N.M. Admin. Code § 8.321.2.12 - ACCREDITED RESIDENTIAL TREATMENT CENTER FOR YOUTH (ARTC)
To help an eligible recipient under 21 years of age when the
need for ARTC has been identified in the eligible recipient's tot to teen
health check screen (EPSDT) program (42 CFR section 441.57) or other
diagnostic evaluation, and for whom a less restrictive setting is not
appropriate, MAD pays for services furnished to them by an ARTC accredited by
the joint commission (JC), the commission on accreditation of rehabilitation
facilities (CARF) or the council on accreditation (COA). A determination must
be made that the eligible recipient needs the level of
A.
Eligible facilities:
(1) In addition to the requirements of
Subsections A and B of
8.321.2.9 NMAC, in order to be
eligible to be reimbursed for providing ARTC services to an eligible recipient,
an ARTC facility :
(a) must provide a copy of
its JC, COA, or CARF accreditation as a children's residential treatment
facility ;
(b) must provide a copy
of its CYFD ARTC facility license per 7.20.12 NMAC and certification per
7.20.11 NMAC;
(c) must have written
utilization review (UR) plans in effect which provide for review of the
eligible recipient's need for the ARTC that meet federal requirements ; see
42 CFR Section
456.201 through
456.245; and
(d) 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) If the ARTC is operated by IHS or by a
federally recognized tribal government, the youth based facility must meet CYFD
ARTC licensing and certification requirements , but is not required to be
licensed or certified by CYFD. In lieu of receiving a license and
certification, CYFD will provide MAD copies of its facility findings and
recommendations. MAD will work with the facility to address recommendations.
Details related to findings and recommendations for an IHS or federally
recognized tribal government's ARTC are detailed in the BH policy and billing
manual; and
(3) In lieu of NM CYFD
licensure, an out-of-state or MAD enrolled border ARTC facility must have JC,
COA or CARF accreditation and be licensed in its own state as an ARTC
residential treatment facility .
B.
Covered services: MAD covers
accommodation and residential treatment services which are medically necessary
for the diagnosis and treatment of an eligible recipient's condition. An ARTC
facility must provide an interdisciplinary psychotherapeutic treatment program
on a 24-hour basis to the eligible recipient. The ARTC will coordinate with the
educational program of the recipient, if applicable.
(1) Treatment must be furnished under the
direction of a MAD enrolled board eligible or certified psychiatrist.
(2) Treatment must be based on the eligible
recipient's individualized treatment plans rendered by the ARTC 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) Treatment must be reasonably expected to
improve the eligible recipient's condition. The treatment must be designed to
reduce or control symptoms or maintain levels of functioning. Avoiding acute
psychiatric hospitalization or further deterioration are also reasonable
expectations of treatment.
(4) The
following services must be performed by the ARTC agency to receive
reimbursement from MAD:
(a) performance of
necessary evaluations, psychological testing and development of the eligible
recipient's treatment plan, while ensuring that evaluations already performed
are not repeated;
(b) provide
regularly scheduled counseling and therapy sessions in an individual, family or
group setting following the eligible recipient's treatment plan;
(c) facilitation of age-appropriate skills
development in the areas of household management, nutrition, personal care ,
physical and emotional health, basic life skills, time management, school
attendance and money management to the eligible recipient;
(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;
(f) consultation with
other professionals or allied caregivers regarding the needs of the eligible
recipient, as applicable;
(g)
non-medical transportation services needed to accomplish the eligible
recipient's treatment objective; and
(h) therapeutic services to meet the
physical, social, cultural, recreational, health maintenance and rehabilitation
needs of the eligible recipients.
C.
Non-covered services: ARTC
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 ARTC services to an
eligible recipient:
(1) 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; ARTC and group services are covered only for eligible recipients
under 21 years of age;
(4) formal
educational and vocational services which relate to traditional academic
subjects or vocation training; and
(5) activity therapy, group activities, and
other services primarily recreational or diversional in nature.
D.
Treatment plan:
The treatment plan must be developed by a team of professionals in consultation
with the eligible recipient, their parent, legal guardian and others in whose
care they will be released after discharge. The plan must be developed within
14 calendar days of the eligible recipient's admission to an ARTC facility . The
interdisciplinary team must review the treatment plan at least every 30
calendar days. In addition to the requirements of Subsection K of
8.321.2.9 NMAC, all supporting
documentation must be available for review in the eligible recipient's file.
The treatment plan must also include a statement of the eligible recipient's
cultural needs and provision for access to cultural practices.
E.
Prior authorization: Before
any ARTC services are furnished to an eligible recipient, prior authorization
is required from MAD or its designee. Services for which prior authorization
was obtained remain subject to utilization review at any point in the payment
process.
F.
Reimbursement: An ARTC 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) The MAD fee
schedule is based on actual cost data submitted by the ARTC agency. Cost data
is grouped into various cost categories for purposes of analysis and rate
setting. These include direct service, direct service supervision , therapy,
admission and discharge planning, clinical support, non-personnel operating,
administration and consultation.
(a) The MAD
reimbursement covers those 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.
(b) 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, are
billed directly by the applicable providers and are governed by applicable
sections of NMAC rules.
(c)
Services which are not covered in the routine rate and are not a MAD covered
service include services not related to medical necessity, clinical treatment,
and patient care .
(2) A
vacancy factor of 24 days annually for each eligible recipient is built in for
therapeutic leave and trial community placement. Since the vacancy factor is
built into the rate, an ARTC agency cannot bill nor be reimbursed for days when
the eligible recipient is absent from the facility .
(3) An ARTC agency must submit annual cost
reports in a form prescribed by MAD. Cost reports are due 90 calendar days
after the close of the agency's fiscal year end.
(a) If an agency cannot meet this due date,
it can request a 30 calendar day extension for submission. This request must be
made in writing and received by MAD prior to the original due date.
(b) Failure to submit a cost report by the
due date or the extended due date, when applicable, will result in suspension
of all MAD payments until the cost report is received.
(4) Reimbursement rates for an ARTC
out-of-state provider located more than 100 miles from the NM border (Mexico
excluded) are at the fee schedule unless a separate rate is
negotiated.
Notes
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