TITLE 8 SOCIAL
SERVICES
CHAPTER 314 LONG TERM CARE SERVICES - WAIVERS
PART 6 MI VIA HOME AND COMMUNITY-BASED
SERVICES WAIVER
8.314.6.1 ISSUING AGENCY: New
Mexico Human Services Department (HSD).
[8.314.6.1 NMAC -
Rp, 8.314.6.1 NMAC, 3/1/2016]
8.314.6.2 SCOPE: The
rule applies to the general public.
[8.314.6.2 NMAC -
Rp, 8.314.6.2 NMAC, 3/1/2016]
8.314.6.3 STATUTORY AUTHORITY: The
New Mexico medicaid program and other health care programs are administered
pursuant to regulations promulgated by the federal department of health and
human services under Titles XI, XIX, and XXI of the Social Security Act as
amended or by state statute. See Section
27-2-12 et seq. NMSA 1978.
[8.314.6.3 NMAC -
Rp, 8.314.6.3 NMAC, 3/1/2016]
8.314.6.4 DURATION: Permanent.
[8.314.6.4 NMAC -
Rp, 8.314.6.4 NMAC, 3/1/2016]
8.314.6.5 EFFECTIVE DATE: March 1, 2016, unless a later date is cited
at the end of a section.
[8.314.6.5 NMAC -
Rp, 8.314.6.5 NMAC, 3/1/2016]
8.314.6.6 OBJECTIVE: The
objective of this rule is to provide instructions for the service portion of
the New Mexico medical assistance programs (MAP).
[8.314.6.6 NMAC -
Rp, 8.314.6.6 NMAC, 3/1/2016]
8.314.6.7 DEFINITIONS:
A. Authorized annual budget (AAB): The eligible recipient works with his or her
consultant to develop an annual budget request which is submitted to the
third-party assessor (TPA) for review and approval. The total annual amount of the mi via
services and goods includes the frequency, the amount, and the duration of the
services and the cost of goods approved by the TPA. Once approved, this is the AAB.
B. Authorized representative: The individual designated to represent and
act on the member’s behalf. The eligible
recipient or authorized representative must provide formal documentation
authorizing the named individual or individuals to access the identified case
information for a specified purpose and time frame. An authorized representative may be an
attorney representing a person or household, a person acting under the
authority of a valid power of attorney, a guardian, or any other individual or
individuals designated in writing by the eligible recipient. The eligible recipient’s authorized
representative may be a service provider (depending on what the eligible
recipient or court order allows) for the eligible recipient. An authorized representative cannot approve
his or her own timesheet. The authorized
representative cannot serve as the eligible recipient’s consultant.
C. Category of eligibility (COE): To qualify for medical assistance program
(MAP) services, an applicant must meet financial criteria and belong to one of
the groups that the New Mexico medical assistance division (MAD) has defined as
eligible. An eligible recipient in the
mi via program must belong to one of the MAP categories of eligibility (COE)
described in 8.314.6.13 NMAC.
D. Centers for medicare and medicaid services
(CMS): Federal agency within the
United States department of health (DOH) and human services that works in
partnership with New Mexico to administer medicaid and MAP services under HSD.
E. Consultant provider: An agency
or an individual that provides consultant and support guide services to the
eligible recipient that assist the eligible recipient (or the eligible
recipient's family, personal representative or the authorized representative,
as appropriate) in arranging for, directing and managing mi via services and
supports, as well as developing, implementing and monitoring the service and
support plan (SSP) and AAB.
F. Eligible recipient: An
applicant meeting the financial and medical level of care (LOC) criteria who is
approved to receive MAD services through the mi via program.
G. Employer
of record (EOR): The employer of record (EOR) is the
individual responsible for directing the work of mi via employees, including
recruiting, hiring, managing and terminating all employees. The EOR tracks expenditures for employee
payroll, goods, and services. EORs authorize
the payment of timesheets by the financial management agency (FMA). An eligible recipient is required to have an
EOR when he or she utilizes employees for mi via services. An eligible recipient may be his or her own
EOR unless the eligible recipient is a minor, or has a plenary or limited
guardianship or conservatorship over financial matters in place. An eligible recipient may also designate an
individual of his or her choice to serve as the EOR, subject to the EOR meeting
the qualifications specified in this rule.
A power of attorney (POA) or other legal instrument may not be used to
assign the EOR responsibilities, in part or in full, to another individual and
may not be used to circumvent the requirements of the EOR as designated in this
rule.
H. Financial management agency (FMA): Contractor that helps implement the AAB by
paying the eligible recipient’s service providers and tracking expenses.
I. Home and community-based services (HCBS)
waiver: A set of MAD services that
provides alternatives to long-term care services in institutional settings,
such as the mi via waiver program. CMS
waives certain statutory requirements of the Social Security Act to allow HSD
to provide an array of community-based options through these waiver programs.
J. Individual budgetary allotment (IBA): The maximum budget allotment available to an
eligible recipient, determined by his or her age established level of care
(LOC). Based on this maximum amount, the
eligible recipient will develop a plan to meet his or her assessed functional,
medical and habilitative needs to enable the eligible recipient to remain in
his or her community.
K. Intermediate care facilities for
individuals with intellectual disabilities (ICF/IID): Facilities that are licensed and certified by
the New Mexico DOH to provide room and board, continuous active treatment and
other services for eligible recipients with a primary diagnosis of
intellectually disabled.
L. Legally responsible
individual (LRI): A person who has a
duty under state law to care for another person. This category typically includes: the parent (biological, legal, or adoptive)
of a minor child, or a guardian who must provide care to an eligible recipient
under 18 years of age or the spouse of an eligible recipient.
M. Level of care (LOC): The level of care an eligible recipient must
meet to be eligible for the mi via program.
N. Mi via:
Mi via is the name of the Section 1915 (c) MAD self-directed HCBS waiver
program through which an eligible recipient has the option to access services
to allow him or her to remain in the community.
O. Personal representative: The eligible recipient may select an
individual to act as his or her personal representative for the purpose of
offering support and assisting the eligible recipient understand his or her mi
via services. The eligible recipient
does not need a legal relationship with his or her personal representative. The personal representative will not have the
authority to direct the member’s mi via waiver services or make decisions on
behalf of the eligible recipient.
Directing services remains the sole responsibility of the eligible
recipient or his or her authorized representative. The personal representative cannot serve as
the eligible recipient’s consultant and cannot approve his or her specific
timesheet.
P. Reconsideration: An eligible recipient who disagrees with a
clinical or medical utilization review decision or action may submit a written
request to the third-party assessor for reconsideration of its decision. The eligible recipient or his or her
authorized representative may submit the request for a reconsideration through
the consultant or the consultant agency or may submit the request directly to
MAD.
Q. Self-direction: The process applied to the service delivery
system wherein the eligible recipient identifies, accesses and manages the
services (among the MAD approved mi via waiver services and goods) that meet
his or her assessed therapeutic, rehabilitative, habilitative, health or safety
needs to support the eligible recipient to remain in his or her community.
R. Service and support plan (SSP): A plan that includes mi via services that
meet the eligible recipient’s needs that include: the projected amount, the frequency and the
duration of the services; the type of provider who will furnish each service;
other services the eligible recipient will access; and the eligible recipient’s
available supports that will compliment mi via services in meeting his or her
needs.
S. Support guide: A function of the consultant provider that
directly assists the eligible recipient in implementing the SSP to ensure
access to mi via services and supports and to enhance success with
self-direction. Support guide services
provide assistance to the eligible recipient with employer or vendor functions
or with other aspects of implementing his or her SSP.
T. Third-party assessor (TPA): The MAD contractor who determines and
re-determines LOC and medical eligibility for mi via services. The TPA also reviews the eligible recipient's
SSP and approves an AAB for the eligible recipient. The TPA performs utilization management
duties of all mi via services.
U. Waiver:
A program in which the CMS has waived certain statutory requirements of
the Social Security Act to allow states to provide an array of HCBS options
through MAD as an alternative to providing long-term care services in an
institutional setting.
[8.314.6.7 NMAC -
Rp, 8.314.6.7 NMAC, 3/1/2016; A, 11/1/2018]
8.314.6.8 [RESERVED]
[8.314.6.8 NMAC -
Rp, 8.314.6.8 NMAC, 3/1/2016; A, 11/1/2018]
8.314.6.9 MI
VIA HOME AND COMMUNITY-BASED SERVICES WAIVER:
A. New Mexico’s
medicaid self-directed waiver program known as mi via is intended to provide a
community-based alternative to institutional care that allows an eligible
recipient to have control over services and supports. Mi via provides self-directed home and
community-based services to eligible recipients who are living with
developmental disabilities (DD), or medically fragile (MF) conditions. (See 42 CFR 441.300.)
B. The mi via
program is for an eligible recipient who meets the LOC otherwise provided in an
ICF/IID.
(1) DOH,
at the direction of MAD, is responsible for the daily administration of the mi
via program.
(2) Enrollment
in mi via is limited to the number of federally authorized unduplicated
eligible recipients and funding appropriated by the New Mexico legislature for
this purpose.
[8.314.6.9 NMAC -
Rp, 8.314.6.9 NMAC, 3/1/2016]
8.314.6.10 MI
VIA CONTRACTED ENTITIES AND PROVIDERS SUPPORTING SELF-DIRECTED SERVICES:
Services are to be provided in the least restrictive manner. HSD does not allow for the use of any
restraints, restrictive interventions, or seclusions to an eligible mi via recipient. The following resources and services have
been established to assist eligible recipients to self-direct services. These include the following:
A. Consultant services: Consultant services are direct services
intended to educate, guide and assist the eligible recipient to make informed
planning decisions about services and supports, to develop a SSP that is based
on the eligible recipient’s assessed disability-related needs and to assist the
eligible recipient with quality assurance related to the SSP and AAB.
B. Third-party assessor: The TPA or MAD’s designee is responsible for
determining medical eligibility through a LOC assessment, assigning the
applicable IBA, approving the SSP and authorizing an eligible recipient’s
annual budget in accordance with 8.314.6 NMAC and the mi via service
standards. The TPA:
(1) determines
medical eligibility using the LOC criteria in 8.314.6.13 NMAC; determinations
are done initially for an eligible recipient who is newly enrolled in the mi
via program and thereafter at least annually for currently enrolled mi via
eligible recipients; the LOC assessment is done in person with the eligible
recipient in his or her home, a location agreed upon by the eligible recipient
and TPA and approved by HSD, or in an inpatient setting; the TPA may
re-evaluate the LOC more often than annually if there is an indication that the
eligible recipient’s medical condition or LOC has changed;
(2) applies
the information from the LOC documentation and the following assessments: long-term care assessment abstract (ICF/IID),
the comprehensive individual assessment (CIA), or other MAD approved assessment
tools, as appropriate for the COE, to assign the IBA for the eligible recipient
that is medically eligible; and
(3) reviews
and approves the SSP and the annual budget request resulting in an AAB, at
least annually or more often if there is a change in the eligible recipient’s
circumstances, in accordance with 8.314.6 NMAC and mi via service standards.
C. Financial management agent (FMA): The FMA acts as the intermediary between the
eligible recipient and the MAD payment system and assists the eligible
recipient or the EOR with employer-related responsibilities. The FMA pays employees and vendors based upon
an approved SSP and AAB. The FMA assures
there is eligible recipient and program compliance with state and federal
employment requirements, monitors, and makes available to the eligible
recipient the reports related to utilization of services and budget
expenditures. Based on the eligible
recipient’s approved individual SSP and AAB, the FMA must:
(1) verify
that the recipient is eligible for MAD services prior to making payment for
services;
(2) receive
and verify that all required employee and vendor documentation and
qualifications are in compliance with 8.314.6 NMAC and mi via service
standards;
(3) establish
an accounting for each eligible recipient’s AAB;
(4) process
and pay invoices for goods, services, and supports approved in the SSP and the
AAB and supported by required documentation;
(5) process
all payroll functions on behalf of the eligible recipient and EORs including:
(a) collect
and process timesheets of employees;
(b) process
payroll, withholding, filing, and payment of applicable federal, state and
local employment-related taxes and insurance; and
(c) track
and report disbursements and balances of the eligible recipient’s AAB and
provide a monthly report of expenditures and budget status to the eligible
recipient and his or her consultant, and quarterly and annual documentation of
expenditures to MAD;
(6) receive
and verify employee and vendor agreements, including collecting required
provider qualifications;
(7) monitor
hours billed for services provided by the LRI and the total amounts billed for
all goods and services during the month;
(8) answer
inquiries from the eligible recipient and solve problems related to the FMA’s
responsibilities; and
(9) report
to the consultant provider, MAD and DOH any concerns related to the health and
safety of an eligible recipient or if the eligible recipient is not following
the approved SSP and AAB.
[8.314.6.10 NMAC -
Rp, 8.314.6.10 NMAC, 3/1/2016; A, 11/1/2018]
8.314.6.11 QUALIFICATIONS
FOR ELIGIBLE INDIVIDUAL EMPLOYEES, INDEPENDENT PROVIDERS, PROVIDER AGENCIES,
AND VENDORS:
A. Requirements for individual
employees, independent providers, provider agencies and vendors: In
order to be approved as an individual employee, an independent provider,
including non-licensed homemaker or direct support worker, a provider agency,
(excluding consultant providers which are covered in a different subsection) or
a vendor, including those that provide professional services, each individual
or entity must meet the general and service specific qualifications set forth
in this rule initially and continually meet licensure requirements as
applicable, and submit an employee or vendor enrollment packet, specific to the
provider or vendor type, for approval to the FMA. The provider agency is responsible to ensure
that all agency employees meet the required qualifications. In order to be an authorized provider for the
mi via program and receive payment for delivered services, the provider must
complete and sign an employee or vendor provider agreement and all required tax
documents. Individual employees may not
provide more than 40 hours of services in a consecutive seven-day work week. The provider must have credentials verified
by the eligible recipient or the EOR and the FMA.
(1) Prior
to rendering services to an eligible mi via recipient as an independent
contractor for homemaker or direct support worker, respite, community direct
support, employment supports, and in-home living support provider, an
individual seeking to provide these services must complete and submit a nature
of services questionnaire to the FMA.
The FMA will determine, based on the nature of services questionnaire if
the relationship is that of an employee or an independent contractor.
(2) An
authorized consultant provider must have a MAD approved provider participation
agreement (PPA) and the appropriate approved DOH developmental disabilities
division (DDSD) agreement.
B. General qualifications:
(1) Individual
employees, independent providers, including non-licensed homemaker/direct
support workers who are employed by a mi via eligible recipient to provide
direct services shall:
(a) be
at least 18 years of age;
(b) be
qualified to perform the service and demonstrate capacity to perform required
tasks;
(c) be
able to communicate successfully with the eligible recipient;
(d) prior
to the initial hire and every three years after initial hire pass a nationwide
caregiver criminal history screening pursuant to Section 29-17-2 et seq. NMSA
1978 and 7.1.9 NMAC and an abuse registry screen pursuant to Section 27-7a-1 et
seq. NMSA 1978 and 8.11.6 NMAC; additionally employees must pass the employee
abuse registry (EAR) pursuant to 7.1.12 NMAC, certified nurse aide registry
pursuant to 16-12.20 NMAC, office of inspector exclusion list pursuant to
section 1128B(f) of the Social Security Act; and the national sex offender
registry pursuant to 6201 as federal authority for active programs.
(e) complete
training on critical incident, abuse, neglect, and exploitation reporting;
(f) complete
training specific to the eligible recipient’s needs; an assessment of training
needs is determined by the eligible recipient or his or her authorized
representative; the eligible recipient is also responsible for providing and
arranging for employee training and supervising employee performance; training
expenses for paid employees cannot be paid for with the eligible recipient’s
AAB; and
(g) meet
any other service specific qualifications, as specified in this rule and its
service standards.
(2) Vendors,
including those providing professional services shall meet the following
qualifications:
(a) shall
be qualified to provide the service;
(b) shall
possess a valid business license, if applicable;
(c) meet
financial solvency, maintain and adhere to training requirements, record
management, quality assurance policy and procedures, if applicable;
(d) be
in good standing with and comply with his or her New Mexico practice board or
other certification or licensing required to render mi via services in New
Mexico; and
(e) must
not have a DOH current adverse action against them.
(f) assure
that employees of the vendor:
(i) are
at least 18 years of age;
(ii) are qualified to perform the service and
demonstrate capacity to perform required tasks;
(iii) are able to communicate successfully with the eligible recipient;
(iv) pass a nationwide caregiver
criminal history screening pursuant to Section 29-17-2 et seq. NMSA 1978 and
7.1.9 NMAC and an abuse registry screen pursuant to Section 27-7a-1 et seq.
NMSA 1978 and 8.11.6 NMAC;
(v) complete
training on critical incident, abuse, neglect, and exploitation reporting;
(vi) complete
training specific to the eligible recipient’s needs; an assessment of training
needs is determined by the eligible recipient or his or her authorized
representative; the eligible recipient is also responsible for providing and
arranging for employee training and supervising employee performance; training
expenses for paid employees cannot be paid for with the eligible recipient’s
AAB; and
(g) meet
any other service specific qualifications, as specified in this rule and its
service standards.
(3) Qualified
and approved relatives, authorized representatives or personal representatives
may be hired as employees and paid for the provision of mi via services (except
consultant and support guides, customized community group supports services,
transportation services for a minor, and individual directed goods and
services). The services must be
identified in the eligible recipient’s approved SSP and AAB, and the EOR is
responsible for verifying that services have been rendered by completing, signing,
and submitting documentation, including the timesheet, to the FMA. These services must be provided within the
limits of the approved SSP and AAB and may not be paid in excess of 40 hours in
a consecutive seven-day work week. LRIs,
authorized representatives, personal representatives or relatives may not be
both a paid employee for the eligible recipient and serve as the eligible
recipient’s EOR. An authorized or
personal representative who is also an employee may not approve his or her own
timesheet.
(4) A
LRI may be hired and paid for provision of mi via services (except
transportation services when requested for a minor, a consultant and support
guide, and customized community group supports services, and related goods)
under extraordinary circumstances (i) in order to assure the health and welfare
of the eligible recipient and (ii) to avoid institutionalization when approved
by DOH. MAD must be able to receive
federal financial participation (FFP) for the services.
(a) Extraordinary
circumstances include the inability of the LRI to find other qualified,
suitable caregivers when the LRI would otherwise be absent from the home and,
thus, the caregiver must stay at home to ensure the eligible recipient’s health
and safety.
(b) LRIs
may not be paid for any services that they would ordinarily perform in the
household for individuals of the same age who do not have a disability or
chronic illness.
(c) Services
provided by LRIs must:
(i) meet
the definition of a service or support and be specified in the eligible
recipient’s approved SSP and AAB;
(ii) be
provided by a parent or spouse who meets the provider qualifications and
training standards specified in the mi via rule for that service; and
(iii) be
paid at a rate that does not exceed that which would otherwise be paid to a
provider of a similar service,and be approved by the TPA.
(d) A
LRI who is a service provider must comply with the following:
(i) a
parent, parents in combination, legal guardian of a minor, or a spouse of the
eligible recipient, may not provide more than 40 hours of services in a
consecutive seven-day work week; for parents or legal guardians of the eligible
recipient, 40 hours is the total amount of service regardless of the number of
eligible recipients under the age of 21 who receive services through the mi via
program;
(ii) planned
work schedules must be identified in the approved SSP and AAB, and variations
to the schedule must be reported to the eligible recipient’s consultant and
noted and supplied to the FMA when billing; and
(iii) timesheets
and other required documentation must be maintained and submitted to the FMA
for hours paid.
(e) An
eligible recipient must be offered a choice of providers. There must be written approval from DOH when
a provider is chosen who is:
(i) a
parent or legal guardian of an eligible recipient who is a minor; or
(ii) the
eligible recipient’s spouse.
(f) This
written approval must be documented in the SSP.
(g) The
FMA monitors, on a monthly basis, hours billed for services provided by the LRI
and the total amounts billed for all goods and services during the month.
(5) Once
enrolled, providers, vendors and contractors receive a packet of information
from the eligible recipient or FMA, including billing instructions, and other pertinent
materials. Mi via eligible recipients or
EOR’s or authorized representatives are
responsible for ensuring that providers, vendors and contractors have received
these materials and for updating them as new materials are received from MAD
and DOH. MAD makes available on its
website, and in hard copy format, information necessary to participate in
medical assistance programs administered by HSD or its authorized agents,
including program rules, billing instructions, utilization review instructions,
and other pertinent materials. DOH makes
available on its website information, instructions and guidance on its
administrative requirements for the mi via program. When enrolled, an eligible recipient or his
or her authorized representative, or the provider, vendor or contractor
receives instruction on how to access these documents. It is the responsibility of the eligible
recipient or authorized representative, or the provider, vendor, or contractor
to access these instructions or ask for paper copies to be provided, to
understand the information provided and to comply with the requirements. The eligible recipient or authorized
representative, or the provider, vendor, or contractor must contact HSD or its
authorized agents to request hard copies of any program rules manuals, billing
and utilization review instructions, and other pertinent materials and to
obtain answers to questions on or not covered by these materials.
(a) No
employee of any type may be paid in excess of 40 hours within the established
consecutive seven day work week for any one eligible recipient or EOR.
(b) No
provider agency is permitted to perform both LOC assessments and provide any
services for the eligible recipients.
(c) Providers
may market their services, but are prohibited from soliciting eligible
recipients under any circumstances such as offering an eligible recipient or
his or her authorized representative gratuities in the form of entertainment,
gifts, financial compensation to alter that eligible recipient’s selection of
provider agencies, service agreements, medication, supplies, goods or services.
(d) Those
signing a payment request form for vendor services rendered to an eligible
recipient may not serve as an employee, contractor or subcontractor of that vendor
for that eligible recipient. An eligible
recipient who does not have an authorized representative providing oversight of
the eligible recipient’s financial matters may sign off on the payment request
form.
(6) The
EOR is the individual responsible for directing the work of the eligible
recipient’s employees. An eligible
recipient is required to have an EOR when utilizing employees. The EOR may be the eligible recipient or a
designated qualified individual. A
recipient through the use of the mi via EOR questionnaire will determine if an
individual meets the requirements to serve as an EOR. The recipient’s consultant will provide him
or her with the questionnaire. The questionnaire
shall be completed by the recipient with assistance from the consultant upon
request. The consultant shall maintain a
copy of the completed questionnaire in the recipient’s file. When utilizing both vendors and employees, an
EOR is required for oversight of employees and to sign payment request forms
for vendors. The EOR must be documented
with the FMA, whether the EOR is the eligible recipient or a designated
qualified individual. A POA or other
legal instrument may not be used to assign the EOR responsibilities, in part or
in full, to another individual and may not be used to circumvent the
requirements of the EOR as designated in 8.314.6 NMAC.
(a) An
eligible recipient that has a plenary or limited guardianship or
conservatorship over the eligible recipient’s financial matters may not be his
or her own EOR nor sign payment vendor request forms for vendors.
(b) A
person under the age of 18 years may not be an EOR.
(c) An
EOR who lives outside New Mexico shall reside within 100 miles of the New
Mexico state border. Any out of state
EOR residing beyond this radius who has been approved prior to the effective
date of this rule may continue to serve as the EOR.
(d) The
eligible recipient’s provider may not also be his or her EOR nor sign payment
vendor request forms for vendors.
(e) An
EOR whose performance compromises the health, safety or welfare of the eligible
recipient, may have his or her status as an EOR terminated.
(f) An
EOR may not be paid for any other services utilized by the eligible recipient
for whom he or she is the EOR, whether as an employee of the eligible
recipient, a vendor, or an employee or contactor, or subcontractor of an
agency. An EOR makes important
determinations about what is in the best interest of the eligible recipient,
and should not have any conflict of interest.
An EOR assists in the management of the eligible recipient’s budget and
should have no personal benefit connected to the services requested or approved
on the budget.
(g) An
EOR is not required if an eligible recipient is utilizing only vendors for
services; however, an EOR can be identified by an eligible recipient to assist
with the use of vendors. In some
instances an EOR for vendor services may be required by MAD. A recipient utilizing vendors only who
selects not to have an EOR will submit documentation to the FMA identifying an
authorized signer who will be responsible for signing payment request
forms. The authorized signer for vendor
services rendered to an eligible recipient may not serve as an employee, contractor
or subcontractor of that vendor for that eligible recipient. An eligible recipient who does not have a
plenary or limited guardianship or conservatorship providing oversight of the
eligible recipient’s financial matters may be his or her own authorized signer
for the payment request form. A POA may
not be used to assign the responsibilities of the authorized signer, in part or
in full, to another individual and may not be used to circumvent the
requirements of the authorized signer as designated in this rule.
(h) An
EOR, or authorized signer, is required to complete and provide documents to the
FMA according to the timelines and rules established by the state. Documents include, but are not limited to:
vendor and employee enrollment agreements, vendor information forms, criminal
background check forms, timesheets, payment request forms, invoices, and other
documents needed by the FMA to enroll and process payment to employees and
vendors. The mi via program requires
that employee timesheets be submitted online unless the recipient has an
approved exception from HSD.
C. Service specific qualifications for
consultant services providers: In
addition to general requirements, a consultant provider shall ensure that all
individuals hired or contracted to provide consultant services meet the criteria
specified in this section and comply with all applicable NMAC MAD rules and mi
via service standards.
(1) Consultant
providers shall:
(a) possess
a minimum of a bachelor’s degree in social work, psychology, human services,
counseling, nursing, special education or a closely related field, and have one
year of supervised experience working with people living with disabilities; or
(b) have
a minimum of six years of direct experience related to the delivery of social
services to people living with disabilities; and
(c) be
employed by an enrolled mi via consultant provider agency; and
(d) complete
all required mi via program orientation and training courses; and
(e) be at least 21 years of age.
(2) Consultant
providers may also use non-professional staff to carry out support guide
functions. Support guides provide more
intensive supports, as detailed in the service section of these rules. Support guides help the eligible recipient
more effectively self-direct services when there is an identified need for this
type of assistance. Consultant providers
shall ensure that non-professional support staff:
(a) are
supervised by a qualified consultant as specified in this rule;
(b) have
experience working with people living with disabilities;
(c) demonstrate
the capacity to meet the eligible recipient’s assessed needs related to the
implementation of the SSP;
(d) possess
knowledge of local resources, community events, formal and informal community
organizations and networks;
(e) are
able to accommodate a varied, flexible and on-call type of work schedule in
order to meet the needs of the eligible recipient; and
(f) complete
training on self-direction and incident reporting; and
(g) be
at least 18 years of age.
D. Service specific qualifications for
personal plan facilitation providers:
In addition to general MAD requirements, a personal plan facilitator
agency must hold a current business license, and meet financial solvency,
training, records management, and quality assurance rules and
requirements. Personal plan facilitators
must possess the following qualifications in addition to the general
qualifications:
(1) have
at least one year of experience working with persons with disabilities; and
(2) be
trained and mentored in the planning tool(s) used; and
(3) have
at least one year experience in providing the personal plan facilitation
service.
E. Service specific qualification for living
supports providers: In addition to general MAD requirements, the
following types of providers must meet additional qualifications specific to
the type of services provided.
(1) Qualifications of homemaker direct support
service providers: Provider agencies
must be homemaker agencies certified by the MAD or its designee or a home
health agency holding a New Mexico home health agency license. A homemaker and home health agency must hold
a current business license when applicable, and meet financial solvency,
training, records management, and quality assurance rules and requirements.
(2) Qualifications of home health aide service
providers: Home health or homemaker
agencies must hold a New Mexico current home health agency, rural health
clinic, or federally qualified health center license. Home health aides must have successfully
completed a home health aide training program, as described in 42 CFR
484.36(a)(1) and (2) or have successfully completed a home health aide training
program pursuant to 7.28.2.30 NMAC. Home
health aides must also be supervised by a registered nurse (RN) licensed in New
Mexico. Such supervision must occur at
least once every 60 calendar days in the eligible recipient’s home, and shall
be in accordance with the New Mexico Nurse Practice Act and be specific to the
eligible recipient’s SSP.
(3) Qualifications of in-home
living supports providers: Provider agencies must hold a current
business license, and meet financial solvency, training, records management,
and quality assurance rules and requirements.
In-home living agency staff and its direct staff rendering the service
must have one year of experience working with people with disabilities. In-home living support agencies must
assure appropriate staff for a 24 hour response capability to address scheduled
or unpredictable needs related to health, safety, or security in order to meet
the needs of the recipient. In-home
living support agencies are not fiscal intermediaries and cannot bill nor be
paid for work that the recipient or EOR are responsible for as required by
Paragraph (6) of Subsection B of 8.314.6.11 NMAC and the mi via service
standards.
F. Service specific qualifications for
community membership support providers:
In addition to general MAD requirements, the following types of
providers must meet additional qualifications specific to the type of services
provided. An agency providing community
membership services must hold a current business license, and meet financial
solvency, training, records management, and quality assurance rules and requirements.
(1) Qualifications of supported employment
providers:
(a) A
job developer, whether an agency or individual provider, must:
(i) be
at least 21 years of age;
(ii) pass
criminal background check and abuse registry screen;
(iii) have
experience developing and using job and task analyses;
(iv) have
experience working with the division of vocational rehabilitation (DVR), a
traditional DD waiver employment provider, an independent living center or
other organization that provides employment supports or services for people
with disabilities and be trained on the purposes, functions and general
practices of entities such as the department of workforce solutions navigators, one-stop career centers, business
leadership network, chamber of commerce, job accommodation network, small
business development centers, local businesses, retired executives, DDSD
resources, and have substantial knowledge of the Americans with Disabilities
Act (ADA); and
(v) complete
training on critical incident, abuse, neglect, and exploitation.
(b) Job
coaches whether an agency or individual provider, must:
(i) be
at least 18 years of age;
(ii) have
a high school diploma or GED;
(iii) pass
criminal background check and abuse registry screen;
(iv) be
qualified to perform the service;
(v) have experience with providing
employment supports and training methods;
(vi) be
knowledgeable about business and employment resources;
(vii) have
the ability to successfully communicate with the employer and with the eligible
recipient and his or her coworkers to develop and encourage natural supports on
the job; and
(viii) complete
training on critical incident, abuse, neglect, and exploitation.
(2) Qualifications of customized community
group supports providers: Agencies
providing community group support services must hold a current business
license, and meet financial solvency, training, records management, and quality
assurance rules and requirements.
Providers, whether an agency staff or an individual provider must meet
the following qualifications:
(i) must
be at least 18 years of age;
(ii) pass
criminal background check and abuse registry screen;
(iii) demonstrate
capacity to perform required tasks;
(iv) complete
training on critical incident, abuse, neglect, and exploitation reporting; and
(v) have
the ability to successfully communicate with the eligible recipient.
G. Service specific qualifications for
providers of health and wellness supports:
In addition to the general MAD qualifications, the following types of
providers must meet additional qualifications specific to the type of services
provided.
(1) Qualifications of extended state plan
skilled therapy providers for adults:
Physical and occupational therapists, speech/language pathologists,
physical therapy assistants and occupational therapy assistants must possess a
therapy license in their respective field from the New Mexico regulation and
licensing department (RLD). Speech
clinical fellows must possess a clinical fellow license from the New Mexico
RLD.
(2) Qualifications
of behavior support consultation providers: Behavior support consultation
provider agencies shall have a current business license issued by the state,
county or city government, if required.
Behavior support consultation provider agencies shall comply with all
applicable federal, state, and rules and procedures regarding behavior
consultation. Providers of
behavior support consultation services must possess qualifications in at least
one of the following areas:
(a) a
licensed psychiatrist by his or her New Mexico practice board;
(b) a
regulation and licensing department (RLD) licensed clinical psychologist;
(c) a
RLD licensed psychologist associate, (masters or Ph.D. level);
(d) a
RLD licensed independent social worker (LISW);
(e) a
RLD licensed master social worker (LMSW);
(f) a
RLD licensed professional clinical counselor (LPCC);
(g) a
licensed clinical nurse specialist (CNS) or a certified nurse practitioner
(CNP) who is certified in psychiatric nursing by a national nursing
organization who can furnish services to adults or children as his or her
certification permits;
(h) a
RLD licensed marriage and family therapist (LMFT); or
(i) a
RLD licensed practicing art therapist (LPAT) by RLD.
(3) Qualifications of nutritional counseling
providers: Nutritional counseling
providers must maintain a current registration as dietitians by the commission
on dietetic registration of the American dietetic association and licensed by
the RLD, (Nutrition and Dietetics Practice Act Section 61-7A-7 et seq. NMSA
1978).
(4) Qualifications of private duty nursing
providers for adults: Direct nursing
services are provided by individuals who are currently licensed as registered
or practical nurses by the New Mexico state board of nursing, (Sections 61-3-14
and 61-3-18 NMSA 1978).
(5) Qualifications of specialized therapy
providers: For each type of
specialized therapy providers, the provider must hold the appropriate New
Mexico licensure or certification for the services he or she renders to an
eligible recipient:
(a) a
RLD license in acupuncture and oriental medicine;
(b) a
license or certification with the appropriate specialized training and clinical
experience and supervision whose scope of practice includes biofeedback;
(c) a
RLD license in chiropractic medicine;
(d) a
license or certification for which he or she has appropriate specialized
training and clinical experience and whose scope of practice includes cognitive
rehabilitation therapy;
(e) a
RLD license in a physical therapy, or occupational therapy, or speech therapy
and whose scope of practice includes hippotherapy with the appropriate
specialized training and experience;
(f) a
RLD license in massage therapy;
(g) a
RLD license in naprapathic medicine;
(h) a
master’s or a higher level behavioral health degree with specialized play
therapy training, clinical experience and supervision and whose RLD license’s
scope of practice includes play therapy; and
(i) a
native American healer who is recognized as a traditional healer within his or
her community.
H. Service specific qualifications for other
supports providers: In addition to
the general MAD qualifications, the following types of providers must meet
additional qualifications specific to the type of services provided.
(1) Qualifications of transportation providers:
(a) Individual
transportation providers must:
(i) possess
a valid New Mexico driver’s license with the appropriate classification;
(ii) complete
training on critical incident, abuse, neglect and exploitation reporting
procedures; and
(iii) have
a current insurance policy and vehicle registration.
(b) Transportation
vendors must hold a current business license and tax identification
number. Each agency will ensure any
vehicle used to transport an eligible recipient is equipped with an up-to-date
first aid kit. Each agency will ensure
transportation drivers meet the following qualifications:
(i) holds
a valid New Mexico driver’s license of the appropriate classification to
transport an eligible recipient;
(ii) holds
a current vehicle insurance policy meeting New Mexico’s insurance mandates in
place for the vehicle used to transport an eligible recipient; and
(iii) holds
a New Mexico vehicle registration for the vehicle used to transport an eligible
recipient.
(2) Qualifications of emergency response
providers: Emergency response
providers must comply with all laws, rules and regulations of the state of New
Mexico.
(3) Qualifications of respite providers: Respite services may be provided by eligible
individual respite providers; RN or practical nurses (LPN); or respite provider
agencies. Individual RN or LPN providers
must be licensed by the New Mexico board of nursing as an RN or LPN. Respite provider agencies must hold a current
business license, and meet financial solvency, training, records management and
quality assurance rules and requirements.
(4) Qualifications of individual directed goods
and services vendors: Individual
directed goods and services vendors must hold a current business license and
tax identification for New Mexico and the federal government. Vendors for individual directed goods and
services are retail stores, community health centers, or medical supply stores.
(5) Qualifications of environmental
modifications providers:
Environmental modification providers must possess an appropriate
plumbing, electrician, contractor or other appropriate New Mexico licensure.
[8.314.6.11 NMAC -
Rp, 8.314.6.11 NMAC, 3/1/2016; A, 11/1/2018]
8.314.6.12 RECORDKEEPING AND DOCUMENTATION Responsibilities:
Service providers and vendors who furnish goods and services to mi via
eligible recipients are reimbursed by the FMA and must comply with all
applicable NMAC MAD rules and service standards. The FMA, consultants and service providers
must maintain records, which are sufficient to fully disclose the extent and
nature of the goods and services provided to the eligible recipients, as
detailed in applicable NMAC MAD provider rules and comply with random and
targeted audits conducted by MAD and DOH or their audit agents. MAD or its designee will seek recoupment of
funds from service providers when audits show inappropriate billing for
services. Mi via vendors who furnish
goods and services to mi via eligible recipients and bill the FMA must comply
with all MAD PPA requirements and NMAC MAD rules and requirements, including
but not limited to 8.310.2 NMAC and 8.321.2 NMAC and 8.302.1 NMAC.
[8.314.6.12 NMAC -
Rp, 8.314.6.12 NMAC, 3/1/2016]
8.314.6.13 Eligibility
requirements for Recipient enrollment in Mi via: Enrollment
in the mi via program is contingent upon the applicant meeting the eligibility
requirements as described in this rule, the availability of funding as
appropriated by the New Mexico legislature, and the number of federally
authorized unduplicated eligible recipients.
When sufficient funding as well as waiver positions are available, DOH
will offer the opportunity to eligible recipients to select mi via. Once an allocation has been offered to the
applicant, he or she must meet certain medical and financial criteria in order
to qualify for mi via enrollment located in 8.290.400 NMAC. The eligible recipient must meet the LOC
required for admittance to an ICF-IID. After
initial eligibility has been established for a recipient, on-going eligibility
must be determined on an annual basis.
[8.314.6.13 NMAC -
Rp, 8.314.6.13 NMAC, 3/1/2016]
8.314.6.14 ELIGIBLE
RECIPIENT AND EOR RESPONSIBILITIES: Mi via eligible recipients have
certain responsibilities to participate in the program. Failure to comply with these responsibilities
or other program rules and service standards can result in termination from the
program. The eligible recipient and EOR,
or authorized signer if the recipient has vendors only, have the following
responsibilities:
A. To maintain
eligibility the recipient must complete required documentation demonstrating
medical and financial eligibility both upon application and annually at
recertification, meet in person with the TPA for a comprehensive LOC assessment
in the eligible recipient’s home, or in a location approved by the state and
seek assistance with the application and the recertification process as needed
from a mi via consultant.
B. To participate
in the mi via program, the eligible recipient must:
(1) comply
with applicable NMAC rules to include this rule, mi via service standards and
requirements that govern the program;
(2) collaborate
with the consultant to determine support needs related to the activities of
self-direction;
(3) collaborate
with the consultant to develop an SSP using the IBA in accordance with
applicable NMAC rules to include this rule and service standards;
(4) use
mi via program funds appropriately by only requesting and purchasing goods and
services covered by the mi via program in accordance with program rules which
are identified in the eligible recipient’s approved SSP;
(5) comply
with the approved SSP and not exceed the AAB;
(a) if
the eligible recipient does not adequately allocate the resources contained in
the AAB resulting in a premature depletion of the AAB amount during an SSP year
due to mismanagement or failure to properly track expenditures, the failure to
properly allocate does not substantiate a claim for a budget increase (i.e., if
all of the AAB is expended within the first three months of the SSP year, it is
not justification for an increase in the budget for the SSP year);
(b) revisions
to the AAB may occur within the SSP year, and the eligible recipient is
responsible for assuring that all expenditures are in compliance with the most
current AAB in effect;
(i) the
SSP must be amended first to reflect a change in the eligible recipient’s needs
or circumstances before any revisions to the AAB can be requested;
(ii) other
than for critical health and safety reasons, budget revisions may not be
submitted to the TPA for review within the last 60 calendar days of the budget
year;
(c) no
mi via program funds can be used to purchase goods or services prior to TPA
approval of the SSP and annual budget request;
(d) any
funds not utilized within the SSP and AAB year cannot be carried over into the
following year;
(6) access
consultant services based upon identified need(s) in order to carry out the
approved SSP;
(7) collaborate
with the consultant to appropriately document service delivery and maintain
those documents for evidence of services received;
(8) report
concerns or problems with any part of the mi via program to the consultant or
if the concern or problem is with the consultant, to DOH;
(9) work
with the TPA agent by attending scheduled meetings, in the eligible recipient’s
home if necessary and providing documentation as requested;
(10) respond
to requests for additional documentation and information from the consultant
provider, FMA, and the TPA within the required deadlines;
(11) report
to the local HSD income support division (ISD) office within 10 calendar days
any change in circumstances, including a change in address, which might affect
eligibility for the program; changes in address or other contact information
must also be reported to the consultant provider and the FMA within 10 calendar
days;
(12) report
to the TPA and consultant provider if hospitalized for more than three
consecutive nights so that an appropriate LOC can be obtained;
(13) keep
track of all budget expenditures and assure that all expenditures are within
the AAB;
(14) have
monthly contact and meet face-to-face quarterly with the consultant; and
(15) have
an EOR if utilizing employees for services; the eligible recipient may be his
or her own EOR unless the eligible recipient is a minor, or he or she has a
plenary or limited guardianship or conservatorship over financial matters; an
eligible recipient may also designate an individual of his or her choice to
serve as the EOR, subject to the EOR meeting the qualifications specified in
this rule. If the recipient is using
vendors only and selects not to have an EOR then the recipient will identify an
authorized signer for payment request forms; the eligible recipient may be his
or her own authorized signer unless the eligible recipient is a minor, or he or
she has a plenary or limited guardianship or conservatorship over financial
matters. A POA or other legal instrument
may not be used to assign the EOR, or authorized signer, responsibilities, in
part or in full, to another individual and may not be used to circumvent the
requirements of the EOR, or authorized signer, as designated in this rule.
C. Additional
responsibilities of the eligible recipient or EOR, or authorized signer, are
detailed below:
(1) Submit
all required documents to the FMA according to the timelines and rules
established by the state to meet employer-related responsibilities. This includes, but is not limited to,
documents for payment to employees and vendors and payment of taxes and other
financial obligations within required timelines. The EOR is responsible for submitting mi via
employee timesheets online unless the recipient has an approved exception from
HSD.
(2) Report
any incidents of abuse, neglect or exploitation to the appropriate state
agency.
(3) Arrange
for the delivery of services, supports and goods.
(4) Hire,
manage, and terminate employees.
(5) Maintain
records and documentation for at least six years from first date of service and
ongoing.
D. Voluntary termination: An eligible recipient has a choice of
receiving services through the non-self-directed waiver or through the mi via
HCBS waiver. If the eligible recipient
wishes to change to the non-self-directed HCBS waiver, a waiver change must occur
in accordance with the mi via NMAC rule and mi via service standards. Transitions can only occur at the first of a
month.
E. Involuntary termination: A mi via eligible recipient may be terminated
involuntarily by MAD and DOH and offered services through a non-self-directed
waiver or the medicaid state plan under the following circumstances.
(1) The
eligible recipient refuses to comply with this rule and mi via service
standards after receiving focused technical assistance on multiple occasions, support
from the program staff, consultant, or FMA, which is supported by documentation
of the efforts to assist the eligible recipient.
(2) The
eligible recipient is in immediate risk to his or her health or safety by
continued self-direction of services, e.g., the eligible recipient is in
imminent risk of death or serious bodily injury related to participation in the
mi via program. Examples include but are
not limited to the following.
(a) The
eligible recipient refuses to include and maintain services in his or her SSP
and AAB that would address health and safety issues identified in his or her
medical assessment or challenges the assessment after repeated and focused
technical assistance and support from program staff, consultant, or FMA.
(b) The
eligible recipient is experiencing significant health or safety needs, and,
after a referral to the state contractor for level of risk determination and
assistance, refuses to incorporate the contractor’s recommendations into his or
her SSP and AAB.
(c) The
eligible recipient exhibits behaviors which endanger himself or herself or
others.
(3) The
eligible recipient misuses mi via funds following repeated and focused
technical assistance and support from the consultant or FMA, which is supported
by documentation.
(4) The
eligible recipient commits medicaid fraud.
(5) When
DOH is notified the eligible recipient continues to utilize either an employee
or a vendor, or both who have consistently been substantiated against for
abuse, neglect, exploitation while providing mi via services after notification
of this on multiple occasions by DOH.
(6) The
eligible recipient who is involuntarily terminated from the mi via program will
be offered a non self-directed waiver alternative. If transfer to another waiver is authorized
and accepted by the eligible recipient, he or she will continue to receive the
services and supports from mi via until the day before the new waiver services
start. This will ensure that no break in
service occurs. The mi via consultant
and the case manager in the new waiver will work closely together with the
eligible recipient to ensure that the eligible recipient’s health and safety is
maintained.
[8.314.6.14 NMAC -
Rp, 8.314.6.14 NMAC, 3/1/2016; A, 11/1/2018]
8.314.6.15 service
descriptions and coverage criteria: The services covered by the mi
via program are intended to provide a community-based alternative to
institutional care for an eligible recipient that allows greater choice,
direction and control over services and supports in a self-directed
environment. Mi via services must
specifically address a therapeutic, rehabilitative, habilitative, health or
safety need that results from the eligible recipient’s qualifying condition. The mi via program is the payor of last
resort. The coverage of mi via services
must be in accordance with 8.314.6 NMAC and mi via service standards. Waiver recipients in all living arrangements
are assessed individually and service plan development is individualized. The TPA will assess the service plans of
recipients living in the same residence to determine whether or not there are
services that are common to more than one recipient living in the same
household in order to determine whether one or more employees may be needed to
ensure that individual different cognitive, clinical, and habilitative needs
are met. Mi via services must be
provided in integrated settings and facilitate full access to the community;
ensure the recipient receives services in the community to the same degree of
access as those individuals not receiving HCBS services; maximize independence
in making life choices; be chosen by the recipient in consultation with the
guardian as applicable; ensure the right to privacy, dignity, respect, and
freedom from coercion and restraint; optimize recipient initiative, autonomy
and independence in making life choices; provide an opportunity to seek
competitive employment; and facilitate choice of service and who provides them.
A. General requirements regarding mi via
covered services. To be considered a
covered service under the mi via program, the following criteria must be
met. Services, supports and goods must:
(1) directly
address the eligible recipient’s qualifying condition or disability;
(2) meet
the eligible recipient’s clinical, functional, medical or habilitative needs;
(3) be
designed and delivered to advance the desired outcomes in the eligible
recipient’s service and support plan; and
(4) support
the eligible recipient to remain in the community and reduce the risk of
institutionalization.
B. Consultant pre-eligibility and enrollment
services: Consultant pre-eligibility
and enrollment services are intended to provide information, support, guidance,
and assistance to an individual during the medicaid financial and medical
eligibility process. The level of
support provided is based upon the unique needs of the individual. When an opportunity to be considered for mi
via program services is offered to an individual, he or she must complete a
primary freedom of choice form. The
purpose of this form is for the individual to select a consultant
provider. The chosen consultant provider
offers pre-eligibility and enrollment services as well as on-going consultant
services. Once the individual is
determined to be eligible for mi via services, the consultant service provider
will continue to render consultant services to the newly enrolled eligible
recipient as set forth in the consultant service standards.
C. Consultant services: Consultant services are required for all mi
via eligible recipients to educate, guide, and assist the eligible recipients
to make informed planning decisions about services and supports. The consultant helps the eligible recipient
develop the SSP based on his or her assessed needs. The consultant assists the eligible recipient
with implementation and quality assurance related to the SSP and AAB. Consultant services help the eligible
recipient identify supports, services and goods that meet his or her needs,
meet the mi via requirements and are covered mi via services. Consultant services provide support to
eligible recipients to maximize their ability to self-direct their mi via
services.
(1) Contact requirements: Consultant providers shall make contact with
the eligible recipient in person or by telephone at least monthly for a routine
follow-up. Consultant providers shall
meet face-to-face with the eligible recipient at least quarterly; one visit
must be conducted in the eligible recipient’s home at least annually. During monthly contact the consultant:
(a) reviews
the eligible recipient’s access to services and whether they were furnished per
the SSP;
(b) reviews
the eligible recipient’s exercise of free choice of provider;
(c) reviews
whether services are meeting the eligible recipient’s needs;
(d) reviews
whether the eligible recipient is receiving access to non-waiver services per
the SSP;
(e) reviews
activities conducted by the support guide, if utilized;
(f) documents
changes in status;
(g) monitors
the use and effectiveness of the emergency back-up plan;
(h) documents
and provides follow up, if necessary, if challenging events occur that prevent
the implementation of the SSP;
(i) assesses
for suspected abuse, neglect, or exploitation and report accordingly; if not
reported, takes remedial action to ensure correct reporting;
(j) documents
progress of any time sensitive activities outlined in the SSP;
(k) determines
if health and safety issues are being addressed appropriately; and
(l) discusses
budget utilization concerns.
(2) Quarterly
visits will be conducted for the following purposes:
(a) review
and document progress on implementation of the SSP;
(b) document
usage and effectiveness of the emergency backup plan;
(c) review
SSP and budget spending patterns (over and under-utilization);
(d) assess
quality of services, supports and functionality of goods in accordance with the
quality assurance section of the SSP and any applicable sections of the mi via
rules and service standards;
(e) document
the eligible recipient’s access to related goods identified in the SSP;
(f) review
any incidents or events that have impacted the eligible recipient’s health,
welfare or ability to fully access and utilize support as identified in the
SSP; and
(g) other
concerns or challenges, including but not limited to complaints, eligibility
issues, and health and safety issues, raised by the eligible recipient,
authorized representative or personal representative.
(3) Change of consultants: Consultants are responsible for assisting
eligible recipients to transition to another consultant provider when
requested. Transition from one
consultant provider to another can only occur at the first of the month.
(4) Critical incident management
responsibilities and reporting requirements: The consultant provider shall report incidents
of abuse, neglect, exploitation, suspicious injury, environmental hazards, and
eligible recipient death as directed by the appropriate state agency(ies). The consultant provider shall provide
training to eligible recipients EOR, authorized representatives or other
designated individuals regarding recognizing and reporting critical
incidents. Critical incidents include abuse,
neglect, exploitation, suspicious injury, environmental hazards and eligible
recipient deaths. The consultant
provider shall maintain a critical incident management system to identify,
report, and address critical incidents.
The consultant provider is responsible for follow-up and assisting the
eligible recipient to help ensure health and safety when a critical incident
has occurred. Critical incident
reporting requirements for mi via eligible recipients who have been designated
with an ICF/IID LOC, critical incidents should be directed in the following
manner.
(a) DOH
triages, and investigates all reports of alleged abuse, neglect, exploitation,
suspicious injury, environmental hazards, and eligible recipient deaths for mi
via services and eligible recipients to include expected and unexpected
deaths. The reporting of these critical
incidents is mandated for all those providing mi via services pursuant to
7.1.14 NMAC. Any critical incidents must
be reported to the children, youth and families department (CYFD) child
protective services (CPS) or the DOH division of health improvement (DHI)
incident management bureau (IMB) for eligible recipients under 18 years. For eligible recipient’s 18 years and older,
IMB is contacted to report any critical incidents. The reporter must then fax DHI the abuse,
neglect and exploitation or report of death form within 24 hours of a verbal
report. If the reporter has internet
access, the report form shall be submitted via DHI’s website. Anyone may report an incident; however, the
person with the most direct knowledge of the incident is the individual who is
required to report the incident.
(b) With
respect to mi via services provided by any employee, contractor, vendor or
other community-based waiver service agency having a provider agreement with DOH,
any suspected abuse, neglect, exploitation, suspicious injury, environmental
hazard, eligible recipient death must be reported to the CYFD/CPS or
DOH/DHI/IMB for the eligible recipient under 18 years or to IMB for eligible
recipients age 18 years or older. See
Sections 27-7-14 through 27-7-31 NMSA 1978 (Adult Protective Services Act) and
in Sections 32A-4-1 through 32A-4-34 NMSA 1978 (Child Abuse and Neglect Act).
(5) Conflict of interest: An eligible recipient’s consultant may not
serve as the eligible recipient’s EOR, authorized representative or personal
representative for whom he or she is the consultant. A consultant may not be paid for any other
services utilized by the eligible recipient for whom he or she is the
consultant, whether as an employee of the eligible recipient, a vendor, an
employee or subcontractor of an agency.
A consultant may not provide any other paid mi via services to an
eligible recipient unless the recipient is receiving consultant services from
another agency. The consultant agency
may not provide any other direct services for an eligible recipient that has an
approved SSP, an approved budget, and is actively receiving services in the mi
via program. The consultant agency may
not employ as a consultant any immediate family member or guardian for an
eligible recipient of the mi via program that is served by the consultant
agency. A consultant agency may not
provide guardianship services to an eligible recipient receiving consultant
services from that same agency. The consultant
agency may not provide any direct support services through any other type of
1915 (c) Home and Community Based Waiver Program. A consultant agency shall not engage
in any activities in their capacity as a provider of services to an eligible
recipient that may be a conflict of interest.
As such a consultant agency shall not hold a business or financial
interest in an affiliated agency that is paid to provide direct care for any
individuals receiving mi via services.
An affiliated agency is defined as a direct service agency providing mi
via services that has a marital, domestic partner, blood, business interest or
holds financial interest in providing direct care for individuals receiving mi
via services. Affiliated agencies must
not hold a business or financial interest in any entity that is paid to provide
direct care for any individuals receiving HCBS services. Any direct service agency or consultant
agency that has been referred to the DOH internal review committee (IRC) or is
on a moratorium will not be approved to provide mi via services.
D. Personal plan facilitation:
Personal plan facilitation supports planning activities that may be used
by the eligible recipient to develop his or her SSP as well as identify other
sources of support outside the SSP process.
This service is available to an eligible recipient one time per budget
year.
(1) In
the scope of personal planning facilitation, the personal plan facilitator
will:
(a) meet
with the eligible recipient and his or her family (or authorized
representative, or personal representative as appropriate) prior to the
personal planning session to discuss the process, to determine who the eligible
recipient wishes to invite, and determine the most convenient date, time and
location; this meeting preparation shall include an explanation of the
techniques the facilitator is proposing to use or options if the facilitator is
trained in multiple techniques; the preparation shall also include a discussion
of the role the eligible recipient prefers to play at the planning session,
which may include co-facilitation of all or part of the session;
(b) arrange
for participation of invitees and location;
(c) conduct
the personal planning session;
(d) document
the results of the personal planning session and provide a copy to the eligible
recipient, his or her authorized representative, or personal representative,
the consultant and any other parties the eligible recipient would like to
receive a copy.
(2) Elements
of this report shall include:
(a) recommended
services to be included in the SSP;
(b) services
from sources other than MAD to aid the eligible recipient;
(c) long-term
goals the eligible recipient wishes to pursue;
(d) potential
resources, especially natural supports within the eligible recipient’s
community that can help the eligible recipient to pursue his or her desired
outcomes(s)/goal(s); and
(e) a
list of any follow-up actions to take, including timelines.
(3) Provide
session attendees, including the eligible recipient, with an opportunity to
provide feedback regarding the effectiveness of the session.
E. Living supports: Living supports are provided in the individual’s own home or in the
community and may not be provided in residential facilities or agency owned
homes.
(1) Homemaker direct support services: Homemaker direct support services are
provided on an episodic or continuing basis to assist an eligible recipient 21
years and older with activities of daily living, performance of general
household tasks, and enable the eligible recipient to accomplish tasks he or
she would normally do for himself or herself if he or she did not have a
disability. Homemaker direct support
services are provided in the eligible recipient’s own home and in the
community, depending on the eligible recipient’s needs. The eligible recipient identifies the
homemaker direct support worker’s training needs, and, if the eligible
recipient is unable to do the training for him or herself, the eligible
recipient arranges for the needed training.
Services are not intended to replace supports available from a primary
caregiver. Personal care services are
covered under the medicaid state plan as enhanced early and periodic screening,
diagnostic and treatment (EPSDT) benefits for mi via eligible recipients under
21 years of age and are not to be included in an eligible recipient’s AAB.
(2) Home health aide services: Home health aide services provide total care
or assist an eligible recipient 21 years and older in all activities of daily
living. Home health aide services assist
the eligible recipient in a manner that will promote an improved quality of
life and a safe environment for the eligible recipient. Home health aide services can be provided in
the eligible recipient’s own home and outside the eligible recipient’s
home. Home health aide services under
the waiver differ in nature, scope, supervisory arrangements, or provider type
from home health aide services in the state plan. Home health aide services under the waiver
provide total care or assistance to a recipient in all activities of daily
living in a manner that will promote an improved quality of life and a safe
environment to support the recipient’s independence and health needs in the
home and in the community. Home health
aide services can be provided on a long-term basis for the recipient’s
habilitative supports whereas, state plan home health aide services address
acute conditions; the purpose of which is curative and restorative, with the
goal of assisting the recipient to return to an optimum level of functioning
and to facilitate timely discharge of the recipient to self-care or to care by
his or her family. Home health aide
services are not duplicative of homemaker services. Home health aides may provide basic
non-invasive nursing assistant skills within the scope of their practice. Homemakers do not have this ability to
perform such tasks. Home health aides
are supervised by a RN. Supervision must
occur at least once every 60 calendar days in the eligible recipient’s home and
be in accordance with the New Mexico Nurse Practice Act, Section 61-3-4 et seq.
NMSA 1978.
(3) In-home living supports: In-home living supports are related to the
eligible recipient’s qualifying condition or disability and enable him or her
to live in his or her apartment or house.
Services must be provided in the home or apartment owned or leased by
the eligible recipient or in the eligible recipient’s home, not to include
homes or apartments owned by agency providers.
Service coordination and nursing services are not included in this
service.
(a) These
services and supports are provided in the eligible recipient’s own home and are
individually designed to instruct or enhance home living skills as well as
address health and safety.
(b) In-home
living supports include assistance with activities of daily living and
assistance with the acquisition, restoration, or retention of independent
living skills. This service is provided
on a regular basis at least four or more hours per day one or more days per
week and may be up to 24 hours per day as specified in the eligible recipient’s
SLRISP.
(c) Eligible
recipients receiving in-home living supports may not use homemaker and direct
support home health aide services or respite because they duplicate in-home
living supports.
F. Community membership supports:
(1) Community
direct support: Community direct
support providers deliver support to the eligible recipient to identify,
develop and maintain community connections and access social and educational
options. This service does not include formal educational (including home schooling and tutoring related
activities), or vocational services related to traditional academic subjects or
vocational training.
(a) The
community direct support provider may be a skilled independent contractor or a
hired employee depending on the level of support needed by the eligible
recipient to access the community.
(b) The
community direct support provider may instruct and model social behavior
necessary for the eligible recipient to interact with community members or in
groups, provide assistance in ancillary tasks related to community membership,
provide attendant care and help the eligible recipient schedule, organize and
meet expectations related to chosen community activities.
(c) Community
direct support services include:
(i) provide
assistance to the eligible recipient outside of his or her residence;
(ii) promote
the development of social relationships and build connections within local
communities;
(iii) support
the eligible recipient in having frequent opportunities to expand roles in the
community to increase and enhance natural supports, networks, friendships and
build a sense of belonging; and
(iv) assist
in the development of skills and behaviors that strengthen the eligible
recipient’s connection with his or her community.
(d) The
skills to assist someone in a community setting may be different than those for
assisting an eligible recipient at home.
The provider will:
(i) demonstrate
knowledge of the local community and resources within that community that are
identified by the eligible recipient on the SSP; and
(ii) be
aware of the eligible recipient’s barriers to communicating and maintaining
health and safety while in the community setting.
(2) Employment supports: The objective of employment supports services
is to provide assistance that will result in community employment jobs for an
eligible recipient which increases economic independence, self-reliance, social
connections and the ability to grow within his or her career. Employment supports services are geared to
place and support an eligible recipient with disabilities in competitive,
integrated employment settings with non-disabled co-workers within the general
workforce; or assist the eligible recipient in business ownership. Employment supports include job development
and job coaching supports after available vocational rehabilitation supports
have been exhausted, including programs funded under Section 110 of the
Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act
(IDEA) to an eligible recipient.
Employment Services are to be individualized to meet the needs of the
recipient and not the needs of a group.
(a) Job
development is a service provided to an eligible recipient by a skilled
individual. The service has several
components:
(i) conducting
situational and or vocational assessments;
(ii) developing
and identifying community based job opportunities that are in line with the
eligible recipient’s skills and interests;
(iii) supporting
the eligible recipient in gainful skills or knowledge to advocate for his or
herself in the workplace;
(iv) promoting
career exploration for the eligible recipient based on interests within various
careers through job sampling, job trials or other assessments as needed;
(v) arranging
for or providing benefits counseling;
(vi) facilitating
job accommodations and use of assistive technology such as communication
devices for the eligible recipient’s use;
(vii) providing
job site analysis (matching workplace needs with those of the eligible
recipient); and
(viii) assisting
the eligible recipient in gaining or increasing job seeking skills (interview skills,
resume writing, work ethics, etc.).
(b) The
job coach provides the following services:
(i) training
the eligible recipient to perform specific work tasks on the job;
(ii) vocational
skill development to the eligible recipient;
(iii) employer consultation specific to the
eligible recipient;
(iv) eligible
recipient co-worker training;
(v) job
site analysis for an eligible recipient;
(vi) education
of the eligible recipient and co-workers on rights and responsibilities;
(vii) assistance
with or utilization of community resources to develop a business plan if the
eligible recipient elects to start his or her own business;
(viii) conduct
market analysis and establish the infrastructure to support a business specific
for the eligible recipient; and
(ix) increasing
the eligible recipient’s capacity to engage in meaningful and productive
interpersonal interactions co-workers, supervisors and customers.
(c) Employment
supports will be provided by staff at current or potential work sites. When employment services are provided at a
work site where persons without disabilities are employed, payment is made only
for the adaptations; supervision and training required by the eligible recipient
receiving mi via services as a result of his or her disabilities but does not
include payment for the supervisory activities rendered as a normal part of the
business setting. Federal financial
participation (FFP) is not claimed for incentive payments, subsidies, or
unrelated vocational training expenses such as the following:
(i) incentive
payments made to an employer to encourage or subsidize the employer's
participation in a supported employment program;
(ii) payments
that are passed through to users of supported employment programs; or
(iii) payments
for training that is not directly related to the eligible recipient’s supported
employment program; and
(iv) FFP
cannot be claimed to defray expenses associated with an eligible recipient’s
start-up or operation of his or her business.
(3) Customized community group supports: Customized community group supports can
include participation in congregate community day programs and community
centers that offer functional meaningful activities that assist with
acquisition, retention, or improvement in self-help, socialization and adaptive
skills for an eligible recipient.
Customized community group supports may include adult day habilitation
programs, and other day support models.
Customized community group supports are provided in integrated community
settings such as day programs and community centers which can take place in
non-institutional and non-residential settings.
These services are available at least four or more hours per day one or
more days per week. Service hours and
days are specified in the eligible recipient’s SSP.
G. Health and wellness:
(1) Extended skilled therapy for eligible
recipients 21 years and older:
Extended skilled therapy for adults may include physical therapy,
occupational therapy or speech language therapy when skilled therapy services
under the medicaid state plan are exhausted or are not a covered benefit. Eligible recipients 21 years and older in the
mi via program access therapy services under the state medicaid plan for acute
and temporary conditions that are expected to improve significantly in a
reasonable and generally predictable period of time. Therapy services provided to eligible recipients
21 years and older in the mi via program focus on improving functional
independence, health maintenance, community integration, socialization, and
exercise, or enhance support and normalization of family relationships.
(a) Physical therapy: Diagnosis and management of movement
dysfunction and the enhancement of physical and functional abilities. Physical therapy addresses the restoration,
maintenance and promotion of optimal physical function, wellness and quality of
life related to movement and health.
Physical therapy activities do the following:
(i) increase,
maintain or reduce the loss of functional skills;
(ii) treat
a specific condition clinically related to the eligible recipient’s disability;
(iii) support
the eligible recipient’s health and safety needs; or
(iv) identify,
implement, and train on therapeutic strategies to support the eligible
recipient and his or her family or support staff consistent with the eligible
recipient’s SSP desired outcomes and goals.
(b) Occupational therapy: Diagnosis, assessment, and management of
functional limitations intended to assist the eligible recipient to regain,
maintain, develop, and build skills that are important for independence,
functioning, and health. Occupational
therapy services typically include:
(i) customized
treatment programs to improve the eligible recipient’s ability to perform daily
activities;
(ii) comprehensive
home and job site evaluations with adaptation recommendations;
(iii) skills
assessments and treatment;
(iv) assistive
technology recommendations and usage training;
(v) guidance
to family members and caregivers;
(vi) increasing
or maintaining functional skills or reducing the loss of functional skills;
(vii) treating
specific conditions clinically related to the eligible recipient’s
developmental disability;
(viii) support
for the eligible recipient’s health and safety needs; and
(ix) identifying,
implementing, and training therapeutic strategies to support the eligible
recipient and his or her family or support staff consistent with the eligible
recipient’s SSP desired outcomes and goals.
(c) Speech
and language pathology: Diagnosis,
counseling and instruction related to the development and disorders of communication
including speech fluency, voice, verbal and written language, auditory
comprehension, cognition, swallowing dysfunction, oral pharyngeal or laryngeal,
and sensor motor competencies. Speech
language pathology is also used when an eligible recipient requires the use of
an augmentative communication device.
Based upon therapy goals, services may be delivered in an integrated
natural setting, clinical setting or in a group. Services are intended to:
(i) improve
or maintain the eligible recipient’s capacity for successful communication or
to lessen the effects of the loss of communication skills; or
(ii) improve
or maintain the eligible recipient’s ability to eat foods, drink liquids, and
manage oral secretions with minimal risk of aspiration or other potential
injuries or illness related to swallowing disorders;
(iii) provide
consultation on usage and training for augmentative communication devices;
(iv) identify,
implement and train therapeutic strategies to support the eligible recipient
and his or her family or support staff consistent with the eligible recipient’s
SSP desired outcomes and goals.
(d) Behavior support consultation: Behavior support consultation services
consist of functional support assessments, positive behavior support plan that
is part of the eligible recipient’s treatment plan development, and training
and support coordination for the eligible recipient’s related to behaviors that
compromise the eligible recipient’s quality of life. Based on the eligible recipient’s SSP,
services are delivered in an integrated, natural setting, or in a clinical
setting. Behavior support consultation:
(i) informs
and guides the eligible recipient’s service and support employees or vendors
toward understanding the contributing factors to the eligible recipient’s
behavior;
(ii) identifies
support strategies to ameliorate contributing factors with the intention of
enhancing functional capacities, adding to the provider’s competency to
predict, prevent and respond to interfering behavior and potentially reducing
interfering behavior(s);
(iii) supports
effective implementation based on a functional assessment and support plans;
(iv) collaborates
with medical and ancillary therapies to promote coherent and coordinated
services addressing behavioral issues, and to limit the need for
psychotherapeutic medications; and
(v) monitors
and adapts support strategies based on the response of the eligible recipient
and his or her service and support providers in order for services to be
provided in the least restrictive manner; HSD does not allow the use of any
restraints, restrictive interventions, or seclusion to an eligible recipient.
(e) Nutritional counseling: Nutritional counseling services include
assessment of the eligible recipient’s nutritional needs, development or
revision of the eligible recipient’s nutritional plan, counseling and
nutritional intervention and observation and technical assistance related to
implementation of the nutritional plan.
(f) Private duty nursing for adults: Private duty nursing for eligible recipients
21 years or older includes activities, procedures, and treatment for the
eligible recipient’s physical condition, physical illness or chronic
disability. Services include medication management,
administration and teaching, aspiration precautions, feeding tube management,
gastrostomy and jejunostomy care, skin care, weight management, urinary
catheter management, bowel and bladder care, wound care, health education,
health screening, infection control, environmental management for safety,
nutrition management, oxygen management, seizure management and precautions,
anxiety reduction, staff supervision, behavior and self-care assistance.
(2) Specialized therapies: Specialized therapies are non-experimental
therapies or techniques that have been proven effective for certain
conditions. Experimental or
investigational procedures, technologies or therapies and those services
covered as a medicaid state plan benefit are excluded. Services in this category include the
following therapies:
(a) Acupuncture: Acupuncture is a distinct system of primary health care with the goal of
prevention, cure, or correction of any disease, illness, injury, pain or other
physical or behavioral health condition by controlling and regulating the flow
and balance of energy, form and function to restore and maintain physical
health and increased mental clarity.
Acupuncture may provide effective pain control, decreased symptoms of
stress, improved circulation and a stronger immune system, as well as other
benefits. See 16.2.1 NMAC.
(b) Biofeedback: Biofeedback uses visual, auditory or other
monitors to provide eligible recipients with physiological information of which
they are normally unaware. This technique
enables an eligible recipient to learn how to change physiological,
psychological and behavioral responses for the purposes of improving emotional,
behavioral, and cognitive health performance.
The use of biofeedback may assist in strengthening or gaining conscious
control over the above processes in order to self-regulate. Biofeedback therapy is also useful for muscle
re-education of specific muscle groups or for treating pathological muscle
abnormalities of spasticity, incapacitating muscle spasm, or weakness.
(c) Chiropractic: Chiropractic care is designed to locate and
remove interference with the transmissions or expression of nerve forces in the
human body by the correction of misalignments or subluxations of the vertebral
column and pelvis, for the purpose of restoring and maintaining health for
treatment of human disease primarily by, but not limited to, adjustment and
manipulation of the human structure.
Chiropractic therapy may positively affect neurological function,
improve certain reflexes and sensations, increase range of motion, and lead to
improved general health. See 16.4.1
NMAC.
(d) Cognitive rehabilitation therapy: Cognitive rehabilitation therapy services are
designed to improve cognitive functioning by reinforcing, strengthening, or
reestablishing previously learned patterns of behavior, or establishing new
patterns of cognitive activity or compensatory mechanisms for impaired
neurological systems. Treatments may be
focused on improving a particular cognitive domain such as attention, memory,
language, or executive functions.
Alternatively, treatments may be skill-based, aimed at improving
performance of activities of daily living.
The overall goal is to restore function in a cognitive domain or set of
domains or to teach compensatory strategies to overcome an eligible recipient’s
specific cognitive problems.
(e) Hippotherapy: Hippotherapy is a physical, occupational, and
speech-language therapy treatment strategy that utilizes equine movement as
part of an integrated intervention program to achieve functional outcomes. Hippotherapy applies multidimensional
movement of a horse for an eligible recipient with movement dysfunction and may
increase mobility and range of motion, decrease contractures and aid in normalizing
muscle tone. Hippotherapy requires that
the eligible recipient use cognitive functioning, especially for sequencing and
memory. An eligible recipient with
attention deficits and behavior problems are redirecting attention and
behaviors by focusing on the activity.
Hippotherapy involves therapeutic exercise, neuromuscular education,
kinetic activities, therapeutic activities, sensory integration activities, and
individual speech therapy. The
activities may also help improve respiratory function and assist with improved
breathing and speech production.
Hippotherapy must be performed by a RLD licensed physical therapist,
occupational therapist, or speech therapist.
(f) Massage therapy: Massage therapy is the assessment and
treatment of soft tissues and their dysfunctions for therapeutic purposes
primarily for comfort and relief of pain.
It includes gliding, kneading, percussion, compression, vibration,
friction, nerve strokes, stretching the tissue and exercising the range of
motion, and may include the use of oils, salt glows, hot or cold packs or
hydrotherapy. Massage increases the
circulation, helps loosen contracted, shortened muscles and can stimulate weak
muscles to improve posture and movement, improves range of motion and reduces
spasticity. Massage therapy may
increase, or help sustain, an eligible recipient’s ability to be more
independent in the performance of activities of daily living; thereby,
decreasing dependency upon others to perform or assist with basic daily
activities. See 16.7.1 NMAC.
(g) Naprapathy: Naprapathy focuses on the evaluation and
treatment of neuro-musculoskeletal conditions, and is a system for restoring
functionality and reducing pain in muscles and joints. The therapy uses manipulation and
mobilization of the spine and other joints, and muscle treatments such as
stretching and massage. Based on the
concept that constricted connective tissue (ligaments, muscles, and tendons)
interfere with nerve, blood, and lymph flow, naprapathy uses manipulation of
connective tissue to open these
channels of body function. See 16.6.1
NMAC.
(h) Native American healers: Native American healing therapies encompass a
wide variety of culturally-appropriate therapies that support eligible
recipients in their communities by addressing their physical, emotional and
spiritual health. Treatments may include
prayer, dance, ceremony, song, plant medicines, foods, participation in sweat
lodges, and the use of meaningful symbols of healing, such as the medicine
wheel or other sacred objects.
(i) Play therapy: Play therapy is a variety of play and
creative arts techniques utilized to alleviate chronic, mild and moderate
psychological and emotional conditions for an eligible recipient that are
causing behavioral problems or are preventing the eligible recipient from realizing
his or her potential. The play therapist
works integratively using a wide range of play and creative arts techniques,
mostly responding to the eligible recipient’s direction.
H. Other supports:
(1) Transportation: Payment for transportation is limited to the costs of transportation needed to access waiver services, activities, and resources identified in the recipient's SSP. Transportation services are offered to enable eligible recipients to gain access to services, activities, and resources, as specified by the SSP. Transportation services under the waiver are offered in accordance with the eligible recipient’s SSP. Transportation services provided under the waiver are non-medical in nature whereas transportation services provided under the medicaid state plan are to transport eligible recipients to medically necessary physical and behavioral health services. Non-medical transportation services enable recipients to gain access to waiver and non-medical community services, events, activities and resources as specified in the recipient’s SSP related to community resources and services, work, volunteer sites, homes of local family or friends, civic organizations or social clubs, public meetings or other civic activities, and spiritual activities or events. Payment for mi via transportation services is made to the eligible recipient’s individual transportation employee or to a public or private transportation service vendor. Payment cannot be made to the eligible recipient. Whenever possible, family, neighbors, friends, or community agencies that can provide this service without charge shall be identified in the SSP and utilized. Transportation services for minors cannot be provided by a LRI as these are services a LRI would ordinarily provide for household members of the same age who do not have a disability of chronic illness.
(2) Emergency response services: Emergency response services provide an
electronic device that enables the eligible recipient to secure help in an
emergency at home and avoid institutionalization. The eligible recipient may also wear a
portable help button to allow for mobility.
The system is connected to the eligible recipient’s phone and programmed
to signal a response center when a help button is activated. The response center is staffed by trained
professionals. Emergency response
services include:
(a) testing
and maintaining equipment;
(b) training
eligible recipients, caregivers and first responders on use of the equipment;
(c) 24-hour
monitoring for alarms;
(d) checking
systems monthly or more frequently, if warranted by electrical outages, severe
weather, etc.;
(e) reporting
emergencies and changes in the eligible recipient’s condition that may affect
service delivery; and
(f) ongoing
emergency response service is covered, but initial set up and installation is
not.
(3) Respite: Respite is a flexible family support service,
the primary purpose of which is to provide intermittent support to the
recipient and give the unpaid primary caregiver relief from his or her duties
on a short-term basis. Respite is
provided on a short-term basis to allow the recipient’s primary unpaid
caregiver a limited leave of absence in order to reduce stress, accommodate a
caregiver illness, or meet a sudden family crisis or emergency. Services must only be provided on an
intermittent or short-term basis because of the absence or need for relief of
those persons normally providing care to the recipient. If there is a paid primary caregiver
residing with the eligible recipient providing living supports or community
membership supports, or both, respite services cannot be utilized. Respite services include assisting the
eligible recipient with routine activities of daily living (e.g., bathing,
toileting, preparing or assisting with meal preparation and eating), enhancing
self-help skills, and providing opportunities for leisure, play and other
recreational activities; assisting the eligible recipient to enhance self-help
skills, leisure time skills and community and social awareness; providing
opportunities for community and neighborhood integration and involvement; and
providing opportunities for the eligible recipient to make his or her own
choices with regard to daily activities.
Respite services are furnished on a short-term basis and can be provided
in the eligible recipient’s home, the provider's home, in a community setting
of the family's choice (e.g., community center, swimming pool and park) or at a
center in which other individuals are provided care. FFP is not claimed for the cost of room and
board as part of respite services.
Respite cannot be used for purposes of day-care nor can it be provided
to school age children during school (including home school) hours.
(4) Individual directed goods and services: Individual directed goods and services are
equipment, supplies or services, not otherwise provided through mi via, the
medicaid state plan, or medicare.
Individual directed goods and services must directly relate to the
member’s qualifying condition or disability.
Individual directed goods and services must explicitly address a
clinical, functional, medical, or habilitative need and:
(a) Individual
directed goods and services must address a need identified in the eligible
recipient’s SSP and meet the following requirements:
(i) supports
the eligible recipient to remain in the community and reduces the risk for
institutionalization; and
(ii) promote
personal safety and health; and afford the eligible recipient an accommodation
for greater independence; and
(iii) decrease
the need for other medicaid services; and
(iv) accommodate
the eligible recipient in managing his or her household or facilitate
activities of daily living.
(b) Individual
directed goods and services must be documented in the SSP, comply with
Subsection D of 8.314.6.17 NMAC, and be approved by the TPA. The cost and type of related good is subject
to approval by the TPA. Eligible
recipients are not guaranteed the exact type and model of individual directed
good or service that is requested. If
the eligible recipient requests a good or service, the consultant TPA and MAD
can work with the eligible recipient to find other, including less costly,
alternatives.
(c) The
individual directed goods and services must not be available through another
source and the eligible recipient must not have the personal funds needed to
purchase the goods or services.
(d) These
items are purchased from the eligible recipient’s AAB and advance outcomes in
the eligible recipient’s SSP.
(e) Experimental
or prohibited treatments and goods are excluded.
(f) Services
and goods that are recreational or diversional in nature are excluded. Recreational and diversional in nature is
defined as inherently and characteristically related to activities done for
enjoyment.
(g) Goods
and services purchased under this coverage may not circumvent other
restrictions on the claiming of federal financial participation (FFP) for
waiver services.
(5) Environmental modifications: Environmental modification services include
the purchase and installation of equipment or making physical adaptations to
the eligible recipient’s residence that are necessary to ensure the health,
safety, and welfare of the eligible recipient or enhance the eligible recipient
level of independence.
(a) Singular
or in combination of adaptations include:
(i) the
installation of ramps;
(ii) widening
of doorways and hallways;
(iii) installation
of specialized electric and plumbing systems to accommodate medical equipment
and supplies;
(iv) installation
of lifts or elevators; modifications of a bathroom facility, such as roll-in
showers, sink, bathtub, and toilet modifications, water faucet controls, floor
urinals, bidet adaptations and plumbing;
(v) turnaround
space adaptations;
(vi) specialized
accessibility and safety adaptations or additions;
(vii) trapeze
and mobility tracks for home ceilings; automatic door openers and doorbells;
(viii) voice-activated,
light-activated, motion-activated, and other such electronic devices;
(ix) fire
safety adaptations;
(x) air
filtering devices; heating and cooling adaptations;
(xi) glass
substitute for windows and doors;
(xii) modified
switches, outlets or environmental controls for home devices; and alarm and
alert systems or signaling devices.
(b) All
services shall be provided in accordance with applicable federal, state, and
local building codes.
(c) Excluded
are those adaptations or improvements to the home that are of general utility
and are not of direct medical or remedial benefit to the eligible recipient,
such as fences, storage sheds or other outbuildings. Adaptations that add to the total square
footage of the home are excluded from this benefit except when necessary to
complete an adaptation.
(d) The
environmental modification provider must:
(i) ensure
proper design criteria is addressed in the planning and design of the
adaptation;
(ii) be
a licensed and insured contractor or approved vendor that provides construction
and remodeling services;
(iii) provide
administrative and technical oversight of construction projects;
(iv) provide
consultation to family members, mi via providers and contractors concerning
environmental modification projects to the eligible recipient’s residence; and
(v) inspect
the final environmental modification project to ensure that the adaptations
meet the approved plan submitted for environmental adaptation.
(e) Environmental
modifications are managed by professional staff available to provide technical
assistance and oversight to environmental modification projects.
(f) Environmental
modification services are limited to $5,000 every five years. An eligible recipient transferring into the
mi via program will carry his or her history for the previous five years of MAD
reimbursed environmental modifications.
Environmental modifications must be approved by the TPA.
(g) Environmental
modifications are paid from a funding source separate from the AAB.
[8.314.6.15 NMAC -
Rp, 8.314.6.15 NMAC, 3/1/2016; A, 11/1/2018]
8.314.6.16 Non-Covered
Services: The waiver does not pay for the
purchase of goods or services that a household without a person with a
disability would be expected to pay for as a routine household or personal
expense. Non-covered services include, but are not limited to the following:
A. services covered
by the medicaid state plan (including EPSDT), MAD school-based services,
medicare and other third-parties; the TPA may verify that a good or service is
not covered by another payor source by requesting a denial letter;
B. any service or
good, the provision of which would violate federal or state statutes,
regulations, rules or guidance;
C. formal academic
degrees or certification-seeking education, educational services covered by
IDEA or vocational training provided by the public education department (PED),
division of vocational rehabilitation (DVR);
D. food and shelter
expenses:
(1) including
property-related costs, such as rental or purchase of real estate and
furnishing, maintenance, utilities and utility deposits; and
(2) related
administrative expenses; utilities include gas, electricity, propane, fire
wood, wood pellets, water, sewer, and waste management;
E. experimental or
investigational services, procedures or goods, as defined in 8.310.2 NMAC;
F. home schooling
materials or related supplemental materials and activities;
G. any goods or
services that are considered recreational or diversional in nature as defined
in Subparagraph (f) of Paragraph (4) of Subsection (H) of 8.314.6.15 NMAC
including but not limited to tickets for movies, theatrical and musical
performances, sporting events; zoos, or museums;
H. personal goods
or items not related to the disability;
I. animals and
costs of maintaining animals including the purchase of food, veterinary visits,
grooming and boarding but with the exception of training and certification for
service dogs;
J. gas cards and
gift cards;
K. purchase of
insurance, such as car, cell phone, health, life, burial, renters, home-owners,
service warrantees or other such policies;
L. purchase of a
vehicle, and long-term lease or rental of a vehicle;
M. purchase of
recreational vehicles, such as motorcycles, campers, boats or other similar
items;
N. firearms,
ammunition or other weapons;
O. gambling, games
of chance (such as bingo or lottery), alcohol, tobacco, or similar items;
P. vacation
expenses, including airline tickets, cruise ship or other means of transport,
guided tours, meals, hotel, lodging or similar recreational expenses; mileage
or driver time reimbursement for vacation travel by automobile;
Q. purchase of
usual and customary furniture and home furnishings, unless adapted to the eligible recipient’s disability or use, or of
specialized benefit to the eligible recipient’s condition; requests for adapted
or specialized furniture or furnishings must include a recommendation from the
eligible recipient’s health care provider and, when appropriate, a denial of
payment from any other source;
R. regularly
scheduled upkeep, maintenance and repairs of a home and addition of fences,
storage sheds or other outbuildings, except
upkeep and maintenance of modifications or alterations to a home which are an
accommodation directly related to the eligible recipient’s qualifying condition
or disability;
S. regularly
scheduled upkeep, maintenance and repairs of a vehicle, or tire purchase or
replacement, except upkeep and
maintenance of modifications or alterations to a vehicle or van, which is an
accommodation directly related to the eligible recipient’s qualifying condition
or disability; requests must include documentation that the adapted vehicle is
the eligible recipient’s primary means of transportation;
T. clothing and
accessories, except adaptive clothing or accessories based on the eligible
recipient’s disability or condition;
U. training
expenses for paid employees;
V. conference or
class fees may be covered for eligible recipients or unpaid caregivers, but
costs associated with such conferences or class cannot be covered, including
airfare, lodging or meals;
W. consumer
electronics such as computers, including laptops or any electronic tablets,
printers and fax machines, or other electronic equipment that does not meet the
criteria specified in Subsection A of 8.314.6.15 NMAC; no more than one of each
type of item may be purchased at one time; and consumer electronics may not be
replaced more frequently than once every three years; an eligible recipient
transferring into the mi via program will carry his or her history for the
previous three years of MAD reimbursed consumer electronics;
X. cell phone
services that include more than one cell phone line per eligible recipient;
cell phone service, including cell phone service that includes data, is limited
to the cost of one hundred dollars per month;
Y. dental services
utilizing mi via individual budgetary allotments.
[8.314.6.16 NMAC -
Rp, 8.314.6.16 NMAC, 3/1/2016; A, 11/1/2018]
8.314.6.17 Service
AND SUPPORT plan (SSP) and AUTHORIZED ANNUAL BUDGET(AAB): A SSP
and an annual budget request are developed at least annually by the eligible
recipient in collaboration with the eligible recipient’s consultant and others
that the eligible recipient invites to be part of the process. The consultant serves in a supporting role to
the eligible recipient, assisting the eligible recipient to understand the mi
via program, and with developing and implementing the SSP and the AAB. The SSP and annual budget request are
developed and implemented as specified in 8.314.6 NMAC and mi via service
standards and submitted to the TPA for final approval. Upon final approval the annual budget request
becomes an AAB.
A. SSP development process: For development of the participant-centered
service plan, the planning meetings are scheduled at times and locations
convenient to the eligible recipient.
This process obtains information about eligible recipient strengths,
capacities, preferences, desired outcomes and risk factors through the LOC
assessment and the planning process that is undertaken between the consultant
and eligible recipient to develop his or her SSP. If the eligible recipient chooses to purchase
personal plan facilitation services, that assessment information would also be
used in developing the SSP.
(1) Assessments:
(a) Assessment
activities that occur prior to the SSP meeting assist in the development of an
accurate and functional plan. The
functional assessments conducted during the LOC determination process address
the following needs of a person: medical, behavioral health, adaptive behavior
skills, nutritional, functional, community/social and employment; LOC
assessments are conducted in person and take place in the eligible recipient’s
home, or in a HSD approved location.
(b) Assessments
occur on an annual basis or during significant changes in circumstance or at
the time of the LOC determination. After
the assessments are completed, the results are made available to the eligible
recipient and his or her consultant for use in planning.
(c) The
eligible recipient and the consultant will assure that the SSP addresses the
information and concerns, if any, identified through the assessment process.
(2) Pre-planning:
(a) The
consultant contacts the eligible recipient upon his or her choosing enrollment
in the mi via program to provide information regarding this program, including
the range and scope of choices and options, as well as the rights, risks, and
responsibilities associated with self-direction.
(b) The
consultant discusses areas of need to address on the eligible recipient’s
SSP. The consultant provides support
during the annual re-determining process to assist with completing medical and
financial eligibility in a timely manner.
(c) Personal
plan facilitators are optional supports.
To assist in pre-planning, the eligible recipient is also able to access
an approved provider to develop a personal plan.
(3) SSP components: The SSP contains:
(a) the
mi via services that are furnished to the eligible recipient, the projected
amount, frequency and duration, and the type of provider who furnishes each
service;
(i) the
SSP must describe in detail how the services or goods relate to the eligible
recipient’s qualifying condition or disability;
(ii) the
SSP must describe how the services and goods support the eligible recipient to
remain in the community and reduce his or her risk of institutionalization; and
(iii) the
SSP must specify the hours of services to be provided and payment arrangements;
(b) other
services needed by the mi via eligible recipient regardless of funding source,
including state plan services;
(c) informal
supports that complement mi via services in meeting the needs of the eligible
recipient;
(d) methods
for coordination with the medicaid state plan services and other public
programs;
(e) methods
for addressing the eligible recipient’s health care needs when relevant;
(f) quality
assurance criteria to be used to determine if the services and goods meet the
eligible recipient’s needs as related to his or her qualifying condition or
disability;
(g) information,
resources or training needed by the eligible recipient and service providers;
(h) methods
to address the eligible recipient’s health and safety, such as emergency and
back-up services; and
(i) the
IBA.
(4) Service and support plan meeting:
(a) The
eligible recipient receives an LOC assessment and local resource manual prior
to the SSP meeting.
(b) The
eligible recipient may begin planning and drafting the SSP utilizing those
tools prior to the SSP meeting.
(c) During
the SSP meeting, the consultant assists the eligible recipient to ensure that
the SSP addresses the eligible recipient’s goals, health, safety and
risks. The eligible recipient and his or
her consultant will assure that the SSP addresses the information and concerns
identified through the assessment process.
The SSP must address the eligible recipient’s health and safety needs
before addressing other issues. The
consultant ensures that:
(i) the
planning process addresses the eligible recipient’s needs and goals in the
following areas: health and wellness and
accommodations or supports needed at home and
in the community;
(ii) services
selected address the eligible recipient’s needs as identified during the
assessment process; needs not addressed in the SSP will be addressed outside
the mi via program;
(iii) the
outcome of the assessment process for assuring health and safety is considered
in the plan;
(iv) services
do not duplicate or supplant those available to the eligible recipient through
the medicaid state plan or other programs;
(v) services
are not duplicated in more than one service code;
(vi) job
descriptions are complete for each provider and employee in the plan; a job
description will include frequency, intensity and expected outcomes for the
service;
(vii) the
quality assurance section of the SSP is complete and specifies the roles of the
eligible recipient, consultant and any others listed in this section;
(viii) the
responsibilities are assigned for implementing the plan;
(ix) the
emergency and back-up plans are complete; and
(x) the
SSP is submitted to the TPA after the SSP meeting, in compliance with mi via
rules and service standards.
B. Individual budgetary allotment (IBA): Each eligible recipient’s annual IBA is
determined by MAD or its designee as follows.
(1) Budgetary
allotments are based on calculations developed by MAD for each mi via
population group, utilizing historical traditional waiver care plan authorized
budgets within the population, minus the case management costs, and minus a ten
percent discount.
(2) The
determination of each eligible recipient’s sub-group is based on a
comprehensive assessment. The eligible
recipient then receives the IBA available to that category of need, according
to the eligible recipient’s age.
(3) An
eligible recipient has the authority to expend the IBA through an AAB that is
to be expended on a monthly basis and in accordance with the mi via rules and
program service standards.
(a) The state and CMS approves a range of rates, as applicable, for mi
via services wherein each recipient or EOR can self-direct and establish his or
her own rate with a particular provider of a service. The current rate schedule is available on the
HSD and DOH websites. Mi via recipients,
or EORs, are required to negotiate and determine the rate for their employees
and services within the range of rates established by the state. Justification for paying more than the
established rates must be submitted, in writing, to the TPA for
consideration. The established rate may
not be exceeded in order to pay for additional services the employee or
provider may provide which are outside the scope of the specific service for
which the employee or provider is approved; nor can a rate exception be
approved for credentials that exceed those required to provide the service
unless the credentials specifically meet criteria below. To exceed the established range of rates the
following criteria must be met:
(i) behavioral
conditions: the recipient’s behaviors are of a severity
that pose considerable risk to the eligible recipient, caregivers or the
community; and require a frequency and intensity of assistance to ensure the
eligible recipient’s health and safety in the home or the community or
supervision or consultation requiring specialized or unique behavioral
supports; these services cannot be accessed through other services; or
(ii) medical
conditions: the recipient has ongoing
need for intense medical supports including oxygen monitoring, diabetic
monitoring, skin breakdown, J and G tube feedings, ostomy and urology care,
catheter insertion, digital extractions, suctioning, nebulizer treatments,
routine order treatments in the prevention of infections, and responsive
awareness to severe allergic reactions; or
(iii) specialized
supports: in order to support the
recipient’s inclusion in the community the recipient requires specialized
support that can enhance communicative or functional skills such as american
sign language or programming of adaptive communication devices; or
(iv) location: the recipient lives in a geographic location,
within New Mexico, with limited providers.
The recipient, or guardian, has researched multiple providers and has
been unable to identify another provider in the geographic location available
to provide the service within the range of rates. The service goal must specify the recipient’s
need for this service and contact with available local provider within six
months of the date of request including reason why alternate providers are not
available.
(b) The
AAB shall contain goods and services necessary for health and safety (i.e.,
direct care services and medically related goods) which will be given priority
over goods and services that are non-medical or not directly related to health
and safety. This prioritization applies
to the IBA, AAB, and any subsequent modifications.
C. SSP review criteria: Services and related goods identified in the
eligible recipient’s requested SSP may be considered for approval if the
following requirements are met:
(1) the
services or goods must be responsive to the eligible recipient’s qualifying
condition or disability and must address the eligible recipient’s clinical,
functional, medical or habilitative needs; and
(2) the
services or goods must accommodate the eligible recipient in managing his or
her household; or
(3) the
services or goods must facilitate activities of daily living; or
(4) the
services or goods must promote the eligible recipient’s personal health and
safety; and
(5) the
services or goods must afford the eligible recipient an accommodation for
greater independence; and
(6) the
services or goods must support the eligible recipient to remain in the
community and reduce his/her risk for institutionalization; and
(7) the
services or goods must be documented in the SSP and advance the desired
outcomes in the eligible recipient’s SSP; and
(8) the
SSP contains the quality assurance criteria to be used to determine if the
service or goods meet the eligible recipient’s need as related to the
qualifying condition or disability; and
(9) the
services or goods must decrease the need for other MAD services; and
(10) the
eligible recipient receiving the services or goods does not have the funds to
purchase the services or goods; or
(11) the
services or goods are not available through another source; the eligible
recipient must submit documentation that the services or goods are not
available through another source, such as the medicaid state plan or medicare;
and
(12) the
service or good is not prohibited by federal regulations, NMAC rules, billing
instructions, standards, and manuals; and
(13) each
service or good must be listed as an individual line item whenever possible;
however, when a service or a good are ‘bundled’ the SSP must document why
bundling is necessary and appropriate.
D. Budget review criteria: The eligible recipient’s proposed annual
budget request may be considered for approval, if all of the following
requirements are met:
(1) the
proposed annual budget request is within the eligible recipient’s IBA; and
(2) the
proposed rate for each service is within the mi via range of rates for that
chosen service; and
(3) the
proposed cost for each good is reasonable, appropriate and reflects the lowest
available cost for that chosen good; and
(4) the
estimated cost of the service or good is specifically documented in the
eligible recipient’s budget worksheets; and
(5) no
employee exceeds 40 hours paid work in a consecutive seven-day work week.
E. Modification of the SSP:
(1) The
SSP may be modified based upon a change in the eligible recipient’s needs or
circumstances, such as a change in the eligible recipient’s health status or
condition or a change in the eligible recipient’s support system, such as the
death or disabling condition of a family member or other individual who was
providing services.
(2) If
the modification is to provide new or additional services than originally
included in the SSP, these services must not be able to be acquired through
other programs or sources. The eligible
recipient must document the fact that the services are not available through
another source.
(3) The
eligible recipient must provide written documentation of the change in needs or
circumstances as specified in the mi via service standards. The eligible recipient submits the
documentation to the consultant. The
consultant initiates the process to modify the SSP by forwarding the request
for modification to the TPA for review.
(4) The
SSP must be modified before there is any change in the AAB.
(5) The
SSP may be modified once the original SSP has been submitted and approved. Only one SSP revision may be submitted at a
time, e.g., a SSP revision may not be submitted if an initial SSP request or
prior SSP revision request is under initial review by the TPA. This requirement also applies to any
re-consideration of the same revision request.
Other than for critical health and safety reasons, neither the SSP nor
the AAB may be modified within 60 calendar days of expiration of the current
SSP.
F. Modifications to the eligible recipient’s
annual budget: Revisions to the AAB may
occur within the SSP year, and the eligible recipient is responsible for
assuring that all expenditures are in compliance with the most current AAB in
effect. The SSP must be amended first to
reflect a change in the eligible recipient’s needs or circumstances before any
revisions to the AAB can be requested.
(1) Budget
revisions involve requests to add new goods or services to a budget or to
reallocate funds from any line item to another approved line item. Budget revisions must be submitted to the TPA
for review and approval. Other than for
critical health and safety reasons for the eligible recipient, budget revisions
may not be submitted to the TPA for review within the last 60 calendar days of
the budget year.
(2) The
amount of the AAB cannot exceed the eligible recipient’s annual IBA. The rare exception would be the eligible
recipient whose assessed or documented needs, based on his or her qualifying
condition, cannot be met within the annual IBA, in which case the eligible
recipient would initiate a request for an adjustment through his or her
consultant.
(3) Mi
via budgets are developed by service. A
recipient may request an increase to his or her budget above his or her annual
IBA, or AAB, as applicable if services necessary for health and safety cannot
be met within the IBA, or AAB.
Prioritization, as described in Subparagraph (b) of Paragraph (3) of
Subsection B of 8.314.6.17 NMAC applies.
Requests for additional funding are built in the annual budget and are
specific to the service that is being requested. If the eligible recipient requests an
increase in his or her budget above his or her annual IBA, or AAB, as
applicable, the eligible recipient must show at least one of the following four
circumstances related to the specific service for which an increase to the
additional funding is being requested:
(a) chronic
physical condition: the eligible
recipient has one or more chronic physical conditions, which are identified
during the initial or reevaluation of the LOC, that result in a prolonged
dependency on medical services or care, for which daily intervention is
medically necessary; and the eligible recipient’s needs cannot be met within
the assigned IBA or other current resources, including natural supports,
medicaid state plan services, medicare or other sources; the eligible recipient
must submit a written, dated, and signed evaluation or letter from a medical
doctor (MD), doctor of osteopathy (DO), a certified nurse practitioner (CNP) or
a physician assistant (PA) that documents the chronic physical condition in the
eligible recipient’s health status relevant to the criteria; the evaluation or
letter must have been completed after the last LOC assessment or less than one
year from the date the request is submitted, whichever is most recent; the
chronic physical conditions are characterized by at least one of the following:
(i) a
life-threatening condition with frequent or constant periods of acute
exacerbation that places the eligible recipient at risk for
institutionalization; that could result in the eligible recipient’s inability
to remember to self-administer medications accurately even with the use of
assistive technology devices; or that requires a frequency and intensity of
assistance, supervision, or consultation to ensure the eligible recipient’s
health and safety in the home or in the community; or which, in the absence of
such skilled intervention, assistance, medical supervision or consultation,
would require hospitalization or admission to a NF or ICF-IID;
(ii) the
need for administration of specialized medications, enteral feeding or
treatments that are ordered by a medical doctor, doctor of osteopathy,
certified nurse practitioner or physician’s assistant; which require frequent and
ongoing management or monitoring or oversight of medical technology;
(b) change in physical status: the eligible recipient has experienced a
deterioration or permanent change in his or her health status such that the
eligible recipient’s needs for services and supports can no longer be met
within the IBA, current AAB or other current resources, including natural
supports, medicaid state plan services, medicare or other sources; the eligible
recipient must submit a written, dated, and signed evaluation or letter from a
MD, OD, CNP, or PA that documents the change in the eligible recipient’s health
status relevant to the criteria; the evaluation or letter must have been
completed after the last LOC assessment
or less than one year from the date
the request is submitted, whichever is most recent; the eligible recipient may
submit additional supportive documentation by others involved in the eligible
recipient’s care, such as a current individual service plan (ISP) if the
eligible recipient is transferring from another waiver, a recent evaluation
from a specialist or therapist, a recent discharge plan, relevant medical
records or other documentation or recent statements from family members,
friends or other support individuals; types of physical health status changes
that may necessitate an increase in the IBA or current AAB are as follows:
(i) the
eligible recipient now requires the administration of medications via
intravenous or
injections on a daily or weekly basis;
(ii) the
eligible recipient has experienced recent onset or increase in aspiration of
saliva, foods or liquids;
(iii) the
eligible recipient now requires external feedings, e.g. naso-gastric,
percutaneous endoscopic gastrostomy, gastric-tube or jejunostomy-tube;
(iv) the
eligible recipient is newly dependent on a ventilator;
(v) the
eligible recipient now requires suctioning every two hours, or more frequently,
as needed;
(vi) the
eligible recipient now has seizure activity that requires continuous monitoring
for injury and aspiration, despite anti-convulsant therapy; or
(vii) the
eligible recipient now requires increased assistance with activities of daily
living as a result of a deterioration or permanent changes in his or her
physical health status;
(c) chronic or intermittent behavioral
conditions or cognitive difficulties: the
eligible recipient has chronic or intermittent behavioral conditions or
cognitive difficulties, which are identified during the initial or reevaluation
LOC assessment, or the eligible recipient has experienced a change in his or
her behavioral health status, for which the eligible recipient requires
additional services, supports, assistance, or supervision to address the
behaviors or cognitive difficulties in order to keep the eligible recipient
safe; these behaviors or cognitive difficulties are so severe and intense that
they result in considerable risk to the eligible recipient, caregivers or the
community; and require a frequency and intensity of assistance, supervision or
consultation to ensure the eligible recipient’s health and safety in the home
or the community; in addition, these behaviors are likely to lead to
incarceration or admission to a hospital, nursing facility or ICF-IID; require
intensive intervention or medication management by a doctor or behavioral
health practitioner or care practitioner which cannot be effectively addressed
within the IBA, current AAB or other resources, including natural supports, the
medicaid state plan services, medicare or other sources;
(i) examples
of chronic or intermittent behaviors or cognitive difficulties are such that
the eligible recipient injures him or herself frequently or seriously; has
uncontrolled physical aggression toward others; disrupts most activities to the
extent that his or her SSP cannot be implemented or routine activities of daily
living cannot be carried out; withdraws personally from contact with most
others; or leaves or wanders away from the home, work or service delivery
environment in a way that puts him or herself or others at risk;
(ii) the
eligible recipient must submit a written, dated, and signed evaluation or
letter from a licensed MD, doctor of osteopathy (DO), CNP, physician assistant
(PA), psychiatrist, or RLD licensed psychologist that documents the change in
the eligible recipient’s behavioral health status relevant to the criteria; the
evaluation or letter must have been completed after the last LOC assessment or
less than one year from the date the request is submitted, whichever is most
recent; the eligible recipient may submit additional supportive documentation
including a current ISP if the eligible recipient is transferring from another
waiver, a positive behavioral support plan or assessment, recent notes, a
summary or letter from a behavioral health practitioner or professional with
expertise in intellectual or developmental disabilities, recent discharge plan,
recent recommendations from a rehabilitation facility, any other relevant
documentation or recent statements from family members, friends or other
support individuals involved with the eligible recipient.
(d) change in natural supports: the eligible recipient has experienced a
loss, as a result of situations such as death, illness, or disabling condition,
of his or her natural supports, such as family members or other community
resources that were providing direct care or services, whether paid or
not. This absence of natural supports or
other resources is expected to continue throughout the period for which
supplemental funds are requested. The
type, intensity or amount of care or services previously provided by natural
supports or other resources cannot be acquired within the IBA and are not
available through the medicaid state plan services, medicare, other programs or
sources in order for the eligible recipient to live in a home and
community-based setting.
(4) The
eligible recipient is responsible for tracking all budget expenditures and
assuring that all expenditures are within the AAB. The eligible recipient must not exceed the
AAB within any SSP year. The eligible
recipient’s failure to properly allocate the expenditures within the SSP year
resulting in the depletion of the AAB, due to mismanagement of or failure to
track the funds, prior to the calendared expiration date does not substantiate
a claim for a budget increase (i.e., if all of the AAB is expended within the
first three months of the SSP year, it is not justification for an increase in
the annual budget for that SSP year).
Amendments to the AAB may occur within the SSP year and the eligible
recipient is responsible for assuring that all expenditures are in compliance
with the most current AAB in effect.
Amendments to the AAB must be preceded by an amendment to the SSP.
(5) The
AAB may be revised once the original annual budget request has been submitted
and approved. Only one annual budget
revision request may be submitted at a time, e.g., an annual budget revision
request may not be submitted if a prior annual budget revision request is under
initial review by the TPA. The same
requirement also applies to any reconsideration of the same revision request.
G. SSP and annual budget supports: As specified in 8.314.6 NMAC and its service
standards, the eligible recipient is assisted by his or her consultant in
development and implementation of the SSP and AAB. The FMA assists the eligible recipient with
implementation of the AAB.
H. Submission for
approval: The TPA must approve the
SSP and associated annual budget request (resulting in an AAB). The TPA must approve certain changes in the
SSP and annual budget request, as specified in 8.314.6 NMAC and mi via service
standards and in accordance with 8.302.5 NMAC.
(1) At
any point during the SSP and associated annual budget utilization review
process, the TPA may request additional documentation from the eligible
recipient. This request must be in
writing and submitted to both the eligible recipient and the consultant
provider. The eligible recipient has
seven working days from the date of the initial request to respond with
additional documentation. The TPA will
issue a second request for information on the seventh day if information was
not received and issue a final request for information 14 working days after the
initial request. The eligible recipient
has a total of 21 working days to respond with additional documentation. Failure by the eligible recipient to submit
the requested information may subject the SSP and annual budget request to
denial.
(2) Services
cannot begin and goods may not be purchased before the start date of the
approved SSP and AAB or approved revised SSP and revised AAB.
(3) Any
revisions requested for other than critical health or safety reasons within 60
calendar days of expiration of the SSP and AAB are subject to denial for that
reason.
[8.314.6.17 NMAC -
Rp, 8.314.6.17 NMAC, 3/1/2016; A, 11/1/2018]
8.314.6.18 Prior
AUTHORIZATION and Utilization Review: All MAD services, including
services covered under the mi via program, are subject to utilization review
for medical necessity and program requirements.
Reviews by MAD or its designees may be performed before services are
furnished, after services are furnished, before payment is made, or after
payment is made in accordance with 8.310.2 NMAC.
A. Prior
authorization: Services, supports,
and goods specified in the SSP and AAB require prior authorization from HSD/MAD
or its designee. The SSP must specify
the type, amount and duration of services.
Services for which prior authorization was obtained remain subject to
utilization review at any point in the payment process.
B. Eligibility
determination: To be eligible for mi
via program services, eligible recipients must require the LOC of services provided
in an ICF-IID. Prior authorization of
services does not guarantee that applicants or eligible recipients are eligible
for MAP or mi via services.
C. Reconsideration: If there is a disagreement with a prior
authorization denial or other review decision, the consultant provider on
behalf of the eligible recipient, can request reconsideration from the TPA that
performed the initial review and issued the initial decision. Reconsideration must be requested within
30-calendar days of the date on the denial notice, must be in writing and
provide additional documentation or clarifying information regarding the
eligible recipient’s request for the denied services or goods.
D. Denial of payment: If a service, support, or good is not covered
under the mi via program, the claim for payment may be denied by MAD or its
designee. If it is determined that a
service is not covered before the claim is paid, the claim is denied. If this determination is made after payment,
the payment amount is subject to recoupment or repayment.
[8.314.6.18 NMAC -
Rp, 8.314.6.18 NMAC, 3/1/2016]
8.314.6.19 Reimbursement:
A. Mi via eligible recipients must follow all billing instructions
provided by the FMA to ensure payment of service providers, employees, and
vendors.
B. Claims must be
billed to the FMA per the billing instructions.
Reimbursement to a service provider and a vendor in the mi via program
is made, as follows:
(1) mi
via service provider and vendor must enroll with the FMA;
(2) the
eligible recipient receives instructions and documentation forms necessary for
a service provider’s and a vendor’s claims processing;
(3) an
eligible recipient must submit claims for payment of his or her mi via service
provider and vendor to the FMA for processing; claims must be filed per the
billing instructions provided by the FMA;
(4) the
eligible recipient and his or her mi via service provider and vendor must
follow all FMA billing instructions; and
(5) reimbursement
of a mi via service provider and vendor is made at a predetermined
reimbursement rate negotiated by the eligible recipient with the mi via service
provider or vendor, approved by the TPA contractor, and documented in the SSP
and in the mi via provider or vendor agreement; at no time can the total
expenditure for services exceed the eligible recipient’s AAB.
C. The FMA must
submit claims that have been paid by the FMA on behalf of eligible recipient to
the MAD fiscal contractor for processing.
D. Reimbursement
may not be made directly to the eligible recipient, either to reimburse him or
her for expenses incurred or to enable the eligible recipient to pay a service
provider directly.
[8.314.6.19 NMAC -
Rp, 8.314.6.19 NMAC, 3/1/2016]
8.314.6.20 RIGHT TO A HSD ADMINISTRATIVE HEARING:
A. MAD must grant an
opportunity for a HSD administrative hearing as described in 8.314.6.20 NMAC in
the following circumstances and pursuant to 42 CFR Section 431.220(a)(1) and
(2), Section 27-3-3 NMSA 1978 and 8.352.2 NMAC:
(1) when
an applicant has been determined not to meet the LOC requirement for mi via
program services;
(2) when
an applicant has not been given the choice of HCBS as an alternative to
institutional care;
(3) when
an applicant is denied the services of his or her choice or the provider of his
or her choice;
(4) when
an eligible recipient’s services are denied, suspended, reduced or terminated;
(5) when
an eligible recipient has been involuntarily terminated from the program;
(6) when
an eligible recipient’s request for a budget adjustment has been denied; and
(7) when
any other adverse action is taken by MAD against the eligible recipient, see
8.352.2 NMAC.
B. DOH and its
counsel, if necessary, shall participate in any relevant HSD administrative
hearing involving an eligible recipient.
HSD’s office of general counsel may elect to participate in the administrative
hearing. See 8.352.2 NMAC for a complete
description, instructions, and hearing process of a HSD administrative hearing
for an eligible recipient.
[8.314.6.20 NMAC -
Rp, 8.314.6.20 NMAC, 3/1/2016]
8.314.6.21 CONTINUATION
OF BENEFITS PURSUANT TO TIMELY APPEAL:
A. Continuation of
benefits may be provided to an eligible recipient who requests a HSD
administrative hearing within the timeframe defined in 3.352.2 NMAC. The notice will include information on the
right to continue the eligible recipient’s benefits and on his or her
responsibility for repayment if the HSD administrative final hearing decision
is not in the eligible recipient’s favor.
See 8.352.2 NMAC for a complete description of the continuation of
benefits process of a HSD administrative hearing for an eligible recipient.
B. The continuation
of a benefit is only available to an eligible recipient that is currently
receiving the appealed benefit. The
continuation of the benefit will be the same as the eligible recipient’s
current allocation, budget or LOC. The
continuation budget may not be revised until the conclusion of the HSD administrative
hearing process unless one of the criteria to modify the budget in 8.314.6.17
NMAC is met. See 8.352.2 NMAC for a
complete description, instructions and process of a HSD administrative hearing
and continuation of benefits process of a MAP eligible recipient.
[8.314.6.21 NMAC -
Rp, 8.314.6.21 NMAC, 3/1/2016]
8.314.6.22 GRIEVANCE/COMPLAINT SYSTEM: An
eligible recipient has the opportunity to register a grievance or complaint
concerning the mi via program. An
eligible recipient may register complaints with DOH via e-mail, mail or
phone. Complaints will be referred to
the appropriate DOH division or as appropriate referred to MAD for
resolution. The filing of a complaint or
grievance does not preclude an eligible recipient from pursuing a HSD
administrative hearing. The eligible
recipient is informed that filing a grievance or complaint is not a
prerequisite or substitute for requesting a HSD administrative hearing.
[8.314.6.22 NMAC -
Rp, 8.314.6.22 NMAC, 3/1/2016]
HISTORY OF 8.314.6 NMAC:
History of Repealed Material:
8.314.6 NMAC, Mi Via
Home and Community-Based Services Waiver, filed 11/16/2006 - Repealed effective
4/1/2011.
8.314.6 NMAC, Mi Via
Home and Community-Based Services Waiver, filed 3/15/2011 - Repealed effective
10/15/2012.
8.314.6 NMAC, Mi Via
Home and Community-Based Services Waiver, filed 10/2/2012 - Repealed effective
3/1/2016.