reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide policies for the
				  service portion of the New Mexico medical assistance program (MAP). These
				  policies describe eligible providers, covered services, non-covered services,
				  utilization review, and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.8 - MISSION STATEMENT: (RESERVED)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.9 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico MAP pays for medically necessary services
				  furnished to eligible recipients. To help New Mexico recipients receive
				  services in a cost-effective manner, the New Mexico medical assistance division
				  (MAD) has obtained a waiver of certain federal regulations to provide home and
				  community-based services (HCBS) waiver programs to recipients as an alternative
				  to institutionalization. See
				  42 CFR 441.300.
				  Section 8.314.3.9 NMAC describes the HCBS waiver program for the medically
				  fragile population, including eligible providers, covered waiver services,
				  service limitations, and general reimbursement methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				approval of New Mexico MAP provider participation agreements by MAD, providers
				who meet the following requirements are eligible to be reimbursed for
				furnishing waiver services to recipients:
(1)
				standards established by the HCBS waiver program; and
(2) provide services to recipients in the
				same scope, quality and manner as provided to the general public; see Section
				8.302.1.14
				NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. A
				provider who furnishes services to an eligible recipient must comply with all
				federal and state laws, regulations, rules, and executive orders relevant to
				the provision of services as specified in the MAD provider participation
				agreement and the DOH provider agreement. A provider also must meet and adhere
				to all applicable NMAC rules and instructions as specified in the MAD provider
				rules manual and its appendices, MFW service standards, MFW service
				definitions, and program directions and billing instructions, as updated. A
				provider is also responsible for following coding manual guidelines and the
				centers for medicare and medicaid services (CMS) correct coding initiatives,
				including not improperly unbundling or upcoding services. Provider must
				maintain current knowledge and adherence to MFW requirements.
B. Providers must verify that individuals are
				eligible for medicaid at the time services are furnished and determine if
				medicaid recipients have other health insurance.
C. Providers must maintain records which are
				sufficient to fully disclose the extent and nature of the services provided to
				recipients. See Section 8.302.1 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.12 - ELIGIBLE RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Enrollment in the MFW 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. Once an allocation has been
				offered to the applicant, he or she must meet certain medical and financial
				criteria in order to qualify. This criteria is contained in Section 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.
B. Eligibility is limited to individuals who
				in addition to a developmental disability, developmental delay, or are at risk
				of developmental delay, have a medically fragile condition, diagnosed before
				the age of 22, defined as a chronic physical condition, which results in a
				prolonged dependency on medical care for which daily skilled (nursing)
				intervention is medically necessary and is characterized by one or more of the
				following:
(1) a life threatening condition
				characterized by reasonably frequent periods of acute exacerbation which
				require frequent medical supervision, or physician consultation and which in
				the absence of such supervision or consultation, would require
				hospitalization;
(2) a condition
				requiring frequent, time consuming administration of specialized treatments
				which are medically necessary; or
(3) dependence on medical technology such
				that without the technology a reasonable level of health could not be
				maintained; examples include but are not limited to ventilators, dialysis
				machines, enteral or parenteral nutrition support and continuous
				oxygen.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.13 - COVERED WAIVER SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The services covered by the MFW program are intended to
				  provide a home and community-based alternative to institutional care for an
				  eligible recipient. In all services covered under the MFW the recipient has the
				  right to privacy, dignity, and respect. The recipient further has the right to
				  freedom from coercion and restraint. The MFW program covers the following
				  services for a specified number of medically fragile recipients. The program is
				  limited by the number of federally authorized unduplicated recipient (UDR)
				  positions and program funding.
A.
Case management services:
Case management services assist
				recipients in gaining access to needed waiver and other state plan services, as
				well as medical, social, educational, and other services regardless of the
				funding source for the services. Case management services are offered in a
				manner that allows direct communication between the case manager, the
				recipient, and the family and appropriate service personnel. Case managers
				provide a link between recipients and care providers and coordinate the use of
				community resources needed for that care. At least every other month, the case
				manager conducts a face-to-face contact with the recipient, and on a monthly
				basis conducts a telephonic or electronic contact with the recipient. The scope
				of the case manager's duties includes the following:
(1) identifying medical, social, educational,
				family and community support resources;
(2) scheduling and coordinating timely
				interdisciplinary team (IDT) meetings to develop and modify the ISP annually
				and as needed by any team member;
(3) documenting contacts with the recipient
				and providers responsible for delivery of services to the recipient;
(4) verifying eligibility on an annual
				basis;
(5) ensuring the medically
				fragile long-term care assessment abstract (LTCAA) is completed and signed by
				the physician, physician assistant or clinical nurse practitioner
				(CNP);
(6) submitting the LOC
				packet including the LTCAA to the third-party assessor (TPA) contractor for
				prior authorization on a timely basis;
(7) ensuring the waiver review form (MAD 046)
				is submitted timely, both annually and as needed;
(8) initiating an ongoing monitoring process
				that provides for evaluation of delivery, effectiveness, appropriateness of
				services and support provided to the recipient as identified in the
				ISP;
(9) performing an annual
				recipient satisfaction survey; and
(10) coordinating services provided though
				the MFW program and other sources (state plan, family infant toddler (FIT),
				commercial insurance, educational and community).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.14 - NON-COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Only services listed as covered waiver services are covered
				  under the waiver program. Ancillary services can be available to waiver
				  recipients through the MAP state plan services. These ancillary services are
				  subject to the limitations and coverage restrictions which exist for other MAP
				  services. See Section 8.301.3 NMAC for an overview of non-covered
				  services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.16 - Utilization Review

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid services, including services covered under the
				  MFW, are subject to utilization review for medical necessity and program
				  compliance. Reviews can be performed before services are furnished, after
				  services are furnished and before payment is made, or after payment is made.
				  See Section
				  8.310.2.14
				  NMAC. Once enrolled, providers receive instructions and documentation forms
				  necessary for prior approval and claims processing.
A.
Prior approval:
To be
				eligible for MFW program services, recipients must require an ICF/IID LOC and
				meet the eligibility requirements defined in Subsection B of Section
				8.314.3.12
				NMAC. LOC determinations are made by MAD or its designee. The ISP must specify
				the type, amount and duration of services. Certain procedures or services
				specified in the ISP can require prior approval from MAD or its designee.
				Services for which prior approval was obtained remain subject to utilization
				review at any point in the payment process.
B.
Eligibility determination:
Prior approval of services does not guarantee that individuals are eligible for
				MAP. Providers must verify that individuals are eligible for MAP at the time
				services are furnished and determine if recipients have other health
				insurance.
C.
Reconsideration:
Providers who disagree with prior approval
				request denials or other review decisions can request a re-review and
				reconsideration. See Section 8.350.2 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Waiver service providers must submit claims for reimbursement
				  to MAD's fiscal contractor for processing. Claims must be filed per the billing
				  instructions in the medicaid policy manual. Providers must follow all medicaid
				  billing instructions. See Section 8.302.2 NMAC. Once enrolled, providers
				  receive instructions on documentation, billing, and claims processing.
				  Reimbursement to providers of medicaid waiver services is made at a
				  predetermined reimbursement rate.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.18 - RIGHT TO A HSD ADMINISTRATIVE HEARING

Current through Register Vol. 35, No. 13, July 16, 2024
A. Pursuant to
				42 CFR Section
				431.220(a)(1) and (2),
				Section 27-3-3 NMSA 1978 an eligible recipient may request a HSD administrative
				hearing to appeal an adverse action or adverse decision. See Section 8.352.2
				NMAC for a description of the HSD administrative hearing process. In addition
				to adverse actions defined in Section 8.352.2 the recipient may request an
				administrative hearing in the following circumstances:
(1) when an applicant has been determined not
				to meet the LOC requirement for medically fragile waiver program services;
				and
(2) when an applicant has not
				been given the choice of HCBS as an alternative to institutional
				care.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.19 - CONTINUATION OF BENEFITS PURSUANT TO TIMELY APPEAL

Current through Register Vol. 35, No. 13, July 16, 2024
A. Continuation of benefits may be provided
				to an eligible recipient who requests a HSD administrative hearing within the
				timeframe defined in Section 8.352.2 NMAC.
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. See Section 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.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 3 - MEDICALLY FRAGILE HOME AND COMMUNITY-BASED SERVICES WAIVER SERVICES › Section 8.314.3.20 - GRIEVANCE SYSTEM

Current through Register Vol. 35, No. 13, July 16, 2024
An eligible recipient has the opportunity to register a
				  grievance or complaint concerning the MFW 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.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 4 - ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) OR AIDS-RELATED CONDITION HOME AND COMMUNITY-BASED SERVICES WAIVER [REPEALED]

Current through Register Vol. 35, No. 13, July 16, 2024
[This part was repealed effective July 15,
				2014.]
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program is administered pursuant to
				  regulations promulgated by the federal department of health and human services
				  under Title XIX of the Social Security Act, as amended and by the state health
				  care authority pursuant to state statute. See Section 27-2-12 et seq. NMSA
				  1978. Section 9-8-1 et seq. NMSA 1978 establishes the health care authority
				  (HCA) as a single, unified department to administer laws and exercise functions
				  relating to health care facility licensure and health care purchasing and
				  regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
December 1, 2018, unless a later date is cited at the end of
				  a section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instruction for the
				  service portion of the New Mexico medical assistance programs
				  (MAP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.8 - SAFEGUARDS CONCERNING RESTRAINTS, RESTRICTIONS AND SECLUSION

Current through Register Vol. 35, No. 13, July 16, 2024
A. Seclusion
				and isolation is prohibited during waiver services.
B. Use of restraints or restrictions is only
				permitted during the course of delivery of waiver services under strict
				limitations and oversight.
(1) Certain
				specific interventions are considered ethically unacceptable for application
				and, as such, are unequivocally prohibited. Interventions that are prohibited
				include but are not limited to:
(a) contingent
				electrical aversion procedures;
(b)
				seclusion and isolation;
(c) use of
				time out (for an adult);
(d) use of
				mechanical or chemical restraints;
(e) use of manual application of any physical
				restraint, except in emergent situations involving imminent risk of harm to
				self or others (personal restraints);
(f) overcorrection;
(g) forced physical guidance;
(h) forced exercise;
(i) withholding food, water, or
				sleep;
(j) public or private
				humiliation including overreliance on prescribed protective gear or recommended
				assistive technology that is applied for programmatic convenience, calls undue
				attention to someone, and is therefore humiliating to the person supported;
				or
(k) application of water mist,
				noxious taste, smell, or skin agents.
(l) privacy violations such as body checks
				and electronic surveillance, remote monitoring in private areas such as
				bathrooms or bedrooms; or
(m)
				restricting a person from exiting their home using locks on doors and
				windows.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.9 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medical assistance division (MAD) has
				  obtained a waiver from certain medicaid payment and benefit statutes
				  (42 CFR 441.300)
				  to provide home and community-based services (HCBS) to eligible recipients as
				  an alternative to institutionalization. DDW services are intended to enhance,
				  not replace, existing natural supports and other available community resources.
				  Services will emphasize and promote the use of natural and generic supports to
				  address the eligible recipient's assessed needs in addition to paid supports.
				  Provider agencies are required to ensure the settings in which they provide
				  services meet the below requirements. All providers have a responsibility to
				  monitor settings for compliance; monitor that waiver recipients are given
				  choices; and, ensure rights are respected. DDW services must be provided in a
				  setting that:
A. is integrated in and
				facilitates full access to the greater community;
B. ensures the individual receives services
				in the community to the same degree of access as individuals not receiving
				medicaid HCBS;
C. maximizes
				independence in making life choices;
D. is chosen by the individual (in
				consultation with the guardian if applicable) from among residential and day
				options, including non-disability specific settings;
E. ensures the right to privacy, dignity,
				respect and freedom from coercion and restraint;
F. supports health and safety based upon the
				individual's needs, decisions or desires;
G. optimizes individual initiative, autonomy
				and independence in making life choices;
H. provides an opportunity to seek
				competitive employment;
I. provides
				individuals an option to choose a private unit in a residential setting;
				and
J. facilitates choice of
				services and who provides them.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. A provider who
				furnishes services to an eligible recipient must comply with all federal and
				state laws, regulations, rules, and executive orders relevant to the provision
				of services as specified in the MAD provider participation agreement and the
				DOH provider agreement. A provider also must meet and adhere to all applicable
				NMAC rules and instructions as specified in the MAD provider rules manual and
				its appendices, DDW service standards, DDW service definitions, and program
				directions and billing instructions, as updated. A provider is also responsible
				for following coding manual guidelines and the centers for medicare and
				medicaid services (CMS) correct coding initiatives, including not improperly
				unbundling or upcoding services.
B.
				A provider must verify that an individual is eligible for a specific health
				care program administered by the HSD and its authorized agents and must verify
				the eligible recipient's enrollment status at the time services are furnished.
				A provider must determine if an eligible recipient has other health insurance.
				A provider must maintain records that are sufficient to fully disclose the
				extent and nature of the services provided to an eligible recipient.
C. Provider agencies must mitigate any
				conflict of interest issues by adhering to at least the following:
(1) Any individual who operates or is an
				employee or subcontractor of a DDW provider shall not serve as guardian for a
				person served by that agency, except when related by affinity or consanguinity
				Paragraph (1) of Subsection A of Section
				45-5-31 NMSA 1978. Affinity which
				stems solely from the caregiver relationship is not sufficient to satisfy this
				requirement.
(2) DDW provider
				agencies may not employ or sub-contract with a direct support person who is an
				immediate family member to support the person in services, except when the
				person is in family living, respite, or customized in home supports
				(CIHS).
(3) DDW provider agencies
				may not employ or subcontract with the spouse of the participant to support the
				person in any DDW funded services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.12 - ELIGIBLE RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
The MAP category of eligibility criteria for DDW services is
				  found in 8.290.400 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.14 - DDW COVERED WAIVER SERVICES FOR IDENTIFIED POPULATION UNDER 18 YEARS OF AGE

Current through Register Vol. 35, No. 13, July 16, 2024
The DDW program is limited to the number of federally
				  authorized unduplicated eligible recipient (UDR) positions and program funding.
				  All DDW covered services in an ISP must be authorized. DDW services must be
				  provided in accordance with all requirements set forth by DDW service
				  definitions, all requirements outlined in the DDW service standards, and the
				  applicable NMAC rules, supplements and guidance. The DDW covers the following
				  services for a specified and limited number of waiver eligible recipients as a
				  cost effective alternative to institutionalization in an intermediate care
				  facilities for individuals with intellectual disabilities (ICF-IID).
A.
Eligible recipients age birth to
				18:
Services funded within this age category must be coordinated with
				and shall not duplicate other services such as the medicaid school-based
				services program, the MAD early periodic screening diagnosis and treatment
				(EPSDT) program, services offered through the New Mexico public education
				department (PED), or the early childhood education and care department (ECECD)
				family infant toddler (FIT) program.
B.
Service options available
				include:
(1) environmental
				modifications;
(2) assistive
				technology;
(3) remote personal
				support technology;
(4) preliminary
				risk screening and consultation;
(5) socialization and sexuality
				education;
(6) behavioral support
				consultation;
(7) customized
				community support;
(8)
				respite;
(9) non-medical
				transportation;
(10) case
				management;
(11) nutritional
				counseling; and
(12) crisis
				supports.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.15 - DDW COVERED WAIVER SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The DDW program is limited to the number of federally
				  authorized unduplicated eligible recipient (UDR) positions and program funding.
				  All DDW covered services in an ISP must be authorized by DOH. DDW services must
				  be provided in accordance with all requirements set forth by DOH DDW service
				  definition, all requirements outlined in the DDW service standards, and the
				  applicable NMAC rules, supplements and guidance and must be based on assessed
				  need. Services for individuals under the age of 21 must be coordinated with and
				  shall not duplicate other services such as the medicaid school-based services
				  program, the MAD early periodic screening diagnosis and treatment (EPSDT)
				  program, or the early childhood education and care department (ECECD) family
				  infant toddler (FIT) program. Services offered through the New Mexico public
				  education department (PED), the Individuals with Disabilities Education Act
				  (IDEA), the New Mexico division of vocational rehabilitation (DVR), the
				  Rehabilitation Act, the Workforce Innovation and Opportunities Act (WIOA), the
				  New Mexico department of workforce solutions (DWS) must be utilized prior to
				  accessing funding from the DDW. DDW covers the following services for a
				  specified and limited number of waiver eligible recipients as a cost effective
				  alternative to institutionalization in an ICF-IID.
A. Information and documentation that
				justifies the need for services based on the eligible recipient's assessed need
				may be required and requested. Justification for services must:
(1) outline the eligible recipient's
				clinical, functional, physical, behavioral or habilitative needs;
(2) promote and afford support to the
				eligible recipient for their greater independence and to maintain current level
				of function or minimize risk of further decline; or contribute to and support
				the eligible recipient's efforts to remain in the community;
(3) to contribute and be engaged in their
				community, and to reduce their risk of institutionalization;
(4) address the eligible recipient's physical
				health, behavioral, and social support needs, not including financial support,
				that arise as a result of their functional limitations or conditions, such as:
				self-care, receptive and expressive language, learning, mobility,
				self-direction, capacity for independent living, and economic self-sufficiency;
				and
(5) relate to an outcome in the
				eligible recipient's individual service plan (ISP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.16 - NON-COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Only those services listed in the DDW benefit package may be
				  reimbursed through the DDW. Room, board and ancillary services are not covered
				  under DDW services. An eligible recipient may access, as medically necessary,
				  all medicaid state plan benefits in addition to their DDW services. If the
				  eligible recipient is an enrolled member of a HSD managed care organization
				  (MCO), they may access, as medically necessary, the benefits listed in 8.308.9
				  NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.17 - INDIVIDUALIZED SERVICE PLAN (ISP)

Current through Register Vol. 35, No. 13, July 16, 2024
A. CMS requires a
				person-centered service plan for every individual receiving HCBS. The ISP must
				be developed annually through an ongoing person-centered planning process. The
				ISP development must:
(1) Involve those whom
				the participant wishes to attend and participate in developing the service plan
				and are provided adequate notice;
(2) Use assessed needs to identify services
				and supports;
(3) Include
				individually identified goals and preferences related to relationships,
				community participation, employment, income and savings, healthcare and
				wellness, education and others;
(4)
				Identify roles and responsibilities of IDT members responsible for implementing
				the plan;
(5) Include the timing of
				the plan and how and when it is updated, including response to changing
				circumstances and needs; and
(6)
				Outline how the individual is informed of available services funded by the DDW
				as well as other natural and community resources.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.19 - Reimbursement

Current through Register Vol. 35, No. 13, July 16, 2024
DDW service providers must submit claims for reimbursement to
				  MAD's fiscal contractor for processing. A DDW provider must follow 8.302.2
				  NMAC, MAD billing instructions, utilization review instructions, and
				  supplements. Reimbursement to providers of waiver services is made at a
				  predetermined reimbursement rate.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.21 - CONTINUATION OF BENEFITS PURSUANT TO A TIMELY APPEAL AND A HSD ADMINISTRATIVE HEARING PROCEEDING

Current through Register Vol. 35, No. 13, July 16, 2024
A continuation of an existing DDW benefit or benefits is
				  automatically provided to an eligible recipient claimant pending the resolution
				  of the agency review conference and any subsequent fair hearing. The
				  continuation of a benefit is only available to a claimant that is currently
				  receiving the appealed benefits. The continuation of the benefits will be the
				  same as the claimant's current allocation, budget or LOC unless a revision is
				  agreed to in writing by the eligible recipient (or authorized representative)
				  and HSD.
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 8.314.6.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
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. Section 9-8-1 et seq. NMSA 1978 establishes the health care
				  authority (HCA) as a single, unified department to administer laws and exercise
				  functions relating to health care facility licensure and health care purchasing
				  and regulation.
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 8.314.6.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
March 1, 2016, unless a later date is cited at the end of a
				  section.
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 8.314.6.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instructions for the
				  service portion of the New Mexico medical assistance programs (MAP).
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 8.314.6.9 - MI VIA HOME AND COMMUNITY-BASED SERVICES WAIVER

Current through Register Vol. 35, No. 13, July 16, 2024
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.
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 8.314.6.10 - MI VIA CONTRACTED ENTITIES AND PROVIDERS SUPPORTING SELF-DIRECTED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
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.
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 8.314.6.11 - QUALIFICATIONS FOR ELIGIBLE INDIVIDUAL EMPLOYEES, INDEPENDENT PROVIDERS, PROVIDER AGENCIES, AND VENDORS

Current through Register Vol. 35, No. 13, July 16, 2024
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.
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 8.314.6.12 - RECORDKEEPING AND DOCUMENTATION RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
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.
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 8.314.6.13 - ELIGIBILITY REQUIREMENTS FOR RECIPIENT ENROLLMENT IN MI VIA

Current through Register Vol. 35, No. 13, July 16, 2024
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.
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 8.314.6.15 - SERVICE DESCRIPTIONS AND COVERAGE CRITERIA

Current through Register Vol. 35, No. 13, July 16, 2024
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.
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 8.314.6.16 - NON-COVERED SERVICES

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