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 8.314.5.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Health care to
				eligible recipients is furnished by a variety of providers and provider groups.
				The reimbursement and billing for these services is administered by MAD. Upon
				approval of a New Mexico MAD provider participation agreement (PPA) by MAD or
				its designee, licensed practitioners, facilities, and other providers of
				services that meet applicable requirements are eligible to be reimbursed for
				furnishing covered services to eligible recipients. A provider must be enrolled
				before submitting a claim for payment to the MAD claims processing contractors.
				MAD makes available on the HSD/MAD website, on other program-specific websites,
				or in hard copy format, information necessary to participate in health care
				programs administered by HSD or its authorized agents, including New Mexico
				administrative code (NMAC) rules, billing instructions, utilization review
				instructions, EVV requirements and instructions, service definitions and
				service standards and other pertinent materials. When enrolled, a provider
				receives instruction on how to access these documents. It is the provider's
				responsibility to access these instructions, to understand the information
				provided and to comply with the requirements. The provider must contact HSD or
				its authorized agents to obtain answers to questions related to the material or
				not covered by the material. To be eligible for reimbursement, a provider must
				adhere to the provisions of the MAD PPA and all applicable statutes,
				regulations, and executive orders. MAD or its selected claims processing
				contractor issues payments to a provider using electronic funds transfer (EFT)
				only.
B. All DDW eligible providers
				must be approved by DOH or its designee and have an approved MAD PPA and a DOH
				provider agreement.
C. MAD through
				its designee, DOH/DDSD, follows a subcontractor model for certain DDW services.
				The agency, following the DOH/DDSD model, must ensure that its subcontractors
				or employees meet all required qualifications. The agency must provide
				oversight of subcontractors and supervision of employees to ensure that all
				required MAD and DOH/DDSD qualifications and service standards are met. In
				addition, the agency must provide oversight and supervision of subcontractors
				and employees to ensure that services are delivered in accordance with all
				requirements set forth by the DOH/DDSD DDW service definition, all requirements
				outlined in the DDW services standards, applicable NMAC rules, MAD supplements,
				and as applicable, their New Mexico licensing board's scope of practice and
				licensure. Pursuant to federal regulations, an agency may not employ or
				subcontract with the spouse of an eligible recipient or the parent of an
				eligible recipient under 18 years of age to provide direct care services to the
				eligible recipient.
D.
Qualifications of case management provider agency:
A case
				management provider agency, its case managers, whether subcontractors or
				employees must comply with
				8.314.5.10 NMAC. In addition, case
				management provider agency must ensure that a case manager meets the following
				qualifications:
(1) one year of clinical
				experience, related to the target population; and
(2) one or more of the following:
(a) hold a current social worker license as
				defined by the New Mexico regulation and licensing department (RLD);
				or
(b) hold a current registered
				nurse (RN) license as defined by the New Mexico board of nursing; or
(c) hold a bachelor's or master's degree in
				social work, psychology, sociology, counseling, nursing, special education, or
				a closely related field or have a minimum of six years of direct experience
				related to the delivery of social services to people with disabilities;
				or
(d) have a high school diploma
				or GED and a minimum of six years of direct experience related to the delivery
				of social services to people with disabilities.
(3) comply with all training requirements as
				specified by DOH/DDSD; and
(4) have
				received written notification from DOH that they do not have a disqualifying
				conviction after submitting to the caregiver criminal history screening
				(CCHS);
(5) does not provide any
				direct waiver services through the same 1915 (c) HCBS waiver program;
				and
(6) any exception to the above
				must be approved by DOH/DDSD.