N.M. Admin. Code § 8.321.2.26
Current through Register Vol. 35, No. 17, September 10, 2024
Section 8.321.2.26 - INTENSIVE OUTPATIENT PROGRAM FOR MENTAL HEALTH CONDITIONS (IOP)MAD pays for IOP services which provide a time-limited, multi-faceted approach to treatment for an eligible recipient with a SMI or SED including an eating disorder or borderline personality disorder who requires structure and support to achieve and sustain recovery. IOP must utilize a research and evidence-based model approved by the IOP interdepartmental council, and target specific behaviors with individualized behavioral interventions. The effective date will be January 1, 2019, or as otherwise approved by the centers for medicare and medicaid services (CMS).
A. Eligible providers: Services may only be delivered through an agency approved by HSD and CYFD after demonstrating that the agency meets all the requirements of IOP program services and supervision. See Subsections A and B of 8.321.2.9 NMAC for MAD general provider requirements. (1) IOP services are provided through an integrated interdisciplinary approach by staff with expertise in the mental health condition being addressed. This team may have services rendered by non-independent practitioners under the direction of the IOP supervisor including LMSW, LMHC, a master's level psych associates, RNs or registered dieticians.(2) Each IOP program must have a clinical supervisor. Both clinical services and supervision by licensed practitioners must be conducted in accordance with respective licensing board regulations. An IOP clinical supervisor must meet all of the following requirements:(a) be licensed as a MAD approved independent practitioner; see Subsection C of 8.321.2.9 NMAC;(b) have two years relevant experience in providing the evidence-based model to be delivered; and(c) have one year demonstrated supervisory experience.(3) The IOP agency is required to develop and implement a program outcome evaluation system.(4) The agency must maintain the appropriate state facility licensure if offering medication treatment.(5) The agency must hold an IOP approval letter 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. A MAD IOP agency will be provisionally approved for a specified timeframe to render IOP services to an eligible recipient. During this provisionally approved time, MAD or its designee will determine if the IOP meets MAD IOP requirements and if so, the agency will receive an approval letter for IOP full enrollment.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 by the IOP interdepartmental council. A list of pre-approved EBPs is available through the council, as are the criteria for having another model approved. They are also listed in the BH policy and billing manual.(2) Treatment services must address co-occurring disorders when indicated.C. Covered services: (1) IOP core services include: (b) group therapy (group membership may not exceed 15 in number); and(c) psycho-education for the eligible recipient and his or her family.(2) Medication management services are available either in the IOP agency or by referral to oversee the use of psychotropic medications and medication assisted treatment of substance use disorders.(3) The amount of weekly services per eligible recipient is directly related to the goals specified in his or her IOP treatment plan and the IOP EBP in use.(4) Treatment services must address co-occurring disorders when indicated.D.Identified population:(1) IOP services are provided to an eligible recipient, 11 through 17 years of age diagnosed with a SED.(2) IOP services are provided to an eligible adult recipient 18 years of age and older diagnosed with a SMI.(3) Prior to engaging in a MAD IOP program, the eligible recipient must have a treatment file containing: (a) one diagnostic evaluation with a diagnosis of serious mental illness or severe emotional disturbance; or diagnosis for which the IOP is approved; and(b) one individualized service plan that includes IOP as an intervention.E. Non-covered services: IOP services are subject to the limitations and coverage restrictions which exist for other MAD 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: (2) residential treatment services (i.e., ARTC, RTC, group home, and transitional living services);(4) partial hospitalization;(5) outpatient therapies which do not meet Subsection C of 8.321.2.9 NMAC;(6) multi-systemic therapy (MST);(8) psychosocial rehabilitation (PSR) group services.F. Reimbursement: See Subsection H of 8.321.2.9 NMAC for MAD behavioral health general reimbursement. (1) For IOP services, the agency must submit claims for reimbursement on the CMS-1500 claim form or its successor.(2) Core IOP services are reimbursed through a bundled rate. Medications and other mental health therapies are billed and reimbursed separately from the bundled 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 the rule are not a MAD covered service and are subject to recoupment.N.M. Admin. Code § 8.321.2.26
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