N.M. Admin. Code § 8.321.2.14 - ASSERTIVE COMMUNITY TREATMENT SERVICES
To help an eligible recipient with medically necessary services MAD pays for covered assertive community treatment services (ACT). See Subsections A and B of 8.321.2.9 NMAC for MAD general provider requirements.
A.
Eligible providers:
(1) An ACT
agency must demonstrate compliance with administrative, financial, clinical,
quality improvement and information services infrastructure standards
established by MAD or its designee, including compliance and outcomes
consistent with the ACT fidelity model. See Subsections A and B of
8.321.2.9 NMAC for MAD general
provider requirements.
(2) An ACT
agency providing coordinated specialty care for an individual with first
episode psychosis must provide services consistent with the coordinated
specialty care (CSC) model.
(3) ACT
services must be provided by an agency designated team of 10 to 12 members; see
Paragraph (5) of Subsection A of
8.321.2.14 NMAC for the required
composition. A lower number of team member compositions may be considered by
BHSD. The waiver request is dependent on the nature of the clinical severity
and rural vs. urban environment pending BHSD approval. Each team must have a
designated team leader. Practitioners on this team shall have sufficient
individual competence, professional qualifications and experience to provide
service coordination; crisis assessment and intervention; symptom assessment
and management; individual counseling and psychotherapy; prescription,
administration, monitoring and documentation of medications; substance use
disorder treatment; work-related services; activities of daily living services;
support services or direct assistance to ensure that the eligible recipient
obtains the basic necessities of daily life; and coordination, support and
consultation to the eligible recipient's family and other major supports. The
agency must coordinate its ACT services with local hospitals, local crisis
units, local law enforcement agencies, local behavioral health agencies, and
consider referrals from social service agencies.
(4) Each ACT team staff member must be
successfully and currently certified or trained according to ACT fidelity model
standards. The training standards focus on developing staff competencies for
delivering ACT services according to the most recent ACT evidenced-based
practices and ACT fidelity model. Each ACT team shall have a sufficient number
of qualified staff to provide treatment, rehabilitation, crisis and support
services 24-hours a day, seven days a week.
(5) Each ACT team shall have a staff-to
eligible recipient ratio dependent on the nature of the team based on clinical
severity and rural vs. urban environment pending BHSD approval to ensure
fidelity with current model.
(6)
Each ACT team must comply with
8.321.2.9 NMAC for specific
licensing requirements for ACT staff team members as appropriate, and must
include:
(a) one team leader who is an
independently licensed behavioral health practitioner (LPCC, LMFT, LISW, LCSW,
LPAT, psychologist);
(b) medical
director/prescriber:
(i) board certified or
board eligible psychiatrist; or
(ii) NM licensed psychiatric certified nurse
practitioner; or
(iii) NM licensed
psychiatric clinical nurse specialist; or
(iv) prescribing psychologist under the
supervision or consultation of an MD; or
(c) two licensed nurses, one of whom shall be
a RN, or other allied medical professionals may be used in place of one
nurse;
(d) at least one other MAD
recognized licensed behavioral health professional;
(e) at least one MAD enrolled licensed
behavioral health practitioner with expertise in substance use
disorders;
(f) at least one
employment specialist;
(g) at least
one NM certified peer support worker (CPSW) through the approved state of NM
certification program; or certified family peer support worker
(CFPSW);
(h) one administrative
staff person; and
(i) the eligible
recipient shall be considered a part of the team for decisions impacting their
ACT services.
(7) The
agency must have a HCA ACT approval letter to render ACT services to an
eligible recipient. The approval letter will authorize an agency also
delivering CSC model.
(8) Any
adaptations to the model require an approved variance from BHSD.
B.
Coverage criteria:
(1) MAD covers medically necessary ACT
services required by the condition of the eligible recipient.
(2) The ACT program provides four levels of
interaction with the participating individuals:
(a) face-to-face encounters.
(b) collateral encounters designated as
members of the recipient's family or household, or significant others who
regularly interact with the recipient and are directly affected by or have the
capability of affecting their condition and are identified in the treatment
plan as having a role in treatment.
(c) assertive outreach defined as the ACT
team having knowledge of what is happening with an individual. This occurs in
either locating the individual or acting quickly and decisively when action is
called for, while increasing client independence. This is done on behalf of the
client and can comprise only five percent per individual of total service time
per month.
(d) Group encounters
defined by the following types:
(i) basic
living skills development;
(ii)
psychosocial skills training;
(iii)
peer groups; or
(iv) wellness and
recovery groups.
(3) The ACT therapy model is based on
empirical data and evidence-based interventions that target specific behaviors
with an individualized treatment plan for the eligible recipient. Specialized
therapeutic and rehabilitative interventions falling within the fidelity of the
ACT model are used to address specific areas of need, such as experiences of
repeated hospitalization or incarcerations, severe problems completing
activities of daily living and individuals who have a significant history of
involvement in behavioral health services.
C.
Identified population:
(1) ACT services are provided to an eligible
recipient aged 18 and older whose diagnosis or diagnoses meet the criteria of
SMI with a special emphasis on psychiatric disorders, including schizophrenia,
schizoaffective disorder, bipolar disorder or psychotic depression for
individuals who have severe problems completing activities of daily living, who
have a significant history of involvement in behavioral health services and who
have experienced repeated hospitalizations or incarcerations due to mental
illness.
(2) ACT services can also
be provided to eligible individuals 15 to 30 years of age who are within the
first two years of their first episode of psychosis.
(3) A co-occurring diagnosis of SUD shall not
exclude an eligible recipient from ACT services.
D.
Covered services: ACT is a
voluntary medical, comprehensive case management and psychosocial intervention
program. See the BH policy and billing manual for a complete service
description.
E.
Non-covered
services: ACT 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 MAD general
non-covered behavioral health services. MAD does not cover other psychiatric,
mental health nursing, therapeutic, non-intensive outpatient substance use
disorder treatment or crisis services when billed in conjunction with ACT
services to an eligible recipient, except for medically necessary medications
and hospitalizations. Psychosocial rehabilitation and intensive outpatient
services can be billed concurrently if indicated in treatment plan but must be
identified as a component of the treatment plan.
F.
Reimbursement: ACT agencies
must submit claims for reimbursement on the CMS-1500 claim form or its
successor. See Subsection H of 8.321.2.9 for MAD general reimbursement
requirements.
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.
No prior version found.