CurrentNew Mexico Health Care AuthorityPolicy N/A

Medicaid Section 1115 SUD Demonstration — Implementation, Monitoring, and Milestone Evaluation (Coverage Criteria)

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Governs New Mexico's Medicaid Section 1115 substance use disorder (SUD) demonstration implementation, monitoring, and milestone evaluation for Medicaid enrollees with an SUD diagnosis during the demonstration period. Affects state Medicaid program, participating providers, MCOs, and enrolled beneficiaries.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyMedicaid Section 1115 SUD Demonstration — Implementation, Monitoring, and Milestone Evaluation (Coverage Criteria)

Policy CodePolicy N/A

Change TypeInformational (mid‑point assessment summary)

Effective DateJan 1, 2019

Next Review Date

Key ActionDocument and report Treat First MAT initiation (including ED‑initiated buprenorphine) and referrals/warm handoffs to community programs to support milestone metrics and continuity of care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

01/01/2019-12/31/2023Demonstration approval period

05/21/2019SUD Implementation Plan

3Critical discordant metrics

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CurrentNew Mexico Health Care AuthorityPolicy N/A

Medicaid Section 1115 SUD Demonstration — Implementation, Monitoring, and Milestone Evaluation (Coverage Criteria)

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Policy Summary

PayerNew Mexico Health Care Authority

PolicyMedicaid Section 1115 SUD Demonstration — Implementation, Monitoring, and Milestone Evaluation (Coverage Criteria)

Policy CodePolicy N/A

Change TypeInformational (mid‑point assessment summary)

Effective DateJan 1, 2019

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

01/01/2019-12/31/2023Demonstration approval period

05/21/2019SUD Implementation Plan

3Critical discordant metrics

Milestone 1 complete

22%Milestone 6 complete

270%Increase in withdrawal management

Coverage Criteria Summary

The assessment found no decreases in statewide SUD treatment capacity; rather, New Mexico reported measurable expansions across the ASAM continuum while still facing persistent workforce constraints. Key capacity increases noted in milestone reporting include a 123% rise in early intervention (metric #7), 45% increase in IOP/partial hospitalization (metric #9), 134% increase in residential/inpatient services (metric #10), and a 270% increase in withdrawal management capacity (metric #11).

Despite these gains, capacity remains limited by a chronic shortage of nursing and other clinical staff (exacerbated during COVID when some hospitals operated at over 130% capacity), which restricts bed availability and slows scale-up of IMD services. Telehealth expansion during the pandemic has partially mitigated access barriers—particularly in rural areas and for patients with transportation challenges—but workforce shortages are the principal constraint to further service expansion.

Provider Actions, Authorization & Documentation

Prior Authorization

Buprenorphine prior authorization removed

Prior authorization for buprenorphine has been removed statewide to increase access as a harm‑reduction measure.

Documentation Required

Follow PDMP and prescribing safeguards

Follow PDMP best practices implemented by the state: use PMP delegates, ensure daily pharmacy reporting, participate in MCO drug utilization review activities, and adhere to the state’s opioid prescribing guidelines (e.g., 90 MME limit; max 7‑day supply for new prescriptions).

Use PMP delegates and enable daily pharmacy reporting.
Engage with MCO Drug Utilization Review committees and provider feedback reports.
Follow evidence‑based opioid prescribing guidelines (maximum 90 MME; refill thresholds and 7‑day max for new scripts).

Prior Authorization

Reduced buprenorphine prior authorization to increase access

Statewide reductions in prior authorization for buprenorphine are documented as a deliberate harm‑reduction and access strategy.

Note

No explicit prior‑authorization rules specified here

No specific prior‑authorization rules are detailed in these sections; the document instead describes program expansions (NM Bridge, MAT ECHO), billing allowances for supervised trainees, and related implementation supports.

Community behavioral health agencies may bill for services provided by trainees if supervisory requirements are met.
NM Bridge and MAT ECHO programs are described to expand ED inductions and office‑based MAT support.

Step Therapy

No step‑therapy requirements specified

The document does not specify any step‑therapy requirements for MAT or buprenorphine in the reviewed sections.

Documentation Required

Participate in drug monitoring and NMCL care coordination

MCOs implemented a standard drug monitoring program for controlled substances and SUD was added to NM CareLink (NMCL) to enable care coordination; providers should use NMCL and health IT (e.g., ED information exchange) to coordinate follow‑up.

Engage with MCO drug monitoring programs for clinician review of patient controlled‑substance history.
Document and coordinate SUD care within NM CareLink (NMCL) to support follow‑up and readmission avoidance.
Leverage ED information exchange and NMCL HHs for post‑ED care coordination.

Step Therapy

Step‑therapy not specified (confirmation)

No step‑therapy requirements are described in these sections (confirmation).

Step Therapy

Step‑therapy not specified (confirmation)

No step‑therapy requirements are described in these sections (further confirmation).

Documentation Required

Accepted documentation sources for monitoring

Acceptable documentation sources for monitoring and assessments include the state’s quarterly and annual SUD waiver monitoring reports submitted to CMS, Implementation Plan action items, provider availability assessments, and qualitative stakeholder interview notes.

Use State quarterly/annual SUD waiver monitoring reports submitted to CMS as evidence.
Reference Implementation Plan action items and provider availability assessment results.
Include qualitative stakeholder interview notes and narrative demonstration documents as supporting materials.

Documentation Required

Use Table 3 legend for metric definitions

Metric definitions and measurement codes are provided in Table 3 and its legend (for example, #17(1) = percentage of ED visits for AOD with follow‑up within 30/7 days).

Refer to Table 3 legend for metric codes (e.g., #17(1) = ED AOD follow‑up within 30/7 days).

Documentation Required

Document MAT initiation, Treat First, and warm handoffs

Document Treat First use, any MAT initiation (including ED‑initiated buprenorphine via NM Bridge), and referrals/warm handoffs to community programs to support continuity of care and milestone metrics.

Record use of Treat First approaches and ED‑initiated buprenorphine inductions.
Document referrals and warm handoffs to community treatment and NMCL HHs.
Include evidence of linkage to outpatient MAT (e.g., MAT ECHO‑supported referrals).

Documentation Required

Incorporate state dissemination into discharge planning

State will disseminate NMCL HH eligibility changes and educate hospital discharge planners and care coordinators; providers should expect outreach and incorporate these updated referrals into discharge planning.

Accept and act on state dissemination about NMCL HH eligibility for patients with SUD.
Ensure hospital discharge planners and care coordinators are aware of updated referral pathways.

Denial Risk

Be aware: medium/high‑risk monitoring flags may trigger review

Milestones rated medium or high risk based on critical monitoring metrics that fail to trend as expected may trigger additional evaluation or review.

Note

Critical metrics that may trigger concern

Three critical metrics were identified with discordant trends that could trigger concern: Metric #25 (SUD readmissions), Metric #17(1) (ED AOD follow‑up within 7/30 days), and Metric #27 (overdose death rate).

Metric #25: Readmissions among beneficiaries with SUD.
Metric #17(1): ED visits for AOD with follow‑up within 30/7 days.
Metric #27: Overdose death rate (noted 38.5% rise 2019–2020).

Billing Rule

Confirm local processes reflect buprenorphine PA reductions

Prior authorization reductions for buprenorphine were implemented statewide; providers should confirm there are no remaining local PA barriers that could impede access and update internal processes accordingly.

Confirm local billing/PA workflows reflect reduced buprenorphine PA.
Update clinic policies to remove unnecessary PA steps for buprenorphine initiation.

Denial Risk

Risk: inadequate care coordination may affect metrics and oversight

Failure to implement care coordination and timely ED follow‑up for SUD patients may put critical metrics (readmissions and ED follow‑up) at risk and could prompt additional oversight of milestone performance.

Prioritize timely follow‑up after ED visits and robust care coordination (NMCL HH enrollment where eligible).
Use peers and care navigators to reduce readmissions and improve timely engagement.

Program Background & Scope

This demonstration targets Medicaid beneficiaries with substance use disorders and aligns implementation with the ASAM continuum of care to expand detection, outpatient, intensive outpatient/partial hospitalization, withdrawal management, and medically managed inpatient services. The state’s approach emphasizes evidence-based placement, broadening provider capacity for Medication-Assisted Treatment (including ED-initiated buprenorphine), and integrating prevention and harm-reduction strategies.

Affected populations include Medicaid enrollees diagnosed with SUD across age groups and geographic areas; implementation actions explicitly expand services into emergency departments, primary care and community settings and extend eligibility for NM CareLink Health Homes to beneficiaries with SUD to improve care coordination and follow-up.

State activities described in the implementation plan and monitoring reports are closely mapped to ASAM levels of care: workforce training and MAT supports (e.g., NM Bridge ED inductions, MAT ECHO mentorship), SBIRT expansion for screening and brief intervention, telehealth to improve engagement and reach, and establishment of Crisis Treatment Centers and withdrawal management capacity to support higher-acuity needs.

Key Definitions and Metric Glossary

ASAM levels of care — ASAM continuum used to organize services

FrameworkAmerican Society of Addiction Medicine (ASAM) continuum of care used to organize SUD services across levels (outpatient, IOP, partial hospitalization, withdrawal management, inpatient).

PurposeImplementation Plan and milestone activities are organized by ASAM levels to expand access and align services with CMS SUD milestones.

Scope of levelsIncludes early intervention, outpatient, intensive outpatient (IOP), partial hospitalization, withdrawal management (ASAM Level 2), residential/inpatient and medically managed inpatient withdrawal.

SBIRT — Screening, Brief Intervention, and Referral to Treatment definition and expansion

DefinitionScreening, Brief Intervention, and Referral to Treatment (SBIRT) — universal screening with brief intervention and referral pathways for SUD.

Level-of-Care Criteria (ASAM-Aligned)

ASAM continuum (Outpatient, IOP, Partial Hospitalization, Withdrawal Management, Inpatient)

Admission and continued stay criteria aligned to the ASAM continuum. Covered when the following ASAM-aligned access and retention objectives are met:

ASAM continuum access: State implemented ASAM-aligned expansions across detection, outpatient, intensive outpatient (IOP), partial hospitalization, withdrawal management, and medically managed inpatient withdrawal to increase access to appropriate levels of care.

Supports rapid placement using Treat First and expanded service definitions (e.g., partial hospitalization eligibility to all ages).

Retention and adherence: State milestone goals include increasing adherence to and retention in treatment for OUD and other SUDs as part of monitoring and evaluation.

Continued stay decisions should consider documented ongoing engagement and retention efforts consistent with milestone objectives.

Health Home / Care Coordination

Enrollment and care coordination criteria for Health Home (NM CareLink) participation and follow-up:

Covered Treatment Modalities & Operational Notes

MAT (buprenorphine, OTP access)

Criteria for offering Medication-Assisted Treatment (buprenorphine access and OTP integration):

MAT access expansion: Significant expansion of MAT providers, ED-initiated buprenorphine (NM Bridge), inclusion of buprenorphine in OTPs, and removal/reduction of prior authorization for buprenorphine to increase access.

Providers should document MAT initiation, transitions of care, and referrals/warm handoffs to community programs. Treat First approaches and ED inductions are supported.

Harm reduction / Prevention

Harm reduction and prevention activities eligible for use and documentation:

Harm reduction services: State harm reduction activities include naloxone distribution and fentanyl test strip distribution and are part of comprehensive prevention strategies.

Document distribution efforts and linkage to treatment when applicable.

Visit Limits & Implementation Tracking

Implementation action item completion tracking per milestone (percent complete reported)

MetricImplementation action item completion tracked by milestone as percent complete (e.g., Milestone 1 = 87% complete [33/38]; Milestone 6 = 22% complete [2/9]).

ReportingCompletion percentages are reported in Table 4 findings from the Mid-Point Assessment to reflect implementation progress and implementation risk level.

UsePercent complete per milestone used to assess implementation risk and identify areas needing additional attention (e.g., Milestone 6 low completion and higher assessed risk).

No explicit visit limits described in this section.

Visit limits summaryNo explicit visit limits are described in the midpoint assessment section; capacity and service expansions are discussed but not visit caps.

Implication

Policy Summary

PayerNew Mexico Health Care Authority

PolicyMedicaid Section 1115 SUD Demonstration — Implementation, Monitoring, and Milestone Evaluation (Coverage Criteria)

Policy CodePolicy N/A

Change TypeInformational (mid‑point assessment summary)

Effective DateJan 1, 2019

Next Review Date

SourceLink

On This Page

SBIRT training and implementation expanded into physical health locations and adolescent settings; claims rose from 1,878 (2018) to 4,845 (2021).

Role in Milestone 1Integrated as part of detection strategies to increase early identification and engagement in treatment.

Metric #17(1) — percent of ED visits for AOD with timely follow-up definition

DefinitionMetric #17(1) = Percentage of ED visits for alcohol or other drug (AOD) abuse or dependence for which the beneficiary received follow-up within 30 days (17(1)a) or within 7 days (17(1)b) of the ED visit.

Data sourceDefined in Table 3 legend used by NM Medicaid for SUD monitoring and milestone assessment.

Operational useUsed to track timely post-ED follow-up and to inform care coordination activities (e.g., NMCL HH outreach, discharge planning).

Metric #27 — overdose death rate definition

DefinitionMetric #27 = Overdose death rate (OUD-related mortality) per the specified Medicaid population as defined in the monitoring table legend and narratives.

ContextUsed as a critical metric for Milestone 5; monitoring narratives link rising overdose deaths to fentanyl-laced drugs and COVID-related riskier use conditions.

Program implicationAn increase in Metric #27 was identified and cited as a driver for expanded harm reduction and treatment strategies.

CTC — Crisis Treatment Centers definition

DefinitionCrisis Treatment Centers (CTCs) — facilities providing crisis intervention and ASAM Level 2 withdrawal management services outside the ED.

State implementationTwo Crisis Triage/Crisis Treatment Centers were established in 2021 with a third planned to begin operations by the end of 2022.

Payment/policy noteProvider-specific, cost-based rates established for the first two CTCs as described in monitoring narratives.

MAT — Medication assisted treatment including buprenorphine and methadone across settings

DefinitionMedication-assisted treatment (MAT) — delivery of medications for addiction treatment (including buprenorphine and methadone) across ED, office-based, and Opioid Treatment Program (OTP)/IMD settings.

State actionsState added buprenorphine to OTPs and reduced prior authorization requirements to increase access to MAT.

SettingsMAT delivered via ED inductions, office-based prescribing, and OTPs with supporting training and programs (e.g., MAT ECHO, NM Bridge).

NMCL HH — NM CareLink Health Homes expanded to include SUD eligibility

DefinitionNM CareLink Health Homes (NMCL HH) — Medicaid health home model providing care coordination for beneficiaries; eligibility was expanded to include those with SUD.

ImplementationCMS approved the State Plan Amendment to add SUD to HH eligibility in mid-2021; NMCL providers have experience serving co-occurring SMI and SUD populations.

Role in care coordinationNMCL HHs are leveraged to facilitate post-ED follow-up and reduce readmissions through care coordination and discharge planner education.

MAT (Medication for Addiction Treatment) — expansion via provider training and NM Bridge program

Expansion pathwaysMAT expansion supported via provider training (e.g., MAT ECHO), ED induction program (NM Bridge), and increased billing flexibility for community behavioral health agencies.

Workforce supportsTrainings, hands-on mentorship for rural providers seeking DEA waivers, and MAT ECHO education to increase office-based MAT capacity.

Operational supportsED-based NM Bridge supports buprenorphine induction with referral networks; addition of buprenorphine in OTPs further broadens MAT access.

NM Care Link Health Homes (NMCL HHs) — health home model for care coordination and ED follow-up

ModelNM CareLink Health Homes (NMCL HHs) are the state's health home model to provide care coordination, support ED follow-up, and address readmissions for behavioral health/SUD populations.

Policy changeState Plan Amendment to add SUD to health home eligibility was approved in mid-2021, enabling NMCL HHs to serve beneficiaries with SUD.

Planned actionsState will disseminate new SUD eligibility to hospitals, EDs, and CTCs and educate discharge planners and care coordinators to improve timely follow-up.

Health Home eligibility expansion: SUD was added to eligibility for NM CareLink Health Homes (NMCL HHs); beneficiaries with SUD may be enrolled to receive integrated care coordination services.

Expansion occurred in Spring 2021; full effects on follow-up metrics may lag enrollment growth.

Care coordination activities: NMCL HHs provide integrated care coordination including outreach, follow-up after ED visits/hospital discharges, and linkage to community SUD services.

Documentation should demonstrate enrollment and active care coordination (e.g., outreach attempts, warm handoffs).

Follow-up expectations: Follow-up after ED visit for substance use disorder should target 7- and 30-day contact windows consistent with metric #17(1).7/30 days

Improved follow-up depends on HH capacity; use of peers and telehealth are acceptable modalities to achieve follow-up.

Crisis Treatment Centers (CTC) / Withdrawal Management

Criteria for access to Crisis Treatment Centers (CTCs) and Withdrawal Management services:

CTC availability: State established Crisis Triage/Crisis Treatment Centers to provide ASAM Level 2 withdrawal management services; two were operational in 2021 with a third planned.

Providers should use available CTC capacity for patients requiring ASAM Level 2 withdrawal management and document placement decisions.

Withdrawal management placement: Patients presenting with acute withdrawal or need for medically monitored withdrawal may be admitted to CTCs, RTCs, or IMDs offering withdrawal management codes expanded by the state.

Use clinical assessment consistent with ASAM placement criteria to determine appropriate site (CTC vs RTC vs IMD).

Inpatient/IMD services for SUD

Criteria for use of inpatient and IMD services for SUD:

IMD utilization evidence: IMD claims for beneficiaries with SUD were reported, demonstrating use of IMDs to treat SUD under the waiver (Q1–Q3 totals reported).

Admission to IMD should follow ASAM placement criteria and be documented; capacity constrained by workforce shortages may affect bed availability.

Inpatient care supports: Medically managed inpatient withdrawal and residential/inpatient services expanded as part of the continuum; inpatient admission should be based on clinical need and ASAM-level determination.

Document medical necessity, withdrawal severity, and inability to safely manage at lower levels of care.

ASAM continuum (early intervention, IOP/partial hospitalization, residential/inpatient, withdrawal management)

Criteria and operational considerations for expanding capacity across ASAM levels (early intervention through withdrawal management):

Capacity expansion metrics: State demonstrated percentage increases in early intervention, IOP/partial hospitalization, residential/inpatient, and withdrawal management capacity (example increases: early intervention +123%, IOP/partial hospitalization +45%, residential/inpatient +134%, withdrawal management +270%).

Use metrics and provider availability assessments to prioritize expansion activities and align placements with ASAM levels.

Capacity needs: Identified needs include shifting focus from training to implementation of MAT prescribing, expanding CTCs (ASAM Level 2), supporting ED clinicians in prescribing MAT, and expanding peer support into outpatient settings.

Plans to expand capacity should address workforce shortages (nursing and behavioral health clinicians) that constrain bed availability.

Medication safety / PDMP

Criteria for medication safety and PDMP use in prescribing controlled substances:

PDMP and prescribing safeguards: State implemented PDMP best practices including PMP delegates, daily pharmacy reporting, provider feedback reports, and evidence-based opioid prescribing guidelines (e.g., 90 MME limit, 7-day max for new prescriptions).

MCOs developed a Drug Utilization Review program for controlled substance monitoring; providers should comply with PDMP practices and documentation.

MAT (buprenorphine, methadone)

Criteria supporting access to buprenorphine and methadone as part of MAT expansion:

ED and office-based MAT: State actions include ED-initiated buprenorphine via NM Bridge, reduced prior authorizations for buprenorphine, addition of buprenorphine in OTPs, and MAT ECHO support for office-based providers to expand access to buprenorphine and methadone-based treatment.

Providers should document initiation, dosing, and linkage to follow-up care; training and telehealth supports are available.

Peer Support Services

Criteria for provision and reimbursement of peer support services:

Peer support expansion: Accelerated training and certification of peer support workers and introduction across agencies and EDs; recommendations to expand reimbursable peer services and settings to improve linkage to care.

Community behavioral health agencies may bill for services provided by trainees under supervision; peers can provide outreach, navigation, and linkage to follow-up.

Telehealth

Telehealth criteria to support engagement, follow-up, and MAT delivery:

Telehealth for engagement and MAT: Telehealth was expanded (including during the PHE) to improve follow-up, reduce no-shows, extend MAT training/prescribing support, and facilitate rural access to services.

Telehealth may be used for follow-up contacts (7/30 day goals), MAT consultations, and peer support engagement; document modality and clinical content.

Medication-Assisted Treatment (MAT)

Operational criteria for Medication-Assisted Treatment (MAT) services and supports:

MAT supports include ED induction via NM Bridge, office-based MAT supported by MAT ECHO, and training for advanced practice nurses, physician assistants, and residents to expand prescribing capacity.

State activities prioritize shifting from training to implementation of MAT prescribing and expanding provider capacity across settings.

Peer support / recovery coaching

Criteria for peer support and recovery coaching services:

Peer support expansion and roles: Accelerated training and certification of peer support workers, peer navigation from ED/hospital to outpatient care, and expansion into outpatient settings using evidence-based modalities (e.g., Seeking Safety, Motivational Interviewing).

Peers are expected to support linkage to follow-up and retention; documentation of peer contacts and navigation efforts should be maintained.

Providers should note that the document does not impose specified per-member visit limits within the described sections.

Related noteImplementation and workforce constraints are discussed separately from visit limit policy; billing flexibilities for trainees are described but not visit caps.

No explicit visit limits described in these chunks (confirmation)

ConfirmationAcross the cited chunks for visit limits, the assessment does not specify numeric visit limits or utilization caps for SUD services.

ContextThe document focuses on capacity, workforce, and service expansion (e.g., MAT, CTCs, NMCL HH) rather than per-visit restrictions.

Provider guidanceAbsent explicit visit limits, providers should follow existing Medicaid billing rules and any MCO-specific policies documented elsewhere.