To help an eligible recipient under 21 years of age who is
in need of behavior management intervention receive services, MAD pays for
behavior management services (BMS) as part of the EPSDT program and when the
need for BMS is identified in a tot to teen health check screen or other
diagnostic evaluation (see 42 CFR Section 441.57). BMS
services are designed to provide highly supportive and structured therapeutic
behavioral interventions to maintain the eligible recipient in their home or
community. BMS assists in reducing or preventing inpatient hospitalizations or
out-of-home residential placement of the eligible recipient through use of
teaching, training and coaching activities designed to assist them in
acquiring, enhancing, and maintaining the life, social and behavioral skills
needed to function successfully within their home and community settings. BMS
is provided as part of a comprehensive approach to treatment and in conjunction
with other services as indicated in the eligible recipient's comprehensive
behavioral health treatment plan. BMS is not provided as a stand-alone service
but delivered as part of an integrated plan of services to maintain eligible
recipients in their communities as an alternative to out-of-home
services.
A.
Eligible
providers: An agency must be certified by CYFD to provide BMS services
per
7.20.11 NMAC. See Subsections A and B of
8.321.2.9 NMAC for MAD general
provider requirements.
B.
Coverage criteria: MAD reimburses for behavior management services
specified in the eligible recipient's individualized treatment plan which are
designed to improve their performance in targeted behaviors, reduce emotional
and behavioral episodic events, increase social skills, and enhance behavioral
skills through a regimen of positive intervention and reinforcement.
(1) Implementation of the eligible
recipient's BMS treatment plan, which includes crisis planning, must be based
on a clinical assessment that includes identification of skills deficits that
will benefit from an integrated program of therapeutic services. A detailed
description of required elements of the assessment and treatment plan are found
in the BH policy and billing manual.
(2) 24-hour availability of appropriate staff
or implementation of crisis plan, which may include referral, to respond to the
eligible recipient's crisis situations.
(3) Supervision of behavioral management
staff by an independent level practitioner is required for this service
(
8.321.2.9 NMAC). Policies governing
supervisory responsibilities are detailed in the BH policy and billing manual.
The supervisor must ensure that:
(a) a
clinical assessment of the eligible recipient is completed upon admission into
BMS. The clinical assessment identifies the need for BMS as medically necessary
to prevent inpatient hospitalizations or out-of-home residential placement of
the eligible recipient;
(b) the
assessment is signed by the recipient or their parent or legal guardian;
and
(c) the BMS worker receives
documented supervision for a minimum of two hours per month dependent on the
complexity of the needs presented by recipients and the supervisory needs of
the BMS worker.
(4) An
eligible recipient's treatment plan must be reviewed at least every 30 calendar
days after implementation of the comprehensive treatment plan. The BMS, in
partnership with the client and family as well as all other relevant treatment
team members such as school personnel, juvenile probation officer (JPO), and
guardian ad litem (GAL), shall discuss progress made over time relating to the
BMS service goals. If the BMS treatment team assesses the recipient's lack of
progress over the last 30 days, the treatment plan will be amended as agreed
upon during the treatment team meeting. Revised BMS treatment plans will be
reviewed and approved by the BMS supervisor, which must be documented in the
recipient's file.
C.
Identified population: In order to receive BMS services, an
eligible recipient must be under the age of 21 years, be diagnosed with a
behavioral health condition and:
(1) be
at-risk for out-of-home residential placement due to unmanageable behavior at
home or within the community;
(2)
need behavior management intervention to avoid inpatient hospitalizations or
residential treatment; or
(3)
require behavior management support following an institutional or other
out-of-home placement as a transition to maintain the eligible recipient in
their home and community.
(4)
either the need for BMS is not listed on an individualized education plan
(IEP), or it is listed in the supplementary aid and service section of the
IEP.
D.
Non-covered services: BMS services are subject to the limitations
and coverage restrictions which exist for other MAD covered services. See
Subsection G of
8.321.2.9 NMAC for general
non-covered MAD behavioral health services or activities. MAD does not cover
the following specific services billed in conjunction with BMS services:
(1) activities which are not designed to
accomplish the objectives in the BMS treatment plan;
(2) services provided in residential
treatment facilities; and
(3)
services provided in lieu of services that should be provided as part of the
eligible recipient's individual educational plan (IEP) or individual family
treatment plan (IFTP).
(4) BMS is
not a reimbursable service through the medicaid school-based service
program.
E.
Reimbursement: A BMS agency must submit claims for reimbursement
on the CMS-1500 claim form or its successor. See Subsection H of
8.321.2.9 NMAC for MAD general
reimbursement requirements and
8.302.2 NMAC.
Notes
N.M. Admin.
Code §
8.321.2.17
Adopted by
New
Mexico Register, Volume XXX, Issue 23, December 17, 2019, eff.
1/1/2020, Adopted by
New
Mexico Register, Volume XXXII, Issue 15, August 10, 2021, eff.
8/10/2021, Adopted
by
New
Mexico Register, Volume XXXV, Issue 23, December 10, 2024, eff.
12/10/2024
