New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
"Acquired
				brain injury" (ABI)
means a brain injury that is the result of trauma
				arising from an insult to the brain from an outside physical force via open or
				closed head injury; shaken baby syndrome; anoxia; near-drowning; electrical
				shock; brain infection; brain tumors; cerebrovascular lesions or insults,
				including stroke and aneurysm; or unintended toxic or chemical exposure. The
				definition excludes conditions that are congenital, degenerative, induced by
				birth trauma, or resulting from abuse of alcohol or other substances. The
				injury may be focal or diffuse, causing temporary or permanent impairments in
				cognitive, psychosocial or physical functioning affecting one or more areas of
				the brain and result in partial or total functional disability. Brain injury
				related impairments may affect one or more areas of functioning such as:
				cognition; language; memory; attention; reasoning; abstract thinking; judgment;
				problem-solving; information processing; sensory, perceptual, and motor
				abilities; physical functioning; sleep; psychosocial and behavioral
				functioning; and, or speech.
B.
"Activities of daily living" (ADL)
means the basic tasks that are
				necessary for independent functioning to care for one's personal needs and may
				include bathing and showering, personal hygiene and grooming, dressing,
				toileting, transferring or moving the physical body in space while performing
				activities, and self-feeding. Instrumental activities of daily living (IADLs)
				are not necessary for fundamental functioning but do allow an individual to
				live independently in their home or community; these include cleaning and
				maintaining the home, doing laundry, managing personal finances, preparing
				meals, shopping for groceries, taking prescribed medications, and using the
				telephone or other communication devices.
C.
"Brain injury".
See
				definition for acquired brain injury and traumatic brain injury.
D.
"Brain injury services fund (BISF)
				program"
means a non-medicaid program administered by HSD through
				programmatic oversight and contractual management of agencies, providing
				short-term crisis interim home and community-based services for eligible
				individuals living with brain injury, who have a defined crisis related to
				living with brain injury and no responsible funding source to pay for needed
				services or goods. Direct participant care services are provided through
				service coordination or BISF home and community-based services.
E.
"Crisis"
means an emergency
				or unstable situation that has reached a critical phase with a distinct
				possibility of adverse outcome and poses a serious potential danger. As related
				to a brain injury, a crisis may include homeless status, unemployment,
				substantial loss of income, lack of health insurance or means to pay for
				brain-injury related healthcare, separation from support systems, abandonment
				or other endangering circumstances. For the purposes of the BISF, the absence
				of service coordination, long-term care, long-term case management or need for
				long-term case management does not constitute a crisis.
F.
"Crisis interim period
" means
				a short-term period of six months upon which an enrolled participant can be
				reassessed to extend approved services for another six month period depending
				upon available funding and limited to no more than one consecutive year, if the
				crisis has not resolved and goals for independent living have not reached
				completion, or until another funding source has been obtained. Time limitations
				on services apply to both service coordination and to BISF HCBS.
G.
"Education"
means providing
				individuals living with brain injury training and understanding of brain
				injury, acquiring life skills or fulfilling activities of daily living, which
				can be applied day to day, to assist in the attainment of an independent
				lifestyle.
H.
"Fiscal
				intermediary agency"
means an agency that arranges for BISF home and
				community-based services and goods and processes payment or reimbursement for
				services and goods for eligible participants of the New Mexico human services
				department brain injury services fund program.
I.
"Formulary" or "BISF
				formulary"
means the list of medications approved by the BISF program
				for treatment of specific categories of brain injury symptoms and related
				conditions. Coverage is in the form of copayments for participants who have no
				other responsible payer sources. Approved generic and brand name medications
				are categorized by class or function. BISF service coordinators are authorized
				to review prescribed participant medications against the formulary in the event
				that other responsible payer sources to cover the medication do not exist prior
				to referral for BISF HCBS.
J.
"Grievance"
means a complaint or disagreement with regard to how
				or whether a service provided through the program is or can be
				provided.
K.
"Home and
				community-based services" (HCBS)
are defined as services to promote
				independent living that are provided in a person's home or community, i.e.,
				those not provided under institutional care. BISF HCBS are those that may be
				required when there is an imminent risk to a participant's health and safety;
				there has been a sudden change in the medical, psychological or physical
				condition of a participant; when there is acceleration in the amount of
				services needed; when needs have suddenly changed; or when another payer source
				will not pay for the unique brain injury services assessed as a need.
L.
"Human services department
				(HSD)"
is the New Mexico state government agency that administers
				services to New Mexico's more vulnerable populations to improve health outcomes
				through state and federal funding. The brain injury services fund is
				administered through the medical assistance division and receives only state
				funding.
M.
"ICD code"
means an international classification of diseases diagnosis, which includes
				codes for traumatic and other acquired brain injuries and has been documented
				in writing by a duly licensed medical professional or psychologist for the
				purpose of assisting an individual with brain injury to qualify for the BISF
				program. Current ICD codes may be accepted from medical doctors (MDs),
				osteopathic doctors (DOs), certified nurse practitioners (CNPs), physician
				assistants (PAs), and Ph.D. psychologists.
N.
"Imminent"
means impending
				and threatening, referring to a crisis that is bound to happen with a clear and
				present danger to the health and safety of a person who has sustained a brain
				injury and who has exhausted all available resources.
O.
"Independence"
means the
				ability to live in a home and community setting and perform activities of daily
				living with little or no assistance from others while having access to
				available community resources.
P.
"Individual"
means a person living with brain injury and may be an
				applicant or a program participant.
Q.
"Independent living plan"
(ILP) means a written person-centered plan that outlines definite goals for
				resolving a participant's identified crisis which is designed to assist the
				participant toward greater independence; lists measurable objectives in the
				form of action steps and strategies that are targeted to comprehensively
				address and resolve each identified crisis; and specifies a plan for discharge.
				The ILP identifies all services and supports as well as payer sources that are
				assisting the participant toward greater independence, specifying those that
				pertain directly to service coordination and BISF HCBS. It must also list
				ancillary services and supports, not paid for by the BISF program, noting
				related payer sources, as well as services refused but needed to resolve or
				address identified crises.
R.
"Interim"
means a time period defined by the BISF program in which
				temporary services are provided. The interim period for the BISF program is six
				months.
S.
"Legal resident of
				New Mexico"
means a person residing in New Mexico at the time of
				application.
T.
"Life skills
				coach"
means a person, who may be defined as a "life coach", is
				certified through an accredited organization, and provides targeted customized
				training to an individual with brain injury to assist in relearning and
				completing activities of daily living while addressing related cognitive,
				behavioral or social impairments that are preventing the return to independent
				functioning.
U.
"Participant"
means a person living with brain injury, who has qualified for, been
				approved for, and is actively receiving BISF program services, while working
				toward greater independence and resolution of crisis needs.
V.
"Payer of last resort"
refers
				to the BISF Program as a source of funding available to pay for BISF HCBS only
				after all payer sources with responsibility to pay have been denied or
				exhausted including private insurance, medicaid, medicare, Indian health
				services, veterans administration, adult protective services and other state or
				federal programs, or community programs in which the participant participates
				voluntarily.
W.
"Residency"
means the status of a person who is a legal resident
				of New Mexico and is able to produce documentation of a physical address within
				New Mexico at which the person resides within a home and community setting. It
				does not include residence in an institution wherein the individual is unable
				to function independently.
X.
"Risk"
means a possible loss or injury, a hazard increasing the
				probability or chance that loss or injury will occur.
Y.
"Self-determination"
means
				the right of individuals to make decisions that direct the path their life
				follows with regard to medical, financial and all other matters, including the
				right to refuse measures needed to improve their outcome.
Z.
"Service coordination"
means
				the goal-oriented initiation, organization and management of a BISF
				participant's services, including determination of eligibility, initial and
				interim assessments, development and monitoring of the participant's
				independent living plan (ILP), referrals for BISF program and community
				resources, assistance with benefits applications for other payer sources, and
				problem-solving to assist in the resolution of the crisis that motivated entry
				to the BISF program, while moving the participant toward greater independence
				in daily living. Service coordination may continue during resolution of an
				identified crisis need. Service coordination is not defined as case management,
				and the need for long-term case management does not constitute a qualifying
				crisis for remaining on the BISF.
AA.
"Short-term"
means an
				intervention period with beginning and end points within which BISF funding for
				service coordination or BISF HCBS may be used to prevent or alleviate a crisis
				situation until circumstances stabilize or other funding is obtained.
BB.
"Traumatic brain injury
				(TBI)"
means an insult to the brain from an outside physical force that
				may or may not have produced a diminished or altered state of consciousness
				causing temporary or permanent impairments in one or more areas of the brain
				and resulting in partial or total functional disability and or psychosocial
				disorientation. The term applies to open or closed head injuries resulting in
				an impairment of cognitive, psychosocial or physical functions. Brain injury
				related impairments may occur in one or more areas such as: cognition;
				language; memory; attention; reasoning; abstract thinking; judgment;
				problem-solving; information processing, sensory, perceptual, and motor
				abilities; physical functioning; sleep; psychosocial and behavioral
				functioning; and speech.