TITLE 8              SOCIAL SERVICES

CHAPTER 326  CASE MANAGEMENT SERVICES

PART 8                CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS

 

8.326.8.1              ISSUING AGENCY:  New Mexico Health Care Authority.

[2/1/1995; 8.326.8.1 NMAC - Rn, 8 NMAC 4.MAD.000.1, 3/1/2012; A, 7/1/2024]

 

8.326.8.2              SCOPE:  The rule applies to the general public.

[2/1/1995; 8.326.8.2 NMAC - Rn, 8 NMAC 4.MAD.000.2, 3/1/2012]

 

8.326.8.3              STATUTORY AUTHORITY:  The New Mexico medicaid program is administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act, as amended and by the state [human services department] health care authority pursuant to state statute.  See Section 27-2-12 et seq. NMSA 1978 (Repl. Pamp. 1991).  Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a single, unified department to administer laws and exercise functions relating to health care facility licensure and health care purchasing and regulation.

[2/1/1995; 8.326.8.3 NMAC - Rn, 8 NMAC 4.MAD.000.3, 3/1/2012; A, 7/1/2024]

 

8.326.8.4              DURATION:  Permanent

[2/1/1995; 8.326.8.4 NMAC - Rn, 8 NMAC 4.MAD.000.4, 3/1/2012]

 

8.326.8.5              EFFECTIVE DATE:  March 1, 2000

[2/1/1995; 8.326.8.5 NMAC - Rn, 8 NMAC 4.MAD.000.5, 3/1/2012]

 

8.326.8.6              OBJECTIVE:  The objective of these regulations is to provide policies for the service portion of the New Mexico medicaid program.  These policies describe eligible providers, covered services, noncovered services, utilization review, and provider reimbursement.

[2/1/1995; 8.326.8.6 NMAC - Rn, 8 NMAC 4.MAD.000.6, 3/1/2012]

 

8.326.8.7              DEFINITIONS:  [RESERVED]

 

8.326.8.8              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.

[2/1/1995; 8.326.8.8 NMAC - Rn, 8 NMAC 4.MAD.002, 3/1/2012]

 

8.326.8.9              CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS:  The New Mexico human services department (HSD) pays for medically necessary case management services furnished to identified clients under nineteen (19) years of age who are under the supervision of a juvenile probation and parole officer (JPPO) and have an identified physical or mental condition which has a high probability of impairing their cognitive, emotional, neurological, social or physical development.  See Section 1915(g) of the Social Security Act.  This part describes eligible providers, eligible clients, covered services, service restrictions and general reimbursement methodology.

[3/1/2000; 8.326.8.9 NMAC - Rn, 8 NMAC 4.MAD.778, 3/1/2012]

 

8.326.8.10            Eligible Providers:  Upon approval of a New Mexico medical assistance program provider participation agreement by the New Mexico medical assistance division (MAD), the following agency is reimbursed for furnishing case management services to clients in the identified population: New Mexico children, youth and families department.  See the New Mexico Children’s Code, Chapter 32A-2-5.

               A.           Agency qualifications:

               B.           Case manager qualification:

                              (1)          Case managers employed by the New Mexico children, youth and families department must possess the knowledge, skills, abilities and experience to perform case management services for the targeted population and when necessary, possess language skills, cultural sensitivity and acquired knowledge unique to a geographic area.  Case managers must meet at least one of the following qualifications: a bachelor’s degree in social work, counseling, psychology or a related field and experience serving the targeted population.

                              (2)          All children, youth and families department, juvenile probation and parole officers (JPPOs) and JPPO supervisors performing targeted case management services must have documentation in their personnel file of completion of structured decision making training and any other additional or supplemental training developed by CYFD specific for this program.

                              (3)          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.

[3/1/2000; 8.326.8.10 NMAC - Rn, 8 NMAC 4.MAD.778.1, 3/1/2012]

 

8.326.8.11            Provider Responsibilities:  Providers who furnish services to medicaid clients must comply with all specified medicaid participation requirements.  See 8.302.1 NMAC, General Provider Policies.  Providers must verify that individuals are eligible for medicaid at the time services are furnished and determine if medicaid clients have other health insurance.  Providers must maintain records which are sufficient to fully disclose the extent and nature of the services furnished to clients.  See 8.302.1 NMAC, General Provider Policies.  Documentation must substantiate the date of service, nature of contact, reason the service was furnished, nature/content of the service furnished, result of service or intended result and relationship of the service furnished to goals identified in the plan of care.

[3/1/2000; 8.326.8.11 NMAC - Rn, 8 NMAC 4.MAD.778.2, 3/1/2012]

 

8.326.8.12            Eligible Recipients (Target Population):  Medicaid covers case management services furnished to medicaid clients under nineteen (19) years of age who are involved with the juvenile justice system or who have committed a delinquent act and have an identified physical or mental condition which has a high probability of impairing their cognitive, emotional, neurological, social or physical development.  Juveniles who are adjudicated and incarcerated or who are placed in a detention center for longer than sixty (60) pre-adjudication days) are not eligible for medicaid and/or case management services paid for by medicaid.

[3/1/2000; 8.326.8.12 NMAC - Rn, 8 NMAC 4.MAD.778.3, 3/1/2012]

 

8.326.8.13            Covered Services:  Case management is defined as services which assist clients in the target population in gaining access to needed medical, social, educational and other services.

               A.           Medicaid covers the following case management service activities for clients in the target population:

                              (1)          assessment of the client’s medical, social, educational and other service needs and functional limitations using standardized needs assessment instruments;

                              (2)          development and implementation of individualized plan of care;

                              (3)          mobilizing the use of “natural helping” networks, such as family members, church members and friends;

                              (4)          development of increased opportunities for community access and involvement including assistance in the location of housing, community living skills, vocational, social, educational or other service programs;

                              (5)          coordination and monitoring of the delivery of services; and

                              (6)          evaluation of the effectiveness of services furnished under the plan of care and revision of the plan as conditions warrant.

               B.           For clients in the target population that participate in the medicaid managed care program, HSD covers only those activities that relate to accessing social, educational, and other services.  The medicaid managed care organizations are responsible for ensuring that clients have access to medical services and coordination occurs with other case managers.

               C.           For clients in the target population that are not enrolled in the medicaid managed care program, HSD covers all delineated case management activities.

[3/1/2000; 8.326.8.13 NMAC - Rn, 8 NMAC 4.MAD.778.4, 3/1/2012]

 

8.326.8.14            Noncovered Services:  Case management services are subject to the limitations and coverage restrictions which exist for other medicaid services.  See 8.301.3 NMAC, General Noncovered Services.  In addition, medicaid does not cover the following specific activities:

               A.           services furnished to individuals who are not medicaid eligible or who are not eligible for these services;

               B.           services furnished by case managers which are not substantiated with appropriate documentation in the client’s file;

               C.           formal educational or vocational services related to traditional academic subjects or job training;

               D.           outreach and identification activities in which providers attempt to contact potential clients;

               E.           administrative activities, such as medicaid eligibility determinations and intake processing;

               F.            discharge planning from inpatient hospital, residential facility or community-based placement;

               G.           services which are furnished under other categories, such as therapies, transportation or counseling;

               H.           services provided to clients that are not part of the target population or services which are not documented in the client file; or

               I.            services provided to clients that relate to the legal and/or corrections functions performed by JPPOs.

[3/1/2000; 8.326.8.14 NMAC - Rn, 8 NMAC 4.MAD.778.5, 3/1/2012]

 

8.326.8.15            Plan of Care:

               A.           Case managers develop and implement plans of care in conjunction with the clients, families or legal guardian(s), therapists, physicians or others who assist with the client’s 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 client’s file:

                              (1)          statement of the nature of the specific problem and the specific needs of the client;

                              (2)          description of the functional level of the client, including an assessment and evaluation using the structured decision making assessment tool developed by CYFD and approved by HSD or its successor.

                              (3)          description of the intermediate and long-range goals with the projected timetable for their attainment, including information about the duration and scope of services;

                              (4)          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 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 client’s condition.

[3/1/2000; 8.326.8.15 NMAC - Rn, 8 NMAC 4.MAD.778.6, 3/1/2012]

 

8.326.8.16            Prior Approval and Utilization Review:  All medicaid services are subject to utilization review for medical necessity and program compliance.  Case management services furnished to clients in this targeted population do not require prior approval.  Reviews can be performed before services are furnished, after services are furnished and before payment is made, or after payment is made.  See 8.302.5 NMAC, Prior Authorization and Utilization Review.  Once enrolled, providers receive instructions and documentation forms necessary for prior approval and claims processing.

               A.           Prior approval:  Certain procedures or services which are part of the plan of care can require prior approval from MAD or its designee.  See utilization instructions for the specific service.  Services for which prior approval was obtained remain subject to utilization review at any point in the payment process.

               B.           Eligibility determination:  Prior approval of services does not guarantee that individuals are eligible for medicaid.  Providers must verify that individuals are eligible for medicaid at the time services are furnished and determine if medicaid clients have other health insurance.

               C.           Reconsideration:  Providers who disagree with prior approval request denials or other review decisions can request a re-review and a reconsideration.  See Section MAD-953, Reconsideration of Utilization Review Decisions.

[3/1/2000; 8.326.8.16 NMAC - Rn, 8 NMAC 4.MAD.778.7, 3/1/2012]

 

8.326.8.17            Reimbursement:  Case management providers must submit claims for reimbursement on the HCFA 1500 claim form or its successor.  See 8.302.2 NMAC, Billing for Medicaid Services.  Instructions on documentation, billing and claims processing are sent to approved medicaid providers.

               A.           Reimbursement for non-governmental providers:  For community agencies, tribal government, or Indian health services, reimbursement for case management services is made at the lesser of the following:

                              (1)          the provider’s billed charge; or

                              (2)          the MAD fee schedule for the specific service or procedure.

               B.           The provider’s billed charge must be the provider’s usual and customary charge for services.

               C.           “Usual and customary charge” refers to the amount which the individual provider charges the general public in the majority of cases for a specific procedure or service.

               D.           Reimbursement for governmental providers:  For case management services rendered by governmental agencies to the target population, reimbursement rates, rate setting methodology and reimbursement process will be delineated under the terms of the joint powers agreement between the government agencies and the human services department.

[3/1/2000; 8.326.8.17 NMAC - Rn, 8 NMAC 4.MAD.778.8, 3/1/2012]

 

HISTORY OF 8.326.8 NMAC:  [RESERVED]