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

21 II. ADMISSION CRITERIA (MEETS ALL): 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.the consumer cannot be safely treated in a less intensive or structured setting. B. The consumer exhibits acute disabling psychiatric symptoms of sufficient severity to bring about a significant impairment in day to day social, vocational, and/or educational functioning. C. The consumer is able to exhibit adequate control over behavior so that he or she is not an immediate danger to self or others. The consumer or consumer s support system is able and willing to access emergency services when necessary. D. The consumer has the capacity for active participation in all phases of the treatment program, and support systems are adequate to assist the consumer to participate in the program and remain in the community. 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 Partial Hospitalization 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. 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 21 of 82

22 Electroconvulsive Therapy NM Collaborative service definition: None available. Governing NMAC reference(s): None Value Added (non-entitlement) Service. Reference citation: Citation: American Psychiatric Association. (2001). The Practice of Electroconvulsive Therapy: Recommendations for Training, Treatment, and Privileging (2nd edition). Washington, DC: Author. I. DEFINITION OF SERVICE: Electroconvulsive therapy (ECT) is a beneficial treatment for certain disorders and is usually administered in an inpatient or outpatient facility that provides both psychiatric and anesthesiology services. ECT should be considered when a consumer has severe or treatment resistant depression, psychotic disorders, or prolonged or severe mania. In addition, ECT may be indicated when there is a history of a positive response to ECT, a contraindication to standard psychotropic medication treatments, or when there is an urgent need for response, such as severe suicidality or food refusal leading to nutritional compromise. A valid consent must be obtained for ECT; if the consumer is not competent to refuse or consent to the procedure, then a treatment guardian should be obtained. The person giving consent should be informed of the risks and benefits of ECT along with alternative treatments considered, and the record should document that the consumer or guardian clearly understands these elements of the consent. These criteria will be used to authorize the procedure of ECT. Authorization for this procedure does not imply authorization for a particular level of care or for anesthesia services. OptumHealth New Mexico has adopted the recommendations for electroconvulsive therapy (ECT) provided in The Practice of Electroconvulsive Therapy: Recommendations for Training, Treatment, and Privileging (2nd edition) as its best practice guideline for ECT. This reference in its entirety is available from American Psychiatric Publishing, Inc. which can be contacted at: or by calling: Citation: American Psychiatric Association. (2001). The Practice of Electroconvulsive Therapy: Recommendations for Training, Treatment, and Privileging (2nd edition). Washington, DC: Author. II. CRITERIA FOR APPROVAL (MEETS ALL): 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. OHNM Level of Care Guidelines Page 22 of 82

23 B. A second opinion from a psychiatrist confirms that ECT is an appropriate treatment for the consumer. C. A medical evaluation indicates no contraindication for ECT. D. Informed consent for ECT has been obtained and documented in the treatment record. E. The consumer has treatment resistant depression or psychotic disorder, is experiencing a severe or prolonged manic episode unresponsive to usual treatments, cannot tolerate usual psychotropic medications, exhibits food refusal leading to nutritional compromise or is experiencing such intense suicidal ideation that there is an urgent need for response, or it is the consumer s choice for treatment. II. CRITERIA FOR MAINTENANCE ELECTROCONVULSIVE THERAPY (MEETS ALL): A. The consumer meets the criteria for approval for ECT as outlined above, received ECT, and had a positive response. B. Other treatment options are not viable for the consumer. C. A second opinion from another (other than the current treating psychiatrist) is obtained every 6 months documenting the need for maintenance ECT. V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. Value Added Services funding exhausted for current fiscal year. OHNM Level of Care Guidelines Page 23 of 82

24 Substance Abuse Inpatient Detoxification NM Collaborative service definition: None. Governing NM Administrative Code (NMAC) reference(s): None Value Added (nonentitlement) Service American Society for Addiction Medicine (ASAM) reference: Social Detoxification, Level III.2-D I. DEFINITION OF SERVICE: Substance Abuse Inpatient Detoxification ( social detox ) is a 24-hour secure and protected, medically staffed, psychiatrically supervised treatment service and is comprised of services that are provided for the purpose of completing a medically safe withdrawal from substances. This service is typically indicated when there is minimal risk of severe withdrawal and co-occurring mental health and/or medical conditions if present can be safely managed in a hospital setting. The care must be provided under the direction of an attending physician who performs a face-toface 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 corrections system or simply to serve as respite or temporary housing. This level of care is available for all age ranges, but admission should be to a unit that is age appropriate. "Social detoxi cation" for the purposes of this service means detoxi cation in an organized hospital setting delivered by appropriately trained staff who provide safe, twenty-four-hour monitoring, observation, and support in a supervised environment for a consumer to achieve initial recovery from the effects of alcohol or another drug. Social detoxi cation is characterized by its emphasis on peer and social support and it provides care for clients whose intoxication or withdrawal signs and symptoms are sufficiently severe to require twenty-four-hour structure and support but the full resources of a medically monitored inpatient detoxi cation are not necessary. Inpatient Detoxification is distinguished from medically managed detoxification in the following ways: 1. The consumer s behavior and symptoms do not require intensive medical intervention and subsequent management in order to ensure the consumer s safety. 2. The consumer meets criteria for treatment at ASAM level III.2-D, and does not meet criteria for treatment at ASAM level IV. This is a value added service not part of the core Medicaid benefit package and therefore available only to those consumers with full Medicaid Managed Care (Salud!) benefits. OHNM Level of Care Guidelines Page 24 of 82

25 II. ADMISSION CRITERIA (MEETS A THROUGH D, AND 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. The consumer s use of alcohol and/or drugs is heavy and continuous, and is associated with either of the following: 1. Current symptoms of mild to moderate withdrawal that do not include evidence of seizures or delirium tremens, and require monitoring and management. 2. Emerging symptoms or a history of use which indicate that mild to moderate withdrawal is imminent and requires monitoring and management. D. Co-occurring mental health conditions, if present, can be safely managed in the detoxification setting. E. There is a co-existing medical illness that complicates the substance abuse disorder 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. F. Clinical Institutes Withdrawal Assessment Scale (CIWA-Ar) score of 8 to 15. 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 detoxification has been developed within two (2) days of admission, was implemented and updated (as necessary), 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 follow-up care is in place. OHNM Level of Care Guidelines Page 25 of 82

26 V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. The consumer is experiencing symptoms which appear to require full medically monitored detoxification services. B. The primary reason for admission is a co-existing medical condition. OHNM Level of Care Guidelines Page 26 of 82

27 Sub- Acute Residential Treatment NM Collaborative service definition: None available. Governing NMAC reference(s): NMAC I. DEFINITION OF SERVICE: Sub Acute Residential Treatment Center Services (Sub Acute RTC) is a service offered by OptumHealth New Mexico which has chosen to use NMAC (Accredited Residential Treatment Center Services) as our template for service description. This is not a core benefit for consumers enrolled in the NM Medicaid program, and is not a value-added service, but is a service available to consumers enrolled in the NM Medicaid Managed Care (Salud!) program. Sub Acute RTC is provided to consumers under the age of 21 who, because of the severity or complexity of their behavioral health needs, and who require services beyond the scope of the usual Residential Treatment Center Services (RTC) milieu or other out-of-home or community-based treatment services. These are consumers who, as a result of a recognized psychiatric disorder(s) are a significant danger to themselves or others, but not so acute as to be in need of inpatient hospitalization. Sub Acute RTC facilities must be licensed by the New Mexico Department of Children Youth & Family, Licensing and Credentialing Authority (or similar body when located in other states). The need for RTC services must be identified in the tot to teen Healthcheck or other diagnostic evaluation furnished through a Healthcheck referral and the consumer must meet medical necessity criteria as part of early and periodic screening, diagnosis and treatment (EPSDT) services [42 CFR Section ]. Sub Acute RTC services are provided in a 24-hour a day/ 7 days a week JCAHOaccredited (The Joint Commission, facility. Facilities provide all the diagnostic and therapeutic services provided by an RTC, but with a higher staff to client ratio. Sub Acute RTC units are medically staffed at all times with direct psychiatric services provided several days a week and with 24-hour psychiatric consultation availability. The services are provided under the direction of an attending psychiatrist. The treatment plan is reviewed frequently and updated based on consumer s clinical status. Regular family therapy is a key element of treatment and is required except when clinically contraindicated. Discharge planning should begin at admission, including plans for successful reintegration into the home, school and community. If discharge to a home/family may not be a realistic option, alternative placement/housing must be identified as soon as possible and documentation of active efforts to secure such placement must be thorough. This service should not be authorized solely as a substitute for management within the 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. Academic schooling funded through the local school system OHNM Level of Care Guidelines Page 27 of 82

28 or by the facility is expected. Failure to comply with treatment at a detention center does not automatically constitute unsuccessful treatment at a less restrictive level of care. As discussed in NMAC , in addition to regularly scheduled structured counseling and therapy sessions (individual, group, family, or multifamily - based on individualized needs, and as specified in the treatment plan), Sub Acute RTC also includes facilitation of 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. Sub Acute RTC also includes therapeutic services to meet the physical, social, cultural, recreational, health maintenance and rehabilitation needs of recipients that are not primarily recreational or diversional in nature. Also, Sub Acute RTC shall not implement experimental or investigational procedures, technologies, or non-drug therapies or related services. Sub Acute RTC is a service OptumHealth New Mexico has chosen to make available to consumers eligible for Managed Care Medicaid. It is not a Value Added Service, and is only available to providers contracted specifically to provide this service. II. ADMISSION CRITERIA (MEETS ALL): 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. The consumer is experiencing emotional or behavioral problems in the home and/or community to such an extent that the safety or well being of the consumer or others is substantially at risk. These problems require a supervised, structured, and 24-hour continuous therapeutic milieu beyond that provided in the usual RTC setting, but do not require acute inpatient hospitalization. C. A licensed behavioral health professional has made the assessment that the consumer is likely to experience a deterioration of his/her condition to the point that inpatient hospitalization may be required if the individual is not treated at this level of care. D. Less restrictive or intensive levels of treatment have been tried and were unsuccessful, or have proven inadequate to meet the consumer s needs. Documentation exists to support these contentions. 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 Sub Acute RTC treatment has been developed, implemented and updated, with the consumer s or OHNM Level of Care Guidelines Page 28 of 82

29 guardian s participation whenever possible, which includes consideration of all applicable and appropriate treatment modalities. C. An individualized discharge plan has been developed/ updated 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. D. The consumer is participating in treatment, or there are active efforts being made that can reasonably be expected to lead to the consumer s engagement in treatment. E. The consumer s parent(s), guardian or custodian is participating in the treatment and discharge planning, or persistent efforts are being made and documented to involve them, unless it is clinically contraindicated. IV. DISCHARGE CRITERIA (MEETS A OR B, AND C AND D): A. The consumer has met his/her individualized discharge criteria. B. The consumer has not benefited from Sub Acute Residential Treatment Center Services despite documented persistent efforts to engage the consumer. C. The consumer can be safely treated at a less intensive/restrictive level of care. D. An individualized discharge plan with linkage to appropriate, realistic and timely follow-up care is in place. V. EXCLUSIONARY CRITERIA FOR SUB-ACUTE RTC: (MAY MEET ANY) A. There is evidence (documented) that the Sub Acute RTC placement is intended as an alternative to incarceration or community corrections involvement, and medical necessity have not been met. B. There is evidence that the Sub Acute RTC treatment episode is intended to defer or prolong a permanency plan determination. The inability of unwillingness of a parent or guardian to receive the consumer back into the home is not grounds for continued Sub Acute RTC care. C. The individual demonstrates a clinically significant level of institutional dependence and/or detachment from their community of origin. D. OHNM Common Criterion # 5 has not been met: 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. E. OHNM Common Criterion # 8 has not been met: 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. OHNM Level of Care Guidelines Page 29 of 82

30 Residential Treatment Center Services NM Collaborative service definition: None available. Governing NMAC reference(s): NMAC and NMAC I. DEFINITION OF SERVICE: Residential Treatment Center Services (RTC), as governed by NMAC (accredited RTC) and NMAC (non-accredited RTC) are provided to consumers under the age of 21 years who require 24-hour treatment and supervision in a safe therapeutic environment. NMAC citation 321.4/ MAD citation NON-ACCREDITED RESIDENTIAL TREATMENT CENTERS AND GROUP HOMES: The New Mexico Medicaid program (Medicaid) pays for medically necessary health services furnished to eligible recipients. To help New Mexico recipients under twentyone (21) years of age who need the level of care furnished by psychosocial rehabilitation services in a residential setting, the New Mexico Medical Assistance Division (MAD) pays for services furnished in non-accredited residential treatment centers or group homes as part of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services [42 CFR ]. The need for non-accredited residential treatment center and group home services must be identified in the Tot to Teen Healthcheck screen or other diagnostic evaluation furnished through a Healthcheck referral. This section describes eligible providers, covered services, service limitations, and general reimbursement methodology Eligible Providers Upon approval of New Mexico Medical Assistance Program Provider Participation Agreements by MAD, residential treatment centers which are not accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or group homes that meet the certification standards established by MAD or its designee and are licensed and certified as residential services providers by the New Mexico Children, Youth and Families Department (CYFD) are eligible for Medicaid reimbursement. Once enrolled, providers receive a packet of information; including Medicaid program policies, billing instructions, utilization review instructions, and other pertinent material from MAD. Providers are responsible for ensuring that they have received these materials and for updating them as new materials are received from MAD 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. OHNM Level of Care Guidelines Page 30 of 82

31 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 POLICIES. Providers must maintain records documenting the source and amount of nay financial resource collected or receive by provider by behalf of recipients, including federal or state governmental sources and document receipt and disbursement of recipient funds Covered Services Medicaid covers those medically necessary services for recipients under twenty-one (21) years of age which are designed to develop skills necessary for successful reintegration into the family or transition into the community. A level of care determination must indicate that the recipient needs the level of care that is furnished in non-accredited residential treatment centers or group homes. Residential services must be rehabilitative and provide access to necessary treatment services in a therapeutic environment. The following services must be furnished by centers to receive reimbursement from Medicaid. Payment for performance of these services is included in the center's reimbursement rate: 1. Performance of 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 multifamily groups based on individualized needs, as specified in the treatment plan; 3. Facilitation of 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. Assistance to recipients in self-administration of medication in compliance with state policies and procedures; 5. Appropriate staff available on a twenty-four (24) hour basis to respond to crisis situations, determine the severity of the situation, stabilize recipients by providing support, 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 the treatment objective; and 8. Therapeutic services to meet the physical, social, cultural, recreational, health maintenance, and rehabilitation needs of recipients Noncovered Services Services furnished by non-accredited treatment centers or group homes 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 OHNM Level of Care Guidelines Page 31 of 82

32 the following specific activities furnished in non-accredited residential treatment centers or group homes: 1. Services not considered medically necessary for the condition of the recipients, as determined by MAD or its designee; 2. Room and board; 3. Services for which prior approval was not obtained; 4. Services furnished after the determination is made by MAD or its designee that the recipient no longer needs care 5. Formal educational or vocational services related to traditional academic subjects or vocational training; 6. Experimental or investigations procedures, technologies, or non-drug therapies and related services; 7. Drugs classified as "ineffective" by FDA Drug Evaluations; and 8. Activity therapy, group activities, and other services which are primarily recreational or diversional in nature Treatment Plan An individualized treatment plan used in non-accredited residential treatment centers or group homes must be developed by a team of professionals in consultation with recipients, parents, legal guardians or others in whose care recipients will be released after discharge. The plan must be developed within fourteen (14) days of the recipient's admission. (A) The interdisciplinary team must review the treatment plan at least every thirty (30) days. (B) The following must be contained in the treatment plan or documents used in the development of the treatment plan. The treatment plan and all supporting documentation must be available for review in the recipient's file: 1. Statement of the nature of the specific problem and the 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; OHNM Level of Care Guidelines Page 32 of 82

33 4. Description of intermediate and long-range goals, with the projected timetable for their attainment and the duration and scope of therapy services; 5. Statement and rationale of the plan of treatment for achieving these intermediate and long-range goals, which includes provisions for review and modification of the plan; 6. Specification of staff responsibilities, description of 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 release to less restrictive settings for treatment, discharge plans, criteria for discharge, and projected date of discharge. II. ADMISSION CRITERIA (MEETS ALL): 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. The consumer is experiencing emotional or behavioral problems in the home, community and/or treatment setting to such an extent that the safety or wellbeing of the consumer or others is at risk. These problems require a supervised, structured, and 24-hour continuous therapeutic milieu in a residential setting. C. A licensed behavioral health professional has made the assessment that the consumer is likely to experience a deterioration of his/her condition to the point that a more restrictive treatment setting may be required if the individual is not treated at this level of care at this time. D. Less restrictive or intensive levels of treatment have been tried and were unsuccessful, or have proven inadequate to meet the consumer s needs. Documentation exists to support these contentions. 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 Residential 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, or other barriers to discharge exist which the provider has made reasonable efforts to mitigate. OHNM Level of Care Guidelines Page 33 of 82

34 D. The consumer is participating in treatment, or there are active efforts being made that can reasonably be expected to lead to the consumer s engagement in treatment. E. The consumer s parent(s), guardian or/or custodian is participating in treatment and discharge planning, or persistent efforts are being made and documented to involve these individuals unless it is clinically contraindicated. IV. DISCHARGE CRITERIA (MEETS A OR B, AND C AND D): A. The consumer has met his/her individualized discharge criteria. B. The consumer has not realized substantial benefit from Residential Treatment Services despite documented persistent efforts to engage the consumer. C. The consumer can be safely treated at a less intensive/restrictive level of care. D. An individualized discharge plan with linkage to appropriate, realistic and timely follow-up care is in place. V. EXCLUSIONARY CRITERIA FOR RTC: (MAY MEET ANY) A. There is evidence that the RTC placement is intended as an alternative to incarceration or community corrections involvement, and medical necessity have not been met. B. There is evidence that the RTC treatment episode is intended to defer or prolong a permanency plan determination. The inability or unwillingness of a parent or guardian to receive the consumer back into the home is not grounds for continued RTC care. C. The individual demonstrates a clinically significant level of institutional dependence and/or detachment from their community of origin. D. OHNM Common Criterion # 5 has not been met: 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. E. OHNM Common Criterion # 8 has not been met; 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. OHNM Level of Care Guidelines Page 34 of 82

35 Treatment Foster Care I and II NM Collaborative service definition: None available. Governing NMAC reference(s): NMAC (TFC I) and NMAC (TFC II). I. DEFINITION OF SERVICE: Treatment Foster Care (TFC), as governed by NMAC and NMAC , is a behavioral health service provided to consumers under the age of 21 years who are placed in a 24-hour community-based supervised, trained, surrogate family through a TFC placement agency licensed by the New Mexico Department of Children Youth & Family, Licensing and Credentialing Authority. NMAC citation / MAD citation TREATMENT FOSTER CARE Level I and Level II: The New Mexico Medicaid program (Medicaid) pays for medically necessary health services furnished to eligible recipients. The New Mexico Medical Assistance Division (MAD) pays for mental health services furnished to recipients under twenty-one (21) years of age who have an identified need for treatment foster care and meet this level of care as part of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services [42 CFR ]. The need for treatment foster care services must be identified in the Tot to Teen HealthCheck or other diagnostic evaluation furnished through a HealthCheck referral. This section describes eligible providers, covered services, service limitations, and general reimbursement methodology Eligible Providers Upon approval of New Mexico Medical Assistance Program Provider Participation Agreements by MAD, agencies that meet the following requirements are eligible to be reimbursed for furnishing treatment foster care: 1. Certified as providers of Treatment Foster Care by the Children, Youth and Families Department (CYFD); 2. Services are furnished either through agency staff or contracted personnel; and 3. Services are furnished by licensed clinical professionals or under their supervision. Recipients have the right to receive services from the eligible provider of their choice. Once enrolled, providers receive a packet of information; including Medicaid program policies, billing instructions, utilization review instructions, certification standards, and other pertinent material from MAD. Providers are responsible for ensuring that they have received these materials and for updating them as new materials are received from MAD. OHNM Level of Care Guidelines Page 35 of 82

36 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 provided to recipients. See Section MAD-701, GENERAL PROVIDER POLICIES. Providers must maintain records documenting the source and amount of any financial resource collected or receive by provider by behalf of recipients, including federal or state governmental sources and document receipt and disbursement of recipient funds Covered Services Medicaid covers those services included in individualized treatment plans which are designed to help recipients develop skills necessary for successful reintegration into the natural family or transition into the community. (A) The family living experience is the core treatment service to which other individualized services can be added. Treatment foster parents are employed or contracted by the treatment foster care agency. Their responsibilities include: 1. Participation in the development of treatment plans for recipients by providing input based on their observations; 2. Assumption of primary responsibility for implementing the in-home treatment strategies specified in a treatment plan; 3. Recording information and documentation of activities, as required by the foster care agency and the standards under which it operates; 4. Helping recipients maintain contact with their families and enhancement of those relationships; 5. Supporting efforts specified by the treatment plan to meet the recipient's permanency planning goals; and 6. Assisting recipients obtain medical, educational, vocational, and other services to reach goals identified in treatment plans. (B) The following services must be furnished by the agency certified for treatment foster care to receive reimbursement from Medicaid. Payment for performance of these services is included in the provider's reimbursement rate: 1. Assessment of the recipient's progress in TFC and assessment of family interactions and stress; 2. Regularly scheduled counseling and therapy sessions for recipients in individual, family, or group sessions; 3. Facilitation of age-appropriate skill development in the areas of household management, nutrition, physical and emotional health, basic life skills, time management, school attendance, money management, independent living, relaxation techniques, and selfcare techniques; 4. Crisis intervention, including twenty-four (24) hour availability of appropriate staff to respond to crisis situations; and OHNM Level of Care Guidelines Page 36 of 82

37 5. When a return to the natural family is planned, assessment of family strengths and needs and development of a family service plan Noncovered Service Treatment foster care services 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 services: 1. Room and Board; 2. Formal educational or vocational services related to traditional academic subjects or vocational training; and 3. Respite care Treatment Plan The treatment plan must be developed by the treatment team in consultation with recipients, families or legal guardians, physicians, if applicable, and others in whose care recipients will be released after discharge. The plan must be developed within fourteen (14) days of a recipient's admission to the TFC program. (A) The treatment team must review the treatment plan every thirty (30) days. (B) The following must be contained in the treatment plan or documents used in the development of the treatment plan. The treatment plan and all supporting documentation must be available for review in the recipient's file: 1. Statement of the nature of the specific problem and the 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 the projected timetable for their attainment and the duration and scope of therapy services; 5. Statement and rationale of the treatment plan for achieving these intermediate and long-range goals, including provisions for review and modification of the plan; OHNM Level of Care Guidelines Page 37 of 82

38 6. Specification of staff and TFC parent responsibilities, description of proposed staff involvement, 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 release to less restrictive settings for treatment, discharge plans, criteria for discharge, and projected date of discharge. NMAC citation 322.5/ MAD citation TREATMENT FOSTER CARE (LEVEL II): The New Mexico Medicaid program (Medicaid) pays for medically necessary health services furnished to eligible recipients. The New Mexico Medical Assistance Division (MAD) pays for mental health services furnished to recipients under twenty-one (21) years of age who have an identified need for treatment foster care and meet this level of care as part of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services [42 CFR ]. The need for treatment foster care services must be identified in the Tot to Teen HealthCheck or other diagnostic evaluation furnished through a HealthCheck referral. This section describes eligible providers, covered services, service limitations, and general reimbursement methodology. [ ] Eligible Providers Upon approval of New Mexico Medical Assistance Program Provider Participation Agreements by MAD, agencies that meet the following requirements are eligible to be reimbursed for furnishing treatment foster care: 1. Certified as providers of Treatment Foster Care by the Children, Youth and Families Department (CYFD); 2. Services are furnished either through agency staff or contracted personnel; and 3. Services are furnished by licensed clinical professionals or under their supervision. Recipients have the right to receive services from the eligible provider of their choice. Once enrolled, providers receive a packet of information; including Medicaid program policies, billing instructions, utilization review instructions, certification standards, and other pertinent material from MAD. Providers are responsible for ensuring that they have received these materials and for updating them as new materials are received from MAD. [ ] 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 provided to recipients. See Section MAD-701, GENERAL PROVIDER POLICIES. Providers must maintain records documenting the source and OHNM Level of Care Guidelines Page 38 of 82

39 amount of any financial resource collected or received by the provider on behalf of recipients, including federal or state governmental sources and document receipt and disbursement of recipient funds. [ ] Covered Services Treatment Foster Care II is a mental and behavioral health treatment modality provided by a specially trained treatment foster care parent or family in his or her or their home. Treatment parents are employed by or contracted for and trained by a TFC agency certified by The New Mexico Children, Youth and Families Department (CYFD). TFC II combines the normalizing influence of family-based care with individualized treatment interventions and social supports, thereby creating a therapeutic environment in the family context or maintaining and extending an existing therapeutic context established in TFC. Through the provision of TFC II services, the child's symptoms are expected to decrease and functional level to improve or maintain so that he or she may be discharged successfully to a less restrictive setting, that best meets the child's needs. Medicaid covers those services included in the individualized treatment plan which are designed to help recipients develop skills necessary for successful reintegration into the biological, foster or adoptive family or transition to the community. TFC II will allow for a step-down from TFC when the child improves and no longer meets those utilization review criteria. TFC II will also allow entry into the program at a lower level of care for those children who would benefit optimally from the treatment foster care model. (A) The therapeutic family living experience is the core treatment service to which other individualized services can be added. Treatment foster parents are employed or contracted by the treatment foster care agency. Their responsibilities include: 1. Participation in the development of treatment plans for recipients by providing input based on their observations; 2. Assumption of primary responsibility for implementing the in-home treatment strategies as specified in an individualized treatment plan; 3. Recording of information and documentation of all activities required by the foster care agency and the standards under which it operates; 4. Helping recipients maintain contact with their families and fostering enhancement of those relationships as appropriate; 5. Supporting efforts specified by the treatment plan to meet the recipient's permanency planning goals; and 6. Through coordinating, linking and monitoring services, assist recipients to obtain medical, educational, vocational, and other necessary services to reach goals identified in the treatment plan. (B) The following services must be performed by the agency or be contracted for and overseen by the agency certified for treatment foster care to receive reimbursement from Medicaid. OHNM Level of Care Guidelines Page 39 of 82

40 1. Assessment of the recipient and his biological, foster or adoptive family's strengths and needs; 2. Development of a discharge plan that includes a strengths and needs assessment of the recipient's family when a return to that family is planned, including a family service plan; 3. Development and monitoring of the treatment plan; 4. Assessment of the recipient's progress in TFC II; 5. Assessment of the TFC II family's interaction with the recipient, his or her biological, foster or adoptive family, and any stressors identified; 6. Facilitation of age-appropriate skills development in the areas of household management, nutrition, physical, behavioral and emotional health, basic life skills, social skills, time management, school and/or work attendance, money management, independent living skills, relaxation techniques, and self-care techniques; 7. Ensuring the occurrence of counseling or therapy sessions for recipients in individual, family and/or group sessions as specified in the treatment plan; and 8. Ensuring the availability of crisis intervention, including twenty-four (24) hour a day, seven (7) days a week) availability of appropriately licensed parties to respond to crisis situations. [ ] Noncovered Service Treatment foster care services 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 services: 1. Room and Board; 2. Formal educational or vocational services related to traditional academic subjects or vocational training; and 3. Respite care. [ ] Treatment Plan The treatment plan must be developed by the treatment team in consultation with the recipient, his or her biological, foster or adoptive family or legal guardian, physician(s), when applicable, and others in whose care the recipient is involved and/or in whose care to whom the recipient will be released after discharge. The plan must be developed within fourteen (14) days of a recipient's admission to the TFC II program. (A) The treatment coordinator must review the treatment plan every thirty (30) days. (B) The following must be contained in the treatment plan or documents used in the development of the treatment plan. The treatment plan and all supporting documentation must be available for review in the recipient's file: 1. Statement of the nature of the specific problem and the specific needs and strengths of the recipient; OHNM Level of Care Guidelines Page 40 of 82

41 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 the projected timetable for their attainment; 5. Statement and rationale of the treatment plan for achieving these intermediate and long-range goals, including provisions for review and modification of the plan; 6. Specification of staff and TFC II parent responsibilities and the description and frequency of the following components: proposed staff involvement, orders for medication(s), treatments, restorative and rehabilitative services, activities, therapies, social services, special diet, and special procedures recommended for the health and safety of the recipient; and 7. Criteria for release to less restrictive settings for treatment, discharge plans, criteria for discharge, and projected date of discharge. [ ] II. ADMISSION CRITERIA (Meets A, B, E, and C or D): *These admission criteria are for both TFC I and II, with some caveats, as noted below. 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 interventions.implemented in a TFC/ family living experience treatment setting. B. The consumer s current (within 30 days of proposed admission) medical and psychiatric symptoms require and can be managed safely in a 24-hour supervised community/home-based setting. C. The consumer is immediately at risk for needing a higher level of services and/or being excluded from community, home or school activities due to clinically significant disruptive symptoms or behaviors. These symptoms or behaviors are not amenable to treatment in the consumer s own home or a standard foster care environment. OHNM Level of Care Guidelines Page 41 of 82

42 D. A licensed behavioral health professional has made the assessment that the consumer is likely to experience a deterioration of his/her condition to the point that a more restrictive treatment setting may be required if the individual is not treated at this level of care at this time. E. There is a recent history (within the past 6 months) of less restrictive or intensive levels of treatment having been tried and proving unsuccessful, or these services are not currently appropriate to meet the consumer s needs. FOR TFC I THE FOLLOWING ADDITIONAL ADMISSION CRITERIA MUST BE MET: F. The consumer is unable to participate independently (without 24-hour adult supervision) in age appropriate activities. FOR TFC II THE FOLLOWING ADDITIONAL ADMISSION CRITERIA MUST BE MET: G. The consumer has met the treatment goals of TFC I or is able to participate independently in age appropriate activities without 24-hour adult supervision. Additionally, to be appropriate for TFC II, the consumer s treatment needs or social, behavioral, emotional, or functional impairments are not as serious or severe as those exhibited by consumers who meet criteria for TFC I; therefore services are less clinically intensive than those provided in TFC I. Consumers in TFC II can generally participate independently in age appropriate activities (e.g. dressing self at age 7, working at age 16, attending school without parental classroom supervision), while consumers in TFC I could require supervision for those activities. TFC II is often, but not always, used as a transition from TFC I; consumers may be admitted directly to TFC II. Conversely, not all consumers in TFC I need to go to TFC II before discharge from TFC. III. CONTINUED STAY CRITERIA (MEETS ALL): A. The consumer continues to meet all relevant admission criteria. B. The consumer continues to need 24-hour adult supervision and/or assistance to develop, restore or maintain skills and behaviors that are necessary to live safely in their own home and community. C. An individualized treatment plan that addresses the consumer s specific symptoms and behaviors that required TFC treatment has been developed, implemented and updated according to licensing rules, with the consumer s and/or legal guardian s participation, which includes consideration of all applicable and appropriate treatment modalities. D. An individualized discharge plan has been developed (and updated since the last clinical review/approval) which includes specific realistic, objective and measurable discharge criteria and plans for appropriate follow-up care. A OHNM Level of Care Guidelines Page 42 of 82

43 timeline for expected implementation and completion is in place but discharge criteria have not yet been met. E. The consumer is participating in treatment, or there are active, persistent efforts being made that can reasonably be expected to lead to the consumer s engagement in treatment. F. The parent, legal guardian or custodian is participating in the treatment, discharge and/or permanency planning, or persistent efforts are being made and documented to involve them, unless it is clinically indicated otherwise. VI. CRITERIA FOR TRANSITION FROM TFC I TO TFC II (MEETS ALL): A. A review of the individualized treatment and permanency plan shows that the consumer has met a significant portion of all TFC I treatment goals. B. Continued stay in a treatment foster care setting is necessary to maintain the gains made in TFC I, but consumer does not require the intensity of supervision associated with TFC I. C. The consumer is able to participate independently in age appropriate activities without continuous adult supervision. VII. DISCHARGE CRITERIA (MEETS A OR B, AND C AND D): A. The consumer has met his/her individualized discharge criteria. B. The consumer has not benefited from Treatment Foster Care despite documented persistent efforts to engage the consumer. C. The consumer can be safely treated at a less intensive level of care. D. An individualized discharge plan with appropriate, realistic and timely followup care is in place. VIII. EXCLUSIONARY CRITERIA FOR TFC I AND TFC II (MAY MEET ANY) A. There is evidence that the TFC placement is intended as an alternative to incarceration or community corrections involvement, and medical necessity have not been met. B. There is evidence that the TFC treatment episode is intended to defer or prolong a permanency plan determination, or is substituting for permanent housing. C. The individual demonstrates a clinically significant level of institutional dependence and/or detachment from their community of origin. D. OHNM Common Criterion # 5 has not been met: 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. E. OHNM Common Criterion # 8 has not been met: Treatment is not primarily for the purpose of providing respite for the family, increasing the consumer s OHNM Level of Care Guidelines Page 43 of 82

44 social activity, or for addressing antisocial behavior or legal problems, but is for the active treatment of a behavioral health condition. OHNM Level of Care Guidelines Page 44 of 82

45 Group Home NM Collaborative service definition: None available. Governing NMAC reference(s): NMAC I. DEFINITION OF SERVICE: Group Home is a lower level of care than Residential Treatment Center Services and is indicated when a structured home-based living situation is unavailable or not clinically appropriate for the consumer s behavioral health needs and the consumer needs services focused on psychosocial skills development. Group Home services also differ from Treatment Foster Care in that they are residentially and group based, rather than family and community based. NMAC citation /MAD citation NON-ACCREDITED RESIDENTIAL TREATMENT CENTERS AND GROUP HOMES: The New Mexico Medicaid program (Medicaid) pays for medically necessary health services furnished to eligible recipients. To help New Mexico recipients under twentyone (21) years of age who need the level of care furnished by psychosocial rehabilitation services in a residential setting, the New Mexico Medical Assistance Division (MAD) pays for services furnished in non-accredited residential treatment centers or group homes as part of Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services [42 CFR ]. The need for non-accredited residential treatment center and group home services must be identified in the Tot to Teen HealthCheck screen or other diagnostic evaluation furnished through a HealthCheck referral. This section describes eligible providers, covered services, service limitations, and general reimbursement methodology Eligible Providers Upon approval of New Mexico Medical Assistance Program Provider Participation Agreements by MAD, residential treatment centers which are not accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or group homes that meet the certification standards established by MAD or its designee and are licensed and certified as residential services providers by the New Mexico Children, Youth and Families Department (CYFD) are eligible for Medicaid reimbursement. Once enrolled, providers receive a packet of information; including Medicaid program policies, billing instructions, utilization review instructions, and other pertinent material from MAD. Providers are responsible for ensuring that they have received these materials and for updating them as new materials are received from MAD 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 OHNM Level of Care Guidelines Page 45 of 82

46 PROVIDER POLICIES. Providers must maintain records documenting the source and amount of nay financial resource collected or receive by provider by behalf of recipients, including federal or state governmental sources and document receipt and disbursement of recipient funds Covered Services Medicaid covers those medically necessary services for recipients under twenty-one (21) years of age which are designed to develop skills necessary for successful reintegration into the family or transition into the community. A level of care determination must indicate that the recipient needs the level of care that is furnished in non-accredited residential treatment centers or group homes. Residential services must be rehabilitative and provide access to necessary treatment services in a therapeutic environment. The following services must be furnished by centers to receive reimbursement from Medicaid. Payment for performance of these services is included in the center's reimbursement rate: 1. Performance of 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 multifamily groups based on individualized needs, as specified in the treatment plan; 3. Facilitation of 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. Assistance to recipients in self-administration of medication in compliance with state policies and procedures; 5. Appropriate staff available on a twenty-four (24) hour basis to respond to crisis situations, determine the severity of the situation, stabilize recipients by providing support, 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 the treatment objective; and 8. Therapeutic services to meet the physical, social, cultural, recreational, health maintenance, and rehabilitation needs of recipients Noncovered Services Services furnished by non-accredited treatment centers or group homes 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 activities furnished in non-accredited residential treatment centers or group homes: 1. Services not considered medically necessary for the condition of the recipients, as determined by MAD or its designee; OHNM Level of Care Guidelines Page 46 of 82

47 2. Room and board; 3. Services for which prior approval was not obtained; 4. Services furnished after the determination is made by MAD or its designee that the recipient no longer needs care 5. Formal educational or vocational services related to traditional academic subjects or vocational training; 6. Experimental or investigations procedures, technologies, or non-drug therapies and related services; 7. Drugs classified as "ineffective" by FDA Drug Evaluations; and 8. Activity therapy, group activities, and other services which are primarily recreational or diversional in nature Treatment Plan An individualized treatment plan used in non-accredited residential treatment centers or group homes must be developed by a team of professionals in consultation with recipients, parents, legal guardians or others in whose care recipients will be released after discharge. The plan must be developed within fourteen (14) days of the recipient's admission. (A) The interdisciplinary team must review the treatment plan at least every thirty (30) days. (B) The following must be contained in the treatment plan or documents used in the development of the treatment plan. The treatment plan and all supporting documentation must be available for review in the recipient's file: 1. Statement of the nature of the specific problem and the 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 the projected timetable for their attainment and the duration and scope of therapy services; OHNM Level of Care Guidelines Page 47 of 82

48 5. Statement and rationale of the plan of treatment for achieving these intermediate and long-range goals, which includes provisions for review and modification of the plan; 6. Specification of staff responsibilities, description of 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 release to less restrictive settings for treatment, discharge plans, criteria for discharge, and projected date of discharge. II. ADMISSION CRITERIA (MEETS A, B AND C, AND EITHER 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. B. The consumer may manifest significant psychological or behavioral disturbances but can participate in age-appropriate community based activities (including school) with assistance from group home staff or with other support. C. Less restrictive or intensive levels of treatment have been tried and were unsuccessful, or are not appropriate to meet the consumer s needs. D. A structured home-based living situation is unavailable or is not appropriate for the consumer s needs. E. The consumer is in need of 24-hour therapeutic milieu, but does not require the intensive staff assistance that is provided in Residential Treatment Center Services. III. CONTINUED STAY CRITERIA (MEETS ALL): A. The consumer continues to meet admission criteria. B. The consumer continues to need 24-hour supervision and assistance to develop or restore skills and behaviors that are necessary to live safely in the home and community. C. An individualized treatment plan that addresses the consumer s specific symptoms and behaviors that required Group Home 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. D. 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. OHNM Level of Care Guidelines Page 48 of 82

49 E. The consumer is participating in treatment, or there are active, persistent efforts being made that can reasonably be expected to lead to the consumer s engagement in treatment. F. The parent, guardian or custodian is participating in the treatment, discharge and/or permanency planning, or persistent efforts are being made and documented to involve them, unless it is clinically indicated otherwise. IV. DISCHARGE CRITERIA (MEETS A OR B, AND C AND D): A. The consumer has met his/her individualized discharge criteria. B. The consumer has not benefited from Group Home services despite documented persistent efforts to engage the consumer. C. The consumer can be safely treated at a less intensive level of care D. An individualized discharge plan with appropriate, realistic and timely followup care is in place. V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. There is evidence that the Group Home placement is intended as an alternative to incarceration or community corrections involvement, and medical necessity have not been met. B. There is evidence that the Group Home treatment episode is intended to defer or prolong a permanency plan determination. The inability of unwillingness of a parent or guardian to receive the consumer back into the home is not grounds for continued Group Home care. C. The individual demonstrates a clinically significant level of institutional dependence and/or detachment from their community of origin. D. OHNM Common Criterion # 5 has not been met: 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. E. OHNM Common Criterion # 8 has not been met: 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. OHNM Level of Care Guidelines Page 49 of 82

50 Adolescent Transitional Living Services (TLS) NM Collaborative service definition: Last update 05/17/10; see below. Governing NMAC reference(s): None Value Added (non-entitlement) Service. I. DEFINITION OF SERVICE: NM Collaborative definition for Long Term Residential (Transitional Living Services) H0019: A long-term residential program offering 24-hour supervised voluntary residential treatment, habilitative, and rehabilitative services in a structured, community-oriented environment. Also called transitional living, the services are designed for individuals who have the potential and motivation to ameliorate some skills deficits through a moderately structured rehabilitative housing program. Services stress normalization and maximum community involvement and integration; and include daily living and socialization skills training; case management (community supports); recreational activities; educational and support activities; and access to therapeutic interventions, when necessary. The focus of services is on placement of the individual in a safe and stable living environment upon discharge. SERVICE DESCRIPTION: Adolescent Transitional Living Services (TLS) is a residential program offering 24-hour supervised treatment services in a structured, community-oriented environment for consumers 16 to20 years of age with an established SED diagnosis. TLS include organized rehabilitation services, as well as assistance in obtaining appropriate long-term living arrangements. The services are designed for consumers who do not need the more intense structure of a residential treatment center but who have the potential and motivation to change skills deficits through a moderately structured rehabilitative program. Services stress normalization and maximum community involvement and integration. They include daily living and socialization skills training; community supports; recreational activities; educational and support activities; and access to therapeutic interventions, when necessary. The focus of services is on placement of the individual in a safe and stable living environment upon discharge from the transitional residential living arrangement. These residential services are treatment-oriented and are not considered custodial care or merely a housing option. TLS skills building component focuses on primary life domains that include but are not limited to self care, daily living, social relationships, employment/ vocation, communication, money management/budget, etc This criterion is not intended for use as a long-term solution to maintain the stabilization acquired during treatment in a residential facility/program. For those consumers served through CYFD funding, the consumer must meet the CYFD funding criteria. Adolescent TLS is intended to be a relatively shortterm treatment program, with individualized treatment goals generally obtainable OHNM Level of Care Guidelines Page 50 of 82

51 within three (3) months time. Adolescent TLS is also a Value-Added Service for those consumers served through Medicaid Managed Care. II. ADMISSION CRITERIA (MUST MEET ALL) 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. Clinical necessity/appropriateness and psychosocial necessity definitions may also be considered with regard to this service. B. The consumer has behavioral health symptoms that interfere significantly with his or her ability to manage activities of daily living, including school, without structured intervention, and these symptoms prevent successful transition to independent living. It is expected that the consumer possesses the capacity to develop, maintain, or regain daily living skills through participation in a structured TLS program. C. Participating in this level of care may assist the consumer in avoiding a more restrictive level of care. In particular, this service may be used to avoid or step down from residential (RTC) placement. D. The consumer has a history of treatment episodes that have required behavioral health interventions. E. The current family situation and /or functioning levels are such that the consumer cannot remain in the home environment and receive community based treatment. III. CONTINUING STAY CRITERIA (MUST MEET A, B, AND C AND D) A. The consumer continues to meet the criteria for admission B. An individualized treatment plan that addresses the consumer s specific symptoms and behaviors that required Transitional Living Services 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. Specific interventions addressing family support issues are included. 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. D. There is documentation that the consumer is participating in the services or is learning to actively participate in self directed recovery and resiliency activities. IV. DISCHARGE CRITERIA (MUST MEET A, AND B OR C OR D) OHNM Level of Care Guidelines Page 51 of 82

52 A. An individualized discharge plan with appropriate, realistic and timely follow-up care is in place. B. The consumer has substantially met the defined goals of the treatment plan and is able to live with family or independently. C. Consumer elects to terminate this level of care D. The consumer has not benefited from this level of care. V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. There is evidence that the TLS placement is intended as an alternative to incarceration or community corrections involvement, B. There is evidence that the TLS treatment episode is intended to defer or prolong a permanency plan determination. C. The individual demonstrates a clinically significant level of institutional dependence and/or detachment from their community of origin. OHNM Level of Care Guidelines Page 52 of 82

53 Adult Transitional Living Services (TLS) NM Collaborative service definition: Last update 05/17/10; see below. Governing NMAC reference(s): None Value Added (non-entitlement) Service, unless funded by BHSD (provider contract-specific). I. DEFINITION OF SERVICE: NM Collaborative definition for Long Term Residential (Transitional Living Services) H0019: A long-term residential program offering 24-hour supervised voluntary residential treatment, habilitative, and rehabilitative services in a structured, community-oriented environment. Also called transitional living, the services are designed for individuals who have the potential and motivation to ameliorate some skills deficits through a moderately structured rehabilitative housing program. Services stress normalization and maximum community involvement and integration; and include daily living and socialization skills training; case management (community supports); recreational activities; educational and support activities; and access to therapeutic interventions, when necessary. The focus of services is on placement of the individual in a safe and stable living environment upon discharge. SERVICE DESCRIPTION: Adult Transitional Living Services (TLS) is a residential program offering 24-hour supervised treatment services in a structured, community-oriented environment for consumers 21 years of age and older. Adult TLS include organized rehabilitation services, as well as assistance in obtaining appropriate long-term living arrangements. The services are designed for individuals who have the potential and motivation to change some skills deficits through a moderately structured rehabilitative program. Services stress normalization and maximum community involvement and integration. They include daily living and socialization skills training; community supports; recreational activities; educational and support activities; and access to therapeutic interventions, when necessary. The focus of services is on placement of the individual in a safe and stable living environment upon discharge from the transitional residential living arrangement. These residential services are treatment-oriented and are not considered custodial care or merely a housing option. This criterion is not intended for use as a long-term solution to maintain the stabilization acquired during treatment in a residential facility/program. For those consumers served through BHSD funding, the consumer must meet the BHSD priority population criteria: 18 years of age or older, 150% or below the federal poverty level, and uninsured. TLS is also a Value-Added Service for those consumers served through Medicaid Managed Care. OHNM Level of Care Guidelines Page 53 of 82

54 Adult TLS is intended to be a relatively short-term treatment program, with individualized treatment goals generally obtainable within three (3) months time. II. ADMISSION CRITERIA (MUST MEET ALL) 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. For consumers covered by BHSD, then clinical necessity has been met according to the New Mexico Behavioral Health Collaborative (Collaborative) definition. B. For all covered consumers, he/she meets criteria for the Collaborative service definition for Serious Mental Illness (SMI). Clinical necessity/appropriateness and psychosocial necessity definitions may also be considered with regard to this service. C. The consumer has behavioral health symptoms that interfere significantly with his or her ability to manage activities of daily living without structured intervention, and these symptoms prevent successful transition to independent living. It is anticipated that the consumer possesses the intellectual capacity to develop, maintain, or regain daily living skills through participation in a structured TLS program. Assessment of current capacity to substantially engage in and benefit from this service will be done as indicated, but is not required; it is the rendering provider s responsibility to demonstrate that the consumer has the capacity to benefit from this service. D. Participating in this level of care may assist the consumer in avoiding a more restrictive level of care. III. CONTINUING STAY CRITERIA (MUST MEET ALL ) A. The consumer continues to meet the criteria for admission. B. An individualized treatment plan that addresses the consumer s specific symptoms and behaviors that required Transitional Living Services 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. D. There is documentation that the consumer is participating in the services or is learning to actively participate in self directed recovery and resiliency activities. OHNM Level of Care Guidelines Page 54 of 82

55 IV. DISCHARGE CRITERIA (MUST MEET A, AND B OR C OR D) A. An individualized discharge plan with appropriate, realistic and timely follow-up care is in place. B. The consumer has substantially met the defined goals of the treatment plan and is able to live independently. C. Consumer elects to terminate this level of care. D. The consumer has not benefited from this level of care. V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. There is evidence that the TLS placement is intended as an alternative to incarceration or community corrections involvement. B. There is evidence that the TLS treatment episode is intended to defer or prolong a permanency plan determination. C. The individual demonstrates a clinically significant level of institutional dependence and/or detachment from their community of origin. OHNM Level of Care Guidelines Page 55 of 82

56 Comprehensive Community Support Services (CCSS) The NM Collaborative service definition and the NMAC regulation are provided below for your reference and guidance. Please note both are under review for revision. NM Collaborative service definition: Last update 07/30/10; see below. Governing NMAC reference(s): NMAC I. DEFINITION OF SERVICE:* * Until such time such Medicaid regulation is updated, the service definition for Comprehensive Community Support Services (CCSS) (H2015) and the Medicaid regulation are set forth below for your reference. NM Collaborative definition for Comprehensive Community Support Services (CCSS) H2015: The purpose of Community Support Services is to surround individuals/families with the services and resources necessary to promote recovery, rehabilitation and resiliency. Community support activities address goals specifically in the following areas: independent living; learning; working; socializing and recreation. Community Support Services consist of a variety of interventions, primarily face-to-face and in community locations, which address barriers that impede the development of skills necessary for independent functioning in the community. Community Support Services also include assistance with identifying and coordinating services and supports identified in an individual s service plan; supporting an individual and family in crisis situations; and providing individual interventions to develop or enhance an individual s ability to make informed and independent choices. SERVICE DESCRIPTION: Comprehensive Community Support Services (CCSS) coordinate and provide services and resources to consumers and families that are necessary to promote recovery, rehabilitation and resiliency. CCSS identifies and addresses the barriers that impede the development of skills necessary for independent functioning in the community; as well as strengths, which may aid the consumer or family in the recovery or resiliency process. Community support activities address goals specifically in the following areas: independent living; learning; working; socializing and recreation. CCSS also includes supporting a consumer and family in crisis situations and providing consumer interventions to develop or enhance a consumer s ability to make informed and independent choices. Target Population: OHNM Level of Care Guidelines Page 56 of 82

57 Individuals having problems accessing services and/or receiving multiple services from a single or multiple providers and/or systems and Individuals needing support in functional living or Individuals transitioning from institutional or highly restrictive settings to community-based settings or Children at risk of/ or experiencing Serious Emotional/ Neurobiological/ Behavioral Disorders or Adults with severe mental illness (SMI) or Individuals with Chronic Substance Abuse or Individuals with a co-occurring disorder (mental illness/substance abuse) and/ or dually diagnosed with a primary diagnosis of mental illness. NMAC references for Comprehensive Community Support Services: NMAC citation/ MAD citation COMPREHENSIVE COMMUNITY SUPPORT SERVICES (CCSS): MAD pays for medically necessary services furnished to eligible recipients. To help New Mexico eligible recipients receive necessary services, MAD pays for covered CCSS. [ NMAC - N, ] ELIGIBLE PROVIDERS: In order to be eligible to be reimbursed for providing CCSS services, a provider agency must be: a federally qualified health center (FQHC); an Indian health service (IHS) hospital or clinic; a PL tribally operated hospital or clinic; a community mental health center licensed by the New Mexico department of health (DOH); or a children s core service agency licensed by the New Mexico children, youth and families department (CYFD). Prior to the introduction of CSA s as a Medicaid provider type, providers of CCSS to adults and to children 18 years of age and older must be an FQHC, IHS hospital or clinic, PL , hospital or clinic, licensed as a CMHC, certified for psychosocial rehabilitation services (PSR) by DOH or certified for targeted case management (TCM) by DOH. Providers of CCSS for children less than 18 years of age must be an FQC, IHS hospital or clinic, PL hospital or clinic, or certified as a targeted case management agency by CYFD. Upon introduction of CSA s as a Medicaid provider type, providers of CCSS to adults and to children 18 years of age or older must be a FQHC, IHS hospital or clinic, PL hospital or clinic, or licensed as a CMHC. Providers of CCSS for children under 18 years of age must be an FQHC, IHS hospital or clinic, PL hospital or clinic, or licensed as a core service agency (CSA). Eligible recipients, ages 18 through 20, may be served by an agency certified or licensed for CCSS by either CYFD or DOH, as appropriate. A. CCSS provided by agencies must be rendered by qualified practitioners. (1) Community support workers (other than a peer or family specialist), who must possess: (a) the education, skills, abilities, and experience to perform the activities that comprise the full spectrum of CCSS; OHNM Level of Care Guidelines Page 57 of 82

58 (b) a bachelor s degree in a human service field from an accredited university and one year of relevant experience with the target population; or, (c) an associate s degree and a minimum of two years of experience working with the target population; or, (d) a high school graduation or general educational development (GED) test and a minimum of three years of experience working with the target population; or, (e) New Mexico peer or family specialist certification; and, (f) 20 hours of documented training or continuing education, as identified in the CCSS service definition. (2) CCSS Agency supervisory staff, who must possess: (a) the education, skills, abilities, and experience to perform the activities that comprise the full spectrum of CCSS; (b) a bachelor s degree in a human services field from an accredited university; (c) four years of relevant experience in the delivery of case management or community support services with the target population; (d) one year of demonstrated supervisory experience, and (e) 20 hours of documented training or continuing education, as identified in the CCSS service definition. (3) Agency clinical supervisory staff, who must possess: (a) the education, skills, abilities, and experience to perform the activities that comprise the full spectrum of CCSS; (b) be a licensed independent practitioner (psychiatrist, psychologist, LISW, LPCC, LMFT, LPAT, CNS) practicing under the scope of his or her licensure; and, (c) have one year of documented supervisory training. (4) Peer specialists, who must: (a) must be 18 years of age or older; and (b) have a high school diploma or GED; and (c) be self-identified as a current or former consumer of mental health or substance abuse services, and (d) have at least one year of mental health or substance abuse recovery; and (e) have received certification as a certified peer specialist (5) Family specialists, who must: OHNM Level of Care Guidelines Page 58 of 82

59 (a) must be 18 years of age or older; and (b) have a high school diploma or GED; and (c) have personal experience navigating any of the child/familyserving systems and/or advocating for family members who are involved with the child/family behavioral health systems. Must also have an understanding of how these systems operate in New Mexico; and (d) if the individual is a current or former consumer, they must be well-grounded in their symptom self-management; and (e) have received certification as a certified family specialist. B. Services must be provided within the scope of the practice and licensure for each agency and each rendering provider within that agency. Services must be in compliance with the statutes, rules and regulations of the applicable practice act NMAC 3 C. Upon approval of a New Mexico medical assistance division provider participation agreement by MAD or its designee, a licensed practitioner or facility that meets applicable requirements is eligible to be reimbursed for furnishing covered services to eligible program recipients. A provider must be enrolled before submitting a claim for payment to the MAD claims processing contractors. MAD makes available on the HSD/MAD website, on other program-specific websites, or in hard copy format, information necessary to participate in health care programs administered by HSD or its authorized agents, including program policies, billing instruction, utilization review instructions, and other pertinent materials. Once enrolled, a provider receives instruction on how to access these documents. It is the provider s responsibility to access these instructions or ask for paper copies to be provided, to understand the information provided and to comply with the requirements. The provider must contact HSD or its authorized agents to request hard copies of any program policy manuals, billing and utilization review instructions, and other pertinent materials and to obtain answers to questions on or not covered by these materials. To be eligible for reimbursement a provider is bound by the provisions of the MAD provider participation agreement. [ NMAC - N, ] PROVIDER RESPONSIBILITIES: A provider who furnishes services to Medicaid and other health care programs eligible recipients agree to comply with all federal and state laws and regulations relevant to the provision of medical services as specified in the MAD provider participation agreement. A provider also agrees to conform to MAD program policies and instruction as specified in this manual and its appendices, and program directions and billing instructions, as updated. A provider is also responsible for following coding manual guidelines and CMS correct coding initiatives, including not improperly unbundling or up-coding services. See NMAC, General Provider Policies. [ NMAC - N, ] ELIGIBLE RECIPIENTS: CCSS are provided to eligible recipients 21 years and under who are at risk of/or experiencing serious OHNM Level of Care Guidelines Page 59 of 82

60 emotional/neurobiological/behavioral disorders or with chronic substance abuse, or adults with severe mental illness. A co-occurring diagnosis of substance abuse shall not exclude an eligible recipient from eligibility for the service. [ NMAC - N, ] COVERAGE CRITERIA: A. MAD covers medically necessary CCSS required by the condition of the eligible recipient. B. This culturally sensitive service coordinates and provides services and resources to eligible recipients and their families necessary to promote recovery, rehabilitation and resiliency. CCSS identifies and addresses the barriers that impede the development of skills necessary for independent functioning in the community, as well as strengths that may aid the eligible recipient or family in the recovery or resiliency process. C. CCSS activities are goal-directed and provided as part of the approved service plan. D. CCSS also includes supporting an eligible recipient or family in crisis situations and providing individual interventions to develop or enhance an eligible recipient s ability to make informed and independent choices. E. All CCSS must be furnished within the limits of MAD benefits, within the scope and practice of the eligible provider s respective profession as defined by state law, and in accordance with applicable federal, state and local laws and regulations. F. All services must be provided in compliance with the current MAD definition of medical necessity. [ NMAC - N, ] COVERED SERVICES: A. CCSS activities include: (1) assistance to the eligible recipient in the development and coordination of the eligible recipient s service plan including a recovery or resiliency management plan, a crisis management plan, and, when requested, advanced directives related to the eligible recipient s behavioral health care; (2) assessment support and intervention in crisis situations, including the development and use of crisis plans that recognize the early signs of crisis or relapse, use of natural supports, use of alternatives to emergency departments and inpatient services; (3) individualized interventions, with the following objectives: a) services and resources coordination to assist the eligible recipient in gaining access to necessary rehabilitative, medical and other services; (b) assistance in the development of interpersonal, community coping and functional skills (e.g., adaptation to home, school and work environments), including: OHNM Level of Care Guidelines Page 60 of 82

61 (i) socialization skills; (ii) developmental issues; (iii) daily living skills; (iv) school and work readiness activities; and (v) education on co-occurring illness; (c) encouraging the development of natural supports in workplace and school environments; (d) assisting in learning symptom monitoring and illness selfmanagement skills (e.g. symptom management, relapse prevention skills, knowledge of medication and side effects, and motivational/skill development in taking medication as prescribed) in order to identify and minimize the negative effects of symptoms that interfere with the eligible recipient s daily living and to support the eligible recipient in maintaining employment and school tenure; (e) assisting the eligible recipient in obtaining and maintaining stable housing; and (f) any necessary follow-up to determine if the services accessed have adequately met the eligible recipient s needs; B. The majority (60% or more) of non facility-based CCSS provided must be face-to-face and in vivo (where the eligible recipient is located). The community support must monitor and follow-up to determine if the services accessed have adequately met the eligible recipient s individual treatment needs. C. CCCS may not be filled in conjunction with the following MAD services: (1) multi-systemic therapy (2) assertive community treatment (3) accredited residential treatment (4) residential treatment (5) group home services (6) impatient hospitalization (7) partial hospitalization (8) treatment foster care D. For eligible recipients or their families, the comprehensive community support worker will make every effort to engage the eligible recipient in achieving treatment or recovery goals. E. When the service is provided by a certified peer or family specialist, the above functions/interventions should be performed with a special emphasis on recovery values and process, such as: (1) empowering the eligible recipient to have hope for, and participate in, his own recovery; (2) helping the eligible recipient to identify strengths and needs related to attainment of independence OHNM Level of Care Guidelines Page 61 of 82

62 in terms of skills, resources and supports, and to use available strengths, resources and supports to achieve independence; (3) helping the eligible recipient to identify and achieve his or her personalized recovery goals; and, (4) promoting the eligible recipient s responsibility related to illness selfmanagement. [ NMAC - N, ] NONCOVERED SERVICES: CCSS are subject to the limitations and coverage restrictions which exist for other MAD services. See NMAC, General Noncovered Services [MAD-602]. MAD does not cover the following mental health specific services: A. hypnotherapy; B. biofeedback; C. conditions that do not meet the standard of medical necessity as defined in MAD policies; D. treatment for personality disorders; E. treatment provided for adults 21 years and older in alcohol or drug rehabilitation units; F. milieu therapy; G. educational or vocational services related to traditional academic subjects or vocational training; H. experimental or investigational procedures, technologies or non-drug therapies and related services; I. activity therapy, group activities and other services which are primarily recreational or divisional in nature; J. electroconvulsive therapy; K. services provided by non-licensed counselors, therapists or social workers; and, L. treatment of mental retardation alone. [ NMAC - N, ] PRIOR AUTHORIZATION AND UTILIZATION REVIEW: All MAD services are subject to utilization review for medical necessity and program compliance. Reviews may be performed before services are furnished, after services are furnished and before payment is made, or after payment is made. See NMAC, Prior Authorization and Utilization Review. Once enrolled, providers receive instructions on how to access provider program policies, billing instructions, utilization review instructions, and other pertinent material and to obtain answers to questions on or not covered by these materials. It is the provider s responsibility to access these instructions or ask for paper copies to be provided, to understand the information provided and to comply with the requirements. A. Prior authorization: Certain procedures or services may require prior authorization from MAD or its designee. Services for which prior authorization OHNM Level of Care Guidelines Page 62 of 82

63 was obtained remain subject to utilization review at any point in the payment process. B. Eligibility determination: Prior authorization of services does not guarantee that an individual is eligible for a Medicaid or other health care program. Providers must verify that individuals are eligible for a specific program at the time services are furnished and determine if eligible recipients have other health insurance. C. Reconsideration: Providers who disagree with prior authorization request denials or other review decisions can request a re-review and reconsideration. See NMAC, Reconsideration of Utilization Review Decisions [MAD-953]. [ NMAC - N, ] II. ADMISSION CRITERIA (MUST MEET ALL)* *This service does not require prior authorization, but consumers must meet target population and funding eligibility requirements for the service which will be evaluated any time a provider requests approval for delivery of the automatically available 72 units (15- minute) over concurrent 90 day periods of time. If, in any 90 day period, the provider anticipates that the consumer will require more than 72 units of CCSS, prior authorization for additional units is required. 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. The consumer is experiencing behavioral symptoms of or meets criteria for one of the following: a) A child at risk of/or experiencing serious emotional//behavioral disorders (SED) b) Adults with severe mental illness (SMI) c) Consumer with chronic substance abuse d) Consumer with a co-occurring disorder mental illness/substance abuse or dually diagnosed with a primary diagnosis of mental illness. Identical criteria are applied to consumers covered by other funding Collaborative funding sources. e) The consumer at baseline exhibits adequate behavioral control to be treated in this setting. (Crises or episodes of diminished behavioral function will be addressed in conjunction with the consumer in the service plan). B. The Consumer is able and willing to participate in CCSS services that will maximize strengths, independent skills, and self-direction through recovery and resiliency. C. The consumer does not meet criteria for a higher level of care. D. The consumer is a participating client of an NM Core Service Agency (CSA) and meets criteria for inclusion in CSA services. III. CONTINUING SERVICE CRITERIA (MUST MEET ALL) OHNM Level of Care Guidelines Page 63 of 82

64 A. The consumer continues to meet the criteria for admission. B. The consumer is participating in services or is learning to be an active participant in self-directed recovery and resiliency activities C. The consumer is working towards goals defined within the service plan and requires additional time to reach these goals D. There is documentation that the consumer could realistically succeed in meeting the goals of a revised service plan. The revised service plan reflects new knowledge about or input from the consumer and clearly defines a revised scope of services and length of time of services. IV. DISCHARGE CRITERIA (MEETS A OR B) A. The consumer has substantially met the defined goals of the service plan and no longer meets admission criteria B. The consumer elects to terminate the CCSS service plan. V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. CCSS is not being used to provide consumer with skills, but is providing the consumer with case management services (NMAC ). B. OHNM Common Criterion # 5 has not been met: 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. C. The consumer meets admission criteria for a higher, or more restrictive, level of care or service and cannot be safely and effectively treated in a community setting. OHNM Level of Care Guidelines Page 64 of 82

65 Adult Substance Abuse Residential Treatment Center (RTC) Services NM Collaborative service definition: Last update 05/17/10; see below. Governing NMAC reference(s): None. I. DEFINITION OF SERVICE: NM Collaborative definition for Short-Term Residential H0018: (Behavioral Health; short-term residential (non-hospital residential treatment program), without room and board, per diem HCPCS H0018) A short-term residential treatment program offering 24-hour intensive residential treatment, habilitative, and rehabilitative services for up to 30 days in a highly structured, communityoriented environment. This type of program is appropriate for individuals who need concentrated therapeutic services prior to community residence. The focus of services is to stabilize the individual and provide a safe and supportive living environment during detox and/or recovery from addictions. Adult Substance Abuse Residential Treatment Services (SA RTC) is a residential program offering 24-hour supervised treatment services in a structured, community-oriented environment for consumers 18 years of age and older. SA RTC services include organized rehabilitation services with a focus on substance abuse and dependence treatment, as well as assistance in obtaining appropriate long-term living arrangements. The services are designed in compliance with Level III Clinically Managed (III.1, III.3, III.5) Residential Treatment guidelines of the ASAM Patient Placement Criteria, Second Edition, Revised (ASAM PPC-2R). Services provide a structured recovery environment in combination with clinical services that support recovery from substance-related disorders. This will include an individualized approach to assessment, treatment and transition planning which provide counseling and groups focused on recovery and substance free socialization. Medically managed intensive inpatient detoxification is not a service offered in this setting. Co-occurring mental and substance-related disorders may also be treated in an SA RTC if the psychiatric disorders are sufficiently stable not to interfere with substance abuse and dependence treatment. These residential services are treatment-oriented and are not considered custodial care. This criterion is not intended for use as a long-term solution to maintain the stabilization acquired during treatment in a residential facility/program. For those consumers served through BHSD funding, the consumer must meet the BHSD priority population criteria: 18 years of age or older, 150% or below the federal poverty level, and uninsured. TARGET POPULATION: Individuals, 18 years of age or older, with: Substance abuse or co-occurring disorders; Who are capable of independent functioning; and Who require a continuous structured program of substance abuse services. OHNM Level of Care Guidelines Page 65 of 82

66 PROGRAM REQUIREMENTS: 1. The program provides 24-hour care and integrated treatment planning to address issues that facilitate re-integration of the individual into the community. 2. Treatment plans must be individualized and established upon admission and shall include discharge criteria and aftercare plans. 3. The program must ensure that evaluations already performed are not unnecessarily repeated. 4. The program must provide: a. Activities that support the development of age-appropriate living skills; b. Interventions including positive behavioral management; c. Regularly scheduled individual, peer, family and group counseling; d. Medication monitoring and assistance in self-administration of medication, as indicated; e. Non-medical transportation services needed to accomplish treatment objectives; and f. Therapeutic services to meet the physical, psychiatric, addiction-related, social, cultural, recreational, health maintenance and rehabilitation needs of clients. 5. The program actively engages the individual in planned, structured, therapeutic and/or recovery activities throughout the day, seven days a week. There is a predictable and orderly routine that allows the individual to develop and enhance recovery and resiliency skills. 6. Families or significant others as appropriate are actively involved and participate in team meetings, program events and therapy sessions. PROVIDER REQUIREMENTS: Services must be delivered by licensed behavioral health practitioners. The organization must be a legally recognized entity in the United States, qualified to do business in New Mexico, and must meet standards established by the State of NM or its designee, and requirements of the funding source (licensure by the Department of Health; and compliance with 7 NMAC 20.0, Comprehensive Behavioral Health Standards). STAFFING REQUIREMENTS: Programs are staffed by: Supervision must be provided by a licensed behavioral health professional or licensed medical professional. Staff must receive relevant training, to include but not limited to safety, basic first aid, CPR, and emergency protocols. All staff must successfully pass a criminal background check. Staffing ratio 1:15 sleeping or awake. Gender-specific shift coverage. Both clinical services and supervision by licensed practitioners must be in accord with their respective licensing board regulations. DOCUMENTATION REQUIREMENTS: OHNM Level of Care Guidelines Page 66 of 82

67 In addition to the standard client record documentation requirements for all services, the following is required for this service: Shift notes Consent for emergency medical treatment Client program orientation form SERVICE EXCLUSIONS: This service may not be billed in conjunction with the following services: Assertive Community Treatment; Outpatient therapies (individual, family, and group); Psychosocial Rehabilitation Services. For services over 30 days, use billing code H0019; II. ADMISSION CRITERIA (MUST MEET A, THROUGH C, and, for some specific programs, D) 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. If the consumer is covered by BHSD then clinical necessity has been met according to the New Mexico Behavioral Health Collaborative (Collaborative) definition. B. Consumers must meet criteria for the New Mexico Behavioral Health Collaborative service definition for Chronic Substance Dependence (CSD) or Co-Occurring Disorder (COD). The psychiatric disorder must be sufficiently stable not to interfere with treatment for substance-related disorders. C. The consumer has substance-related symptoms that interfere significantly with ability to function in activities of daily living, including school, work, and/or relationships and is unable to successfully recover from these symptoms with outpatient treatment alone. These symptoms are appropriate for treatment specified in Level III Clinically Managed (III.1, III.3, III.5) Residential Treatment guidelines of the ASAM Patient Placement Criteria, Second Edition, Revised (ASAM PPC-2R). D. Participating in this level of care may assist the consumer in avoiding inpatient treatment, or it may be an appropriate step down from such treatment. E. Additionally, for some consumers served by BHSD, criteria are met by: A woman diagnosed with a substance abuse disorder that is pregnant, post partum, parenting, or attempting to regain custody of her children. Substance dependence diagnosis is not required. III. CONTINUING STAY CRITERIA A. The consumer continues to meet the criteria for admission. OHNM Level of Care Guidelines Page 67 of 82

68 B. An individualized treatment plan addresses the consumer s specific symptoms and behaviors that required Substance Abuse Residential Treatment Services has been developed, implemented and updated, with the consumer s or guardian s participation whenever possible, which includes all applicable and appropriate treatment modalities. The treatment plan should also specifically assess the consumer for all six dimensional criteria as detailed in the ASAM PPC-2R. C. The consumer is making progress but has not yet achieved the goals in the treatment plan necessary for transition to the next level of treatment, or is not yet making progress but is working toward the goals in the treatment plan, or new problems have been identified that are appropriately treated in this level of care. D. 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 (MUST MEET A, AND B OR C OR D) A. The discharge plan has been successfully implemented B. The consumer has substantially met the defined goals of the treatment plan and is able to live independently C. Consumer elects to terminate this level of care D. The consumer has not benefited from this level of care. V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. The consumer s clinical presentation suggests the need for inpatient social or medically monitored detoxification. B. The S.A. RTC services are being used to defer consequences imposed by the legal system (see common criterion #8). C. The consumer can benefit from community based outpatient or intensive outpatient services (see common criterion #13) which are available within a reasonable time and distance from the consumer s home of record. OHNM Level of Care Guidelines Page 68 of 82

69 Adaptive Skills Building (ABS) NM Collaborative service definition: None available; OHNM instructed in Letter of Direction (LOD) #88, dated January 11, 2010, to use HCPC code H2014 with U1 modifier and reference existing rules for Behavior Management Skills Development, NMAC ; no changes were made to the BMS rules. Governing NMAC reference(s): NMAC I. Definition of Service NM Collaborative definition for Adaptive Skills Building for Autism, as provided with LOD #88, H2014-U1: Adaptive Skill Building services (ASB) are provided to children who need intensive intervention to develop skills necessary to function successfully at home and in the community and who require intensive and specialized treatment approaches to learn adaptive behavior. Eligible children include: very young children (recipients birth up to 3 years of age) with a diagnosis of Autism Disorders (AD), listed in the most current version of the Diagnostic Statistical Manual (DSM) as very young children (recipients birth up to 3 years of age) with a diagnosis of Pervasive Development Disorder/not otherwise specified (PDD/NOS), listed in the most current version of the DSM as young children (recipients 3 up to 5 years of age) with a diagnosis of Autism Disorders (AD), listed in the most current version of the Diagnostic Statistical Manual (DSM) as The evaluation leading to the diagnosis should be thorough and include information from multiple sources, because the child s performance may vary among settings and caregivers. ASB services include the development of an Intervention Plan, implementation of the plan, application of Applied Behavior Analysis, assistance for caregivers in socially purposeful engagement of the recipient, and ongoing monitoring of the plan and recipient progress being made. This service includes the use of basic Applied Behavior Analysis techniques provided as part of a comprehensive approach to the treatment of Autism Disorders. The treatment plan should include caregiver training regarding identification of the specific behavior(s) and interventions, in order to support utilization of the ABA techniques by caregiver(s). Per LOD #88, the initial ASB authorization will be for six months; ongoing ASB interventions shall be authorized for three months. II. Admission Criteria (Must meet all.) OHNM Level of Care Guidelines Page 69 of 82

70 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. There is documentation of a DSM-IV-TR diagnosis by a clinical psychologist or psychiatrist with experience treating Autism of a diagnosis of Autism Disorders (AD) for recipients aged birth up to 5 years of age. C. There is documentation of maladaptive behaviors that would require adaptive skill building services. D. Each qualifying child must need intensive intervention to develop skills necessary to function successfully at home and in the community and also must require intensive and specialized treatment approaches to learn adaptive behaviors. E. There is a reasonable expectation on the part of a treating health care professional that the individual s behavior will improve with adaptive skill building services. F. A comprehensive evaluation has been done which includes the following components: 1. Health, developmental, and behavioral histories that include a family history and a review of systems. 2. Other diagnoses have been considered and an appropriate evaluation has been done to rule out those diagnoses. 3. Confirmation of the presence of a categorical DSMIV-TR diagnosis meeting the criteria for this service using specific evidence to support the diagnosis including standardized tools that operationalize the DSM criteria. 4. The parents /guardians knowledge of ASD, coping skills, and available resources and supports have been assessed and there is evidence that the parents/guardians can participate in Adaptive Skill Building. III. Continued Stay Criteria (Must meet A THROUGH C, OR BOTH A and D.): A. The consumer continues to meet the admission criteria. B. There is evidence the child, family, and social supports can continue to participate effectively in this service. C. There is evidence the consumer is responding positively to the service. D. If the consumer is not responding positively to the service or if the child, family, or social supports are not adequately participating in the service the OHNM Level of Care Guidelines Page 70 of 82

71 treatment plan must reflect what interventions will change to produce effective results. IV. Discharge Criteria (Meets A, or B, or C, or D, and E.): A. The child has met his/her individualized discharge criteria. B. The child can be appropriately treated at a less intensive level of care. C. The child has reached his or her 5 th birthday. D. The child has received 36 months (cumulative) of Adaptive Skill Building services. E. An individualized discharge plan with appropriate, realistic and timely followup care is in place. V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. The child is not responding to ASB services in a way that suggests the services are effective and meets admission criteria for a higher, more intensive, or more restrictive, level of care. B. The child s parent(s) or legal guardian is not substantially involved in the child s treatment and/or the services are being used in place of respite (see common criterion #8). OHNM Level of Care Guidelines Page 71 of 82

72 Behavior Management Services NM Collaborative service definition: None available. Governing NMAC reference(s): NMAC and NMAC I. DEFINITION OF SERVICE: NMAC citation/ MAD citation BEHAVIOR MANAGEMENT SKILLS DEVELOPMENT SERVICES The New Mexico Medicaid program (Medicaid) pays for medically necessary health services furnished to eligible recipients. To help recipients under twenty-one (21) years of age who are in need of behavior management intervention receive services, the New Mexico Medical Assistance Division (MAD) pays for eligible providers to furnish these services as part of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program [42 CFR ]. These services can be accessed only through the Tot to Teen HealthCheck screen or other diagnostic evaluations furnished through a HealthCheck referral. This section describes eligible providers, covered services, service limitations, and general reimbursement methodology Eligible Providers Upon approval of New Mexico Medical Assistance Program Provider Agreements by MAD, agencies that meet the following requirements are eligible to be reimbursed for providing behavior management services: 1. Certification as providers of Behavior Management Skills Development Services by the Children, Youth and Families Department (CYFD); and 2. Employ or contract with behavior management specialists who work under the supervision of a licensed practitioner in the area of behavior management services, as described in the certification criteria. Recipients have the right to receive services from the eligible provider of their choice. Once enrolled, providers receive a packet of information; including Medicaid program policies, billing instructions, utilization review instructions, certification standards, and other pertinent material from MAD. Providers are responsible for ensuring that they have received these materials and for updating them as new materials are received from MAD 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 POLICIES. OHNM Level of Care Guidelines Page 72 of 82

73 Eligible Recipients Behavior management services can be furnished only to Medicaid recipients under twenty one (21) years of age who need behavior management intervention to avoid inpatient hospitalization, residential treatment, separation from their families or who require continued intensive treatment following hospitalization or out-of-home placement as a transition to avoid return to a more restrictive environment. To receive services, recipients must meet the level of care for this service established by MAD or its designee Covered Services Medicaid covers services specified in individualized treatment plans which are designed to improve the recipient's performance in targeted behaviors, reduce emotional and behavioral excess, increase social skills and enhance behavioral skills through a regimen of positive intervention and reinforcement. (A) The following tasks must be performed by behavior management specialists and included in the payment rate: 1. Implementation of the behavior management plan; 2. Instruction and assistance in achieving and/or maintaining appropriate behavior management skills through skilled intervention; 3. Working with foster, adoptive or natural families to help recipients achieve and/or maintain appropriate behavior management skills; and 4. Maintaining case notes and documentation of activities as required by the agency and the standards under which it operates. (B) An agency certified for behavioral management skills development services must perform the following: 1. Assessment of the recipient's progress in behavioral management services; and 2. Twenty-four (24) hour availability of appropriate staff to respond to crisis situations Noncovered Services Behavior management services 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 services: 1. Formal educational or vocational services related to traditional academic subjects or vocational training; and 2. Activities which are not designed to accomplish the objectives delineated in covered services and which are not included in the behavioral management treatment plan. OHNM Level of Care Guidelines Page 73 of 82

74 Treatment Plan The treatment plan must be developed by a team of professionals in consultation with recipients, parents, legal guardians, and physicians, if applicable, prior to service delivery or within fourteen (14) days of initiation of services. (A) The team must review the treatment plan at least every thirty (30) days. (B) The following must be contained in the treatment plan or documents used in the development of the treatment plan. The treatment plan and all supporting documentation must be available for review in the recipient's file: 1. Statement of the nature of the specific problem and the 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 the projected timetable for their attainment and the duration and scope of services; 5. Statement and rationale of the treatment plan for achieving these intermediate and long-range goals, including provisions for the review and modification of the plan; 6. Specification of responsibilities, description of staff involvement, 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 release to less restrictive settings for treatment, discharge plans, criteria for discharge, and projected date of discharge. II. ADMISSION CRITERIA (MUST MEET ALL)* * Note that this service does not require prior authorization for initiation, but that the provider is expected to ensure that the consumer is eligible for the service and that Admission Criteria are met, as they will be assessed at such time as the provider may request additional units beyond those which any consumer is automatically allowed 350 units per 30 day period. A. The consumer is currently covered by New Mexico Medicaid (or another eligible funding stream, such as CYFD) and is under 21 years of age. Additionally, the OHNM Level of Care Guidelines Page 74 of 82

75 consumer has received an EPSDT screening or other appropriate diagnostic evaluation. B. 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. C. The consumer s behavioral health symptoms place the consumer at risk for needing out of home care due to unmanageable behavior at home or within the community. D. A Behavior Management Plan has been developed that is unique to the consumer and that specify individualized interventions targeted to the consumer s problematic behaviors; the Plan may also be incorporated (with all required elements) into the comprehensive treatment plan. E. Both the consumer and the consumer s authorized representative, guardian, parent, or foster parent are actively involved in development of both the treatment plan and the behavior management plan. III. CONTINUED STAY CRITERIA (MUST MEET ALL) A. The consumer continues to meet the criteria for admission. B. The Behavior Management Plan that addresses the consumer s specific symptoms and behaviors that required BMS Services has been implemented and updated (no less than every 30 days), with the consumer s and/or guardian s participation whenever possible. Services documented are congruent with the Service Definition referenced above. C. There is evidence of progress being made on one or more of the consumer s behavior management plan goals and that interventions are appropriate to the established goals. D. An individualized discharge plan has been developed as part of the treatment plan 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. E. There is documentation that the consumer is participating in the services or is learning to actively participate in the service. IV. DISCHARGE CRITERIA (MUST MEET A, AND B OR C OR D) A. An individualized discharge plan with appropriate, realistic and time follow-up care is in place. B. The consumer has substantially met the defined goals of the behavior management plan and is no longer at risk for requiring inpatient hospitalization or a residential level of care. C. The consumer is not participating in the treatment plan or behavior management plans and/or interventions to improve skills. D. The consumer has not demonstrated substantial benefits from these services. OHNM Level of Care Guidelines Page 75 of 82

76 V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. BMS services have not been shown by the provider to be promoting the Collaborative s mission and vision, as described in contract section 1.2.A regarding resiliency and recovery: Services shall be delivered in a manner that is individually (consumer) centered and family-focused, based on principles of an individual s capacity for recovery and resiliency. B. OHNM common criterion #6 has not been met; the consumer s presenting problems have not improved within a reasonable period of time. C. OHNM common criterion #8 appears to have been met Treatment is primarily for the purpose of providing respite for the family or for addressing antisocial behavior or legal problems, rather than for the active treatment of a behavioral health condition. D. The consumer has an Individualized Education Plan (IEP) which specifies behavior management services are necessary to maintain the consumer in the school setting; in this case, the school district should provide these services. OHNM Level of Care Guidelines Page 76 of 82

77 Psychosocial Rehabilitation (PSR) Services NM Collaborative service definition: Last update 08/02/10; see below. Governing NMAC reference(s): NMAC I. DEFINITION OF SERVICE: NM Collaborative definition for Psychosocial Rehabilitation Services, H2017: Psychosocial rehabilitation, either Individual or Integrated/Classroom, is an array of services 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 services are provided in a variety of settings. Use modifier HQ when these services are provided in a group or classroom setting. Psychosocial rehabilitation intervention is intended to be a transitional level of care based on the individual s recovery and resiliency goals. NMAC reference for Psychosocial Rehabilitation Services, H2017 citation/ MAD citation 737: The New Mexico Medicaid program (Medicaid) pays for medically necessary health services furnished to eligible recipients. To help New Mexico adult recipients receive a range of psychosocial services, the New Mexico Medical Assistance Division (MAD) pays for psychosocial rehabilitation services. This section describes eligible providers, eligible recipients, covered services, service limitations, and general reimbursement methodology Eligible Providers Upon approval of New Mexico Medical Assistance Program Provider Participation Agreements by MAD, the following agencies which are certified by the Department of Health (DOH) as a Psychosocial Rehabilitation Agency are eligible to be reimbursed for furnishing psychosocial rehabilitation services: 1. Community psychosocial centers designated by the New Mexico Department of Health; 2. Indian Health Service Agencies; 3. Federally Qualified Health Centers; and 4. Other agencies which meet Department of Health certification criteria Agency Requirements Agencies which furnish psychosocial rehabilitation services must have direct experience in successfully serving individuals with severe and/or persistent functional impairment as a result of a mental disorder Agency Staff Requirements Agency staff must possess the education, skills, abilities, and experience to perform the activities that comprise the full spectrum of psychosocial rehabilitation services. OHNM Level of Care Guidelines Page 77 of 82

78 737.2 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 provided to recipients. See Section MAD-701, GENERAL PROVIDER POLICIES Eligible Recipients Eligible recipients are those who are receiving Medicaid and for whom medical necessity for the services has been determined according to the guidelines for evidencing medical necessity established by the Department of Health. The recipients receiving these services cannot be residents of an institution for mental illness Coverage Criteria Medicaid covers only those psychosocial rehabilitation services which comply with DOH Mental Health standards as detailed in the Psychiatric Rehabilitation User's Manual and are medically necessary to meet the individual needs of the recipient, as delineated in the treatment plan. Medical necessity is based upon the recipient's level of functioning as affected by the mental disability. The services are limited to goal oriented psychosocial rehabilitative services which are individually designed to accommodate the level of the recipient's functioning and which reduce the disability and restore the recipient to his/her best possible level of functioning Covered Services: Medicaid covers psychosocial rehabilitation services which are medically necessary in the assessment and planning of care, and those specific services which reduce symptoms and restores basic skills necessary to function independently in the community. Medicaid covers the following psychosocial rehabilitation services as defined and described in the department of health s psychiatric rehabilitation user s manual: A. psychosocial interventions designed to address the functional limitations, deficits, and behavioral excesses, through capitalizing on personal strengths and developing coping strategies and supportive environments. *Note that other psychosocial rehabilitation services are described by NMAC , but the service (H2017) above is the sole service managed through a prior authorization process by OptumHealth New Mexico; this criteria set applies exclusively to the service described immediately above Non Covered: Psychosocial rehabilitation services are subject to the limitations and coverage restrictions which exist for other Medicaid services. An overview of noncovered services is contained in Section MAD-602, General Noncovered Services [now NMAC, General Noncovered Services]. II. ADMISSION CRITERIA (MUST MEET ALL)* OHNM Level of Care Guidelines Page 78 of 82

79 * Note that this service does not require prior authorization for initiation, but that the provider is expected to ensure that the consumer is eligible for the service and that Admission Criteria are met, as they will be assessed at such time as the provider may request additional units beyond those which any consumer is automatically allowed 350 units per 30 day period. 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. The consumer is currently covered by New Mexico Medicaid or another Collaborative approved funding stream, and meets criteria for this service s target population, as specified by the Collaborative service definition document. i. Adults meeting the criteria for Serious Mental Illness (SMI). (HSD/BHSD & HSD/MAD) ii. Adults diagnosed with co-occurring SMI or Substance Use disorders Abuse disorders. (HSD/BHSD & HSD/MAD) Additionally, the consumer meets criteria necessary to qualify as Seriously Mentally Ill (SMI), and is not a resident of an institution for mental illness. C. The consumer has behavioral health symptoms/diagnoses that interfere significantly with his or her ability to manage activities of daily living without structured intervention. D. The consumer s behavioral health symptoms place the consumer at risk for requiring a more restrictive treatment setting or an acute psychiatric hospitalization. E. A comprehensive treatment plan has been developed that is unique to the consumer and that specifies individualized interventions targeted to the consumer s psychosocial and/or skills development needs. The consumer and, if applicable, the consumer s authorized/legal representative are actively involved in development of both the treatment plan. III. CONTINUING STAY CRITERIA (MUST MEET ALL) A. The consumer continues to meet the criteria for admission. B. The individualized treatment plan has been implemented in a way consistent with the PSR service definition and governing regulations and has been updated as necessary (no less than every 90 days), with the consumer themselves, and their authorized/legal representative s participation, whenever possible. Services documented are congruent with the Service Definition referenced above. C. There is evidence of measurable progress being made on one or more of the consumer s treatment plan goals and that interventions are appropriate to the established goals, such that they can be reasonably expected to improve functioning in one or more life domains. OHNM Level of Care Guidelines Page 79 of 82

80 D. An individualized discharge plan has been developed as part of the treatment plan 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. E. There is documentation that PSR services are being delivered in coordination with other necessary behavioral health and/or physical health services. F. There is documentation that the consumer is participating in the services or is learning to actively participate in the service. IV. DISCHARGE CRITERIA (MUST MEET A, AND B OR C, OR D OR E) A. An individualized discharge plan with appropriate, realistic and timely follow-up care is in place. B. The consumer has substantially met the defined goals of the treatment plan and is no longer at risk for requiring an out of home placement for behavioral health treatment. C. The consumer is not participating in the treatment plan and/or interventions designed to improve life skills. D. The consumer has not demonstrated substantial benefits from PSR services. E. The consumer s behavioral health treatment needs could be met with a less intensive level of care or services, such as Comprehensive Community Support Services (CCSS) or outpatient psychotherapy. V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. PSR services have not been shown by the provider to be promoting the Collaborative s mission and vision, as described in contract section 1.2.A regarding resiliency and recovery, which states: Services shall be delivered in a manner that is individually (consumer) centered and family-focused, based on principles of an individual s capacity for recovery and resiliency. B. OHNM common criterion #6 which states: 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. C. Regarding OHNM common criterion #13 which states: 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. Inactive/ Retired Criteria Sets OHNM Level of Care Guidelines Page 80 of 82

81 ***As of May 1, 2010, this service no longer required any kind of prior authorization, per the Collaborative.*** FAMILY STABILIZATION SERVICES INTENSIVE HOME-BASED NM Collaborative service definition: Last update 05/21/10; see below. Governing NMAC reference(s): Unknown; a Value Added (non-entitlement) Service unless funded through CYFD. I. DEFINITION OF SERVICE: NM Collaborative definition for Family Stabilization Services, S9482: Family Stabilization is a time-limited intensive therapeutic and supportive intervention delivered in the home or in another location that is a natural setting for family interaction. This service is intended for children and adolescents under the age of 21 and their families to prevent the utilization of an out-of-home placement. These services are designed to strengthen and preserve families by providing needs driven, comprehensive, integrated approaches to services. Services are multi-faceted in nature and include: situation management, environmental assessment, interventions to improve individual and family interactions, skill training, self and family management, and coordination and linkage with other services and supports. Family Stabilization Services Intensive Home Based (FSI) is an intensive outpatient service designed to preserve the family unit through a variety of time limited services. This service is intended for children and adolescents under the age of 21 and their families to prevent the utilization of an out-of-home placement. Services are usually delivered in the consumer s home or in a community setting. They are strengths based, culturally relevant, and reflect an appreciation of the unique needs of the consumer and family. Services are multifaceted in nature and include situation management, environmental assessment, interventions to improve individual/family interactions, skill training, self and family management, and coordination and linkage with other services and supports. The treatment will provide family-centered interventions to identify and address family dynamics and build competencies to strengthen family functioning in relationship to the consumer. II. ADMISSION CRITERIA (MUST MEET A, AND B OR C OR D) A. If the consumer is covered by Medicaid Managed Care then medical necessity has been met according to the Medical Assistance Division definition. There is the presence of a pattern of moderate to severe impairment in psychosocial functioning due to a behavioral health condition. B. The consumer requires multiple home or community based services or resources in order to adequately address treatment needs OHNM Level of Care Guidelines Page 81 of 82

82 C. The consumer is transitioning from institutional or highly restrictive settings to community based settings D. The consumer is at risk for out of home placement. III. CONTINUING STAY CRITERIA (MUST MEET ALL) A. The consumer continues to meet the criteria for admission, B. The consumer and family are participating in the services or is learning to be an active participant in services IV. DISCHARGE CRITERIA (MUST MEET A, AND B OR C OR D) A. An individualized discharge plan is in place B. The consumer has substantially met the defined goals of the treatment plan and no longer meets admission criteria C. The consumer of family elects to terminate this level of care D. The consumer and family have not benefited from this level of care. V. EXCLUSIONARY CRITERIA (MAY MEET ANY): A. Not yet established. Should this service require prior authorization in the future, these criteria will be revisited. B. Not yet established. Should this service require prior authorization in the future, these criteria will be revisited OHNM Level of Care Guidelines Page 82 of 82