Adult Chemical Dependency Residential Treatment Center (RTC) Services
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Defines a Value Added Service (VAS) for adults with substance use disorders providing 24-hour supervised residential detox and recovery services, eligibility, limits, and prior authorization requirements for New Mexico Medicaid and ABP members.
No material clinical or coverage changes in this revision.
Value-Added Services Coverage Criteria
Adult Chemical Dependency RTC coverage criteria
Eligibility and limits for Adult Chemical Dependency RTC Services VAS.
Inpatient Detox (non-hospital) coverage criteria
Coverage for medically monitored inpatient detox at non-hospital facilities.
Transitional Living Coverage Criteria
Transitional Living (short-term emergency placement) coverage parameters and eligibility:
Additional Respite Coverage Criteria
Additional Respite benefit:
Environmental Modifications Coverage Criteria
Environmental Modifications benefit:
ECT Coverage Criteria
Electroconvulsive Therapy (ECT):
No-Prior-Authorization VAS and Benefits
Value-added and other benefits with No Prior Authorization required or simple eligibility:
Examples (No Prior Authorization)
- Alternative Healing: $100 annual reimbursement; No Prior Authorization required; available to all UHC members
- Annual Physical Exam: Annual history and physical for non-dual Medicaid members; No Prior Authorization required
- Baby Blocks Program: prenatal/postpartum appointment incentives; No Prior Authorization required
- Cell Phone Minutes: $50 annual for members receiving Personal Care Services; No Prior Authorization required
- Dental Varnish: Fluoride varnish for children 6 months to 3 years; No Prior Authorization required
- Full Medicaid Benefits for Pregnant Mothers (Category 301): No Prior Authorization required
- New Mother's Benefit: incentives and infant supplies via Baby Blocks milestones; No Prior Authorization required
- Pharmacy Purchases Reimbursement: $50 annual reimbursement for eligible Medicare-enrolled members; No Prior Authorization required
- Traditional Native American Healing Benefit: up to $250 inpatient (twice/year) and $200 outpatient (once/year); No Prior Authorization required
- Transitional Housing - Hotel/Motel Card: $200 pre-paid card once every two years for members 18+; request via Wellness Center/Treatment Center or CHR/CHW; No Prior Authorization required
Service-specific coverage criteria
Coverage and access criteria vary by service; eligibility often depends on member category (Medicaid vs ABP), age, and program-specific limits.
Transitional Living Services
Transitional Living Services coverage details
Dental Varnish
Dental varnish
Native American Healers
Native American Healers
Pharmacy Purchases Reimbursement
Pharmacy purchases reimbursement for Medicare-enrolled members
Wellness Benefit
Wellness Benefit
Enhanced Care Coordination
Enhanced Care Coordination - Specialized Services
Adult Routine Physicals
Adult Routine Physicals
SBHC Interdisciplinary Conferences
Certain School Based Health Clinic (SBHC) Services
School Sports Physicals
School Sports Physicals
Pregnancy-related value-added benefits
Expansion of Category 301/035 & New Mother's Benefit
Codes, Limits, and Key Numeric Limits
| No codes listed |
| No codes listed |
| Prescription strength fluoride product delivered to the dentition by a child's PCP; Medicaid covers children 3 years and older; available to children 0-3 in this value-added context |
| No procedure or diagnosis codes were specified in the Molina Healthcare of New Mexico 2016 Value Added Services section |
Authorization and Provider Requirements
Prior Authorization for RTC services
Prior Authorization: A Prior Authorization is required to access these services.
Prior Authorization for inpatient non-hospital detox
Prior Authorization: A Prior Authorization is required to access this service; the service is facilitated through a Care Coordinator.
Prior Authorization note for pregnant members
Prior Authorization: Full Medicaid benefits for pregnant members (Category 301/035) do not require prior authorization for covered services; prior authorization is only required for services that typically require one.
Transitional Living Prior Authorization
Prior Authorization: Prior Authorization is required to access Transitional Living VAS; eligible members are expected to participate in recommended psychiatric or chemical dependency treatment while in this VAS.
Additional Respite Prior Authorization
Prior Authorization: Prior Authorization is required for Additional Respite (150 hours annually) for members receiving Agency Based Community Benefit.
Environmental Modifications Prior Authorization
Prior Authorization: Prior Authorization is required for the Environmental Modifications benefit (increased to $6,500 every 5 years for members with a community NFLOC).
ECT Prior Authorization
Prior Authorization: A Prior Authorization is required to access Electroconvulsive Therapy (ECT).
Enhanced Transportation Authorization/Request Timing
Timing Requirement: Pharmacy transport requests for Enhanced Transportation must be made 72 hours prior to transport unless it is an emergency.
No Prior Authorization Services
No Prior Authorization: Multiple value-added services explicitly state no prior authorization is required (e.g., Alternative Healing, Annual Physical Exam, Baby Blocks/New Mother's Benefit, Cell Phone Minutes, Dental Varnish, Traditional Native American Healing, Transitional Housing hotel/motel card, Pharmacy Purchases Reimbursement, Vision/Enhanced Dental/Enhanced Hearing Care Card where noted).
Traditional Native American Healing — prior auth
No Prior Authorization: The Traditional Native American Healing benefit does not require prior authorization (inpatient up to $250 twice/year; outpatient up to $200 once/year).
Transitional Housing — access request
Access Request: The Transitional Housing hotel/motel card does not require prior authorization but must be requested by the member's Wellness Center/Treatment Center or upon CHR/CHW referral; card is $200 and requestable once every two years.
Care Card — prior auth
No Prior Authorization: Vision/Enhanced Dental/Enhanced Hearing Care Card (Care Card) for ABP members does not require prior authorization ($300 pre-paid card every 24 months).
ECT — prior auth required
Prior Authorization: A Prior Authorization is required to access Electroconvulsive Therapy (ECT).
Infant Mental Health — prior auth
Prior Authorization: A Prior Authorization is required to access Infant Mental Health services.
ABP inpatient detox — prior auth
Prior Authorization: A Prior Authorization is required to access ABP non-general acute care hospital inpatient detox services (one admission per calendar year; inpatient LOS 5–7 days as noted by Molina's VAS).
Medicaid detox services — prior auth
Prior Authorization: A Prior Authorization is required to access non-general acute care hospital inpatient and outpatient detox services for Medicaid (inpatient LOS 5–7 days; outpatient up to 10 days; limits on number of detoxes per year).
Post-discharge meals — prior auth
Prior Authorization: A Prior Authorization is required to access post-discharge home-delivered meals (up to 42 meals per calendar year for homebound members after hospital/SNF discharge).
Post-hospitalization homeless lodging — prior auth
Prior Authorization: A Prior Authorization is required to access post-hospitalization homeless lodging (allows up to two weeks for homeless members transitioning from hospital to home).
Transitional Living — prior auth
Prior Authorization: A Prior Authorization is required to access Transitional Living Services (members age 17+; Medicaid only; maximums and program cost caps apply).
Transitional Living Services
Prior Authorization: Prior Authorization is required for Transitional Living Services as described (supervised voluntary residential treatment; 180 day maximum per member per calendar year; $200,000 total program costs per calendar year).
Enhanced Care Coordination - Specialized Services
Prior Authorization: Prior Authorization is required to access Enhanced Care Coordination - Specialized Services (must be approved by a care coordinator as part of a Level 2 or 3 care plan).
Value-added services without prior authorization
No Prior Authorization: The listed value-added services do not require prior authorization (examples include dental varnish; expansion of Category 301/035 benefits; Native American Healers; pharmacy purchases reimbursement; New Mother's Benefit; wellness benefit; adult routine physicals; certain SBHC services; school sports physicals).
Definitions and Program Descriptions
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