New Mexico Register / Volume XXXIII, Issue 7 / April 5, 2022
This is an amendment to 8.308.9
NMAC, Sections 7, 8, 11, 13, 15 - 17, 19, 22, 23 and 25, effective 4/5/2022.
8.308.9.7 DEFINITIONS:
A. Alternative benefits plan
services with limitations (ABP): The
medical assistance division (MAD) category of eligibility “other adults” has an
alternative benefit plan (ABP). The HSD
contracted managed care organization (MCO) covers ABP specific services for an
ABP member. Services are made available
through MAD under a benefit plan similar to services provided by commercial
insurance plans. ABP benefits include
preventive services and treatment services.
An ABP member has limitations on specific benefits; and does not have
all MCO medicaid benefits available. All early and
periodic screening, diagnosis and treatment (EPSDT) program services are
available to an ABP member under 21 years.
ABP services for an ABP member under the age of 21 years are not subject
to the duration, frequency, and annual or lifetime benefit limitations that are
applied to an ABP eligible recipient 21 years of age and older. A MCO ABP contracted provider and an ABP
member have rights and responsibilities as described in Title 8 Chapter 308
NMAC, Social Services.
B. Alternative benefits
plan general benefits for ABP exempt member (ABP exempt):
An ABP member who self-declares [he or she has] they have
a qualifying condition is evaluated by the MCO’s utilization management for
determination if [he or she meets] they meet the qualifying
condition. An ABP exempt member utilizes
[his or her] their benefits described in 8.308.9 NMAC and in
8.308.12 NMAC.
C. Early childhood home visiting
program: A program that uses home visiting as a primary
service delivery strategy and offers services on a voluntary basis to eligible pregnant
[women] individuals and their children from birth up to
kindergarten entry, according to the program standard.
D. Evidence-based,
early childhood home visiting program: A home visiting program that is recognized by
the U.S. department of health & human services maternal, infant, and early childhood
home visiting (MIECHV) project and:
(1) is grounded in
relevant, empirically-based best practice and knowledge that:
(a) is
linked to and measures the following outcomes:
(i) babies
that are born healthy;
(ii) children
that are nurtured by their parents and caregivers;
(iii) children
that are physically and mentally healthy;
(iv) children
that are ready for school;
(v) children
and families that are safe; and
(vi) families
that are connected to formal and informal supports in their communities;
(b) has
comprehensive home visiting standards that ensure high-quality service delivery
and continuous quality improvement; and
(c) has
demonstrated significant, sustained positive outcomes;
(2) follows
program standards that specify the purpose, outcomes, duration and frequency of
services that constitute the program;
(3) follows
the curriculum of an evidence-based home visiting model;
(4) employs
well-trained and competent staff and provides continual professional
supervision and development relevant to the specific program and model being
delivered;
(5) demonstrates
strong links to other community-based services;
(6) operates
within an organization that ensures compliance with home visiting standards;
(7) continually
evaluates performance to ensure fidelity to the program standards;
(8) collects
data on program activities and program outcomes; and
(9) is
culturally and linguistically appropriate.
[8.308.9.7 NMAC - Rp, 8.308.9.7 NMAC, 5/1/2018; A, 1/1/2019; A,
4/5/2022]
8.308.9.8 [RESERVED] MISSION: To transform lives. Working with our partners, we design and
deliver innovative, high quality health and human services that improve the
security and promote independence for New Mexicans in their communities.
[8.308.9.8 NMAC - Rp, 8.308.9.8 NMAC, 5/1/2018; A, 4/5/2022]
8.308.9.11 GENERAL PROGRAM DESCRIPTION:
A. The MCO shall provide medically necessary
services consistent with the following:
(1) a determination that a health care
service is medically necessary does not mean that the health care service is a
covered benefit; benefits are to be determined by HSD;
(2) in making the determination of
medical necessity of a covered service the MCO shall do so by:
(a) evaluating the member’s physical and
behavioral health information provided by a qualified professional who has
personally evaluated the member within [his or her] their scope
of practice; who has taken into consideration the member’s clinical history,
including the impact of previous treatment and service interventions and who
has consulted with other qualified health care professionals with applicable
specialty training, as appropriate;
(b) considering the views and choices of
the member or [his or her] their authorized representative regarding the proposed covered service as
provided by the clinician or through independent verification of those views;
and
(c) considering the services being provided
concurrently by other service delivery systems;
(3) not denying physical, behavioral
health and long-term care services solely because the member has a poor
prognosis; medically necessary services may not be arbitrarily denied or
reduced in amount, duration or scope to an otherwise eligible member solely because of his or her diagnosis, type
of illness or condition;
(4) governing decisions regarding benefit
coverage for a member under 21 years of age by the EPSDT program
coverage rule to the extent they are applicable; and
(5) making services available 24 hours,
seven days a week, when medically necessary and are a covered benefit.
B. The MCO shall
meet all HSD requirements related to the anti-gag requirement. The MCO shall meet all HSD requirements
related to advance directives. This
includes but is not limited to:
(1) providing a member or his
or her authorized representative with written information on advance directives
that include a description of applicable state and federal law and regulation,
the MCO’s policy respecting the implementation of the right to have an advance
directive, and that complaints concerning noncompliance with advance directive
requirements may be filed with HSD; the information must reflect changes in federal
and state statute, regulation or rule as soon as possible, but no later than 90
calendar days after the effective date of such a change;
(2) honoring
advance directives within its UM protocols; and
(3) ensuring that a member is offered the
opportunity to prepare an advance directive and that, upon request, the MCO
provides assistance in the process.
C. The
MCO shall allow second opinions: A
member or [his or her] their authorized representative shall have
the right to seek a second opinion from a qualified health care professional
within [his or her] their MCO’s network, or the MCO shall arrange
for the member to obtain a second opinion outside the network, at no cost to
the member. A second opinion may be
requested when the member or his or her authorized representative needs
additional information regarding recommended treatment or believes the provider
is not authorizing requested care.
D. The
MCO shall meet all care coordination requirement set forth in 8.308.10 NMAC, Care
Coordination.
E. The
MCO shall meet all behavioral health parity requirements as set forth in CFR
42, Chapter IV, subchapter C, 438.905 - Parity requirements.
[8.308.9.11
NMAC - Rp, 8.308.9.11 NMAC,
5/1/2018; A, 4/5/2022]
8.308.9.13 SPECIFIC CASE MANAGEMENT PROGRAMS: The benefit package includes
case management services necessary to meet an identified service need of a
member. The following are specific case
management programs available when a member meets the requirements of a specific
service.
A. Case
management services for adults with developmental disabilities: Case management services are provided to a
member 21 years of age and older who is developmentally disabled as detailed in
8.326.2 NMAC.
B. Case management services for
pregnant [women] individuals and their infants: Case management services are
provided to a member who is pregnant up to 60 calendar days following the end
of the month of the delivery as detailed in 8.326.3 NMAC.
C. Case management services for
traumatically brain injured adults: Case management services are provided
to a member 21 years of age and older who is traumatically brain injured as
detailed in 8.326.5 NMAC.
D. Case management services for
children up to the age of three: Case management services for a member
up to the age of three years who is medically at-risk due to family conditions
and who does not have a developmental delay as detailed in 8.326.6 NMAC.
E. Case management services for the
medically at risk (EPSDT): Case management services for a member under 21
years of age who is medically at-risk for a physical or behavioral health
condition as detailed in 8.320.2 NMAC.
[8.308.9.13 NMAC - Rp, 8.308.9.13 NMAC,
5/1/2018; A, 4/5/2022]
8.308.9.15 EARLY AND PERIODIC SCREENING DIAGNOSIS AND TREATMENT (EPSDT) SERVICES: The benefit package includes the
delivery of the federally mandated EPSDT services (42 CFR Part 441, Subpart B) provided
by a primary care provider (PCP) as detailed in 8.320.2 NMAC. The MCO shall provide access to early
intervention programs and services for a member identified in an EPSDT screen
as being at-risk for developing or having a severe emotional, behavioral or
neurobiological disorder. Unless
otherwise specified in a service rule, EPSDT services are for a member under 21
years of age. For detailed description
of each service, see 8.320.2 NMAC. EPSDT
behavioral health services are included in 8.308.9.19 NMAC.
A. EPSDT nutritional counseling and services: The benefit package
includes nutritional services furnished to a pregnant member and a member under
21 years of age as detailed in 8.310.2 NMAC.
B. EPSDT
personal care: The benefit package includes personal
care services for a member.
C. EPSDT private duty nursing: The benefit package includes private
duty nursing for a member and the services shall be delivered in either his or
her home or school setting.
D. EPSDT
rehabilitation services: A
member under 21 years of age who is eligible for home and community based
waiver services receives medically necessary rehabilitation services through
the EPSDT program; see 8.320.2 NMAC for a detailed description. The home and community-based waiver program
provides rehabilitation services only for the purpose of community integration.
E. Services
provided in schools: The benefit package includes services
to a member provided in a school, excluding those specified in [his or her]
their individual education plan (IEP) or the individualized family
service plan (IFSP); see 8.320.6 NMAC.
F. Tot-to-teen
health checks:
(1) The MCO shall adhere to the MAD periodicity
schedule and ensure that each eligible member receives age-appropriate EPSDT
screens (tot-to-teen health checks), referrals, and appropriate services and
follow-up care. See 8.320.2 NMAC for
detailed description of the benefits.
The services include, but are not limited to:
(a) education
of and outreach to a member or the member’s family regarding the importance of regular
screens and health checks;
(b) development
of a proactive approach to ensure that the member receives the services;
(c) facilitation
of appropriate coordination with school-based providers;
(d) development
of a systematic communication process with MCO network providers regarding
screens and treatment coordination;
(e) processes
to document, measure and assure compliance with MAD’s periodicity schedule; and
(f) development
of a proactive process to insure the appropriate follow-up evaluation, referral
and treatment, including early intervention for developmental delay, vision and
hearing screening, dental examinations and immunizations.
(2) The
MCO will facilitate appropriate referral for possible or identified behavioral
health conditions. See 8.321.2 NMAC for
EPSDT behavioral health services descriptions.
[8.308.9.15 NMAC - Rp, 8.308.9.15 NMAC,
5/1/2018; A, 4/5/2022]
8.308.9.16 REPRODUCTIVE HEALTH SERVICES: The
benefit package includes reproductive health services as detailed in 8.310.2
NMAC. The MCO shall implement written
policies and procedures approved by HSD which define how a member is educated
about his or her rights to family planning services, freedom of choice, to
include access to non-contract providers, and methods for accessing family
planning services.
A. The
family planning policy shall ensure that a member of the appropriate age of
both sexes who seeks family planning services shall be provided with counseling
pertaining to the following:
(1) human
immunodeficiency virus (HIV) and
other sexually transmitted diseases and risk reduction practices; and
(2) birth
control pills and devices including plan B and long acting reversible
contraception.
B. The
MCO shall provide a member with sufficient information to allow [him or her]
them to make informed choices including the following:
(1) types
of family planning services available;
(2) the
member’s right to access these services in a timely and confidential manner;
(3) freedom
to choose a qualified family planning provider who participates in the MCO
network or from a provider who does not participate in the member’s MCO
network; and
(4) if
a member chooses to receive family planning services from a non-contracted
provider, the member shall be encouraged to exchange medical information
between the PCP and the non-contracted provider for better coordination of
care.
C. Pregnancy
termination procedures: The benefit package includes services
for the termination of a pregnancy as detailed in 8.310.2 NMAC. Medically necessary pregnancy terminations
which do not meet the requirements of 42 CFR 441.202 are excluded from the
capitation payment made to the MCO and shall be reimbursed solely from state
funds pursuant to the provisions of 8.310.2 NMAC.
[8.308.9.16 NMAC - Rp, 8.308.9.16 NMAC,
5/1/2018; A, 4/5/2022]
8.308.9.17 PREVENTIVE PHYSICAL HEALTH SERVICES: The MCO shall follow current
national standards for preventive health services, including behavioral health
preventive services. Standards are
derived from several sources, including the U.S. preventive services task
force, the centers for disease control and prevention; and the American college
of obstetricians and gynecologists. Any
preventive health guidelines developed by the MCO under these standards shall
be adopted and reviewed at least every two years, updated when appropriate and
disseminated to its practitioners and members.
Unless a member refuses and the refusal is documented, the MCO shall
provide the following preventive health services or screens or document that
the services (with the results) were provided by other means. The MCO shall document medical reasons not to
perform these services for an individual member. Member refusal is defined to include refusal
to consent to and refusal to access care.
A. Initial assessment: The MCO shall conduct a health risk
assessment (HRA), per HSD guidelines and processes, for the purpose of
obtaining basic health and demographic information about the member, assisting
the MCO in determining the need for a comprehensive needs assessment (CNA) for
care coordination level assignment.
B. Family planning: The MCO must have a family
planning policy. This policy must ensure
that a member of the appropriate age of both sexes who seeks family planning
services is provided with counseling and treatment, if indicated, as it relates
to the following:
(1) methods
of contraception; and
(2) HIV
and other sexually transmitted diseases and risk reduction practices.
C. Guidance: The MCO shall adopt policies
that shall ensure that an applicable asymptomatic member is provided guidance
on the following topics unless the member’s refusal is documented:
(1) prevention
of tobacco use;
(2) benefits
of physical activity;
(3) benefits
of a healthy diet;
(4) prevention
of osteoporosis and heart disease in a menopausal member citing the advantages
and disadvantages of calcium and hormonal supplementation;
(5) prevention
of motor vehicle injuries;
(6) prevention
of household and recreational injuries;
(7) prevention
of dental and periodontal disease;
(8) prevention
of HIV infection and other sexually transmitted diseases;
(9) prevention
of an unintended pregnancy; and
(10) prevention
or intervention for obesity or weight issues.
D. Immunizations: The
MCO shall adopt policies that to the extent possible, ensure that within six
months of enrollment, a member is immunized according to the type and schedule
provided by current recommendations of the state department of health
(DOH). The MCO shall encourage providers
to verify and document all administered immunizations in the New Mexico
statewide immunization information system (SIIS).
E. Nurse advice line: The
MCO shall provide a toll-free clinical telephone nurse advice line function
that includes at least the following services and features:
(1) clinical
assessment and triage to evaluate the acuity and severity of the member’s
symptoms and make the clinically appropriate referral; and
(2) pre-diagnostic
and post-treatment health care decision assistance based on the member’s symptoms.
F. Prenatal care: The MCO shall operate a proactive
prenatal care program to promote early initiation and appropriate frequency of
prenatal care consistent with the standards of the American college of
obstetrics and gynecology. The program
shall include at least the following:
(1) educational
outreach to a member of childbearing age;
(2) prompt
and easy access to obstetrical care, including an office visit with a
practitioner within three weeks of having a positive pregnancy test (laboratory
or home) unless earlier care is clinically indicated;
(3) risk
assessment of a pregnant member to identify high-risk cases for special
management;
(4) counseling
which strongly advises voluntary testing for HIV;
(5) case
management services to address the special needs of a member who has a high
risk pregnancy, especially if risk is due to psychosocial factors, such as
substance abuse or teen pregnancy;
(6) screening
for determination of need for a post-partum home visit;
(7) coordination
with other services in support of good prenatal care, including transportation,
other community services and referral to an agency that dispenses baby car
seats free or at a reduced price; and
(8) referral
to a home visiting pilot program for eligible pregnant [women] individuals
and children residing in the HSD-designated counties for services as outlined
at 8.308.9.23 NMAC.
G. Screens: The MCO shall
adopt policies which will ensure that, to the extent possible, within six
months of enrollment or within six months of a change in screening standards,
each asymptomatic member receives at least the following preventive screening
services listed below.
(1) Screening
for breast cancer: A female member
between the ages of 40-69 years shall be screened every one to two years by
mammography alone or by mammography and annual clinical breast examination.
(2) Blood
pressure measurement: A member 18
years of age or older shall receive a blood pressure measurement at least every
two years.
(3) Screening
for cervical cancer: A female member
with a cervix shall receive cytopathology testing starting at the onset of
sexual activity, but at least by 21 years of age and every three years
thereafter until reaching 65 years of age when prior testing has been
consistently normal and the member has been confirmed not to be at high
risk. If the member is at high risk, the
frequency shall be at least annual.
(4) Screening
for chlamydia: All sexually active
female members 25 years of age and younger shall be screened for chlamydia. All female members over 25 years of age shall
be screened for chlamydia if they inconsistently use barrier contraception,
have more than one sex partner, or have had a sexually transmitted disease in
the past.
(5) Screening
for colorectal cancer: A member 50
years of age and older, who is at normal risk for colorectal cancer shall be
screened with annual fecal occult blood testing or sigmoidoscopy or colonoscopy
or double contrast barium at a periodicity determined by the MCO.
(6) EPSDT
screening for elevated blood lead levels:
A risk assessment for elevated blood lead levels shall be performed
beginning at six months and repeated at nine months of age. A member shall receive a blood lead
measurement at 12 months and 24 months of age.
A member between the ages of three and six years, for whom no previous
test exists, should also be tested, and screenings shall be done in accordance
with the most current recommendations of the American academy of pediatrics.
(7) EPSDT
newborn screening: A newborn member
shall be screened for those disorders specified in the state of New Mexico
metabolic screen and any screenings shall be done in accordance with the most
current recommendations of the American academy of pediatrics.
(8) Screening
for obesity: A member shall receive
body weight, height and length measurements with each physical exam. A member under 21 years of age shall receive
a BMI percentile designation.
(9) Prenatal
screening: All pregnant members shall be screened for preeclampsia, Rh (D)
incompatibility, down syndrome, neural tube defects, hemoglobinopathies,
vaginal and rectal group B streptococcal infection and screened and counseled
for HIV in accordance with the most current recommendations of the American
college of obstetricians and gynecologists.
(10) Screening
for rubella: All female members of childbearing ages shall be screened for
rubella susceptibility by history of vaccination or by serology.
(11) Screening
for tuberculosis: Routine tuberculin
skin testing shall not be required for all members. The following high-risk members shall be
screened or previous screenings noted:
(a) a
member who has immigrated from countries in Asia, Africa, Latin America or the
middle east in the preceding five years;
(b) a
member who has substantial contact with immigrants from those areas; a member
who is a migrant farm worker;
(c) a
member who is an alcoholic, homeless or is an injecting drug user. HIV-infected persons shall be screened
annually; and
(d) a
member whose screening tuberculin test is positive (>10 mm of induration)
must be referred to the local DOH public health office in his or her community
of residence for contact investigation.
(12) Serum
cholesterol measurement: A male
member 35 years and older and a female member 45 years and older who is at
normal risk for coronary heart disease shall receive serum cholesterol and HDL
cholesterol measurement every five years.
A member 20 years and older with risk factors for heart disease shall
have serum cholesterol and HDL cholesterol measurements annually.
(13) Tot-to-teen
health checks: The MCO shall operate
the tot-to-teen mandated EPSDT program as outlined in 8.320.2 NMAC. Within three months of enrollment lock-in,
the MCO shall ensure that the member is current according to the screening
schedule, unless more stringent requirements are specified in these
standards. The MCO shall encourage its
PCPs to assess and document for age, height, gender appropriate weight, and
body mass index (BMI) percentage during EPSDT screens to detect and treat
evidence of weight or obesity issues in members under 21 years of age.
(14) Screening
for type 2 diabetes: A member with
one or more of the following risk factors for diabetes shall be screened. Risk factors include:
(a) a
family history of diabetes (parent or sibling with diabetes); obesity (>twenty
percent over desired body weight or BMI >27kg/m2);
(b) race
or ethnicity (e.g. hispanic, native American, African American, Asian-Pacific
islander);
(c) previously
identified impaired fasting glucose or impaired glucose tolerance; hypertension
(>140/90 mmHg); HDL cholesterol level <35 mg/dl and triglyceride level
>250 mg/dl; history of gestational diabetes mellitus (GDM); and
(d) a
delivery of newborn over nine pounds.
(15) A
member 21 years of age and older must be screened to detect high risk for
behavioral health conditions at his or her first encounter with a PCP after
enrollment.
(16) The
MCO shall require its PCPs to refer a member, whenever clinically appropriate,
to behavioral health provider, see 8.321.2 NMAC. The MCO shall assist the member with an
appropriate behavioral health referral.
(17) Screens
and preventative screens shall be updated as recommended by the United States
preventative services task force.
[8.308.9.17 NMAC - Rp, 8.308.9.17 NMAC,
5/1/2018; A, 1/1/2019; A, 4/5/2022]
8.308.9.19 BEHAVIORAL HEALTH SERVICES:
A. The MCO shall cover the following behavioral health services
listed below. When an additional
behavioral health service is approved by MAD, the MCO shall cover that service
as well. See 8.321.2 NMAC for detailed
descriptions of each service. MAD makes
available on its website its
behavioral health service definitions and crosswalk, along with other
information.
(1) Applied behavior analysis: The benefit package includes applied behavior
analysis (ABA) services for [a member 12 months of age up to 21 years of age
who has a well-documented medical diagnosis of autism spectrum disorder (ASD),
and for a member 12 months to three years of age who has a well-documented risk
for the development of ASD. The need for
ABA services must be identified in the member’s tot to teen healthcheck screen
or another diagnostic evaluation furnished through a healthcheck referral.]
eligible recipients who have a well-documented medical diagnosis of autism
spectrum disorder (ASD), and for eligible recipients who have well-documented
risk for the development of ASD. As part
of a three-stage comprehensive approach consisting of evaluation, assessment,
and treatment, ABA services may be provided in coordination with other
medically necessary services (e.g., family infant toddler program (FIT)
services, occupational therapy, speech language therapy, medication management,
developmentally disabled waiver services, etc.). ABA services are part of the early periodic
screening, diagnosis and treatment (EPSDT) program (CFR 42 section 441.57). There is no age requirement to receive ABA
services and ABA is a covered benefit for medicaid-enrolled adults.
(2) Assertive community treatment
services (ACT): The benefit
package includes assertive community treatment services for a member 18 years
of age and older.
(3) Behavioral health respite: Behavioral health respite care is provided to
a member under 21 years of age to support the member’s family and strengthen
their resiliency during the respite while the member is in a supportive
environment. Respite care is provided to
a member with a severe emotional disturbance who resides with his or her family
and displays challenging behaviors that may periodically overwhelm the member’s
family’s ability to provide ongoing supportive care. See the New Mexico interagency behavioral
health purchasing collaborative service requirements and utilization guidelines-respite
services-for a detailed description.
Behavioral health respite is not a benefit for ABP eligible recipients.
(4) Comprehensive
community support services: The benefit package includes
comprehensive community support services for a member.
(5) Crisis
Services: The benefit package
includes three types of crisis services:
(a) 24-hour
crisis telephone support; and
(b) mobile
crisis team; and
(c) crisis
triage centers.
(6) Family support services: The benefit package includes family support
services to a member whose focus is on the member and his or her family and the
interactive effect through a variety of informational and supportive activities
that assists the member and his or her family develop patterns of interaction
that promote wellness and recovery over time.
The positive interactive effect between the member and his or her family
strengthens the effectiveness of other treatment and recovery initiatives. See the New Mexico interagency behavioral
health purchasing collaborative service requirements and utilization guidelines
-family support services-for a detailed description. Family support services are not a benefit for
ABP eligible recipients.
(7) Hospital outpatient services: The
benefit package includes outpatient psychiatric and partial hospitalization
services provided in PPS-exempt unit of a general hospital for a member.
(8) Inpatient hospital services: The
benefit package includes inpatient hospital psychiatric services provided in
general hospital units and prospective payment system (PPS)-exempt units in a
general hospital as detailed in 8.311.2 NMAC.
(9) Intensive
outpatient (IOP) services: The benefit package includes intensive
outpatient services for a member 13 years of age.
(10) Medication
assisted treatment (MAT) and Opioid Treatment Programs: The
benefit package includes opioid treatment services for opioid addiction to a
member through an opioid treatment center as defined in 42 CFR Part 8,
Certification of Opioid Treatment; and buprenorphine and related
pharmaceuticals. Medication assisted
treatments include use of buprenorphine and similarly acting products.
(11) Outpatient therapy services: The
benefit package includes outpatient therapy services (individual, family, and
group) for a member.
(12) Psychological rehabilitation services: The benefit package includes adult
psychosocial rehabilitation services for a member 18 years and older.
(13) Recovery services: The
MCO benefit package includes recovery services for a member. Recovery services are peer-to-peer support
within a group setting to develop and enhance wellness and healthcare
practices. The service enables a member
to identify additional needs and goals and link him or herself to additional
support as a result. See the New Mexico
interagency behavioral health purchasing collaborative service requirements and
utilization guidelines -recovery services-for a detailed description. Recovery services are not a benefit for ABP
eligible recipients.
B. Behavioral health EPSDT services: The benefit package includes the
delivery of the federally mandated EPSDT services (42 CFR Section 441.57)
provided by a behavioral health practitioner for a member under 21 years of age. See 8.321.2 NMAC for a detailed description
of each service. The MCO shall provide
access to EPSDT for a member identified in his or her EPSDT tot to teen health
check screen or another diagnostic evaluation as being at-risk for developing
or having a severe emotional, behavioral or neurobiological disorder.
(1) Accredited residential treatment center
(ARTC): The benefit package includes
services furnished in an ARTC furnished as part of the EPSDT program. ARTC services are provided to a member who
needs the LOC furnished in an out-of-home residential setting. The need for ARTC services must be identified
in the member’s tot to teen health check screen or another diagnostic
evaluation furnished through a health check referral.
(2) Behavior management skills development
services (BMS): The benefit package
includes BMS services furnished as part of the EPSDT program. BMS services are provided to a member who has
an identified need for such services and meets the required LOC. The need for BMS services must be identified
in the member’s tot to teen health check screen or another diagnostic
evaluation furnished through a health check referral.
(3) Day treatment services: The
benefit package includes day treatment services furnished as part of the EPSDT
program. Day treatment services are
provided to a member who has an identified need for such services and meets the
required LOC. The need for day treatment
services must be identified in the member’s tot to teen health check screen or
another diagnostic evaluation furnished through a health check referral.
(4) Inpatient hospitalization services provided
in freestanding psychiatric hospitals: The benefit package
includes inpatient psychiatric care furnished in a freestanding psychiatric
hospital furnished as part of the EPSDT program. Inpatient hospitalization services are
provided in a freestanding psychiatric hospital are provided to a member who
has an identified need for such services and meet the required LOC. The need for such services must be identified
in the member’s tot to teen health check screen or another diagnostic
evaluation furnished through a health check referral.
(5) Multi-systemic therapy (MST): The
benefit package includes MST services furnished as part of the EPSDT program. MST services are provided to a member who has
an identified need for such services and meets the required LOC. The need for MST services must be identified
in the member’s tot to teen health check screen or another diagnostic
evaluation furnished through a health check referral.
(6) Psychosocial rehabilitation services (PSR): The benefit package includes PSR services
furnished as part of the EPSDT program.
PSR is provided to a member who has an identified need for such services
and meets the required LOC. The need for
PSR services must be identified in the member’s tot to teen health check screen
or another diagnostic evaluation furnished through a health check referral.
(7) Treatment foster care I (TFC I): The benefit package includes TFC I furnished
as part of the EPSDT program. TFC I
services are provided to a member who has an identified need for such services
and meets the required LOC. The need for
TFC I services must be identified in the member’s tot to teen health check or
another diagnostic evaluation furnished through a health check referral.
(8) Treatment foster care II (TFC II): The benefit package includes TFC II services
furnished as part of the EPSDT program.
TFC II is provided to a member who has an identified need for such
services and meets the required LOC. The
need for TFC II services must be identified in the member’s tot to teen health check
or another diagnostic evaluation furnished through a health check referral.
(9) Residential
non-accredited treatment center (RTC) and group home: The
benefit package includes services furnished in a RTC center or group home as
part of the EPSDT program. RTC or group
home services are provided to a member who needs the LOC furnished in an
out-of-home residential setting. The
need for RTC and group home services must be identified in the member’s tot to
teen health check screen or another diagnostic evaluation furnished through a
health check referral.
[8.308.9.19 NMAC - Rp, 8.308.9.19 NMAC,
5/1/2018; A, 4/5/2022]
8.308.9.22 MAD ALTERNATIVE BENEFITS PLAN
GENERAL BENEFITS FOR ABP EXEMPT MEMBERS (ABP exempt): An ABP member who self-declares [he or she
has] they have a qualifying condition is evaluated by [his or her]
their MCO for determination if [he or she meets] they meet
an ABP qualifying condition. An ABP
exempt member may select to no longer utilize [his or her] their
ABP benefits package. Instead, the ABP
exempt member will utilize [his or her] their MCO’s medicaid
benefits package. See 8.308.9.11-20 NMAC
for detailed description of the MCO medicaid benefit services. All
services, services limitations and co-payments that apply to full benefit
medicaid recipients apply to APB-exempt recipients. An ABP-exempt recipient does not have access
to the benefits that only apply to ABP recipients. The ABP co-payments do not apply to an
ABP-exempt recipient. The limitations on
services that apply only to ABP-recipients do not apply to ABP-exempt
recipients. The MCO shall
comply with all HSD contractual provisions and with all NMAC rules that pertain
to the MCO’s responsibilities to its members as listed below:
A. provider networks found in 8.308.2
NMAC;
B. managed care eligibility found in
8.308.6 NMAC;
C. enrollment and disenrollment from
managed care found in 8.308.7 NMAC;
D. managed care member education -
rights and responsibilities found in 8.308.8 NMAC;
E. care coordination found in 8.308.10
NMAC;
F. transition of care found in
8.308.11 NMAC;
G. community benefits found in 8.308.12
NMAC;
H. managed care member rewards found in
8.308.13 NMAC
I. managed care cost sharing found in
8.308.14 NMAC;
J. managed care grievance and appeals
found in 8.308.15 NMAC;
K. managed care reimbursement found in
8.308.20 NMAC;
L. quality management found in 8.308.21
NMAC; and
M. managed care fraud, waste and abuse
found in 8.308.22 NMAC.
[8.308.9.22 NMAC - Rp, 8.308.9.22 NMAC,
5/1/2018; A, 4/5/2022]
8.308.9.23 CENTENNIAL HOME VISITING (CHV) PILOT PROGRAM SERVICES: Beginning January 1, 2019, the benefit is
available to approximately 300 eligible pregnant medicaid managed care enrolled
members and their children who reside in Bernalillo County (other
HSD-designated counties may be included at a later time and with a distinct
enrollment limit) in accordance with the program standard. The MCO shall contract with agencies operating
in the HSD-designated counties that provide services that are in alignment with
one of the two following evidence-based early childhood home visiting delivery
models:
A. Nurse Family Partnership (NFP): The services to be delivered under the NFP
national program standards are for first-time parents only. In Bernalillo County, the program is anticipated to
serve up to 132 families by the end of the first year of implementation using
one NFP team and to approximately 240 eligible members (annual average at full
implementation) thereafter using two NFP teams. The number of families served
will be determined based on the number of active NFP teams in any program year.
HSD may expand this program to other counties at HSD’s discretion dependent
upon provider capacity. The NFP services will be
suspended once the child reaches two years of age.
B. Parents as Teachers (PAT): The PAT evidence-based program services will
adhere to the national model and curriculum and serve approximately 60 families
(annual average at full implementation) in Bernalillo County. Services will
begin during pregnancy and may continue until the child reaches five years of
age or kindergarten entry. HSD may expand
this program to other counties at HSD’s discretion dependent upon provider
capacity. The
number of families served in other counties will be determined based on the
number of active PAT teams in the program year.
The
MCO may propose other evidence-based early childhood home visiting delivery
models with similar services in lieu of the PAT model if available in the HSD-designated
service areas.
C. Description
of Services: The services available
under the CHV pilot program are described below:
(1) Prenatal
home visits: the benefit package includes the following services for
eligible pregnant [women] individuals during their pregnancy:
(a) monitoring
for high blood pressure or other complications of pregnancy (only covered under
the NFP model);
(b) diet and
nutritional education;
(c) stress management;
(d) sexually
transmitted disease (STD) prevention education;
(e) tobacco
use screening and cessation education;
(f) alcohol
and other substance misuse screening and counseling;
(g) depression
screening; and
(h) domestic
and intimate partner violence screening and education.
(2) Postpartum home visits: the benefit package includes the
following services that may be delivered as part of a postpartum home visit,
when provided during the [60 day] 12-month postpartum period to
an eligible member:
(a) diet
and nutritional education;
(b) stress
management;
(c) sexually
transmitted disease (STD) prevention education;
(d) tobacco
use screening and cessation education;
(e) alcohol
use and other substance misuse screening and counseling;
(f) depression
screening;
(g) domestic
and intimate partner violence screening and education;
(h) breastfeeding
support and education. Members may be
referred to a lactation specialist, but lactation consultant services are not
covered as a home visiting service;
(i) guidance
and education regarding wellness visits to obtain recommended preventive
services;
(j) medical
assessment of the postpartum mother and infant (only covered under the NFP
model);
(k) maternal-infant
safety assessment and education, such as safe sleep education for sudden infant
death syndrome (SIDS) prevention;
(l) counseling
regarding postpartum recovery, family planning, and needs of a newborn;
(m) assistance
to the family in establishing a primary source of care and a primary care
provider, including help ensuring that the mother/infant has a
postpartum/newborn visit scheduled; and
(n) parenting
skills and confidence building.
(3) Infant
and children home visits: the benefit package includes the
following services that may be delivered to newborn infants born to CHV Pilot Project members until the child reaches two years
of age for NFP and five years of age or kindergarten
entry for PAT, as part of an infant home visit:
(a) breastfeeding
support and education. Members may be
referred to a lactation specialist, but lactation consultant services are not
covered as a home visiting service;
(b) child
developmental screening at major developmental milestones from birth to age two
for NFP according to the model standard practice, and age five or kindergarten
entry for PAT; and
(c) parenting
skills and confidence building.
[8.308.9.23 NMAC - N, 1/1/2019; A,
4/5/2022]
8.308.9.25 EMERGENCY AND POST STABILIZATION
SERVICES:
A. In this section, emergency medical condition means a
medical condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) that a prudent layperson, who possesses an average knowledge
of health and medicine, could reasonably expect the absence of immediate
medical attention to result in the following:
(1) Placing the health of the individual
(or, for a pregnant [woman] individual, the health of the [woman
or her] individual or their unborn child) in serious jeopardy.
(2) Serious impairment to bodily
functions.
(3) Serious dysfunction of any bodily
organ or part.
B. In this section, emergency services means covered
inpatient and outpatient services as follows.
(1) Furnished by a provider that is
qualified to furnish these services under the federal rules. See 42 CFR 438.114.
(2) Needed to evaluate or stabilize an
emergency medical condition.
C. Post-stabilization care services means covered services,
related to an emergency medical condition that are provided after a member is
stabilized to maintain the stabilized condition, or, under the circumstances
described 42 CFR 438.114 (e), to improve or resolve the member’s condition.
D. The MCO is responsible for coverage and payment of
emergency services and post-stabilization care services. The MCO must cover and pay for emergency
services regardless of whether the provider that furnishes the services has a
contract with the MCO. The MCO may not
deny payment for treatment obtained under either of the following
circumstances.
(1) A member had an emergency medical
condition, including cases in which the absence of immediate medical attention
would not have had the outcomes specified in the definition of emergency medical
condition in Subsection A of 8.308.9.24 NMAC.
(2) A representative of the MCO instructs
the member to seek emergency services.
E. The MCO may not:
(1) limit what constitutes an emergency
medical condition with reference to Subsection A of 8.308.9.24 NMAC on the
basis of lists of diagnoses or symptoms; or
(2) refuse to cover emergency services
based on the emergency room provider or hospital not notifying the member’s PCP
or the MCO.
F. A member who has an emergency medical condition may not
be held liable for payment of subsequent screening and treatment needed to
diagnose the specific condition or stabilize the member.
G. The attending emergency physician, or the provider
actually treating the member, is responsible for determining when the member is
sufficiently stabilized for transfer or discharge, and that determination is
binding on the MCO that is responsible for coverage and payment.
[8.308.9.24
NMAC - Rp, 8.308.9.24 NMAC, 5/1/2018; 8.308.9.25
NMAC - Rn, 8.308.9.24 NMAC, 1/1/2019; A, 4/5/2022]