New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 7 - SUPPORTS WAIVER › Section 8.314.7.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Activities
				of daily living (ADLs):
Basic personal everyday activities that include
				bathing, dressing, transferring (e.g., from bed to chair), toileting, mobility
				and eating.
B.
Adult:
An individual who is 18 years of age or older.
C.
Agency-based:
Supports waiver
				service delivery model offered to an eligible recipient who does not want to
				direct their supports waiver services. Agency-based services are provided by an
				agency with an approved agreement with department of health (DOH) to provide
				supports waiver services.
D.
Authorized annual budget (AAB):
The total approved annual amount
				of the community support services and goods which includes the frequency, the
				amount, and the duration of the waiver services and the cost of waiver goods
				approved by the third-party assessor (TPA).
E.
Authorized representative:
The individual designated to represent and act on the recipient's behalf. The
				authorized representative does not have budget or employer authority. The
				eligible recipient or authorized representative must provide legal
				documentation authorizing the named individual or individuals for a specified
				purpose and time frame. An authorized representative may be an attorney
				representing a person or household, a person acting under the authority of a
				valid power of attorney, a guardian, or other legal designation. The eligible
				recipient's authorized representative may not be a service provider. The
				authorized representative may not approve their own timesheets. The authorized
				representative cannot serve as the eligible recipient's community supports
				coordinator.
F.
Category of
				eligibility (COE):
To qualify for a medical assistance program (MAP), an
				applicant must meet financial criteria and belong to one of the groups that the
				New Mexico medical assistance division (MAD) has defined as eligible. An
				eligible recipient in the supports waiver program must belong to the MAP
				categories of eligibility (COE) described in 8.314.7.9 NMAC.
G.
Centers for medicare and medicaid
				services (CMS):
Federal agency within the United States department of
				health and human services that works in partnership with New Mexico to
				administer medicaid and MAP services under HSD.
H.
Child:
An individual under
				the age of 18. For purpose of early periodic screening, diagnosis, and
				treatment (EPSDT) services eligibility "child" is defined as an individual
				under the age of 21.
I.
Community supports coordinator (CSC):
An agency or an individual
				that provides case management services to the eligible recipient that assist
				the eligible recipient in arranging for, directing and managing supports waiver
				program services and supports, as well as developing, implementing and
				monitoring the individual service plan (ISP) and AAB.
J.
Electronic visit verification
				(EVV):
A telephone and computer-based system that electronically
				verifies the occurrence of HSD selected service visits and documents the
				precise time the service begins and ends.
K.
Eligible recipient:
An
				applicant meeting the financial and medical level of care (LOC) criteria who is
				approved to receive MAD services through the supports waiver.
L.
Employer of record (EOR):
The
				employer of record (EOR) is the individual responsible for directing the work
				of the support's waiver employees, including recruiting, hiring, managing and
				terminating employees. The EOR is responsible for directing the work of any
				vendors contracted to perform services. The EOR tracks expenditures for
				employee payroll, goods, and services. EORs authorize the payment of timesheets
				and vendor payment requests by the financial management agency (FMA). An
				eligible recipient may be their own EOR unless the eligible recipient is a
				minor or has a plenary or limited guardianship or conservatorship over
				financial matters in place. An EOR must be the waiver participant or an EOR
				must be a legal representative of the recipient.
M.
Financial management agency
				(FMA):
HSD contractor that helps implement the AAB by paying the
				eligible recipient's service providers and tracking expenses.
N.
Individual budgetary allotment
				(IBA):
The maximum budget allotment available to an eligible recipient.
				The maximum IBA under the supports waiver is $10,000 dollars. Based on this
				maximum amount, the eligible recipient will develop a plan to meet his or her
				assessed functional, medical, and habilitative needs to enable the recipient to
				remain in the community.
O.
Individual service plan (ISP):
The ISP is the name of the
				person-centered plan for the supports waiver. The ISP includes waiver services
				that meet the eligible recipient's needs including: the projected amount, the
				frequency and the duration of the waiver services; the type of provider who
				will furnish each waiver service; other services the eligible recipient will
				access; and the eligible recipient's available supports that will complement
				waiver services in meeting their needs.
P.
Intermediate care facilities for
				individuals with intellectual disabilities (ICF/IID):
Facilities that
				are licensed and certified by the New Mexico department of health to provide
				room and board, continuous active treatment and other services for eligible MAD
				recipients with a primary diagnosis of intellectually disabled.
Q.
Legal representative:
A
				person that is a legal guardian, conservator, power of attorney or otherwise
				has a court established legal relationship with the eligible recipient. The
				eligible recipient must provide certified documentation to the community
				support coordinator provider and FMA of the legal status of the representative
				and such documentation will become part of the eligible recipient's
				file.
R.
Level of care (LOC):
The level of care an eligible recipient must meet to be eligible for the
				supports waiver program.
S.
Participant directed:
Supports waiver service delivery model
				wherein the eligible recipient identifies, accesses and manages the employees
				and vendors of services (among the state-determined waiver services and goods)
				that meet their assessed therapeutic, rehabilitative, habilitative, health or
				safety needs to support the eligible recipient to remain in their
				community.
T.
Person-centered
				planning (PCP):
Person-centered planning is a process that places a
				person at the center of planning their life and supports. It is an ongoing
				process that is the foundation for all aspects of the supports waiver and
				provider's work with individuals with intellectual/developmental disabilities
				(I/DD). The process is designed to identify the strengths, capacities,
				preferences, needs, and desired outcomes of the eligible recipient. The process
				may include other persons, freely chosen by the eligible recipient who are able
				to serve as important contributors to the process. It involves person-centered
				thinking, person-centered service planning and person-centered practice. The
				PCP enables and assists the recipients' strengths, capacities, preferences,
				needs, and desired outcomes of the eligible recipient.
U.
Reconsideration:
A written
				request by an eligible recipient who disagrees with a clinical/medical
				utilization review decision or action submitted to the third-party assessor for
				reconsideration of the decision. The eligible recipient or his or her
				authorized representative may submit the request for a reconsideration through
				the community support coordinator or the community support coordinator agency
				may submit the request directly to MAD.
V.
Third-party assessor (TPA):
The MAD contractor who determines and re-determines LOC and medical eligibility
				for the supports waiver program. The TPA also reviews the eligible recipient's
				ISP and approves the AAB for the eligible recipient. The TPA performs
				utilization management duties for all supports waiver services.
W.
Waiver:
A program in which
				the federal government has waived certain statutory requirements of the Social
				Security Act to allow states to provide an array of home and community-based
				service options through MAD as an alternative to providing long-term care
				services in an institutional setting.