TITLE 7 HEALTH
CHAPTER 21 BEHAVIORAL
HEALTH
PART 1 GENERAL
PROVISIONS
7.21.1.1 ISSUING
AGENCY: Human Services Department
[7.21.1.1 NMAC - N, 9-1-11]
7.21.1.2 SCOPE: This rule applies to the general public.
[7.21.1.2 NMAC - N, 9-1-11]
7.21.1.3 STATUTORY
AUTHORITY: Subsection F of Section
9-7-6.4 NMSA 1978 requires the interagency behavioral
health purchasing collaborative (the collaborative) to adopt rules through the
human services department. The
collaborative is created by statute and comprised of the secretaries of aging
and long-term services; Indian affairs; human services; health; corrections;
children, youth and families; finance and administration; workforce solutions;
public education; and transportation; the directors of the administrative
office of the courts; the New Mexico mortgage finance authority; the governor’s
commission on disability; the developmental disabilities planning council; the
vocational rehabilitation division of the public education department; the New
Mexico health policy commission; and the governor’s health policy coordinator,
or their designees.
[7.21.1.3 NMAC - N, 9-1-11]
7.21.1.4 DURATION: Permanent
[7.21.1.4 NMAC - N, 9-1-11]
7.21.1.5 EFFECTIVE
DATE: September 1, 2011, unless a
later date is cited at the end of a section.
[7.21.1.5 NMAC - N, 9-1-11]
7.21.1.6 OBJECTIVE: The objective of this rule is to provide
policies for the standard of delivery for behavioral health services through
contracted behavioral health entities and for approval of contracts by the
collaborative.
[7.21.1.6 NMAC - N, 9-1-11]
7.21.1.7 DEFINITIONS: This section contains the glossary for the
New Mexico behavioral health system. The
following definitions apply to terms used in this chapter and shall guide any
rules promulgated by collaborative members regarding behavioral health.
A. Definitions
beginning with letter “A”:
(1) Abuse, individual: Any intentional, knowing or reckless act or
failure to act that produces or is likely to produce physical or great mental
or emotional harm, unreasonable confinement, sexual abuse or sexual assault
consistent with 30- 47-1 NMSA 1978.
(2) Abuse, provider: Provider
practices that are inconsistent with sound fiscal, business, medical or service
related practices and result in an unnecessary cost to the program, or in
reimbursement for services that are not medically, clinically, or
psychosocially necessary or in services that fail to meet professionally
recognized standards for behavioral health care.
(3) Adult behavioral health
procedures manual: The procedures manual that includes the
psychiatric rehabilitation program requirements and comprehensive community
support services requirements.
(4) Advance directive: Written instructions such
as a mental healthcare advance directive, psychiatric advance directive, living
will, durable health care power of attorney, durable mental health care power
of attorney, or advance health directive, relating to the provision of health
care when an adult is incapacitated.
(See generally, 27-7A-1 - 27-7A-18 NMSA, 1978,
and 24-7B-1 – 24-7B-16 NMSA 1978.)
(5) Adverse determination:
A determination by the BHE that the behavioral
health services furnished, or proposed to be furnished to a consumer, are not
medically, clinically or psychosocially necessary or not appropriate.
(6) American society of
addiction medicine (ASAM): An organization of
professionals in addiction services that developed, in the early 1990s or a set
of criteria and tools to identify the level of care best suited to an
individual in need of addiction services.
B. Definitions
beginning with letter “B”:
(1) Behavioral health (BH): The
umbrella term for mental health and substance abuse. It includes both mental health (MH) ,
including psychiatric illnesses and emotional disorders, and substance abuse
(SA), including addictive and chemical dependency disorders, and includes co-occurring MH and SA disorders and
the prevention of those disorders.
(2) Behavioral health entity (BHE): One or
more managed care organizations selected by HSD and the collaborative to
provide all defined behavioral health service responsibilities, including medicaid behavioral health.
(3) Behavioral health planning council (BHPC):
The body created to meet federal and state advisory council requirements
and to provide consistent, coordinated input to the behavioral health service
delivery system in New Mexico, and with which the BHE
will be expected to interact with as an advisory council. (See 24-1-28 NMSA, 1978)
C. Definitions beginning with letter
“C”:
(1) Chair or co-chairs: The secretary of human services shall serve as
the chair of the collaborative. The secretary of health and the secretary of
children youth and families shall alternate each state fiscal year as the
co-chair of the collaborative.
(2) Clinical necessity: The determination made by a
behavioral health professional exercising prudent clinical judgment as to
whether a behavioral health service would promote growth and development,
prevent, diagnose, detect, treat, ameliorate, or palliate the effects of a
behavioral health condition, injury, or disability for the consumer.
(3)
Collaborative: The
interagency behavioral health purchasing collaborative, responsible for
planning, designing and directing a statewide behavioral health system. The collaborative, established under Section
9-7-6.4 NMSA 1978, by its statutory member agencies
collectively, operates under by-laws adopted by the collaborative.
(4)
Collaborative members or member agencies:
The statutory and ex officio agency representatives who sit on
the collaborative or their agency designees.
(5) Comprehensive
community support services (CCSS): CCSS is a recovery
and resiliency oriented service which is provided in the community, primarily
face-to-face, using natural supports to the maximum extent possible to build on
client and family strengths.
These services are goal-directed mental health rehabilitation services
and supports for children, adolescents, and adults necessary to assist
individuals in achieving recovery and resiliency goals. These services assist in the development and
coordination of a consumer or member’s service plan and include therapeutic
interventions which address barriers that impede the development of skills
necessary for independent functioning in the community. (See, 8.315.6 NMAC, 8.305.1 NMAC and
collaborative adult behavioral health procedural manual.)
(6) Consumer: For purposes of
these rules, a person with a mental health or substance use disorder receiving
or eligible to receive behavioral health services through collaborative or
collaborative member contracts, or a past recipient of such services.
(7) Consumer empowerment:
Activities that address the following areas:
(a) consumer choice
(b) consumer voice
(c) self-management
(d) community integration
(8) Continuous quality improvement (CQI): CQI is a process
for improving quality that assumes opportunities for improvement are unlimited;
is customer-oriented, data driven, and results in implementation of improvements;
and requires continual measurement of implemented improvements and modification
of improvements, as indicated.
(9) Core service agencies (CSAs): Multi-service agencies that help to bridge
treatment gaps in the child and adult treatment systems, promote the
appropriate level of service intensity for consumers with complex behavioral
health service needs, ensure that community support services are integrated
into treatment, and develop the capacity for consumers to have a single point
of accountability for identifying and coordinating their behavioral health,
health and other social services.
(10) Credentialing: A
systematic process whereby the BHE or provider
verifies and warrants that an employed, contracted or affiliated behavioral
health professional or agency meets specified practice standards including
education, experience, licensure and certification.
(11) Cultural competence: A set of congruent behaviors, attitudes, and
policies that come together in a system, agency, or among professionals that
enables them to work effectively in cross-cultural situations, including
situations of diverse culture, race, ethnicity, national origin or disability. Cultural competency involves the integration
and transformation of knowledge, information and data about individuals and
groups of people into specific clinical standards, service approaches,
techniques and marketing programs that match an individual’s culture to
increase the quality and appropriateness of behavioral health care and
outcomes. See, 8.305.1.7 NMAC.
D. Definitions beginning with letter
“D”:
(1) Delegation: A formal process by which a BHE gives another entity the authority to perform certain
functions on its behalf but for which the BHE retains
full accountability for the delegated functions.
(2) Designated
representative: A person designated under a valid mental
health care treatment advance directive as an individual’s authorized agent
according to the provisions of the Mental Health Care Treatment Decisions Act
(Section 24-7B NMSA 1978) and who has personal
knowledge of the respondent and the facts as required in Subsection B of the
act.
E. Definitions beginning with letter
“E”:
(1) EPSDT: Early and periodic
screening, diagnostic and treatment.
(2)
Ex-officio members: Non-voting members of the collaborative,
who otherwise serve as full members (e.g. the secretary of higher education
department, secretary of veteran’s services department, New Mexico public
defender, and the children’s cabinet coordinator).
(3) Executive committee: A
committee of the collaborative comprised of the secretaries of human services,
health, and children youth and families. The executive committee is authorized
to negotiate, approve and execute contracts and amendments on behalf of the
collaborative.
F. Definitions beginning with letter
“F”:
(1) Family-centered care: When a child is the consumer, the system of
care reflects the importance of the family or legal guardian in the way
services are planned and delivered.
Family-centered care facilitates collaboration between family members
and behavioral health professionals, builds on individual and family strengths
and respects diversity of families.
(2) Family specialist: An approved provider who is certified as a family
specialist through an approved state certification program. (See Subsection U of
7.20.11.7 NMAC)
G. Definitions
beginning with letter “G”:
(1) Grievance (consumer): Oral or written statement by a member
expressing dissatisfaction with any aspect of the BHE
or its operations that is not a BHE action.
(2) Grievance (provider): Oral or written statement by a provider to
the BHE expressing dissatisfaction with any aspect of
the BHE or its operations that is not a BHE action.
H. Definitions beginning with letter
“H”: HIPAA: Health Insurance Portability and
Accountability Act of 1996.
I. Definitions beginning with letter
“I”: Indicated prevention: Interventions
that identify individuals who are experiencing early signs of substance abuse,
mental illness and other related problem behavior and target them with special
programs.
J - K [RESERVED]
L. Definitions
beginning with letter “L”:
(1) Letter of direction
(LD): Written instructions, detailed action steps,
and guidelines to clarify the implementation of programs funded by new funding
sources or changes to programs funded by funding sources identified in the BHE contract.
(2) Local collaborative
(LC): An advisory body, delineated by either
judicial district
or tribal grouping and recognized by the collaborative, that
provides input on local and regional behavioral health issues to the
collaborative, the BHPC and the BHE.
(3) Logic model, prevention services: A
logical conceptual framework used to connect the prevention effort with its
intended results and the goal of reducing substance abuse. The framework is based upon existing
knowledge that is refined or revised with new research. The logic model specifically describes the
changes expected within the target population(s), why it is likely that these
changes would result from the proposed prevention services and activities, and
how this logically relates to the needs assessment.
M. Definitions
beginning with letter “M”:
(1) Managed care
organization (MCO): An organization that contracts with the state
of New Mexico to provide a variety of health care services to individuals who
are enrolled.
(2) Management letter:
A document signed by the co-chairs of the collaborative and a
representative of the BHE authorized to bind the BHE that describes a certain task or activity to be pursued
or conducted by the BHE, the specific approach to
that task or activity, the expected result and the schedule to be followed to
implement the task or activity. Such letters are not intended to be amendments
to the BHE contract, but more specific directions for
completing contract requirements.
(3) Medicaid: The medical assistance program authorized
under Title XIX and Title XXI of the Social Security Act or its successors,
furnished to New Mexico residents who meet specific eligibility requirements.
(4) Medically necessary services: Clinical
and rehabilitative physical, mental or behavioral health services that:
(a) are essential to prevent,
diagnose or treat medical or behavioral health conditions or are essential to
enable the consumer to attain, maintain or regain the consumer’s optimal
functional capacity;
(b) are delivered in the
amount, duration, scope and setting that is both sufficient and effective to
reasonably achieve their purposes and clinically appropriate to the specific
physical, mental and behavioral health care needs of the consumer;
(c) are provided within
professionally accepted standards of practice and national guidelines; and
(d) are required to meet the physical, mental
and behavioral health needs of the consumer and are not primarily for the
convenience of the consumer, the provider or the BHE.
(Subparagraphs (a) and (b) of Paragraph (7) of Subsection M of 8.305.1.7 NMAC)
N. Definitions
beginning with letter “N”:
(1) Network provider: An individual provider, clinic, group,
association or facility employed by or contracted with a BHE to furnish covered behavioral health services to
consumers under the provisions of the BHE contract.
(2) Non-network provider:
An individual provider, clinic, group, association or facility that
provides covered services and does not have a contract with the BHE.
O. [RESERVED]
P. Definitions
beginning with letter “P”:
(1) Peer specialist: An
approved provider who is certified as a peer specialist through a state
approved certification program.
(Paragraph (4) of Subsection A of 8.315.6.10 NMAC)
(2) Performance measures:
A system of operational and tracking indicators specified by state or
federal requirements or the collaborative, including but not limited to the
federal national outcome measures (NOMS).
(3)
Prevention services: Services that follow current national
standards for prevention including both physical and behavioral health.
(4) Prevention provider: A
provider under contract for the exclusive or primary purpose of providing
services designed to prevent or reduce the prevalence of substance abuse,
mental illness, or other specified behavioral health disorders.
(5) Psychosocial necessity:
Services or products provided to a consumer with the goal of helping
that individual develop to his/her fullest capacities through learning and
environmental supports and reduce the risk of the consumer developing a
behavioral health disorder or an increase in the severity of behavioral health
symptoms. The consumer need not have a
behavioral health diagnosis but rather have a need to improve psychosocial
functioning.
Q. [RESERVED]
R. Definitions
beginning with letter “R”:
(1) Recovery: Behavioral
health recovery is an individual's personal journey of healing and
transformation enabling a person with a behavioral health problem to live a
meaningful life in a community of his or her choice while striving to achieve
his or her full potential.
(2) Re-credentialing: A
systematic process whereby the BHE verifies and
warrants that an employed or affiliated behavioral health professional who is
currently credentialed, continues to meet specified practice standards,
including education, experience, licensure and certification.
(3) Resiliency: A global term describing a dynamic process,
whereby people overcome adversity and go on with their lives in a productive
and self-satisfying manner.
(4) Responsible offeror: An offeror who
submits a response proposal and who has furnished, when required, information
and data to prove that the offeror’s financial
resources, production or service facilities, personnel, service reputation and
experience are adequate to make satisfactory delivery of the services or items
of tangible personal property described in the proposal.
S. Definitions
beginning with letter “S”:
(1) Selective prevention: Prevention
interventions targeted at a subgroup of the general population that is
determined to be at risk for sexual assault, substance abuse or mental illness.
(2) State: The state of New Mexico,
including any entity or agency of the state and including but not limited to
the collaborative and member agencies.
(3) Subcontract: A written agreement between the BHE and a third party, or between a subcontractor and
another subcontractor, to provide services, and where appropriate approved by
the collaborative.
(4) Subcontractor: A third party who contracts with the BHE or a BHE subcontractor for
the provision of services.
(5) Supported employment: Integrated
work for not less than the federal minimum wage in a setting with ongoing
support services for individuals with severe disabilities for whom competitive
employment:
(a) has not traditionally
occurred;
(b) has been interrupted or
intermittent as a result of severe disability, and who,
(c) because of the nature and
severity of their disabilities need intensive physical, educational, social or
psychological support to perform work.
(6) Supportive housing: Permanent housing that is affordable to
individuals with low or no incomes, is chosen by the individual, which a person
retains even if their service needs change, and which is an essential ingredient
to foster and support a person's journey towards recovery and resiliency.
T. [RESERVED]
U. Definitions
beginning with letter “U”: Universal
prevention: Prevention interventions intended to
reach the entire population or a large share of it, without regard to
individual risk factors.
V - Z [RESERVED]
[7.21.1.7 NMAC - N, 9-1-11; A,
1-15-13]
7.21.1.8 MISSION
STATEMENT: The mission of the
collaborative is to ensure that quality behavioral health services are provided
to both medicaid and non-medicaid
consumers; that providers are reimbursed timely and accurately; that services
promote prevention, recovery, resilience in consumers, and that available
resources are used in the most efficient and effective manner. This mission serves the collaborative’s
vision of establishing a single service delivery system in which consumers and
family members are assisted in participating fully in the life of their
communities; support of recovery and development of resiliency are expected;
behavioral health is promoted; and the adverse effects of substance abuse and
mental illness are prevented or reduced.
[7.21.1.8 NMAC - N, 9-1-11; A,
1-15-13]
HISTORY OF 7.21.1 NMAC: [RESERVED]
