reglab/statecodes huggingface dataset:
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 8.314.6.17 - SERVICE AND SUPPORT PLAN (SSP) AND AUTHORIZED ANNUAL BUDGET (AAB)

Current through Register Vol. 35, No. 13, July 16, 2024
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.
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 8.314.6.18 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

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

Current through Register Vol. 35, No. 13, July 16, 2024
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.
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 8.314.6.20 - RIGHT TO A HSD ADMINISTRATIVE HEARING

Current through Register Vol. 35, No. 13, July 16, 2024
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.
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 8.314.6.21 - 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 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.
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 8.314.6.22 - GRIEVANCE/COMPLAINT 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 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.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 7 - SUPPORTS WAIVER › Section 8.314.7.3 - 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 7 - SUPPORTS WAIVER › Section 8.314.7.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
April 1, 2021, 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 7 - SUPPORTS WAIVER › Section 8.314.7.6 - 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 7 - SUPPORTS WAIVER › Section 8.314.7.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To transform lives. Working with our partners, we design and
				  deliver innovative, high quality health and human services that improve the
				  security and promote independence for New Mexicans in their
				  communities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 7 - SUPPORTS WAIVER › Section 8.314.7.9 - SUPPORTS WAIVER HOME AND COMMUNITY-BASED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A. New Mexico's supports waiver is designed
				to provide temporary assistance to those on the developmental disabilities (DD)
				waiver wait list. It is intended to provide support services to eligible
				recipients to enable work toward self-determination, independence,
				productivity, integration, and inclusion in all facets of community life across
				the lifespan. The services provided are intended to build on each eligible
				recipient's current support structures through person-centered planning to work
				toward individually defined life outcomes, focusing on developing the eligible
				recipient's abilities for self-determination, community living and
				participation, and economic self-sufficiency. An eligible recipient has a
				choice of receiving services through the agency-based service delivery model or
				the participant directed service delivery model.
B. The program is operated by the New Mexico
				department of health developmental disabilities supports division (DOH/DDSD),
				at the direction of the New Mexico human services department medical assistance
				division (HSD/MAD).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 7 - SUPPORTS WAIVER › Section 8.314.7.10 - ELIGIBLITY REQUIREMENTS FOR RECIPIENT ENROLLMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Enrollment in the supports waiver is contingent upon the
				  applicant meeting the eligibility requirements, the availability of funding as
				  appropriated by the New Mexico legislature, and the number of federally
				  authorized unduplicated eligible recipients. When sufficient funding is
				  available, DOH will offer the supports waiver to eligible recipients on the DD
				  wait list. Once an offer has been given to the applicant, they must meet
				  certain medical and financial criteria in order to qualify for enrollment.
				  Eligible recipients must meet the following eligibility criteria: financial
				  eligibility criteria determined in accordance with 8.290.400 NMAC; the eligible
				  recipient must meet the level of care (LOC) required for admittance to an
				  intermediate care facility for individuals with intellectual disabilities
				  (ICF/IID); and additional specific criteria as specified in the categories
				  below.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 7 - SUPPORTS WAIVER › Section 8.314.7.13 - QUALIFICATIONS FOR ELIGIBLE INDIVIDUAL EMPLOYEES, INDEPENDENT PROVIDERS, PROVIDER AGENCIES, AND VENDORS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Agency-based service delivery model requirements for individual
				employees, independent providers, provider agencies and vendors:
All
				supports waiver eligible providers under the agency-based model of service
				delivery must be approved by the DOH or its designee and have an approved MAD
				and DOH provider agreement. MAD through its designee, DOH/DDSD, must ensure
				that its subcontractors or employees meet all required qualifications. The
				provider agency must provide oversight of subcontractors and supervision of
				employees to ensure that all required MAD and DOH/DDSD qualifications;
				compliance with EVV requirements; all requirements outlined in the supports
				waiver services standards, applicable New Mexico administrative code (NMAC)
				rules, MAD supplements, and as applicable, the provider's New Mexico licensing
				board's scope of practice and licensure are met.
B.
Participant directed service
				delivery model requirements for individual employees, independent providers,
				and vendors:
In order to be approved to provide services under the
				participant directed service delivery model, provider agency, employees,
				vendors, or an independent provider, including non-licensed personal care or
				direct support worker, 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. In addition,
				to be an authorized provider for the supports waiver and receive payment for
				delivered services, the provider must complete a vendor or employee provider
				agreement and all required tax documents. The provider must have credentials
				verified by the eligible recipient or the employee of record (EOR) and the FMA.
				The provider agency is responsible to ensure that all agency employees meet the
				required qualifications. Individual employees may not provide more than 40
				hours of services in a consecutive seven-day work week.
(1) prior to rendering services to an
				eligible supports waiver recipient as a personal care or direct support worker,
				respite worker, customized community supports worker, or employment worker, 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 CSC provider must have a MAD approved provider participation
				agreement (PPA) and the appropriate approved DOH/DDSD agreement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 7 - SUPPORTS WAIVER › Section 8.314.7.14 - SERVICE DESCRIPTIONS AND COVERAGE CRITERIA

Current through Register Vol. 35, No. 13, July 16, 2024
The services covered by the supports waiver are intended to
				  provide a community-based alternative to institutional care for an eligible
				  recipient that allow greater choice, direction and control over services and
				  supports in an agency-based service delivery model or participant directed
				  service delivery model. These services must specifically address a therapeutic,
				  rehabilitative, habilitative, health or safety need that results from the
				  eligible recipient's qualifying condition. The supports waiver is the payor of
				  last resort. The coverage of the services must be in accordance with the
				  supports waiver rules and service standards. Supports waiver services must be
				  provided in an integrated setting and facilitate full access to the community;
				  ensure the eligible 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 eligible recipient in
				  consultation with the guardian as applicable; ensure the right to privacy,
				  dignity, respect, and freedom from coercion and restraint; optimize recipient
				  employment; and facilitate choice of services and who provides them.
A.
General requirements regarding
				supports waiver covered services:
To be considered a covered service
				under the supports waiver, 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 7 - SUPPORTS WAIVER › Section 8.314.7.16 - INDIVIDUAL SERVICE PLAN (ISP) AND AUTHORIZED ANNUAL BUDGET(AAB)

Current through Register Vol. 35, No. 13, July 16, 2024
An ISP and an AAB request are developed at least annually by
				  the eligible recipient in collaboration with the eligible recipient's CSC and
				  others that the eligible recipient invites to be part of the process. The CSC
				  serves in a supporting role to the eligible recipient, assisting the eligible
				  recipient to understand the supports waiver program, and with developing and
				  implementing the ISP and the AAB. The ISP and annual budget request are
				  developed and implemented as specified in 8.314.7. NMAC and supports waiver
				  service standards and submitted to the TPA or MAD's designee for final
				  approval. Upon final approval the annual budget request becomes an AAB.
A.
ISP development process:
For
				development of the person-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
				process and the planning process that is undertaken between the CSC and
				eligible recipient to develop their ISP.
(1)
Assessments:
(a) assessment
				activities that occur prior to the ISP 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;
(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 their CSC for use in
				planning;
(c) the eligible
				recipient and the CSC will assure that the ISP addresses the information and
				concerns, if any, identified through the assessment process.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 7 - SUPPORTS WAIVER › Section 8.314.7.17 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All MAD services, including services covered under the
				  supports waiver 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 ISP and
				AAB require prior authorization from HSD/MAD or its designee. The ISP 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 supports waiver
				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 medical assistance program
				(MAP) or supports waiver services.
C.
Reconsideration:
If there is
				a disagreement with a prior authorization denial or other review decision, the
				community supports coordinator 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 supports waiver 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.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 7 - SUPPORTS WAIVER › Section 8.314.7.18 - RECORDKEEPING AND DOCUMENTATION RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Service providers and vendors who furnish goods and services
				  to supports waiver eligible recipients are reimbursed by the financial
				  management agency (FMA) and must comply with all applicable New Mexico
				  administrative code (NMAC), medical assistance division (MAD) rules and service
				  standards. The FMA, community supports coordinators (CSC) 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 department of health (DOH) or their audit
				  agents. MAD or its designee will seek recoupment of funds from service
				  providers when audits show inappropriate billing for services. Supports waiver
				  vendors who furnish goods and services to supports waiver eligible recipients
				  and bill the FMA must comply with all MAD provider participation agreement
				  (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 7 - SUPPORTS WAIVER › Section 8.314.7.20 - RIGHT TO AN HSD ADMINISTRATIVE HEARING

Current through Register Vol. 35, No. 13, July 16, 2024
A. The human services department/medical
				assistance division (HSD/MAD) must grant an opportunity for an administrative
				hearing as described in this section in the following circumstances and
				pursuant to
				42 CFR Section
				431.220(a)(1), Section
				27-3-3 NMSA 1978 and 8.352.2 NMAC
Recipient Hearings
:
(1) when a supports waiver applicant has been
				determined not to meet the LOC requirement for waiver services;
(2) when a supports waiver applicant has not
				been given the choice of HCBS as alternative to institutional care;
(3) when a supports waiver applicant is
				denied the services of their choice or the provider of their choice;
(4) when a supports waiver recipient's
				services are denied, suspended, reduced or terminated;
(5) when a supports waiver recipient has been
				involuntarily terminated from the program; or
(6) when a supports waiver recipient's
				request for a budget adjustment has been denied.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 7 - SUPPORTS WAIVER › Section 8.314.7.21 - 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 eligible recipients who request an HSD administrative hearing within the
				timeframe defined in 8.352.2 NMAC. The notice will include information on the
				right to continued benefits and on the eligible recipient's responsibility for
				repayment if the hearing decision is not in the eligible recipient's favor. See
				8.352.2 New Mexico administrative code (NMAC) for a complete description of the
				continuation of benefits process of an HSD administrative hearing for an
				eligible recipient.
B. The
				continuation of benefit is only available to an eligible recipient that is
				currently receiving the appealed benefit. The eligible recipient's current AAB
				and ISP at the time of the request is termed a 'continuation' of benefits. The
				continuation budget may not be revised until the conclusion of the fair hearing
				process.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 7 - SUPPORTS WAIVER › Section 8.314.7.22 - GRIEVANCE/COMPLAINT SYSTEM

Current through Register Vol. 35, No. 13, July 16, 2024
An eligible recipient has the opportunity to register
				  grievances or complaints concerning the provision of services under the
				  supports waiver program. Eligible recipients may register complaints with
				  either HSD/MAD or DOH/DDSD via e-mail, mail or phone. Complaints will be
				  referred to the appropriate department for resolution. The eligible recipient
				  is informed that filing a grievance or complaint is not a prerequisite or
				  substitute for a fair hearing.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.3 - 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
				  (Repl. Pamp. 1991). 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 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
July 1, 2024, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these regulations is to provide policies for
				  the service portion of the New Mexico medicaid program. These policies describe
				  eligible providers, covered services, noncovered services, utilization review,
				  and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of medicaid-eligible individuals by
				  furnishing payment for quality health services at levels comparable to private
				  health plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.9 - PACE PROGRAM SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program (medicaid) pays for medically
				  necessary health services furnished to eligible recipients, including services
				  furnished in nursing facilities. To help New Mexico recipients receive
				  necessary services, the New Mexico medical assistance division (MAD) pays for
				  capitated and community-based services through the PACE program. This project
				  provides a complete package of acute, long term care, personal care and social
				  services to a frail population that meets nursing facility clinical criteria.
				  See Section 9412(b) of the federal Omnibus Budget Reconciliation Act of 1986
				  and Section 1915(a) of the Social Security Act. This part describes the
				  following: eligible providers, services for recipients who are nursing home
				  eligible, covered services, service limitations, and reimbursement
				  methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				eligible provider will have a professional services agreement (PSA) with the
				HCA. The provider will also meet the following conditions:
(1) be licensed and certified by the
				licensing and certification bureau of the department of health (DOH) to meet
				conditions as a diagnostic and treatment center;
(2) participate in the MAD utilization review
				process and agree to operate in accordance with all policies and procedures of
				that system; and
(3) meet and
				comply with the centers for medicare and medicaid services (CMS) requirements
				for full provider status for PACE organizations.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				provider who furnishes services to medicaid recipients will comply with all
				specified medicaid participation requirements. See 8.302.1 NMAC,
General Provider Policies
. The provider will verify that
				individuals are eligible for medicaid, medicare, or other health insurance at
				the time services are furnished. The provider will verify whether or not an
				individual is self-pay at the time services are provided. The provider will
				maintain records which are sufficient to fully disclose the extent and nature
				of the services provided to recipients. See 8.302.1 NMAC,
General
				Provider Policies
. The provider will provide the coordination which
				will enable the client to utilize PACE as the single source for primary care.
				This will assist the enrollee in the coordination of care by
				specialists.
B. Outreach and
				marketing: The provider will have a written plan which accomplishes the
				following outreach and marketing objectives.
(1) Strategies of how prospective
				participants are provided adequate program descriptions.
(a) The program descriptions shall be written
				in a culturally competent format at a language level understandable by the
				participant (sixth grade). The format should be sensitive to the culture and
				language common to the service area.
(b) Program descriptions should include the
				services available through the program. The services include, but are not
				limited to, the following: enrollment and disenrollment, procedures to access
				services, after hours call-in system, provisions for emergency treatment,
				restrictions against using medical providers or services not authorized by the
				interdisciplinary team, and any other information necessary for prospective
				participants to make informed decisions about enrollment. Prior to enrollment,
				each participant will be informed of what individualized initial assessment and
				treatment plan has been developed by the interdisciplinary team.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.12 - ELIGIBLE RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid recipients who meet the eligibility requirements as
				  stated in the medical assistance division eligibility manual may be eligible to
				  participate in the PACE program.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.13 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The PACE program is a partially capitated, community based
				  service program. The PACE program will ensure access to a comprehensive benefit
				  package of services to a frail population that meets nursing facility clinical
				  criteria. The provider will provide all medicaid services that are included in
				  a capitated rate. Medicare covered services will be reimbursed through a
				  medicare capitated rate. The provider will provide medicare-eligible PACE
				  participants with all medicare services that are included in the medicare
				  capitated rate. Effective Janaury 1, 2006, upon the implementation of medicare
				  part D prescription drug coverage, pharmacy costs for PACE medicare
				  beneficiaries are covered by the medicare capitated rate. Pharmacy costs for
				  medicaid only recipients would be covered by the medicaid only capitated
				  rate.
A. Adult day health center: The
				focal point for coordination and provision of the majority of the PACE program
				services is the adult day health center. The adult day health center will
				include a primary care clinic and areas for therapeutic recreation, restorative
				therapies, socialization, personal care and dining. The center shall include
				the following areas:
(1) examination
				room(s);
(2) treatment
				room(s);
(3) therapy
				room(s);
(4) dining
				room(s);
(5) activity
				room(s);
(6) kitchen;
(7) bathroom(s);
(8) personal care room(s);
(9) administrative office(s);
(10) counseling office(s);
(11) pharmacy/medication room; and
(12) laboratory;
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				following services are not the responsibility of the provider or medicaid:
(1) any medicaid capitated or fee-for-service
				benefit which has not been authorized by the multidisciplinary team;
(2) in inpatient facilities, private room and
				private duty nursing, unless medically necessary, and non-medical items for
				personal convenience, such as telephone charges, radio, or television
				rental;
(3) cosmetic surgery unless
				required for improved functioning of a malformed part of the body resulting
				from an accidental injury or for reconstruction following mastectomy;
(4) experimental medical, surgical or other
				health procedures or procedures not generally available;
(5) care in a government hospital (veterans
				administration, federal/state hospital) unless authorized;
(6) service in any hospital for the treatment
				of chronic, medically uncomplicated drug dependency or alcoholism;
				and
(7) any services rendered
				outside of the United States.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.15 - TREATMENT PLANS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Prior to
				enrollment, an initial assessment and treatment plan for each participant is
				developed by the interdisciplinary team.
B. Each participant will be reassessed by the
				interdisciplinary team on a semiannual basis and informed about a new treatment
				plan.
C. The enrollee, enrollees
				family, or representative shall be included in the initial assessment,
				treatment plan and semiannual reassessment of the treatment plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.16 - ENROLLMENT OF PARTICIPANTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				effective date for the recipient's enrollment in the program is the first day
				of the calendar month following the signing of the enrollment agreement, if an
				approved level of care (LOC) and all financial and non-financial eligibility
				criteria have been approved by the income support division (ISD).
B. The potential participant signs an
				enrollment agreement which includes, but is not limited to, the following
				information:
(1) enrollment and disenrollment
				data that will be collected and submitted to the HCA, including, but not
				limited to, the following:
(a) social security
				number;
(b) health insurance claim
				number (HIC);
(c) last name, first
				name, middle initial;
(d) date of
				birth;
(e) address of current
				residence;
(f) assigned ISD office
				address;
(g) medicare number (part
				A and part B) for medicare beneficiaries;
(h) medicaid number; and
(i) effective date of enrollment in the PACE
				program;
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.17 - DISENROLLMENT OF PARTICIPANTS

Current through Register Vol. 35, No. 13, July 16, 2024
All voluntary and involuntary disenrollments will be
				  documented and available for review by the state medicaid agency. The provider
				  will inform the ISD office when a participant is being disenrolled either
				  voluntarily or involuntarily. Disenrollment is effective by the first day of
				  the second calendar month following the date in which enrollment has
				  changed.
A. Voluntary disenrollment: A
				participant may begin the process of voluntary disenrollment at any time during
				the month. The provider shall use the most expedient process allowed by
				medicaid and medicare procedures while ensuring a coordinated disenrollment
				date. Until enrollment is terminated, the participants are required to continue
				using the PACE program services and remain liable for any premiums. The
				provider shall continue to provide all needed services until the date of
				termination.
B. Involuntary
				disenrollment: A participant may be involuntarily disenrolled if the
				participant:
(1) moves out of the PACE program
				service area;
(2) is a person with
				decision-making capacity who consistently does not comply with the individual
				plan of care and poses a significant risk to self or others;
(3) experiences a breakdown in the physician
				or team participant relationship such that the PACE program provider's ability
				to furnish services to either the participant or other participant(s) is
				seriously impaired;
(4) refuses
				services or is unwilling to meet conditions of participation as they appear in
				the enrollment agreement;
(5)
				refuses to provide accurate financial information, provides false information
				or illegally transfers assets;
(6)
				is out of the PACE program provider service area for more than 30 days (unless
				arrangements have been made with the PACE program provider);
(7) is enrolled in a PACE program that loses
				its contracts or licenses which enable it to offer health care
				services;
(8) ceases to meet the
				financial or non-financial criteria; and
(9) ceases to meet the level of care (LOC) at
				any time.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.18 - APPROPRIATE REFERRAL FOR OTHER SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A. The provider will assist a participant who
				either voluntarily or involuntarily disenrolls from the PACE program to apply
				for other possible services, including medicare or private-pay services;
				and,
B. The provider will work with
				the state medicaid agency to ascertain the individual's potential eligibility
				for other medicaid categories.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.19 - PROVISIONS FOR REINSTATEMENT OF PARTICIPANTS TO THE PACE PROGRAM

Current through Register Vol. 35, No. 13, July 16, 2024
There are no restrictions placed on a former participant's
				  reinstatement into the PACE program, if the former participant continues to
				  meet financial, non-financial and medical eligibility
				  criteria.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.20 - REDETERMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
The ISD office will conduct a redetermination at least
				  annually of all financial and non-financial criteria, per the standards of the
				  medicaid eligibility requirements. See Subsection A of
				  8.280.600.12 NMAC,
Ongoing
				  Benefits, Regular Reviews
. LOC is determined by the HCA's utilization
				  review contractor.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.21 - PARTICIPANT RIGHTS

Current through Register Vol. 35, No. 13, July 16, 2024
The provider will have written policies and procedures for
				  ensuring the rights of participants as well as educating the participants to
				  the PACE program. These policies and procedures should be presented in a
				  culturally competent format at a language level understandable by the
				  participant or their families (sixth grade level) covering, at a minimum, the
				  following:
A. the
				enrollment/disenrollment process;
B. services available through the
				program;
C. procedures to access
				services;
D. after hours call-in
				system;
E. provisions for emergency
				treatment; and
F. restrictions
				against using medical providers or services not authorized by the
				interdisciplinary team.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.22 - GRIEVANCE PROCEDURES

Current through Register Vol. 35, No. 13, July 16, 2024
The provider will have participant grievance procedures which
				  provide the participants and their family members with a process for expressing
				  dissatisfaction with the program services, whether medical or nonmedical in
				  nature. The procedures will explain and permit an orderly resolution of
				  informal and formal grievances. These procedures should be presented in a
				  culturally competent format at a language level understandable by the
				  participant or their families (sixth grade level). The procedures will:
A. ensure that all provider grievance
				procedures and any subsequent changes are prior-approved by MAD in writing and
				included in the enrollment agreement;
B. ensure that a staff member is designated
				as having primary responsibility for the maintenance of the grievance
				procedures, review of their operation, and revision of related policies and
				procedures whenever necessary;
C.
				ensure that the grievance procedures clearly explain to participants which
				staff members are assigned to receive formal and informal complaints, the
				expected procedure, and the time frames for doing so;
D. ensure that a copy of the participant
				grievance procedures and complaint forms are available to
				participants;
E. ensure that
				procedures are in place for tracking, investigating, recording, resolving and
				appealing decisions concerning grievances made by participants or others;
				and
F. ensure there is no
				discrimination against a participant solely on the grounds the participant
				filed a grievance.