N.M. Admin. Code § 8.312.2.13 - [Effective until 8/1/2025] COVERED SERVICES
B. MAD covers physical, occupational and speech therapy services furnished to an eligible recipient or member residing in a NF in the following manner:
(1) if the eligible recipient or member is also eligible for medicare and the NF does part B billing, the co-payment or deductible is processed by MAD or the MCO for services is paid by MAD or the MCO;
(2) if the eligible recipient or member receives high NF level services, services are included in the MAD facility rate; or
(3) if eligible, the recipient or member receives low NF level services, services are billed separately by participating therapy providers.
C. MAD covers a NF per diem add-on for ventilator services in long-term and skilled nursing facilities in New Mexico.
(1) The per diem add-on costs of providing services to the ventilator dependent resident or member shall be maintained separately (as a distinct part) of each facility's annual cost report.
(2) Ventilator dependent per diem add-on rates will cover skilled nursing care services and will be all-inclusive.
(3) Ventilator dependent per diem add-on services must be prior authorized by the MCO. The resident's or member's clinical condition shall be reviewed every 90 days to determine if the resident's or member's medical condition continues to warrant services at the ventilator dependent NF rate. Prior authorization (PA) through the MCO spans a 90-day maximum time period. The NF is required to resubmit requests for continued stay prior to expiration of the current PA. If a resident or member no longer requires the use of a ventilator, the provider shall not receive additional reimbursement beyond the New Mexico medicaid nursing home per diem rate determined for the facility.
(4) Long-term and skilled nursing facilities in New Mexico must be certified by the department of health to provide ventilator services.
(5) Eligible ventilator dependent recipients residing in a NF must meet the following criteria:
(a) Have a health condition that requires close medical supervision defined as 24 hours a day of licensed nursing care along with specialized services or equipment;
(b) Require mechanical ventilation greater than or equal to six hours a day;
(c) Have tracheostomy (with daily care) and require mechanical ventilation for a portion of each day for stabilization;
(d) Require continuous pulse oximetry monitoring to check the stability of oxygen saturation levels;
(e) Require respiratory assessment and daily documentation by a licensed respiratory therapist or registered nurse;
(f) Have a provider's order for respiratory care to include suctioning as needed;
(g) Have tracheostomy care with suctioning and room air mist or oxygen as needed, and one of the four treatment procedures listed below:
(i) total parenteral nutrition;
(ii) inpatient physical, occupational, or speech therapy;
(iii) tube feeding (nasogastric or gastrostomy); or
(iv) inhalation therapy treatments every shift and a minimum of four times per 24-hour period.
(h) The recipient's diagnosis must be consistent with ICD diagnosis codes for ventilator dependency;
(i) The skilled nursing facility must be approved for ventilator care; and
(j) Providers must be specially trained and competent in respiratory and vent care.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
B. MAD covers physical, occupational and speech therapy services furnished to an eligible recipient or member residing in a NF in the following manner:
(1) if the eligible recipient or member is also eligible for medicare and the NF does part B billing, the co-payment or deductible is processed by MAD or the MCO for services is paid by MAD or the MCO ;
(2) if the eligible recipient or member receives high NF level services, services are included in the MAD facility rate; or
(3) if eligible, the recipient or member receives low NF level services, services are billed separately by participating therapy providers.
C. MAD covers a NF per diem add-on for ventilator services in long-term and skilled nursing facilities in New Mexico.
(1) The per diem add-on costs of providing services to the ventilator dependent resident or member shall be maintained separately (as a distinct part) of each facility 's annual cost report.
(2) Ventilator dependent per diem add-on rates will cover skilled nursing care services and will be all-inclusive.
(3) Ventilator dependent per diem add-on services must be prior authorized by the MCO . The resident's or member 's clinical condition shall be reviewed every 90 days to determine if the resident's or member 's medical condition continues to warrant services at the ventilator dependent NF rate. Prior authorization (PA) through the MCO spans a 90-day maximum time period. The NF is required to resubmit requests for continued stay prior to expiration of the current PA. If a resident or member no longer requires the use of a ventilator, the provider shall not receive additional reimbursement beyond the New Mexico medicaid nursing home per diem rate determined for the facility .
(4) Long-term and skilled nursing facilities in New Mexico must be certified by the department of health to provide ventilator services.
(5) Eligible ventilator dependent recipients residing in a NF must meet the following criteria:
(a) Have a health condition that requires close medical supervision defined as 24 hours a day of licensed nursing care along with specialized services or equipment;
(b) Require mechanical ventilation greater than or equal to six hours a day;
(c) Have tracheostomy (with daily care ) and require mechanical ventilation for a portion of each day for stabilization;
(d) Require continuous pulse oximetry monitoring to check the stability of oxygen saturation levels;
(e) Require respiratory assessment and daily documentation by a licensed respiratory therapist or registered nurse;
(f) Have a provider's order for respiratory care to include suctioning as needed;
(g) Have tracheostomy care with suctioning and room air mist or oxygen as needed, and one of the four treatment procedures listed below:
(i) total parenteral nutrition;
(ii) inpatient physical, occupational, or speech therapy;
(iii) tube feeding (nasogastric or gastrostomy); or
(iv) inhalation therapy treatments every shift and a minimum of four times per 24-hour period.
(h) The recipient's diagnosis must be consistent with ICD diagnosis codes for ventilator dependency;
(i) The skilled nursing facility must be approved for ventilator care ; and
(j) Providers must be specially trained and competent in respiratory and vent care .