N.M. Admin. Code § 8.321.2.11 - ADULT ACCREDITED RESIDENTIAL TREATMENT CENTER (AARTC) FOR ADULTS WITH SERIOUS MENTAL HEALTH CONDITIONS
To help an eligible recipient 18 years of age and older, who has been diagnosed as having a serious mental health condition, and the need for AARTC has been identified in the eligible recipient's diagnostic evaluation as meeting criteria of the level of care utilization system (LOCUS) for psychiatric and SUD services level of care five for whom a less restrictive setting is not appropriate. MAD pays for services furnished to them by an AARTC accredited by the joint commission (JC), the commission on accreditation of rehabilitation facilities (CARF) or the council on accreditation (COA).
A.
Eligible facilities:
(1) To be eligible to receive reimbursement
for providing AARTC services to an eligible recipient, an AARTC facility:
(a) must be accredited by JC, COA, or CARF as
an adult (18 and older) residential treatment facility;
(b) must be certified through an application
process with BHSD which includes site visits. Site visit requirements are
outlined in the BH policy and billing manual;
(c) must have written policies and procedures
specifying utilization of the LOCUS evaluation parameters for assessment of
service needs and ensuring that based on the dimensional rating scale, clients
meet LOCUS level 5 criteria as the basis for accepting eligible recipients into
the treatment program;
(d) must
meet LOCUS level five service definitions for the care environment, clinical
services, support services, and crisis stabilization and prevention
services;
(e) must assess for and
treat co-occurring SUDs;
(f) must
provide or refer eligible recipients for MAT for SUD, if appropriate; to
include access to buprenorphine and methadone, if appropriate and desired by
the recipient. Programs may not exclude recipients from receiving AARTC
services on the basis of receiving or desiring to receive MAT
services.
(g) must train all
clinicians or practitioners in the LOCUS for psychiatric and SUD services. The
LOCUS training must be conducted by a LOCUS approved trainer and must be
comprehensive in covering the evaluation parameters for assessment of service
needs and level of care definitions for LOCUS level 5 services;
(h) prior to the initial hire and every three
years thereafter employees must pass a nationwide caregiver criminal history
screening pursuant to Section
29-17-2 et seq. NMSA 1978 and
7.1.9 NMAC and an abuse registry screen pursuant to section
27-7a-1 et seq. NMSA 1978 and
8.11.6 NMAC; additionally employees must pass the employee abuse registry (EAR)
pursuant to 7.1.12 NMAC, certified nurse aide registry pursuant to 16- 12.20
NMAC, office of inspector exclusion list pursuant to section 1128B(f) of the
Social Security Act; and the national sex offender registry pursuant to 6201 as
federal authority for active programs;
(i) must maintain appropriate drug permit
required, issued by the state board of pharmacy, as applicable;
(j) must maintain appropriate food service
permit required, issued by the NMED, as applicable; and
(k) must allow individuals the opportunity to
notify their family that they have been admitted to the facility and shall not
admit an individual for residential treatment without obtaining or providing
evidence that the facility has attempted to obtain contact information for a
family member of the patient.
(2) An out-of-state or MAD enrolled border
AARTC must have JC, CARF or COA accreditation, use LOCUS level five criteria
for accepting recipients, and be licensed in its own state as an AARTC
residential treatment facility.
B.
Coverage criteria:
(1) Treatment must be provided under the
direction of an independently licensed clinician/practitioner and the program
must have sufficient staffing to meet the LOCUS level five clinical
capabilities description.
(2)
Treatment shall be based on the eligible recipient's individualized treatment
plan rendered by the AARTC facility's practitioners, within the scope and
practice of their professions as defined by state law, rule or regulation. See
Subsection B of
8.321.2.9 NMAC for general
behavioral health professional requirements.
(3) The following services shall be performed
by the AARTC agency to receive reimbursement from MAD:
(a) diagnostic evaluation, necessary
psychological testing, and development of the eligible recipient's treatment
plan, while ensuring that evaluations already performed are not
repeated;
(b) provision of
regularly scheduled counseling and therapy sessions in an individual, family or
group setting following the eligible recipient's treatment plan, and according
to LOCUS level five service descriptions the care environment, clinical
services, support services, and crisis stabilization and prevention
services;
(c) facilitation of
age-appropriate life skills development;
(d) assistance to the eligible recipient in
their self-administration of medication in compliance with state statute,
regulation and rules;
(e) maintain
appropriate staff available on a 24-hour basis to respond to crisis situations,
determine the severity of the situation, stabilize the eligible recipient, make
referrals as necessary, and provide follow-up to the eligible recipient;
and
(f) consultation with other
professionals or allied caregivers regarding the needs of the eligible
recipient, as applicable.
(4) Admission and treatment criteria based on
the LOCUS level five criteria based on the dimensional evaluation of service
needs. Length of stay duration is determined by medical necessity and ongoing
LOCUS level five criteria and symptomology. The LOCUS levels of care are based
on the intensity of clinical services, particularly as demonstrated by the
degree of involvement of psychiatric, medical, and nursing professionals. The
defining characteristic of LOCUS level five is that it serves recipients who
need a medically monitored residential setting for stabilization and treatment.
Recipients are transferred to lower levels of care when they have established
sufficient skills to safely continue treatment at a lower level of
care.
(5)
Sub-levels of level
five level of care:
(a) moderate
intensity long term residential treatment services as specified in LOCUS level
of care 5c are covered for recipients whose condition meets the criteria for
LOCUS Level 5c and who are experiencing long term and persistent disabilities
that require extended rehabilitation and skill building to develop capacity for
community living:
(b) moderate
intensity intermediate stay residential treatment programs as specified in
LOCUS levels of care 5b are covered for recipients whose condition meets the
criteria of LOCUS level 5c and who need rehabilitation and skill building
following stabilization of a crisis or to prevent precipitous deterioration in
functioning.
(c) intensive short
term residential services as specified in LOCUS level of care 5a are covered
for recipients whose condition meets the criteria for LOCUS level 5a and who
are stepping down from acute inpatient care or people who are in crisis but who
do not require the security of a locked facility.
C.
Covered services:
AARTCs treating all recipients meeting LOCUS level five criteria. MAD covers
residential treatment services which are medically necessary for the diagnosis
and treatment of an eligible recipient's condition. A LOCUS level five AARTC
facility must provide 24-hour care with trained staff.
D.
Non-covered services: AARTC
services are subject to the limitations and coverage restrictions that exist
for other MAD covered services. See Subsection G of
8.321.2.9 NMAC for general MAD
behavioral health non-covered services or activities. MAD does not cover the
following specific services billed in conjunction with AARTC services to an
eligible recipient:
(1) Comprehensive
community support services (CCSS), except when provided by a CCSS agency in
discharge planning for the eligible recipient from the facility;
(2) Services for which prior approval was not
requested and approved;
(3)
Services furnished to ineligible individuals;
(4) Formal educational and vocational
services which relate to traditional academic subjects or vocational training;
and
(5) Activity therapy, group
activities, and other services primarily recreational or diversional in
nature.
E.
Treatment plan: The treatment plan must be developed by a team of
professionals in consultation with the eligible recipient and in accordance
with LOCUS and accreditation standards. The interdisciplinary team must review
the treatment plan at least every 15 days.
F.
Prior authorization: Prior
authorization is not required for up to five days for eligible recipients
meeting LOCUS level 5 criteria to facilitate immediate admission and treatment
to the appropriate level of care. Within that five day period, the provider
must furnish notification of the admission and if the provider believes that
continued care beyond the initial five days is medically necessary, prior
authorization must be obtained from MAD or its designee. For out-of-state
AARTCs prior authorization is required prior to admission. Services for which
prior authorization was obtained remain subject to utilization review at any
point in the payment process. All MAD services are subject to utilization
review for medical necessity, inspection of care, and program compliance.
Follow-up auditing is done by the accrediting agency per their
standards.
G.
Reimbursement: An AARTC agency must submit claims for
reimbursement on the UB-04 form or its successor. See Subsection H of
8.321.2.9 NMAC for MAD general
reimbursement requirements and see 8.302.2 NMAC. Once enrolled, the agency
receives instructions on how to access documentation, billing, and claims
processing information.
(1) MAD reimbursement
covers services considered routine in the residential setting. Routine services
include, but are not limited to, counseling, therapy, activities of daily
living, medical management, crisis intervention, professional consultation,
transportation, rehabilitative services and administration.
(2) Services which are not covered in routine
services include other MAD services that an eligible recipient might require
that are not furnished by the facility, such as pharmacy services, primary care
visits, laboratory or radiology services. These services are billed directly by
the applicable providers and are governed by the applicable sections of NMAC
rules.
(3) MAD does not cover room
and board.
(4) Detailed billing
instructions can be accessed in the BH policy and billing manual.
Notes
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