Section 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 8.321.2 NMAC 17 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 herapy; 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 h hiatrist; 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 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; 8.321.2 NMAC 18 (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 r 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. [8.321.2.14 NMAC - Rp, 8.321.2.13 NMAC, 12/10/2024] 8.321.2.15 BEHAVIORAL HEALTH PROFESSIONAL SERVICES FOR SCREENINGS, EVALUATIONS, ASSESSMENTS AND THERAPY: MAD covers validated screenings for high-risk conditions in order to provide prevention or early intervention. Brief interventions or the use of the treat first clinical model may be billed with a provisional diagnosis for up to four encounters 8.321.2.14 NMAC - Rp, 8.321.2.13 NMAC, 12/10/2024] 8.321.2.15 BEHAVIORAL HEALTH PROFESSIONAL SERVICES FOR SCREENINGS, EVALUATIONS, ASSESSMENTS AND THERAPY: MAD covers validated screenings for high-risk conditions in order to provide prevention or early intervention. Brief interventions or the use of the treat first clinical model may be billed with a provisional diagnosis for up to four encounters. After four encounters, if continuing treatment is required, a diagnostic evaluation must be performed, and subsequent reimbursement is based on the diagnosis and resulting treatment plan. See the BH policy and billing manual for a description of the treat first clinical model. A. Psychological, counseling, and social work: These services are diagnostic or active treatments with the intent to reasonably improve an eligible recipient’s physical, social, emotional, and behavioral health, or substance use condition. Services are provided to an eligible recipient whose condition or functioning can be expected to improve with these interventions. Psychological, counseling, and social work services are performed by licensed psychological, counseling, and social work practitioners acting within their scope of practice and licensure (see Subsections B through E of 8.321.2.9 NMAC). These services include, but are not limited to assessments that appraise cognitive, emotional, and social functioning and self-concept. Therapy includes planning, managing, and providing a program of psychological services to the eligible recipient meeting a current DSM, ICD, or DC:0-5 behavioral health diagnosis and may include therapy with their family, parent or caretaker, and consultation with their family and other professional staff. B. An assessment as described in the BH policy and billing manual, must be signed by the practitioner operating within their scope of licensure (see Subsection B of 8.321.2.9 NMAC) o the eligible recipient meeting a current DSM, ICD, or DC:0-5 behavioral health diagnosis and may include therapy with their family, parent or caretaker, and consultation with their family and other professional staff. B. An assessment as described in the BH policy and billing manual, must be signed by the practitioner operating within their scope of licensure (see Subsection B of 8.321.2.9 NMAC). A non-independently licensed behavioral health practitioner must have an independently licensed RLD board approved supervisor review and sign the assessment with a diagnosis. Based on the eligible recipient’s current assessment, their treatment file must document the extent to which their treatment goals are being met and whether changes in direction or emphasis of the treatment are needed. See Subsection K of 8.321.2.9 NMAC for detailed description of the required eligible recipient file documentation. C. Outpatient therapy services (individual, family, and group) includes planning, managing, and providing a program of psychological services to the eligible recipient with a diagnosed behavioral health disorder, 8.321.2 NMAC 19 and may include consultation with their family and other professional staff with or without the eligible recipient present when the service is on behalf of the recipient. See the BH policy and billing manual for detailed requirements of treatment plans. [8.321.2.15 NMAC - Rp, 8.321.2.14 NMAC, 12/10/2024] 8.321.2.16 BEHAVIORAL HEALTH RESPITE CARE (Managed Care Organization (MCO)): As part of the managed care comprehensive service system, behavioral health respite service is for short-term direct care and supervision of the eligible recipient in order to afford the parent(s) or caregiver a respite for their care of the recipient and takes place in the recipient’s home or another setting. See Subsections A and B of 8.321.2.9 NMAC for MAD general provider requirements. A CO)): As part of the managed care comprehensive service system, behavioral health respite service is for short-term direct care and supervision of the eligible recipient in order to afford the parent(s) or caregiver a respite for their care of the recipient and takes place in the recipient’s home or another setting. See Subsections A and B of 8.321.2.9 NMAC for MAD general provider requirements. A. Eligible practitioners: (1) Supervisor: (a) bachelor’s degree and three years’ experience working with the target population; (b) supervision activities include a minimum of two hours per month individual supervision covering administrative and case specific issues, and two additional hours per month of continuing education in behavioral health respite care issues, or annualized respite provider training; (c) access to on call crisis support available 24-hours a day; and (d) supervision by RLD board approved clinical supervisors must be in accordance with their respective licensing board regulations. (2) Respite care staff: (a) minimum three years’ experience working with the target population; (b) pass all criminal records and background checks for all persons residing in the home over 18; (c) possess a valid driver’s license, vehicle registration and insurance, if transporting member; (d) CPR and first aid; and (e) documentation of behavioral health orientation, training and supervision as defined in the BH policy and billing manual. B. Coverage criteria: The provider agency will assess the situation and, with the caregiver, recommend the appropriate setting for respite. BH respite services may include a range of activities to meet the social, emotional and physical needs identified through the treatment plan and documented in the treatment record. These services may be provided for a few hours during the day or for longer periods of time involving overnight stays. BH respite, while usually planned, can also be provided in an emergency or unplanned basis. C spite. BH respite services may include a range of activities to meet the social, emotional and physical needs identified through the treatment plan and documented in the treatment record. These services may be provided for a few hours during the day or for longer periods of time involving overnight stays. BH respite, while usually planned, can also be provided in an emergency or unplanned basis. C. Identified population: (1) Members up to 21 years of age diagnosed with a severe emotional disturbance (SED), as defined by the state of NM who reside with the same primary caregivers on a daily basis; or (2) Youth in protective services custody whose placement may be at risk whether or not they are diagnosed with SED. D. Non-covered services: (1) 30 days or 720 hours per year at which time prior authorization must be acquired for additional respite care; (2) May not be billed in conjunction with the following medicaid services: (a) treatment foster care; (b) group home; (c) residential services; (d) inpatient treatment. (3) Non-enrolled siblings of a child receiving BH respite services are not eligible for BH respite benefits; and (4) Cost of room and board are not included as part of respite care.