N.M. Admin. Code § 8.320.2.20

Current through Register Vol. 35, No. 20, October 22, 2024

Section 8.320.2.20 - EPSDT REHABILITATION SERVICES

MAD pays for medically necessary services, including outpatient services furnished to a MAP eligible recipient under 21 years of age by or under the supervision of licensed PT; OT; and master's level SLP. A MAP eligible recipient under 21 years of age who is eligible for a home and community based waiver program receives medically necessary rehabilitation services through the EPSDT rehabilitation services, the home and community based waiver program provides rehabilitation services only for the purpose of community integration.

A. EPSDT rehabilitation eligible providers: A PT, OT and master's level SLP is eligible to be reimbursed for furnishing services to a MAP eligible recipient under 21 years of age in need of EPSDT rehabilitation services. The following providers are eligible to be reimbursed for furnishing outpatient rehabilitation services to a MAP eligible recipient:

(1) a master's level SLP licensed by the regulation and licensing department (RLD) board of speech-language pathology and audiology;

(2) a PT licensed as physical therapists by the RLD physical therapy board;

(3) an OT licensed as occupational therapists by the RLD board of examiners for occupational therapy;

(4) certified outpatient rehabilitation centers with a primary emphasis on physical therapy, occupational therapy or speech therapy, licensed by DOH;

(5) home health agencies licensed and certified by DOH; and

(6) general hospitals eligible to provide outpatient rehabilitation services licensed and certified by the DOH;

(7) a PT assistant licensed by the RLD physical therapy board and working under the supervision of a licensed PT;

(8) an OT assistant licensed by the RLD occupational therapy board and working under the supervision of a licensed OT;

(9) a SLP licensed by the RLD board of speech-language pathology and audiology; and

(10) SLP apprentices and clinical fellows licensed by the RLD board of speech-language pathology and working under the supervision of a licensed SLP.

B. EPSDT rehabilitation covered services: MAD covers speech therapy, physical therapy and occupational therapy services provided to a MAP eligible recipient under 21 years of age. MAD covers evaluations, individual therapy and group therapy in an outpatient setting. Services must be medically necessary and provided for the purpose of diagnostic study or treatment. Even though a MAP eligible recipient is receiving therapy services or can access therapy services at his or her school, he or she may require additional medically necessary services in addition to those provided at a school. Services must be designed to improve, restore or maintain the MAP eligible recipient's condition including controlling symptoms and maintaining the functional level to avoid further deterioration as indicated his or her ITP. The provider, following the MAP eligible recipient's PCP orders, will develop the treatment plan.

(1) Physical, occupational, and speech therapy services must be specifically related to the active written treatment plan developed by qualified a PT, OT, SLP therapist with authorization from the MAP eligible recipient's PCP.

(2) Services must be performed within the scope and practice of the RLD practice board and as defined by state statute and rule.

(3) All services provided by or under the supervision of a SLP, OT, PT must be prescribed or ordered by the MAP eligible recipient's PCP. The PCP must be a physician or doctor of osteopathy, certified nurse practitioner, or physician assistant licensed to practice in New Mexico.

C. EPSDT rehabilitation noncovered services:

(1) Services furnished by or under the supervision of a SLP, OT, PT are subject to the limitations and coverage restrictions that exist for other MAD services.

(2) MAD does not cover these specific services related to activities for the general good and welfare of a MAP eligible recipient, such as general exercises to promote overall fitness and flexibility and activities to provide general motivation, are not considered physical or occupational therapy for MAD reimbursement purposes.

D. Prior Authorization: All therapy services with the exception of the initial evaluation require prior authorization from MAD or its designee.

N.M. Admin. Code § 8.320.2.20

8.320.2.20 NMAC - Rp, 8.323.5 NMAC, 1-1-14