New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 6 - MI VIA HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.6.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
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.