New Mexico Register / Volume XXXIII, Issue 7 / April 5, 2022
This is an amendment to 8.326.3 NMAC, Sections 8 - 10,
12, 13, 15 and part name change, effective 4/5/2022.
PART 3 CASE MANAGEMENT SERVICES FOR PREGNANT [WOMEN]
INDIVIDUALS AND THEIR INFANTS
8.326.3.8 MISSION
STATEMENT: [The mission of the
New Mexico medical assistance division (MAD) is to maximize the health status
of medicaid-eligible individuals by furnishing payment for quality health
services at levels comparable to private health plans.] 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.
[2/1/1995; 8.326.3.8 NMAC - Rn, 8 NMAC 4.MAD.002, 3/1/2012; A, 4/5/2022]
8.326.3.9 CASE
MANAGEMENT SERVICES FOR PREGNANT [WOMEN] INDIVIDUALS AND THEIR
INFANTS: The New Mexico medical
assistance program (medicaid) pays for medically necessary health services
furnished to eligible recipients, including case management services furnished
to medicaid eligible pregnant [women up to sixty (60) days following the end
of the month of the delivery [42 U.S.C. Section 1396n(g)(1)(2)] individuals
on the day the pregnancy ends through the last day in which the 12-month
postpartum period ends. This part
describes eligible providers, eligible recipients, covered services, service
limitations and general reimbursement methodology.
[2/1/1995; 5/15/1996; 8.326.3.9 NMAC - Rn, 8 NMAC 4.MAD.772, 3/1/2012; A, 4/5/2022]
8.326.3.10 Eligible Providers:
A. Upon approval of New Mexico medical
assistance program provider participation agreements by the New Mexico medical
assistance division (MAD), the following certified agencies are eligible to be
reimbursed for furnishing case management services to eligible pregnant [women]
individuals and their infants:
(1) public health offices of the New Mexico department of health;
(2) Indian tribal governments or Indian health services;
(3) federally qualified health centers (FQHC); and
(4) other community-based agencies which meet the requirements for participation.
B. Agency qualifications: Community-based agencies must be certified by the department of health and meet the following criteria:
(1) agencies must have demonstrated direct experience in successfully serving the target population; and
(2) agencies must have demonstrated knowledge of available community services and methods for accessing them.
C. Case manager qualifications: Case managers employed by the agency must possess the education, skills, abilities, and experience to perform case management services. It can be important that case managers have language skills, cultural sensitivity and acquired knowledge and expertise unique to the geographic area. At a minimum, case managers must have one of the following qualifications:
(1) case
managers must be licensed as a registered nurse and have a bachelors degree in
nursing or be licensed as a social worker; the nurse or social worker must have
two [(2)] years of experience in community health and at least one [(1)]
year of experience in maternal health or child health;
(2) or
be a licensed registered nurse or have a bachelors degree in social work with a
minimum of two [(2)] years of experience in community health and at
least two [(2)] years experience in maternal health or child health
nursing;
(3) in
the event that there are no candidates with the above qualifications, an
individual with an associates degree and four [(4)] years of experience
in social, community health [and/or] or maternal health and child
health may be employed as a case manager;
(4) if
no individuals with a college degree and appropriate experience are available,
an individual with a high school diploma and five years of experience in social
services, community health or maternal health and child health may be
considered; agencies that are considering hiring individuals [in option 3 or
4] listed in Paragraph (3) and (4) of 8.326.3.10 NMAC must complete
a waiver process.
D. 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.
[2/1/1995; 5/15/1996; 8.326.3.10 NMAC - Rn, 8 NMAC 4.MAD.772.1, 3/1/2012; A, 4/5/2022]
8.326.3.12 Eligible Recipients: Case management services are available to
medicaid eligible pregnant [women and their infants up to sixty (60) days
following the end of the month of the delivery] individuals and their
infants up to 12-months following the delivery in accordance with 8.291.400.14
NMAC.
[2/1/1995; 5/15/1996; 8.326.3.12 NMAC - Rn, 8 NMAC 4.MAD.772.3, 3/1/2012; A, 4/5/2022]
8.326.3.13 Covered Services and Service Limitations: Medicaid covers case management services for
pregnant [women] individuals and their infants which help
recipients gain access to medical, social, educational or other needed
services. Case management services
provide necessary coordination with providers of non-medical services, such as nutrition
or education programs, when these services are necessary to enable recipients
to benefit from the health services paid for by medicaid.
A. Medicaid covers the following case
management service activities furnished to pregnant [women up to sixty (60)
days following the end of the month of the delivery] individuals:
(1) identification of programs appropriate for the recipient’s needs, including those which teach basic maternal and child health skills;
(2) help in accessing the identified programs;
(3) assessment of the service needs of recipients to coordinate the delivery of services when multiple providers or programs are involved in the provision of care;
(4) reassessment to ensure that the services which were obtained are necessary and appropriate in meeting the recipient’s needs; and
(5) determination of whether any additional services are warranted.
B. Medicaid covers five [(5)]
hours of case management services per client per pregnancy. The five [(5)]
hours include services to both the pregnant recipient and the infant. Additional units of service require prior
approval by MAD or its designee.
[2/1/1995; 5/15/1996; 8.326.3.13 NMAC - Rn, 8 NMAC 4.MAD.772.4, 3/1/2012; A, 4/5/2022]
8.326.3.15 Plan of Care:
A. Case managers develop and implement plans of care for each medicaid recipient. Plans of care are developed in consultation with the recipients, families or legal guardian(s), physicians and others involved with care.
B. The following must be contained in the plan of care or documents used in the development of the plan of care. The plan of care and all supporting documentation must be available for review in the recipient’s file:
(1) statement of the nature of the specific problem and needs of the woman or infant;
(2) description of the intermediate and long-range goals with the projected timetable for their attainment, including specific information on the duration and scope of services; and
(3) statement and rationale of the plan of treatment for achieving these intermediate and long-range goals, including review and modification of the plan.
C. The plan of care must be retained by
agency providers and be available for utilization review purposes. Plans of care must be updated and revised, as
indicated, at least every six [(6)] months or more often, as indicated
by the recipient’s condition.
[2/1/1995; 5/15/1996; 8.326.3.15 NMAC - Rn, 8 NMAC 4.MAD.772.6, 3/1/2012; A, 4/5/2022]