8.372.1 NMAC

8.372.1 NMAC GENERAL PROVISIONS

This section establishes general provisions and a comprehensive glossary for New Mexico's Interagency Behavioral Health Purchasing Collaborative, which oversees the statewide behavioral health service delivery system through contracted behavioral health entities (BHEs/MCOs). It defines key terms—such as behavioral health, clinical necessity, medically necessary services, ASAM, consumer, and provider types—that govern the standards and contracting rules set out in sibling sections 8.372.2 and 8.372.3. Facility operators and contracted providers must understand these definitions as they apply to all behavioral health services delivered under collaborative or Medicaid contracts.

TITLE 8
 
SOCIAL
SERVICES

CHAPTER 372
 
INTERAGENCY BEHAVIORAL HEALTH PURCHASING COLLABORATIVE

PART 1 

GENERAL PROVISIONS

8.372.1.1
 
ISSUING
AGENCY:
 
New Mexico Health Care
Authority.

[8.372.1.1 NMAC - N, 7/1/2024]

8.372.1.2
 
SCOPE:
 
This rule applies to the 
general
public
.

[8.372.1.2 NMAC - N, 7/1/2024]

8.372.1.3
 
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 health care authority (HCA). 
 
The collaborative is created by statute and
comprised of the secretaries of aging and long-term services; Indian affairs; health
care authority; 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. 
 
Section 9-8-1 et seq. NMSA 1978 establishes
the health care authority as a single, unified department to administer laws
and exercise functions relating to health care facility licensure and health
care purchasing and regulation.

[8.372.1.3 NMAC - N, 7/1/2024]

8.372.1.4
 
DURATION:
 
Permanent.

[8.372.1.4 NMAC - N, 7/1/2024]

8.372.1.5
 
EFFECTIVE
DATE:
 
July 1, 2024, unless a later
date is cited at the end of a section.

[8.372.1.5 NMAC - N, 7/1/2024]

8.372.1.6
 
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.

[8.372.1.6 NMAC - N, 7/1/2024]

8.372.1.7
 
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, Sections 27-7A-1
- 27-7A-18 NMSA, 1978, and Section 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, 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 Section 24-1-28 NMSA, 1978)

C.
 
Definitions beginning with letter
“C”:

(1)
 
Chair
or co-chairs:
 The secretary of the health care authority 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 (Subsection B of Section 24-7
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 the health care authority,
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
.
 
Definitions
beginning with letter “J”
:
 
[RESERVED]

K.
 
Definitions
beginning with letter “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.
 
Definitions
beginning with letter “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 their 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.
 
Definitions
beginning with letter “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 their choice
while striving to achieve their 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.
 
Definitions
beginning with letter “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.
 
Definitions
beginning with letter “V”:
 
[RESERVED]

W.
 
Definitions
beginning with letter “W”:
 
[RESERVED]

X.
 
Definitions
beginning with letter “X”:
 
[RESERVED]

Y.
 
Definitions
beginning with letter “Y”:
 
[RESERVED]

Z.
 
Definitions
beginning with letter “Z”:
 
[RESERVED]

[8.372.1.7 NMAC - N, 7/1/2024]

8.372.1.8
 
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.

[8.372.1.8 NMAC - N, 7/1/2024]

HISTORY OF 8.372.1 NMAC:
 
[RESERVED]