current condition cannot be effectively and safely treated in a lower level of care even when the treatment plan is modified, attempts to enhance the consumer s motivation have been made, or referrals to community resources or peer supports have been made. 6. There must be a reasonable expectation that essential and appropriate services will improve the consumer s presenting problems within a reasonable period of time. Improvement in this context is measured by weighing the effectiveness of treatment against the evidence that the consumer s condition will deteriorate if treatment is discontinued in the current level of care. Improvement must also be understood within the framework of the consumer s broader recovery goals. 7. The goal of treatment is to improve the consumer s presenting symptoms to the point that treatment in the current level of care is no longer required. 8. Treatment is not primarily for the purpose of providing respite for the family, increasing the consumer s social activity, or for addressing antisocial behavior or legal problems, but is for the active treatment of a behavioral health condition. 9. The consumer has provided informed consent to treatment. Informed consent includes the following: a) The consumer has been informed of safe and effective alternatives. b) The consumer understands the potential risks and benefits of treatment. c) The consumer is willing and able to follow the treatment plan including the safety precautions for treatment. 10. The treatment/service plan stems from the consumer s presenting condition, and clearly documents realistic and measurable treatment goals as well as the treatments that will be used to achieve the goals of treatment. The treatment/service plan also considers the following: OHNM Level of Care Guidelines Page 6 of 82

7 a) Use of treatments that are consistent with nationally recognized scientific evidence, prevailing medical standards for the treatment of the consumer s current condition and clinical guidelines. b) Significant variables such as the consumer s age and level of development; the consumer s preferences, strengths, broader recovery goals and readiness for change; risks including barriers to care; past response to treatment; the consumer s understanding of his/her condition, its treatment and self-care; and the role that the consumer s family/social supports should play in treatment with the consumer s permission. c) Interventions needed to address co-occurring behavioral health or medical conditions. d) Interventions that will promote the consumer s participation in care, promote informed decision making, and support the consumer s broader recovery goals. Examples of such interventions are psycho-education, motivational interviewing, recovery planning and use of an advance directive, as well as facilitating involvement with natural and cultural supports, and self-help or peer programs. e) Involvement of the consumer s family/social supports in treatment and discharge planning with the consumer s permission when such involvement is clinically indicated. f) How treatment will be coordinated with other behavioral health and medical providers as well as within the school system, legal system and community agencies with the consumer s permission. g) How the treatment plan will be altered as the consumer s condition changes, or when the response to treatment isn t as anticipated. 11. The discharge plan stems from the consumer s response to treatment, and considers the following: a) Significant variables including the consumer s preferences, strengths, broader recovery goals and readiness for change; risks including barriers to care; past response to discharge; the consumer s understanding of his/her condition, its treatment and self-care; and the role that the consumer s family/social supports should play in treatment with the consumer s permission. b) The availability of a lower level of care which can effectively and safely treat the consumer s current clinical condition. c) The availability of treatments which are consistent with nationally recognized scientific evidence, prevailing medical standards for the treatment of the consumer s current condition and clinical guidelines. d) Involvement of the consumer s family/social supports in discharge planning with the consumer s permission when such involvement is clinically indicated. e) How discharge will be coordinated with the provider of post-discharge behavioral health care, medical providers, as well as with the school OHNM Level of Care Guidelines Page 7 of 82

8 system, legal system or community agencies with the consumer s permission. 12. How the risk of relapse will be mitigated including: a) Completing and accurate assessment of the consumer s current level of function and ability to follow through on the agreed upon discharge plan; b) Confirming that the consumer has engaged in shared decision making about the discharge plan and that the consumer understands and agrees with the discharge plan; c) Scheduling a first appointment within 7 days of discharge when care at a lower level is planned; d) Assisting the consumer with overcoming barriers to care (e.g. a lack of transportation or child care challenges); e) Ensuring that the consumer has an adequate supply of medication to bridge the time between discharge and the first scheduled follow-up psychiatric assessment; f) Providing psycho-education and motivational interviewing, assisting with recovery planning and use of an advance directive, and facilitating involvement with self-help and peer programs; g) Confirming that the consumer understands what to do in the event that there is a crisis prior to the first post-discharge appointment, or if the consumer needs to resume services. 13. The availability of resources such natural and cultural supports, such as self-help and peer support programs, and peer-run services which may augment treatment, facilitate the consumer s transition from the current level of care, and support the consumer s broader recovery goals. Note on New Mexico Administrative Code (NMAC) application to this document: OptumHealth New Mexico has developed these guidelines in close collaboration with the OptumHealth New Mexico Clinical Advisory Committee and with the Oversight Team of the New Mexico Interagency Behavioral Health Purchasing Collaborative. In most cases, NMAC rules from Section 8 (Social Services) have been used to develop guidelines and criteria. In some cases, Section 7 (Health) rules have also been consulted, particularly NMAC For any services which require certification by the Children Youth & Families Department (CYFD) Licensing and Certification Authority (LCA), OptumHealth New Mexico has attempted to include consideration of the rules providers must abide by in service delivery. OHNM Level of Care Guidelines Page 8 of 82

9 Discharge Planning OptumHealth New Mexico providers (facilities and practitioners) are responsible for coordinating and monitoring the discharge planning process, which begins when services are initiated, and continues throughout the course of treatment. Discharge planning addresses how consumers needs will be met as they are discharged from one level of care to another, and ensures that consumers have a clear understanding of how to access behavioral health services in the future, if needed. Effective discharge planning, which always includes the consumer, the current treating practitioner or facility, the practitioner or facility at the next level of care, and, as appropriate, the consumer s family, the Primary Physician, and relevant community resources may consist of a number of related activities to be coordinated by the current provider: A. Ongoing assessment of the consumer s clinical needs and the most effective means by which these needs can be met; B. Keeping the consumer and, with the consumer s consent, the consumer s family, informed about the treatment process, beginning as early as possible and continuing throughout a course of treatment. This includes providing information pertaining to: 1. The conditions that would result in the consumer s transfer to a lower or higher level of care; 2. The alternatives to transfer to another level of care; 3. The clinical basis for transfer to another level of care; and 4. The anticipated need for and length of continued care following transfer to another level of care. C. Communicating, with the consumer s consent and in a timely manner, a discharge or transfer plan to the treating practitioner or facility at the next level of care and to the Primary Physician, as appropriate, that includes: 1. The care requested for the consumer; 2. The reason for transferring the consumer; 3. The consumer s bio-psychosocial status at the time of transfer; 4. A summary of the care and services provided to the consumer, as well as progress towards achieving the treatment goals; and 5. A list of the consumer s discharge medications, activity level, diet, and a list of other treating facilities or practitioners who are providing care to the consumer. OHNM Level of Care Guidelines Page 9 of 82

10 D. Identifying the needs of the consumer following discharge from facility-based treatment, and, as appropriate, ensuring that the consumer has the means to meet those needs; E. Ensuring that the facility or practitioner has scheduled for the consumer an outpatient appointment for follow-up care with an appropriately credentialed practitioner or facility within seven (7) days of discharge from an inpatient level of care, and, in the event that the facility has not done so, assisting the consumer, when necessary, with scheduling an appointment within seven (7) days of discharge; F. Providing relevant instruction to the consumer and, with the consumer s consent, the consumer s family, as to how to maintain or improve the consumer s functional status, and promote his/her own health, when indicated. Written instructions are, at the request of a consumer or consumer representative, to be translated into a language based on the consumer s language preference. G. Informing the consumer, as appropriate, of specific health care needs that require follow-up; H. Supporting the consumer compliance with prescribed treatments or regimens; I. Making counseling and facilitating services available, as appropriate, for consumers who are unable to, or are failing to, cooperate in their own treatment; and J. Informing the consumer and the consumer s family, as appropriate, as to how to access additional community services that might be needed in the future. K. Assisting the consumer and the consumer s family, as appropriate, with making the transition between levels of care and/or facilities. OHNM Level of Care Guidelines Page 10 of 82

11 Level of Care Guidelines (LOC) Criteria Sets Acute Inpatient Hospitalization NM Collaborative service definition: None available. Governing NM Administrative Code (NMAC) reference(s): NMAC and NMAC I. DEFINITION OF SERVICE: Acute Inpatient Psychiatric Hospitalization is a 24-hour secure and protected, medically staffed, psychiatrically supervised treatment service. This level of care is for stabilization of urgent or emergent behavioral health problems. Acute Inpatient Hospitalization is provided specifically for those consumers who, as a result of a psychiatric disorder, are an acute and significant danger to themselves or others, or are acutely and significantly disabled, or whose activities of daily living are significantly impaired. This level of care involves the highest level of skilled psychiatric services. It is rendered in a freestanding psychiatric hospital or the psychiatric unit of a general hospital. The care must be provided under the direction of an attending physician who performs a face-to-face interview of the consumer within 24 hours of admission. The care involves an individualized treatment plan that is reviewed and revised frequently based on the consumer s clinical status. This level of care should not be authorized solely as a substitute for management within the adult corrections, juvenile justice or protective services systems, as an alternative to specialized schooling (which should be provided by the local school system), or simply to serve as respite or housing. This level of care is available for all age ranges, but admission should be to a unit that is age appropriate. For school age children and youth, academic schooling funded through the local school system or by the facility is expected. In some instances, additional administrative criteria may apply to an authorization requests, as in the case of BHSD Southern Inpatient fund contracted providers in New Mexico regions 4 and 5. II. ADMISSION CRITERIA (MEETS A AND B, AND C OR D OR E OR F): A. Medical necessity has been demonstrated according to the New Mexico Medical Assistance Division definition contained in NMAC , and the consumer has a DSM-IV TR diagnosed condition that requires, and is likely to benefit from, therapeutic intervention. B. Treatment cannot safely be administered in a less restrictive level of care. C. There is an indication of actual or potential imminent danger to self which cannot be controlled outside of a 24-hour treatment setting. Examples of OHNM Level of Care Guidelines Page 11 of 82

12 indications include serious suicidal ideation or attempts, severe self-mutilation or other serious self-destructive actions. D. There is an indication of actual or potential imminent danger to others and the impulses to harm others cannot be controlled outside of a 24-hour treatment setting. An example of an indication includes a current threat and means to kill or injure someone. E. There is disordered or bizarre thinking, psychomotor agitation or retardation, and/or a loss of impulse control or impairment in judgment leading to behaviors that place the consumer or others in imminent danger. These behaviors cannot be controlled outside of a 24-hour treatment setting. F. There is a co-existing medical illness that complicates the psychiatric illness or treatment. Together the illnesses or treatment pose a high risk of harm for the consumer, and cannot be managed outside of a 24-hour treatment setting. III. CONTINUED STAY CRITERIA (MEETS ALL): A. The consumer continues to meet admission criteria. B. An individualized treatment plan that addresses the consumer s specific symptoms and behaviors that required Inpatient treatment has been developed, implemented and updated, with the consumer s and/or guardian s participation whenever possible, which includes consideration of all applicable and appropriate treatment modalities. C. An individualized discharge plan has been developed which includes specific realistic, objective and measurable discharge criteria and plans for appropriate follow-up care. A timeline for expected implementation and completion is in place but discharge criteria have not yet been met. IV. DISCHARGE CRITERIA (MEETS ALL): A. The consumer has met his/her individualized discharge criteria. B. The consumer can be safely treated at a less intensive level of care. C. An individualized discharge plan with appropriate, realistic and timely followup care is in place. V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. The condition of primary clinical concern is one of a medical nature (not behavioral health) and, as outlined in the current Mixed Services Protocol, should be covered by another managed care entity. B. The consumer appears to have presented for admission for reasons other than a primary psychiatric emergency, such as homelessness or in appropriate seeking of medications. OHNM Level of Care Guidelines Page 12 of 82

13 Inpatient Days Awaiting Placement (DAP) Rate NM Collaborative service definition: None available. Governing NMAC reference(s): NMAC (4.MAD 721.5) and NMAC ( A-C) I. Description: Per NMAC (4.MAD 721.5) and NMAC ( A-C) Inpatient Days awaiting Placement (DAP) is a negotiated rate used when a Medicaid eligible consumer under 21 years of age no longer meets acute care criteria and it is verified that the eligible consumer requires a residential level of care which may not be immediately located, those days during which the eligible consumer is awaiting placement to the lower level of care are termed awaiting placement days.. These circumstances must be beyond the control of the inpatient provider. DAP is intended to be brief and to support transition to the lower level of care. DAP may not be used solely because the inpatient provider did not pursue or implement a discharge plan in a timely manner. II. Approval Criteria (must meet all): A. The consumer 21 years of age or younger, is covered by Medicaid as administered by the Medical Assistance Division definition, and the consumer has a DSM-IV TR diagnosed condition that has required an acute inpatient psychiatric level of care currently. B. The consumer no longer meets continued stay criteria for inpatient acute psychiatric care and/or does meet discharge criteria and there is a specific discharge plan in place to a residential level of care, but documented barriers to implementation of that plan exist that are beyond the control of the provider or facility. C. The provider has made reasonable efforts to identify and obtain the services needed to implement the discharge plan, and continues to actively work to identify resources to implement that plan. D. OptumHealth New Mexico, or another entity, has authorized the residential level of care sought as the discharge, and documentation of this authorization has been made available to OptumHealth New Mexico utilization management personnel. II. Exclusionary Criteria: A. The consumer has met his/her individualized discharge criteria and substantial barriers to discharge no longer exist. B. The inpatient facility cannot demonstrate that it continues to actively work to eliminate barriers to the planned discharge. OHNM Level of Care Guidelines Page 13 of 82

14 C. The inpatient facility is pursuing a discharge to a level of care or service that an OptumHealth New Mexico psychiatrist peer reviewer has explicitly stated does not appear to meet admission criteria at this time. OHNM Level of Care Guidelines Page 14 of 82

15 23 Hour Observation Stay NM Collaborative service definition: None available. Governing NMAC reference(s): NMAC E I. DEFINITION OF SERVICE: A 23 Hour Observation Stay occurs in a secure, medically staffed, psychiatrically supervised facility. This level of care, like acute inpatient hospitalization, involves the highest level of skilled psychiatric services. This service can be rendered in a licensed freestanding psychiatric hospital, psychiatric unit of a general hospital, or in the emergency department of a licensed hospital. The care must be provided under the direction of an attending physician who has performed a face-to-face evaluation of the consumer. The care involves an individual treatment plan that includes access to the full spectrum of psychiatric services. A 23 Hour Observation Stay provides an opportunity to evaluate consumers whose needed level of care is not readily apparent. In addition, it may be used to stabilize a consumer in crisis, when it is anticipated that the consumer s symptoms will resolve in less than 24 hours. This level of care may be considered when support systems and/or a previously developed crisis plan have not sufficiently succeeded in stabilizing the consumer, and the likelihood for further deterioration is high. This level of care is available for all age ranges. If a physician orders an eligible recipient to remain in the hospital for less than 24 hours, the stay is not covered as inpatient admission, but is classified as an observation stay. An observation stay is considered an outpatient service. The following are exemptions to the general observation stay definition: A. The eligible recipient dies; B. Documentation in medical records indicates that the eligible recipient left against medical advice or was removed from the facility by his legal guardian against medical advice; C. An eligible recipient is transferred to another facility to obtain necessary medical care unavailable at the transferring facility; or D. An inpatient admission results in delivery of a child. OptumHealth New Mexico determines whether an eligible recipient's admission falls into one of the exempt categories or considers it to be a one- or two-day stay. A. If an admission is considered an observation stay, the admitting hospital is notified that the services are not covered as an inpatient admission. B. A hospital must bill these services as outpatient observation services. OHNM Level of Care Guidelines Page 15 of 82

16 However, outpatient observation services must be medically necessary and must not involve premature discharge of an eligible recipient in an unstable medical condition. The hospital or attending physician can request a re-review and reconsideration of the observation stay decision. The observation stay review does not replace the review of one- and two-day stays for medical necessity. Medically unnecessary admissions, regardless of length of stay, are not covered benefits. II. ADMISSION CRITERIA (MEETS A AND B, AND C OR D OR E): A. Medical necessity has been demonstrated according to the New Mexico Medical Assistance Division definition contained in NMAC , and the consumer has a DSM-IV TR diagnosed condition that requires, and is likely to benefit from, therapeutic intervention in less than 24 hours in a secure setting. B. The consumer cannot be evaluated in a less restrictive level of care. C. The consumer is expressing suicidal ideation or is expressing threats of harm to others that must be evaluated on a continuous basis for severity and lethality. D. The consumer has acted in disruptive, dangerous or bizarre ways that require further immediate observation and assessment. An evaluation of the etiology of such behaviors is needed, especially if suspected to be chemically or organically induced. E. The consumer presents with significant disturbances of emotions or thought processes that interfere with his/her judgment or behavior that could seriously endanger the consumer or others if not evaluated and stabilized on an emergency basis. III. DISCHARGE CRITERIA (MEETS BOTH): A. The consumer no longer meets admission criteria. B. An individualized discharge plan with appropriate, realistic and timely followup care is in place. IV. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. The consumer meets admission criteria for Acute Inpatient Hospitalization. B. The consumer appears to have presented for admission for reasons other than a primary psychiatric emergency, such as homelessness or in appropriate seeking of medications. OHNM Level of Care Guidelines Page 16 of 82

17 Partial Hospitalization NM Collaborative service definition: None available. Governing NMAC reference(s): NMAC and NMAC I. DEFINITION OF SERVICE: Partial Hospitalization is an intensive, structured and medically staffed, psychiatrically supervised treatment program intended for stabilization of acute psychiatric symptoms. 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 consumer is in the program less than 24 hours a day. Partial Hospitalization is designed for consumers with serious behavioral disorders or disturbances of community functioning that require an intensive, ambulatory and active treatment program. The consumer can be maintained safely in the community but requires close monitoring. Support systems should be available and willing to assist the consumer with participation in treatment whenever possible. Partial Hospitalization offers intensive, multi-modal structured clinical services within a stable therapeutic milieu setting. An individualized treatment plan is developed, reviewed and updated on a regular basis. Partial Hospitalization programs may vary considerably depending upon the age and severity of illness of the consumers for whom the program is designed. This level of care is available for all age ranges, but admission should be to a program that is age appropriate. For school age consumers, elementary and secondary schooling funded through the local school system or by the facility is expected. NM citation/ 722. MAD citation. Partial Hospitalization: Eligible Providers Upon approval of New Mexico Medical Assistance Program Provider Participation Agreements by MAD, general acute care hospitals are eligible to be reimbursed for providing outpatient psychiatric services and partial hospitalization services if they are licensed and certified by the Licensing and Certification Bureau of the New Mexico Department of Health (DOH) to participate in the Title XVIII (Medicare) program Provider Responsibilities Providers who furnish services to Medicaid recipients must comply with all specified Medicaid participation requirements. See Section MAD-701, GENERAL PROVIDER POLICIES. Providers must verify that individuals are eligible for Medicaid at the time services are furnished and determine if Medicaid recipients have other health insurance. Providers must maintain records which are sufficient to fully disclose the extent and nature of the services furnished to recipients. See Section MAD-701, GENERAL PROVIDER OHNM Level of Care Guidelines Page 17 of 82

18 POLICIES: Documentation must be sufficient to demonstrate that coverage criteria are met, including: 1. A treatment plan in which the services are prescribed by a psychiatrist or certified Ph.D. psychologist; 2. Supervision and periodic evaluation of the recipient, either individually or in a group, by the psychiatrist or certified Ph.D. 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. Medicaid does not cover outpatient hospital psychiatric services without periodic psychiatrist or certified Ph.D. psychologist evaluation; and 3. Medical justification of any activity therapies, recipient education programs and psychosocial programs Coverage Criteria Medicaid covers only services which comply with current state mental health codes and standards developed by the Mental Health Division of the DOH Treatment Plan Services must be prescribed by a psychiatrist or certified Ph.D. psychologist and furnished under an individualized written treatment plan established by the psychiatrist or certified Ph.D. psychologist after any necessary consultation with appropriate staff members. The plan must state the type, amount, frequency and duration of the services to be furnished and specify the diagnoses and anticipated goals Supervision and Evaluation Services must be supervised and evaluated periodically as indicated by the recipient's condition, by a psychiatrist or certified Ph.D. psychologist. The evaluation is necessary to determine the extent to which treatment goals are being met and whether changes in direction or emphasis of the treatment are needed. (A) The evaluation must be based on periodic consultations and conferences with therapists and staff, review of medical records and recipient interviews. (B) Psychiatrist or certified Ph.D. psychologist entries in medical records must support this involvement. The psychiatrist or certified Ph.D. psychologist must provide treatment to the recipient periodically, as indicated by the recipient's condition, to determine the extent to which treatment goals are being meet and whether changes in direction or emphasis are needed Reasonable Expectation of Improvement Services must be for the purpose of diagnostic study or be reasonably expected to improve the recipient's condition. At a minimum, the treatment must be designed to reduce or control the recipient's psychiatric symptoms to prevent relapse or hospitalization and improve the recipient's level of functioning. Medicaid covers services to control symptoms and maintain the recipient's functional level to avoid further deterioration or hospitalization. OHNM Level of Care Guidelines Page 18 of 82

19 722.4 Covered Services Medicaid covers outpatient psychiatric hospital services which are medically necessary for the diagnosis and/or treatment of a mental illness, as indicated by the condition of the recipient. Services and stabilization must be for the purpose of diagnostic study or be expected to improve the recipient's condition. (A) Services must be furnished by Medicaid participating providers within the scope and practice of their profession as defined by state laws or regulations. (B) At a minimum, hospitals must provide the following services which are included in the outpatient reimbursement rate: 1. Necessary evaluations and psychological testing for development of the treatment plan, while ensuring that evaluations already performed are not repeated; 2. Regularly scheduled structured counseling and therapy sessions for recipients, groups, families, or multi-family groups based on individualized needs, as specified in the treatment plan; 3. Age-appropriate skills development in household management, nutrition, personal care, physical and emotional health, basic life skills, time management, school attendance, and money management; 4. Assistance to recipients in self-administration of medication in compliance with state policies and procedures; 5. Appropriate staff available twenty-four (24) hours to respond to crisis situations, evaluate the severity of the situation, stabilize recipients, make referrals as necessary, and provide follow-up; 6. Consultation with other professionals or allied care givers regarding a specific recipient; 7. Non-medical transportation services needed to accomplish a treatment objective; and 8. Therapeutic services to meet the physical, social, cultural, recreational, health maintenance, and rehabilitation needs of recipients Noncovered Services Outpatient psychiatric services and partial hospitalization are subject to the limitations and coverage restrictions which exist for other Medicaid services. See Section MAD- 602, GENERAL NONCOVERED SERVICES. Medicaid does not cover the following specific outpatient psychiatric services: 1. Meals and transportation; 2. Activity therapies, group activities, or other services and programs primarily recreational or diversional in nature; 3. Geriatric or other day care programs providing social and recreational activities to recipients who need some supervision during the day; 4. Psychosocial programs, which are usually community support groups for the purpose of social interaction in non-medical settings. Hospital programs may include psychosocial components which are not primarily for social or OHNM Level of Care Guidelines Page 19 of 82

20 recreational purposes; however, if a recipient's outpatient hospital program consists entirely of psychosocial activities, the services are not covered. 5. Formal educational or vocational services related to traditional academic subjects or job training; 6. Hypnotherapy or biofeedback; 7. Services to treat social maladjustments without manifest psychiatric disorders, including occupational maladjustment, marital maladjustment, and sexual dysfunction; and 8. Services not covered under Medicare outpatient hospital psychiatric services regulations Treatment Plan An individualized treatment plan must be developed by a team of professionals in consultation with recipients, parents, legal guardian(s) and/or others who participate in a recipient's care within fourteen (14) days of the initiation of service. (A) The interdisciplinary team must review the treatment plan every thirty (30) days. (B) The following information must be contained in the treatment plan or documents supporting the treatment plan: 1. Statement of the nature of the specific problem and specific needs of the recipient; 2. Description of the functional level of the recipient, including the following: A. Mental status assessment; B. Intellectual function assessment; C. Psychological assessment; D. Educational assessment; E. Vocational assessment; F. Social assessment; G. Medication assessment; and H. Physical assessment. 3. Statement of the least restrictive conditions necessary to achieve the purposes of treatment; 4. Description of intermediate and long-range goals with a projected timetable for their attainment; 5. Statement, duration, frequency, and rationale of services included in the treatment plan for achieving these intermediate and long-range goals, including provisions for review and modification of the plan; 6. Specific staff responsibilities, proposed staff involvement and orders for medication(s), treatments, restorative and rehabilitative services, activities, therapies, social services, diet, and special procedures recommended for the health and safety of the recipient; and 7. Criteria for discharge or discontinuation of services and the projected date of discharge or discontinuation of service. OHNM Level of Care Guidelines Page 20 of 82