N.M. Admin. Code § 8.321.2.33 - PSYCHOSOCIAL REHABILITATION SERVICES

To help an adult eligible recipient 18 years and older who met the criteria of SMI, MAD pays for psychosocial rehabilitation services (PSR). PSR is an array of services offered in a group setting through a clubhouse or a classroom and is designed to help an individual to capitalize on personal strengths, to develop coping strategies and skills to deal with deficits, and to develop a supportive environment in which to function as independently as possible. Psychosocial rehabilitation intervention is intended to be a transitional level of care based on the individual's recovery and resiliency goals. See Subsections A and B of 8.321.2.9 NMAC for MAD general provider requirements.

A. Eligible providers and practitioners:

(1) Agency staff must possess the education, skills, abilities, and experience to perform the activities that comprise the full spectrum of PSR services. See Subsection A of 8.321.2.9 NMAC for MAD general provider requirements. PSR agencies must:

(a) have provided a minimum of three years of CCSS services; and

(b) be approved through the application process described in the BH policy and billing manual.

(2) Staffing requirements:

(a) both clinical services and supervision by licensed practitioners must be in accord with their respective licensing board regulations.

(b) PSR services must meet a staff ratio sufficient to ensure that patients have reasonable and prompt access to services.

(c) in both clubhouse and classroom settings, the entire staff works as a team.

(d) the team must include a clinical supervisor/team lead and can include the following:

(i) certified peer support workers;

(ii) certified family support workers;

(iii) community support workers; and

(iv) other HIPAA trained individuals working under the direct supervision of the clinical supervisor.

(e) minimum qualifications for the clinical supervisor/team lead:

(i) independently licensed behavioral health professional (i.e. psychiatrist, psychologist, LISW, LPCC, LMFT, psychiatrically certified (CNS) practicing under the scope of their NM license;

(ii) have one year of demonstrated supervisory experience;

(iii) demonstrated knowledge and competence in the field of psychosocial; rehabilitation; and

(iv) an attestation of training related to providing clinical supervision of non-clinical staff.

B. Coverage criteria:

(1) MAD covers only those PSR services are medically necessary to meet the individual needs of the eligible recipient, as delineated in their treatment plan. Medical necessity is based upon the eligible recipient's level of functioning as affected by their SMI. The PSR services are limited to goals which are individually designed to accommodate the level of the eligible recipient's functioning, and which reduce the disability and restore the recipient to their best possible level of functioning.

(2) These services must be provided in a facility-based setting, either in a clubhouse model or a structured classroom.

(3) PSR services must be identified and justified in the individual's treatment plan. Recipients shall participate in PSR services for those activities that are identified in the treatment plan and are tied directly to the recipient's recovery and resiliency plan/goals.

(4) Specific service needs (e.g., household management, nutrition, hygiene, money management, parenting skills, etc.) must be identified in the individual's treatment plan.

C. Identified population:

(1) An eligible recipient 18 years or older meeting the criteria for SMI and for whom the medical necessity for PSR services was determined.

(2) Adults diagnosed with co-occurring SMI and SUD and for whom the medical necessity for PSR services was determined.

(3) A resident in an institution for mental illness is not eligible for this service.

D. Covered services: The psychosocial intervention (PSI) program must include the following major components: basic living skills development; psychosocial skills training; therapeutic socialization; and individual empowerment.

(1) Basic living skills development activities address the following areas, including but not limited to:

(a) basic household management;

(b) basic nutrition, health, and personal care including hygiene;

(c) personal safety;

(d) time management skills;

(e) money management skills;

(f) how to access and utilize transportation;

(g) awareness of community resources and support in their use;

(h) child care/parenting skills;

(i) work or employment skill-building; and

(j) how to access housing resources.

(2) Psychosocial skills training activities address the following areas:

(a) self-management;

(b) cognitive functioning;

(c) social/communication; and

(d) problem-solving skills.

(3) Therapeutic socialization activities address the following areas:

(a) understanding the importance of healthy leisure time;

(b) accessing community recreational facilities and resources;

(c) physical health and fitness needs;

(d) social and recreational skills and opportunities; and

(e) harm reduction and relapse prevention strategies (for individuals with co-occurring disorders).

(4) Individual empowerment activities address the following areas:

(a) choice;

(b) self-advocacy;

(c) self-management; and

(d) community integration.

E. Non-covered services: PSR 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 all general non-covered MAD behavioral health services or activities. Specifically, PSR cannot be billed concurrently when the recipient is a resident of an institution for the mentally ill.

F. Prior authorization: No prior authorization is required. To determine retrospectively if the medical necessity for the service has been met, the following factors are considered:

(1) recipient assessment;

(2) recipient diagnostic formation;

(3) recipient treatment plans; and

(4) compliance with 8.321.2 NMAC.

G. Reimbursement: Claims for reimbursement are submitted on the CMS-1500 claim form or its successor. See Subsection H of 8.321.2.9 NMAC for MAD general reimbursement requirements and see 8.302.2 NMAC.

Notes

N.M. Admin. Code § 8.321.2.33

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