Section 22. Day Treatment

MAD pays for services provided by a day treatment provider as part of the EPSDT program for eligible recipients under 21 years of age (42 CFR section 441.57). The need for day treatment services (DTS) must be identified through an EPSDT tot to teen health check or other diagnostic evaluation. Day treatment services include eligible recipient and parent education, skill and socialization training that focus on the amelioration of functional and behavioral deficits. Intensive coordination and linkage with the eligible recipient’s school or other child serving agencies is included. The goals of the service must be clearly documented utilizing a clinical model for service delivery and support. 8.321.2 NMAC 31 A. Eligible providers: An agency must be certified by CYFD to provide day treatment services per 7.20.11 NMAC in addition to meeting the general provider enrollment requirements in Subsections A and B of 8.321.2.9 NMAC. B. Coverage criteria: (1) Day treatment services must be provided in a school setting or other community setting; however, there must be a distinct separation between these services in staffing, program description and physical space from other behavioral health services offered. (2) A family who is unable to attend the regularly scheduled sessions at the day treatment facility due to transportation difficulties or other reasons may receive individual family sessions scheduled in the family’s home by the day treatment agency. (3) Services must be based upon the eligible recipient’s individualized treatment plan goals and should include interventions with a significant member of the family which are designed to enhance the eligible recipients’ adaptive functioning in their home and community. (4) The certified DTS provider delivers adequate care and continuous supervision of the client at all times during the course of the client’s DTS program participation igible recipient’s individualized treatment plan goals and should include interventions with a significant member of the family which are designed to enhance the eligible recipients’ adaptive functioning in their home and community. (4) The certified DTS provider delivers adequate care and continuous supervision of the client at all times during the course of the client’s DTS program participation. (5) 24-hour availability of appropriate staff or implementation of crisis plan (which may include referral) to respond to the eligible recipient’s crisis situation. (6) Only those activities of daily living and basic life skills that are assessed as a clinical problem should be addressed in the treatment plans and deemed appropriate to be included in the eligible recipient’s individualized program. (7) Day treatment services are provided at a minimum of four hours of structured programming per day, two to five days per week based on acuity and clinical needs of the eligible recipient and their family as identified in the treatment plan. C. Identified population: MAD covers day treatment services for an eligible recipient under age 21 who: (1) is diagnosed with an emotional, behavioral, and neurobiological or SUD; (2) may be at high risk of out-of-home placement; (3) requires structured therapeutic services in order to attain or maintain functioning in major life domains of home, work or school; and (4) through an assessment process, has been determined to meet the criteria established by MAD or its designee for admission to day treatment services. D. Covered services: (1) Day treatment services are non-residential specialized services and training provided during or after school, weekends or when school is not in session. Services include parent and eligible recipient education, and skills and socialization training that focus on the amelioration of functional and behavioral deficits. Intensive coordination and linkage with the eligible recipient’s school or other child serving agencies are included dential specialized services and training provided during or after school, weekends or when school is not in session. Services include parent and eligible recipient education, and skills and socialization training that focus on the amelioration of functional and behavioral deficits. Intensive coordination and linkage with the eligible recipient’s school or other child serving agencies are included. Other behavioral health services (e.g. outpatient counseling, ABA) may be provided in addition to the day treatment services when the goals of the service are clearly documented, utilizing a clinical model for service delivery and support. (2) The goal of day treatment is to maintain the eligible recipient in their home or community environment. (3) The service is designed to complement and coordinate with the eligible recipient’s educational system. (4) Services must be identified in the treatment plan, including crisis planning, which is formulated on an ongoing basis by the treatment team. The treatment plan guides and records for each client: individualized therapeutic goals and objectives; individualized therapeutic services provided; and individualized discharge and aftercare plans. Treatment plan requirements are detailed in the BH policy and billing manual. (5) The following services must be furnished by a day treatment service agency to receive reimbursement from MAD: (a) the assessment and diagnosis of the social, emotional, physical and psychological needs of the eligible recipient and their family for treatment planning ensuring that evaluations already performed are not unnecessarily repeated; (b) development of individualized treatment and discharge plans and ongoing reevaluation of these plans; (c) regularly scheduled individual, family, multifamily, group or specialized group sessions focusing on the attainment of skills, such as managing anger, communicating and problem-solving, impulse 8.321.2 NMAC 32 control, coping and mood management, chemical dependency and relapse prevention, as defined in the DT ndividualized treatment and discharge plans and ongoing reevaluation of these plans; (c) regularly scheduled individual, family, multifamily, group or specialized group sessions focusing on the attainment of skills, such as managing anger, communicating and problem-solving, impulse 8.321.2 NMAC 32 control, coping and mood management, chemical dependency and relapse prevention, as defined in the DTS treatment plan; (d) family training and family outreach to assist the eligible recipient in gaining functional and behavioral skills; (e) supervision of self-administered medication, as clinically indicated; (f) therapeutic recreational activities that are supportive of the clinical objectives and identified in each eligible recipient’s individualized treatment plan; (g) 24-hour availability of appropriate staff or implementation of crisis plan, which may include referral, to respond to the eligible recipient’s crisis situations; (h) advance schedules are posted for structured and supervised activities which include individual, group and family therapy, and other planned activities appropriate to the age, behavioral and emotional needs of the client pursuant to the treatment plan. E. Non-covered services: Day treatment 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 non-covered MAD behavioral health services or activities group and family therapy, and other planned activities appropriate to the age, behavioral and emotional needs of the client pursuant to the treatment plan. E. Non-covered services: Day treatment 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 non-covered MAD behavioral health services or activities. MAD does not cover the following specific services billed in conjunction with day treatment services: (1) educational programs; (2) pre-vocational training; (3) vocational training which is related to specific employment opportunities, work skills or work settings; (4) any service not identified in the treatment plan; (5) recreation activities not related to the treatment plan; (6) leisure time activities such as watching television, movies or playing computer or video games; (7) transportation reimbursement for the therapist who delivers services in the family’s home; or (8) a partial hospitalization program and residential programs cannot be offered at the same time as day treatment services. F. Prior authorization: See Subsection J of 8.321.2.9 NMAC for general behavioral health services prior authorization requirements. This service does not require prior authorization. G. Reimbursement: (1) All services described in Subsection D of 8.321.2.22 NMAC are covered in the bundled day treatment rate; (2) Day treatment providers 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, see 8.302.2 NMAC. Once enrolled, a provider receives instructions on how to access documentation, billing, and claims processing information. [8.321.2.22 NMAC - Rp, 8.321.2.21 NMAC, 12/10/2024] 8.321.2.23 FAMILY SUPPORT SERVICES (FSS) (MCO reimbursed only): Family support services are community-based, face-to-face interactions with children, youth or adults and their family, available to managed care members only . Once enrolled, a provider receives instructions on how to access documentation, billing, and claims processing information. [8.321.2.22 NMAC - Rp, 8.321.2.21 NMAC, 12/10/2024] 8.321.2.23 FAMILY SUPPORT SERVICES (FSS) (MCO reimbursed only): Family support services are community-based, face-to-face interactions with children, youth or adults and their family, available to managed care members only. Family support services enhance the member family’s strengths, capacities, and resources to promote the member’s ability to reach the recovery and resiliency behavioral health goals they consider most important. See Subsections A and B of 8.321.2.9 NMAC for MAD general provider requirements. A. Eligible providers: (1) Family support service providers and staff shall meet standards established by the state of NM and documented in the BH policy and billing manual. (2) Family support service staff and supervision by licensed behavioral health practitioners must be in accordance with their respective licensing board regulations or credentialing standards for peer support workers or family peer support workers. (3) Minimum staff qualifications for peer support workers or family peer support workers includes maintenance of credentials as a peer support worker or family peer support worker in NM. (4) Minimum staff qualifications for the clinical supervisor: (a) must be a licensed RLD board approved clinical supervisor (i.e., psychiatrist, psychologist, LISW, LPCC, LMFT, or psychiatrically certified nurse practitioner) practicing under the scope of their NM licensure; 8.321.2 NMAC 33 (b) have four years’ relevant experience in the delivery of case management or comprehensive community support services or family support services with the target population; (c) have one year demonstrated supervisory experience; and (d) have completed both basic and supervisory training regarding family support services. B itioner) practicing under the scope of their NM licensure; 8.321.2 NMAC 33 (b) have four years’ relevant experience in the delivery of case management or comprehensive community support services or family support services with the target population; (c) have one year demonstrated supervisory experience; and (d) have completed both basic and supervisory training regarding family support services. B. Identified population: (1) Members with parents, family members, legal guardians, and other primary caregivers who are living with or closely linked to the member and engaged in the plan of care for the member. (2) Members are young persons diagnosed with a severe emotional disturbance or adults diagnosed with serious mental illness as defined by the state of NM. C. Covered services: (1) Minimum required family support services activities: (a) review of the existing social history and other relevant information with the member and family; (b) review of the existing treatment plans; (c) identification of the member and family functional strengths and any barriers to recovery; (d) participation in treatment planning and delivery with the member and family; and (e) adherence to the applicable code of ethics. (2) The specific services provided are tailored to the individual needs of the member and family according to the individual’s treatment or treatment plan and include but are not limited to support needed to: (a) prevent members from being placed into more restrictive setting; or (b) quickly reintegrate the member to their home and local community; or (c) direct the member and family towards recovery, resiliency, restoration, enhancement, and maintenance of the member’s functioning; or (d) increase the family’s ability to effectively interact with the member de but are not limited to support needed to: (a) prevent members from being placed into more restrictive setting; or (b) quickly reintegrate the member to their home and local community; or (c) direct the member and family towards recovery, resiliency, restoration, enhancement, and maintenance of the member’s functioning; or (d) increase the family’s ability to effectively interact with the member. (3) Family support services focus on psychoeducation, problem solving, and skills building for the family to support the member and may involve support activities such as: (a) working with teams engaged with the member; (b) engaging in treatment planning and service delivery for the member; (c) identifying family strengths and resiliencies in order to effectively articulate those strengths and prioritize their needs; (d) navigating the community-based systems and services that impact the member’s life; (e) identifying natural and community supports; (f) assisting the member and family to understand, adjust to, and manage behavioral health crises and other challenges; (g) facilitating an understanding of the options for treatment of behavioral health issues; (h) facilitating an understanding of the principles and practices of recovery and resiliency; and (i) facilitating effective access and use of the behavioral health service system to achieve recovery and resiliency. (4) Documentation requirements: (a) notes related to all family support service interventions to include how and to what extent the activity promoted family support in relationship to the member’s recovery and resilience goals and outcomes; (b) any supporting collateral documentation. D acilitating effective access and use of the behavioral health service system to achieve recovery and resiliency. (4) Documentation requirements: (a) notes related to all family support service interventions to include how and to what extent the activity promoted family support in relationship to the member’s recovery and resilience goals and outcomes; (b) any supporting collateral documentation. D. Non-covered services: This service may be billed only during the transition phases from these services: (a) accredited residential treatment center (ARTC); (b) adult accredited residential treatment center (AARTC); (c) residential treatment center services; (d) group home services; (e) inpatient hospitalization; 8.321.2 NMAC 34 (f) partial hospitalization; (g) treatment foster care; or (h) crisis triage centers. [8.321.2.23 NMAC - Rp, 8.321.2.22 NMAC, 12/10/2024] 8.321.2.24 INPATIENT PSYCHIATRIC CARE IN FREESTANDING PSYCHIATRIC HOSPITALS AND PSYCHIATRIC UNITS OF ACUTE CARE HOSPITALS: To assist the eligible recipient in receiving necessary mental health services, MAD pays for inpatient psychiatric care furnished in freestanding psychiatric hospitals as part of the EPSDT program (42 CFR 441.57). A freestanding psychiatric hospital (an inpatient facility that is not a unit in a general acute care hospital), with more than 16 beds is an institution for mental disease (IMD) subject to the federal medicaid IMD exclusion that prohibits medicaid payment for inpatient stays for eligible recipients aged 22 through 64 years. Coverage of stays in a freestanding psychiatric hospital that is considered an IMD are covered only for eligible recipients up to age 21 and over age 64. A managed care organization making payment to an IMD as an in lieu of service may pay for stays that do not exceed 15 days. For stays in an IMD that include a SUD refer to 8.321.2.25 NMAC nt stays for eligible recipients aged 22 through 64 years. Coverage of stays in a freestanding psychiatric hospital that is considered an IMD are covered only for eligible recipients up to age 21 and over age 64. A managed care organization making payment to an IMD as an in lieu of service may pay for stays that do not exceed 15 days. For stays in an IMD that include a SUD refer to 8.321.2.25 NMAC. For freestanding psychiatric hospitals, if the eligible recipient who is receiving inpatient services reaches the age of 21 years, services may continue until one of the following conditions is reached: until the date the eligible recipient no longer requires the services, or until the date the eligible recipient reaches the age of 22 years, whichever occurs first. The need for inpatient psychiatric care in a freestanding psychiatric hospital must be identified in the eligible recipient’s tot to teen health check screen or another diagnostic evaluation furnished through a health check referral. Inpatient stays for eligible recipients in an inpatient psychiatric unit of a general acute care hospital are also covered. As these institutions are not considered to be IMDs, there are no age exclusions for their services. A. Eligible providers: A MAD eligible provider must be licensed and certified by the NM DOH (or the comparable agency if in another state), comply with 42 CFR 456.201 through 456.245; and be accredited by at least one of the following: (1) the joint commission (JC); (2) the council on accreditation of services for families and children (COA); (3) the commission on accreditation of rehabilitation facilities (CARF); or (4) another accrediting organization recognized by MAD as having comparable standards; and (5) be an enrolled MAD provider before it furnishes services, see 42 CFR sections 456.201 through 456.245. B the following: (1) the joint commission (JC); (2) the council on accreditation of services for families and children (COA); (3) the commission on accreditation of rehabilitation facilities (CARF); or (4) another accrediting organization recognized by MAD as having comparable standards; and (5) be an enrolled MAD provider before it furnishes services, see 42 CFR sections 456.201 through 456.245. B. Covered services: MAD covers inpatient psychiatric hospital services which are medically necessary for the diagnosis or treatment of mental illness as required by the condition of the eligible recipient. (1) These services must be furnished by eligible providers within the scope and practice of their profession (see 8.321.2.9 NMAC) and in accordance with federal regulations; see (42 CFR 441.156); (2) Services must be furnished under the direction of a physician; (3) In the case of an eligible recipient under 21 years of age these services: (a) must be furnished under the direction of a board prepared, board eligible, board- certified psychiatrist or a licensed psychologist working in collaboration with a similarly qualified psychiatrist; and (b) the psychiatrist must conduct an evaluation of the eligible recipient, in person within 24 hours of admission. (4) In the case of an eligible recipient under 12 years of age, the psychiatrist must be board prepared, board eligible, or board certified in child or adolescent psychiatry d psychiatrist or a licensed psychologist working in collaboration with a similarly qualified psychiatrist; and (b) the psychiatrist must conduct an evaluation of the eligible recipient, in person within 24 hours of admission. (4) In the case of an eligible recipient under 12 years of age, the psychiatrist must be board prepared, board eligible, or board certified in child or adolescent psychiatry. The requirement for the specified psychiatrist for an eligible recipient under age 12 and an eligible recipient under 21 years of age can be waived when all of the following conditions are met: (a) the need for admission is urgent or emergent and transfer or referral to another provider poses an unacceptable risk for adverse patient outcomes; (b) at the time of admission, a psychiatrist who is board prepared, board eligible, or board certified in child or adolescent psychiatry, is not accessible in the community in which the facility is located; (c) there is another facility which has a psychiatrist who is board prepared, board eligible, board certified in child or adolescent psychiatry, but the facility, is not available or is inaccessible to the community in which the facility is located; and (d) the admission is for stabilization only and a transfer arrangement to the care of a psychiatrist who is board prepared, board eligible, board certified in child or adolescent psychiatry, is made as soon 8.321.2 NMAC 35 as possible with the understanding that if the eligible recipient needs transfer to another facility, the actual transfer will occur as soon as the eligible recipient is stable for transfer in accordance with professional standards sfer arrangement to the care of a psychiatrist who is board prepared, board eligible, board certified in child or adolescent psychiatry, is made as soon 8.321.2 NMAC 35 as possible with the understanding that if the eligible recipient needs transfer to another facility, the actual transfer will occur as soon as the eligible recipient is stable for transfer in accordance with professional standards. (5) A freestanding hospital must provide the following components to an eligible recipient to receive reimbursement: (a) performance of necessary evaluations and psychological testing for the development of the treatment plan, while ensuring that evaluations already performed are not repeated; (b) a treatment plan and all supporting documentation must be available for review in the eligible recipient’s file; (c) regularly scheduled structured behavioral health therapy sessions for the eligible recipient, group, family, or a multifamily group based on individualized needs, as specified in the eligible recipient’s treatment plan; (d) 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; (e) assistance to an eligible recipient in their self administration of medication in compliance with state regulations, policies and procedures; (f) appropriate staff available on a 24-hour basis to respond to crisis situations; determine the severity of the situation; stabilize the eligible recipient by providing support; make referrals, as necessary; and provide follow-up; (g) a consultation with other professionals or allied caregivers regarding a specific eligible recipient; (h) non-medical transportation services needed to accomplish treatment objectives; (i) therapeutic services to meet the physical, social, cultural, recreational, health maintenance, and rehabilitation needs of the eligible recipient; and (j) plans for discharge must begin upon admittance to the fa a consultation with other professionals or allied caregivers regarding a specific eligible recipient; (h) non-medical transportation services needed to accomplish treatment objectives; (i) therapeutic services to meet the physical, social, cultural, recreational, health maintenance, and rehabilitation needs of the eligible recipient; and (j) plans for discharge must begin upon admittance to the facility and be included in the eligible recipient’s treatment plan. If the eligible recipient will receive services in the community or in the custody of CYFD, the discharge must be coordinated with those individuals or agencies responsible for post-hospital placement and services. The discharge plan must consider related community services to ensure continuity of care with the eligible recipient, their family, and school and community. (6) MAD covers “awaiting placement days” when the MAD UR contractor determines that an eligible recipient under 21 years of age no longer meets this acute care criteria and determines that the eligible recipient requires a residential placement which cannot be immediately located. Those days during which the eligible recipient is awaiting placement to the step-down placement are termed awaiting placement days. Payment to the hospital for awaiting placement days is made at the average payment for accredited residential treatment centers plus five percent. A separate claim form must be submitted for awaiting placement days. (7) A treatment plan must be developed by a team of professionals in consultation with an eligible recipient, their parent, legal guardian, or others in whose care the eligible recipient will be released after discharge. The plan must be developed within 72 hours of admission of the eligible recipient’s admission to freestanding psychiatric hospitals. The interdisciplinary team must review the treatment plan at least every five calendar days. See the BH policy and billing manual for a description of the treatment team and plan. C ian, or others in whose care the eligible recipient will be released after discharge. The plan must be developed within 72 hours of admission of the eligible recipient’s admission to freestanding psychiatric hospitals. The interdisciplinary team must review the treatment plan at least every five calendar days. See the BH policy and billing manual for a description of the treatment team and plan. C. Non-covered services: Services furnished in a freestanding psychiatric hospital 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 MAD general non-covered services. MAD does not cover the following specific services for an eligible recipient in a freestanding psychiatric hospital in the following situations: (1) conditions defined only by Z codes in the current version of the international classification of diseases (ICD) or the current version of DSM; (2) services in freestanding psychiatric hospital for an eligible recipient 22 years of age through 64, except as allowed in 8.321.2 NMAC; (3) services furnished after the determination by MAD or its designee has been made that the eligible recipient no longer needs hospital care; (4) formal educational or vocational services, other than those covered in Subsection B of 8.321.2.9 NMAC, related to traditional academic subjects or vocational training; MAD only covers non-formal education services if they are part of an active treatment plan for an eligible recipient under the age of 21 receiving inpatient psychiatric services; see 42 CFR Section 441.13(b); or (5) drugs classified as "ineffective" by the food and drug administration (FDA) drug evaluation. 8.321.2 NMAC 36 D. Prior authorization and utilization review: All MAD services are subject to utilization review for medical necessity, inspection of care, and program compliance an for an eligible recipient under the age of 21 receiving inpatient psychiatric services; see 42 CFR Section 441.13(b); or (5) drugs classified as "ineffective" by the food and drug administration (FDA) drug evaluation. 8.321.2 NMAC 36 D. Prior authorization and utilization review: All MAD services are subject to utilization review for medical necessity, inspection of care, and program compliance. Reviews can be performed before services are furnished, after services are furnished and before payment is made, or after payment is made; see 8.310.2 and 8.310.3 NMAC. (1) All inpatient services for an eligible recipient under 21 years of age in a freestanding psychiatric hospital require prior authorization from MAD or its designee. Services for which prior authorization was obtained remain subject to utilization review at any point in the payment process. (2) Prior authorization of services does not guarantee that individuals are eligible for MAD services. Providers must verify that an individual is eligible for MAD services at the time services are furnished and through their inpatient stay and determine if the eligible recipient has other health insurance. (3) A provider who disagrees with prior authorization request denials or other review decisions can request a re-review and a reconsideration; see 8.350.2 NMAC. E. Reimbursement: A freestanding psychiatric hospital service provider must submit claims for reimbursement on the UB-04 claim form or its successor; see 8.302.2 NMAC. Once enrolled, providers receive instructions on how to access documentation, billing, and claims processing information. (1) Reimbursement rates for NM freestanding psychiatric hospital are based on the tax equity and fiscal responsibility act (TEFRA) provisions and principles of reimbursement; see 8.311.3 NMAC t claims for reimbursement on the UB-04 claim form or its successor; see 8.302.2 NMAC. Once enrolled, providers receive instructions on how to access documentation, billing, and claims processing information. (1) Reimbursement rates for NM freestanding psychiatric hospital are based on the tax equity and fiscal responsibility act (TEFRA) provisions and principles of reimbursement; see 8.311.3 NMAC. Covered inpatient services provided in a freestanding psychiatric hospital will be reimbursed at an interim rate established by HCA to equal or closely approximate the final payment rates that apply under the cost settlement TEFRA principles. (2) If a provider is not cost settled, the reimbursement rate will be at the provider’s cost-to- charge ratio reported in the provider’s most recently filed cost report prior to February 1, 2012. Otherwise, rates are established after considering available cost-to-charge ratios, payment levels made by other payers, and MAD payment levels for services of similar cost, complexity, and duration. (3) Reimbursement rates for services furnished by a psychiatrist and licensed Ph.D. psychologist in a freestanding psychiatric hospital are contained in 8.311.3 NMAC. Services furnished by a psychiatrist and psychologist in a freestanding psychiatric hospital cannot be included as inpatient psychiatric hospital charges. (4) When services are billed to and paid by a MAD coordinated services contractor, the provider must also enroll as a provider with the MAD coordinated services contractor and follow that contractor’s instructions for billing and for authorization of services. (5) The provider agrees to be paid by a MCO at any amount mutually-agreed upon between the provider and MCO when the provider enters into contracts with MCO contracting with HCA for the provision of managed care services to an eligible recipient enroll as a provider with the MAD coordinated services contractor and follow that contractor’s instructions for billing and for authorization of services. (5) The provider agrees to be paid by a MCO at any amount mutually-agreed upon between the provider and MCO when the provider enters into contracts with MCO contracting with HCA for the provision of managed care services to an eligible recipient. (a) if the provider and the HCA contracted MCO are unable to agree to terms or fail to execute an agreement for any reason, the MCO shall be obligated to pay, and the provider shall accept, one hundred percent of the “applicable reimbursement rate” based on the provider type for services rendered under both emergency and non-emergency situations. (b) the “applicable reimbursement rate” is defined as the rate paid by HCA to the provider participating in the medical assistance programs administered by MAD and excludes disproportionate share hospital and medical education payments. [8.321.2.24 NMAC - Rp, 8.321.2.23 NMAC, 12/10/2024] 8.321.2.25 INSTITUTION FOR MENTAL DISEASES (IMD) FOR SUBSTANCE USE DISORDER (SUD): IMD is defined as any facility with more than 16 beds that is primarily engaged in the delivery of psychiatric care or treating substance use disorders (SUD) that is not part of a certified general acute care hospital. The federal medicaid IMD exclusion generally prohibits payment to these providers for recipients aged 22 through 64. MAD covers inpatient hospitalization in an IMD for SUD diagnoses only with criteria for medical necessity and based on ASAM admission criteria. The coverage may also include co-occurring behavioral health disorders with the primary SUD. For other approved IMD stays for eligible recipients under age 21 or over age 64, the number of days is determined by medical necessity as the age restriction for IMDs does not apply to ages under 21 or over 65. Also refer to 8.321.2.24 NMAC. A ia for medical necessity and based on ASAM admission criteria. The coverage may also include co-occurring behavioral health disorders with the primary SUD. For other approved IMD stays for eligible recipients under age 21 or over age 64, the number of days is determined by medical necessity as the age restriction for IMDs does not apply to ages under 21 or over 65. Also refer to 8.321.2.24 NMAC. A. Eligible recipients: Adolescents and adults with a mental health or SUD or co-occurring mental health and SUD. B. Covered services: Withdrawal management (detoxification) and rehabilitation. C. Prior authorization is required. Utilize the substance abuse and mental health services administration (SAMHSA) admission criteria for medical necessity. 8.321.2 NMAC 37 D. Reimbursement: An IMD is reimbursed according to the provisions in Subsection E of 8.321.2.23 NMAC. [8.321.2.25 NMAC - Rp, 8.321.2.24 NMAC, 12/10/2024] 8.321.2.26 INTENSIVE OUTPATIENT PROGRAM (IOP) FOR SUBSTANCE USE DISORDERS (SUD): MAD pays for time limited IOP services utilizing a multi-faceted approach to treatment for an eligible recipient who requires structure and support to achieve and sustain recovery. IOP must utilize a research and evidence-based model approved through the process described in the BH policy and billing manual and target specific behaviors with individualized behavioral interventions. A. Eligible providers: Services must be delivered through an agency approved through the application process described in the BH policy and billing manual. Prior to medicaid enrollment the agency must demonstrate that the agency meets all the requirements of IOP program services and supervision. See Subsection A and B of 8.321.2.9 NMAC for MAD general provider requirements. (1) IOP services are provided through an integrated interdisciplinary approach including staff expertise in both SUD and mental health treatment the BH policy and billing manual. Prior to medicaid enrollment the agency must demonstrate that the agency meets all the requirements of IOP program services and supervision. See Subsection A and B of 8.321.2.9 NMAC for MAD general provider requirements. (1) IOP services are provided through an integrated interdisciplinary approach including staff expertise in both SUD and mental health treatment. This team may have services rendered by non-independently licensed and non-licensed practitioners within their scope of practice and under the direction of the IOP RLD board approved clinical supervisor. See Subsection E of 8.321.2.9 NMAC for non-independent and non-licensed practitioners and Subsection C of 8.321.2.9 NMAC for independently licensed professionals eligible to conduct IOP clinical supervision. (2) Each IOP program must have an independently licensed RLD board approved clinical supervisor. Both clinical services and supervision by independently licensed practitioners must be conducted in accordance with respective licensing board regulations. An IOP clinical supervisor must meet all the following requirements: (a) have two or more years of relevant experience with an IOP program or approved exception by submitting a request through the process described in the BH policy and billing manual; and (b) have expertise in both mental health and substance use disorder treatment. (3) The IOP agency is required to develop and implement a program outcome evaluation system which may include consumer satisfaction surveys, retention into service rates, drop-out rates, re-admittance or relapse and lapse rates, incarceration or hospitalization data, or readily identifiable information and data specific to the IOP. (4) The agency must maintain the appropriate state facility licensure and abide by all applicable state and federal regulations if offering medication for opioid use disorder e consumer satisfaction surveys, retention into service rates, drop-out rates, re-admittance or relapse and lapse rates, incarceration or hospitalization data, or readily identifiable information and data specific to the IOP. (4) The agency must maintain the appropriate state facility licensure and abide by all applicable state and federal regulations if offering medication for opioid use disorder. (5) The agency must hold an IOP approval letter as described in the BH policy and billing manual and be enrolled by MAD to render IOP services to an eligible recipient. In the application process each IOP must identify if it is a youth program, an adult program, a transitional age program, or multiple programs. Transitional age programs must specify the age range of the target population. As described in the BH policy and billing manual an IOP will receive provisional approval to begin rendering IOP services prior to receiving full approval. B. Coverage criteria: (1) An IOP is based on research and evidence-based practice (EBP) models that target specific behaviors with individualized behavioral interventions. All EBP services must be culturally sensitive and incorporate recovery and resiliency values into all service interventions. EBPs must be approved through the process described in the BH policy and billing manual. A list of pre-approved EBPs is available through the council, as are the criteria for having another model approved. (2) Treatment services must address co-occurring substance used and mental health disorders. Care coordination should be available to ensure integrated care for medical conditions either by referral or internally. C. Covered services: (1) IOP core services must include: (a) individual SUD related therapy; (b) group therapy (group membership may not exceed 15 in number); and (c) psychoeducation for the eligible recipient and their family or significant other ed and mental health disorders. Care coordination should be available to ensure integrated care for medical conditions either by referral or internally. C. Covered services: (1) IOP core services must include: (a) individual SUD related therapy; (b) group therapy (group membership may not exceed 15 in number); and (c) psychoeducation for the eligible recipient and their family or significant other. (2) Co-occurring mental health and SUD: The IOP agency must accommodate the needs of an eligible recipient with co-occurring substance use and mental health disorders. Treatment services are provided through an integrated interdisciplinary team and through coordinated, concurrent services with behavioral health providers. 8.321.2 NMAC 38 (3) Medication management services must accessible either in the IOP agency or by referral to oversee the use of psychotropic medications and medication assisted treatment of SUD. (4) The amount and intensity of an eligible recipient’s IOP intervention is typically three to six months and between 9-19 hours for adults or 6-19 hours for adolescents per week. The amount of weekly services per eligible recipient is directly related to the goals specified in their IOP treatment plan and the IOP EBP in use. Recipients must meet ASAM 2.1 level of care placement criteria and have been diagnosed with a moderate or severe SUD to be eligible to receive SUD IOP services. (5) Other mental health therapies: Outpatient therapies may be rendered in addition to the IOP therapies of individual and group when the eligible recipient’s co-occurring disorder requires treatment services which are outside the scope of the IOP therapeutic services. The eligible recipient’s file must document the medical necessity of receiving outpatient therapy services in addition to IOP therapies. Such documentation includes, but is not limited to current assessment, a co-occurring diagnosis, and inclusion in the treatment plan for outpatient therapy services disorder requires treatment services which are outside the scope of the IOP therapeutic services. The eligible recipient’s file must document the medical necessity of receiving outpatient therapy services in addition to IOP therapies. Such documentation includes, but is not limited to current assessment, a co-occurring diagnosis, and inclusion in the treatment plan for outpatient therapy services. An IOP agency may: (a) render these services when it is enrolled as a provider covered under Subsection D of 8.321.2.9 NMAC with practitioners listed in Subsections C and E of 8.321.2.9 NMAC whose scope of practice specifically allows for mental health therapy services; or (b) refer the eligible recipient to another provider if the IOP agency does not have such practitioners available; the IOP agency may continue the eligible recipient’s IOP services coordinating with the new provider. D. Identified population: (1) IOP services are provided to an eligible recipient 11 through 17 years of age diagnosed with a substance use disorder or with co-occurring disorders (mental illness and SUD) and that meet the American society of addiction medicine (ASAM) patient placement criteria for level 2.1 - intensive outpatient treatment; or have been mandated by the local judicial system as an option of least restrictive level of care. Adolescents who turn 18 years old while in an IOP program may remain until appropriate discharge. Services are not covered if the recipient is in detention or incarceration. See eligibility rules 8.200.410.17 NMAC cine (ASAM) patient placement criteria for level 2.1 - intensive outpatient treatment; or have been mandated by the local judicial system as an option of least restrictive level of care. Adolescents who turn 18 years old while in an IOP program may remain until appropriate discharge. Services are not covered if the recipient is in detention or incarceration. See eligibility rules 8.200.410.17 NMAC. (2) IOP services are provided to an eligible recipient of a transitional age program of which the age range has been determined by the agency, and that have been diagnosed with substance use disorder or with co-occurring disorders (mental illness and substance use) or that meet the American society of addiction medicine’s (ASAM) patient placement criteria for level 2.1 - intensive outpatient treatment, or have been mandated by the local judicial system as an option of least restrictive level of care. (3) IOP services are provided to an eligible adult recipient 18 years of age and older diagnosed with substance use disorders or co-occurring disorders (mental illness and substance use) that meet the American society of addiction medicine’s (ASAM) patient placement criteria for level 2.1 - intensive outpatient treatment of have been mandated by the local judicial system as an option of least restrictive level of care. (4) Prior to engaging in an IOP program, the eligible recipient must have a treatment file containing: (a) a diagnostic evaluation with a diagnosis of a moderate or severe SUD; (b) an individualized IOP treatment plan that includes IOP and the EBP as the intervention; and (c) both a crisis and safety plan developed with the recipient. The treatment, crisis, and safety plans must be regularly updated in collaboration with the recipient. E the eligible recipient must have a treatment file containing: (a) a diagnostic evaluation with a diagnosis of a moderate or severe SUD; (b) an individualized IOP treatment plan that includes IOP and the EBP as the intervention; and (c) both a crisis and safety plan developed with the recipient. The treatment, crisis, and safety plans must be regularly updated in collaboration with the recipient. E. Non-covered services: IOP 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 and 8.310.2 NMAC for MAD general non-covered services. MAD does not cover the following specific services billed in conjunction with IOP services. (1) acute inpatient; (2) residential treatment services (i.e., ARTC, RTC, group home, and transitional living services); (3) partial hospitalization; (4) outpatient therapies which do not meet Subsection C of 8.321.2.9 NMAC; or (5) activity therapy. F. Reimbursement: See Subsection H of 8.321.2.9 NMAC for MAD behavioral health general reimbursement requirements. (1) For IOP services, the agency must submit claims for reimbursement on the CMS-1500 claim form or its successor. 8.321.2 NMAC 39 (2) Core IOP services are reimbursed through a daily rate. Medication assisted treatment and other mental health therapies are billed and reimbursed separately from the daily rate. (3) IOP services furnished by an IOP team member are billed by and reimbursed to a MAD IOP agency whether the team member is under contract with or employed by the IOP agency. (4) IOP services not provided in accordance with the conditions for coverage as specified in 8.321.2 NMAC are not MAD covered services and are subject to recoupment.